通过基础护理服务提升护理实践

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1 INTRODUCTION

There is growing awareness that there needs to be a reorientation of the nursing profession towards the fundamentals of care (Feo et al., 2019). These fundamentals often receive a low priority in clinical practice settings (Feo et al., 2019), and gaps in fundamental care provision are being exposed in nursing care internationally (McSherry et al., 2018). The concern is significant worldwide, and for this reason, many initiatives are developing to tackle the issue. The International Learning Collaborative (ILC) (2021), a global social learning and lobbying network, is leading the way on this. This network is committed to improving the delivery of person-centred and safe fundamental care, promoting excellence of fundamental care through the integration of clinical practice, research and education, and share the best evidence of Fundamentals of Care (FoC) (ILC, 2021; Kitson, 2018).

2 BACKGROUND

Fundamental care is defined as follows (Feo et al., 2017; ILC, 2021):

Fundamental care involves actions on the part of the nurse that respect and focus on a person's essential needs to ensure their physical and psychosocial wellbeing. These needs are met by developing a positive and trusting relationship with the person being cared for as well as their family/carers

The fundamentals of care are conceptualized within three distinct dimensions of care: (1) the relationship, (2) the integration of care and (3) the care context (ILC, 2021). The relationship involves five core elements: developing and maintaining trust, focusing on the patient being cared for, anticipating the patients' needs, getting to know the patient and how best to provide care for them and evaluating the quality progress and outcomes of the relationship (ILC, 2021). The integration of care provides detailed outline of the physical psychosocial and relational aspects of the fundamentals of care (Table 1).

However, fundamentals of care are very frequently overlooked (Bagnasco et al., 2019), especially where resources are low (Aiken et al., 2014; Blackman et al., 2020; Kim et al., 2017). The reasons for these gaps vary and are the subject of much debate in the literature (Kitson, 2016), and there is often a limited perception of importance of such (fundamental) activities by nurses (Bentzen et al., 2013). As most human daily and social activities revolve around activities such as eating, drinking, washing, and eliminating, when any health change occurs, or unfamiliar circumstances arise (hospitalization, for example), these activities are often the first to be compromised (Kitson et al., 2010). Nurses do not always consider fundamental care as part of their role because health care assistants often carry out these activities (HSE, 2018; Kalisch, 2006; RCN, 2021). Interviews with nurses, for example, reveal that their role is perceived by care assistants as “paperwork and pills” with nurses increasingly “moving away from the bedside” leaving the fundamental care to care assistants (McGuire, 2019). Fundamental aspects of care that are particularly important are safety, dignity (Zahran et al., 2016) and communication/person-centred care (Dickson et al., 2017).

3 WHERE IS FUNDAMENTAL CARE POSITIONED WITHIN ADVANCED PRACTICE?

One such area that could be accused of moving away from acknowledging the importance of getting fundamental care right for patients is advanced nursing practice. The ever-growing global population of nurses prepared to advanced level, to provide for advanced care of patients across the health care continuum. While core nursing competencies (and particularly those related to high quality fundamental care delivery) remain implicit, advanced practice competencies usually focus on developing higher order skills including skills of critical thinking, research, leadership in addition to advanced clinical skills. By default, the fact that as a profession we do not actually know what critical thinking, research and leadership skills are necessary to deliver (and manage the delivery) of fundamental care means we do not have the conceptual scaffolding to make this happen in practice. With the growing impetus on fundamental care, we wonder whether the concept of contemporary advanced nursing practice by its very nature opposes this concept? Can one be at the same time at the forefront of, and advancing nursing practice and also have a role in championing the further understanding of the fundamentals of care?

At the same time there is little research to support the importance of many fundamental activities or to guide evidence-based practice in these areas (Feo et al., 2019). The work of the ILC (2021) also encourages and promotes research. There are certainly gaps in this important topic, possibly due to limited funding opportunities, or a perception of low status topic areas (Richards et al., 2018). However, the increasing emphasis on impactful research means that there is scope now more than ever to revitalize research into fundamentals of care (Hewison & Taylor, 2019). Advanced practitioners, with their clear research agenda, are well positioned within clinical practice to advance research in this field, especially when the need for nursing research has never been stronger:

“Nursing research and scholarship have never been more important than it is today in developing the global profession and ensuring we provide the best, evidence-based care to our patients and communities. The most important aspect of high-quality nursing research is that it has impact—on patient care, service delivery, policy or the science of nursing” (Hayter, 2020, p. e6),

4 CONCLUSION

It is our view that the advancement of nursing practice for the future is reliant on an acknowledgement and indeed a reorientation towards fundamental care delivery. Some of our team's experiences as advanced practitioners reveals that while these nurses are frequently occupied with physical aspects of fundamental of care, such as medication management, infection control and safety, they are invariably presented with other aspects of fundamental care that require attention. Thus the higher order competencies such as critical thinking, research and leadership that shape advanced practice competencies need greater discussion to explore their contribution to supporting effective fundamental care delivery. These fundamentals also need to be viewed as central and core to all nursing practice. Without such dialogue advanced practitioners skills may become subsumed by the requirements for technical competence in advanced clinical skills and diagnostics, which do not necessarily highlight the requirements for continued attention to the fundamentals of care. Moreover, if limited attention is paid to these, as is the case in many parts of healthcare practice, then priority needs may go unrecognized leading to reduced patient satisfaction and lapses in care. In is important to note that many such lapses do not have immediate effect, such as inattention to relational aspects of care, comfort or dignity, but rather these have longer term effects on patient and family satisfaction with hospital care, perceptions of healthcare experiences and also engagement with health care services. Ultimately managers within the nursing profession need to consider the possible effect of subtle inattention to the fundamentals of care in the context of advancements and provision of high level of advanced nursing services. Managers need to lobby for increased awareness of the need to focus on these fundamentals, but also to begin to develop a more expansive evidence base to underpin their delivery.

全文翻译（仅供参考）

1 简介

人们越来越意识到，护理专业需要重新定位于护理的基础。这些基础知识在临床实践环境中的优先级通常较低，而在国际护理中，基础护理提供方面的差距正在暴露出来。这个问题在全球范围内都很重要，因此，正在制定许多举措来解决这个问题。国际学习合作组织 (ILC) ( 2021 ))，一个全球社会学习和游说网络，在这方面处于领先地位。该网络致力于改善以人为本和安全的基础护理服务，通过整合临床实践、研究和教育促进基础护理的卓越性，并分享护理基础 (FoC) 的最佳证据。

2 背景

基本护理定义如下：

基本护理涉及护士方面的行动，尊重并关注一个人的基本需求，以确保他们的身体和心理健康。通过与被照顾者及其家人/照顾者建立积极和信任的关系来满足这些需求

护理的基本原理在护理的三个不同维度中被概念化：（1）关系，（2）护理的整合和（3）护理环境（ILC，  2021）。这种关系涉及五个核心要素：建立和维持信任、关注被照顾的患者、预测患者的需求、了解患者以及如何最好地为他们提供护理以及评估关系的质量进展和结果。国际劳工大会，  2021 年）。护理的整合提供了护理基础的生理心理和关系方面的详细概述（表 1）。

然而，护理的基础知识经常被忽视，尤其是在资源匮乏的情况下。这些差距的原因各不相同，并且是文献中许多争论的主题，而且护士对此类（基本）活动的重要性通常知之甚少。由于大多数人类日常和社交活动都围绕着吃、喝、洗和排泄等活动，当发生任何健康变化或出现不熟悉的情况（例如住院）时，这些活动往往首先受到损害。护士并不总是将基本护理视为其职责的一部分，因为医疗保健助理经常开展这些活动。例如，对护士的采访表明，他们的角色被护理助理视为“文书工作和药丸”，护士越来越多地“远离床边”，将基本护理留给护理助理。特别重要的护理的基本方面是安全、尊严和沟通/以人为本的护理。

3 基础护理在高级实践中的位置在哪里？

高级护理实践是一个可能被指责不承认为患者提供基本护理的重要性的领域。不断增长的全球护士准备进入高级水平，为整个医疗保健连续体的患者提供高级护理。虽然核心护理能力（尤其是与高质量基础护理提供相关的能力）仍然是隐性的，但高级实践能力通常侧重于培养更高层次的技能，包括批判性思维、研究、领导能力以及高级临床技能。默认情况下，作为一种职业，我们实际上并不知道批判性思维是什么，研究和领导技能是提供（和管理提供）基本护理所必需的，这意味着我们没有在实践中实现这一目标的概念支架。随着对基础护理的推动力越来越大，我们想知道当代高级护理实践的概念是否从本质上反对这一概念？一个人能否同时走在护理实践的前沿，推进护理实践，并在促进对护理基础知识的进一步理解方面发挥作用？

同时，很少有研究支持许多基础活动的重要性或指导这些领域的循证实践。的工作也鼓励和促进研究。这个重要主题肯定存在差距，可能是由于资助机会有限，或者对低地位主题领域的看法）。然而，对有影响力研究的日益重视意味着现在比以往任何时候都更有可能重振对护理基础的研究。具有明确研究议程的高级从业人员在临床实践中处于有利地位，可以推进该领域的研究，尤其是在对护理研究的需求从未如此强烈的情况下：

“在发展全球专业和确保我们为患者和社区提供最好的、循证护理方面，护理研究和学术从未像今天这样重要。高质量护理研究最重要的方面是它对患者护理、服务提供、政策或护理科学产生影响”。

4 结论

我们认为，未来护理实践的进步依赖于对基础护理提供的承认和重新定位。我们团队作为高级从业者的一些经验表明，虽然这些护士经常忙于基本护理的身体方面，例如药物管理、感染控制和安全，但他们总是会遇到需要注意的基本护理的其他方面。因此，形成高级实践能力的批判性思维、研究和领导力等更高层次的能力需要更多的讨论，以探索它们对支持有效的基础护理服务的贡献。这些基础知识也需要被视为所有护理实践的核心。如果没有这样的对话，高级从业者的技能可能会被高级临床技能和诊断的技术能力要求所包含，这并不一定强调继续关注护理基础的要求。此外，如果对这些问题的关注有限，就像在医疗保健实践的许多方面一样，那么优先需求可能会被忽视，从而导致患者满意度降低和护理失误。

重要的是要注意，许多此类失误不会立即产生影响，例如不注意护理、舒适或尊严的关系方面，而是对患者和家庭对医院护理的满意度、对医疗保健体验的看法以及也会产生长期影响。参与医疗保健服务。最终，护理行业的管理者需要考虑在进步和提供高水平的高级护理服务的背景下，对护理基础的微妙疏忽可能产生的影响。管理人员需要游说提高对关注这些基本要素的必要性的认识，同时也需要开始建立更广泛的证据基础来支持他们的交付。