社區與醫院間聯盟以提供精神病患持續性護理之初探

A Preliminary Exploration of the Community-Hospital Collaborative Model of Continuous Care for Patients with Schizophrenia

蕭淑貞(Shu-Jen Shiau) ； 李依玲(I-Ling Li) ； 康云瑄(Yun-Xuan Kang) ； 鄭進興(Chen-Chin Hisn) ； 張凱雁(Kai-Yen Chang)

《精神衛生護理雜誌》 3卷1期 (2008/10) Pp. 1-8

https://doi.org/10.6847/TJPMHN.200810_3(1).0002

摘要

研究目的：探討社區與醫院間的夥伴關係，以期能發展聯盟模式提昇精神病患於社區中的持續性照護品質。研究方法：採用行動研究法，經由收集資料、執行持續性社區照護、反思討論照護模式、訂定聯繫方式、執行評值及再修訂等過程。研究對象為醫院護理人員、社區公衛護理人員、長期照護暨個案管理中心個案管理師及康復之家工作人員等並針對5名某區域醫院精神科急性病房診斷為精神分裂症或情感性疾患，自病患出院後進行持續性照護，並進行醫院與社區的聯繫照護。結果：一、建構社區與醫院間夥伴關係聯盟模式。二、初探持續性照護中病患呈現的關懷需求議題。三、初探社區中各個聯盟單位護理人員角色功能與困境。護理上應用：藉由發展醫院與社區之間的夥伴關係聯盟模式，期待未來能推廣應用以提昇精神病患於社區中的持續性照護品質。在未來展望方面，期待能確定社區中各個單位護理人員角色定位及實務能力、確立聯絡者的職位及發展能力培訓認證。

關鍵字

社區 ； 醫院 ； 夥伴關係 ； 持續性護理

並列摘要

Purpose: to explore the partnerships between communities and hospitals in developing the community-hospital collaborative model for improving the quality of continuous care in the community for patients with schizophrenia. Method: The action research method was applied through the process of information-processing, offering care, reflective discussion, establishing collaborative rule, evaluation and revision. Research subjects included hospital nurses, public health nurses, case managers, and nursing staff in rehabilitation homes, who had provided continuous care to five patients with schizophrenia or affective disorder since the latters' discharge from an acute ward of a hospital. Results: 1. Established the community-hospital collaborative model. 2. Explored the issues of concern to patients during continuous care. 3. Explored the functions and difficulties faced by nurses in each of the partner institutions. Applications: The results might serve as a reference for the development of community-hospital collaborative models and the enhancement of continuous care for psychotic patients living in the community. Future study: to confirm the roles and competencies of nurses working in various settings, firmly establish the position of coordinator, and develop competency training and accreditation.

並列關鍵字

community ； hospital ； partnership ； continuous care