姑息治疗中的高级护理实践：证据基础是什么？

Full text

Those of us involved in delivering healthcare recognise that we are in a time of profound transition, particularly within the complex post-pandemic world. Consumer expectations, complexities of healthcare and a global shortage in the nursing workforce present significant challenges. Nursing leaders need to both pause and reflect, as well as adapt and develop new innovative ways to carry the nursing profession into the future. Reports from both the International Council of Nurses (ICN) and the 74th World Health Assembly have advocated for an investment in nursing leadership, in order to encourage nurses to engage and manage the current challenges (ICN, 2020; Burton, 2021). Different care models and practices need to be developed; one area that is under consideration is advanced nursing practice.

An Advanced Nurse Practitioner (ANP) has been defined by the ICN as one who ‘has acquired, through additional education, the expert knowledge base, complex decision-making skills and clinical competencies for expanded nursing practice, the characteristics of which are shaped by the context in which they are credentialed to practice’ (ICN, 2020). In effect, an ANP provides complex care using expert decision-making skills, alongside acting as an educator, leader, innovator, and contributor to research. Based upon the work of Hamric et al (2009), the core competencies of ANPs have been divided into four areas: direct clinical care; leadership; research and evidence-based practice; and education.

Within direct clinical care, ANPs are expected to work autonomously, provide clinical judgement and report quality issues using a person-centred approach, as well as diagnose, prescribe and treat patients within complex care. As leaders, ANPs are expected to develop and sustain partnerships and networks, engage stakeholders, provide professional and clinical advice, demonstrate resilience and develop robust governance systems. As educators, an ANP must keep their own knowledge and skills up to date while educating, supervising and mentoring colleagues. Lastly, as researchers, ANPs must contribute towards research that monitors and improves healthcare, critically appraise research and evaluate outcomes, and advocate for the development of a supportive research culture.

While such roles have been developed in other areas such as emergency care, primary care and oncology, they remain underdeveloped in palliative care, despite the demand for palliative care services having changed and grown. According to Sleeman et al (2019), an estimated 48 million people in 2060 (47% of all deaths globally) will die with serious health-related problems—an 87% increase compared to 2016. Consequently, the need to integrate advanced practice roles into palliative care practice has never been greater.

Internationally, different models have been developed. For example, the advanced nurse role in the US and Australia are well developed and include a protected title, with clear requirements for preparation and supervision in practice. Across Europe, there is no consensus on what advanced practice is, or what roles and role preparation should be included. In addition, not every country recognises or supports advanced practice within their regulatory nursing professions (Lee et al, 2020). For example, the UK's national advanced clinical practice framework was developed in 2017. However, a nation-wide evaluation of the role across England demonstrated that considerable variation was found in the role titles, scope of practice, job descriptions and educational backgrounds of ANPs (Fothergill et al, 2022).

In Ireland, a recent report into the impact of ANPs across rheumatology, respiratory medicine, older person care and unscheduled care concluded that they positiviely impacted patient satisfaction and education, as well as increased continuity, access to care and the rate of avoidable hospitalisations (Department of Health, 2021). However, the evidence-base for palliative care literature is limited. While the ANP role was seen as a valuable source of extending palliative care into oncology (Ferrell et al, 2021), traditional forms of educational preparation were seen as insufficient for specialists in the palliative field (Pawlow et al, 2018).

Opportunities for ANPs within palliative care include improving communication, particularly around early palliative care consultations (Sabolish et al, 2022) and end-of-life care prognostic discussions (Kalowes, 2015). A qualitative study that explored the contribution of ANPs to multi-professional palliative care found the ANPs operated as the ‘thread running through the week’ and helped ensure the continued high quality of the local palliative care teams (Kennedy et al, 2015). However, while Kennedy et al (2015) argued that the fluid boundary between nursing and medicine was a valuable role model for leadership, the boundaries between the nursing and medical role needs to be carefully considered. ANPs are not meant to operate as ‘mini-doctors’—they are designed to contribute their own unique skill sets across clinical care, education, research, and leadership, working to the top level of their licence.

ANP roles is not without its challenges. Such challenges include considerations of levels of preparation and role of clinical supervisor in practice, practical aspects related to governance, regulation and supervision, as well as the need for continuous professional development and necessity to ensure that research aspects are not forgotten. Many questions remain around the development of such roles for professional practice, although it is clear that such roles are becoming more significant—it is hard to envisage the world of palliative care without nurses.

Nurses are the largest workforce in palliative care. Their contributions to the legacy of palliative, holistic and compassionate treatment, as well as the development of a ‘total pain’ approach across the trajectory of living and dying, is evident.

The ANP role provides a vast array of new opportunities for nursing, including building new models within health policy and the implementation of new strategic leaders within specialist- and generalist-palliative care organisations. What is needed now is an evidence base to inform future direction and contribute to clinical practice and patient and family outcomes.

全文翻译（仅供参考）

我们这些参与提供医疗保健的人认识到，我们正处于一个深刻的转型时期，尤其是在复杂的大流行后世界中。消费者的期望、医疗保健的复杂性和全球护理人员短缺带来了重大挑战。护理领导者既需要停下来思考，也需要适应和开发新的创新方式，以将护理专业带入未来。国际护士理事会 (ICN) 和第 74 届世界卫生大会的报告都提倡对护理领导力进行投资，以鼓励护士参与和应对当前的挑战（ICN，2020；Burton，2021）。需要开发不同的护理模式和做法；正在考虑的一个领域是高级护理实践。

ICN 将高级护士从业者 (ANP) 定义为“通过额外的教育，获得了专家知识库、复杂的决策技能和临床能力以扩展护理实践，其特征由他们获得执业资格的背景”（ICN，2020）。实际上，ANP 使用专家决策技能提供复杂的护理，同时充当教育者、领导者、创新者和研究贡献者。基于Hamric 等人 (2009)的工作，ANP 的核心能力分为四个领域：直接临床护理；领导; 研究和循证实践；和教育。

在直接临床护理中，ANP 有望自主工作，使用以人为本的方法提供临床判断和报告质量问题，以及在复杂护理中诊断、开处方和治疗患者。作为领导者，ANP 预计将发展和维持伙伴关系和网络，吸引利益相关者，提供专业和临床建议，展示弹性并发展强大的治理系统。作为教育工作者，ANP 必须在教育、监督和指导同事的同时，不断更新自己的知识和技能。最后，作为研究人员，ANP 必须为监测和改善医疗保健的研究做出贡献，批判性地评估研究和评估结果，并倡导发展支持性研究文化。

尽管此类角色已在紧急护理、初级保健和肿瘤学等其他领域得到发展，但尽管对姑息治疗服务的需求发生了变化和增长，但它们在姑息治疗中仍然不发达。根据Sleeman 等人 (2019)的估计，到 2060 年，估计有 4800 万人（占全球所有死亡人数的 47%）将死于严重的健康相关问题——与 2016 年相比增加了 87%。因此，需要整合高级实践角色进入姑息治疗实践从未如此广泛。

在国际上，已经开发了不同的模型。例如，美国和澳大利亚的高级护士角色发展良好，包括受保护的头衔，对实践中的准备和监督有明确的要求。在整个欧洲，对于什么是高级实践，或者应该包括哪些角色和角色准备，还没有达成共识。此外，并非每个国家都认可或支持其监管护理专业中的先进实践（Lee 等人，2020 年）。例如，英国于 2017 年制定了国家高级临床实践框架。然而，对英国全国范围内的角色评估表明，在 ANP 的角色头衔、实践范围、工作描述和教育背景方面发现了相当大的差异。Fothergill 等人，2022 年）。

在爱尔兰，最近一份关于 ANP 对风湿病学、呼吸内科、老年人护理和计划外护理的影响的报告得出结论，它们对患者的满意度和教育，以及增加的连续性、获得护理的机会和可避免的住院率产生了积极影响。卫生署，2021 年）。然而，姑息治疗文献的证据基础是有限的。虽然 ANP 的作用被视为将姑息治疗扩展到肿瘤学的宝贵资源（Ferrell 等人，2021 年），但传统形式的教育准备对于姑息治疗领域的专家来说被认为是不够的（Pawlow 等人，2018 年）。

姑息治疗中 ANP 的机会包括改善沟通，特别是围绕早期姑息治疗咨询（Sabolish 等人，2022 年）和临终关怀预后讨论（Kalowes，2015 年）。一项探索 ANP 对多专业姑息治疗贡献的定性研究发现，ANP 作为“贯穿一周的主线”运作，有助于确保当地姑息治疗团队的持续高质量（Kennedy 等人，2015 年）。然而，虽然Kennedy 等人 (2015)认为护理和医学之间的流动边界是领导的宝贵榜样，需要仔细考虑护理和医学角色之间的边界。ANP 并不是要以“迷你医生”的身份运作——他们旨在在临床护理、教育、研究和领导力方面贡献自己的独特技能，努力达到其执照的最高水平。

ANP 角色并非没有挑战。这些挑战包括考虑临床主管在实践中的准备水平和作用，与治理、监管和监督相关的实际方面，以及持续专业发展的需要和确保研究方面不被遗忘的必要性。围绕专业实践中此类角色的发展仍然存在许多问题，尽管很明显，此类角色正变得越来越重要——很难想象没有护士的姑息治疗世界。

护士是姑息治疗中最大的劳动力。他们对姑息治疗、整体治疗和富有同情心的治疗遗产的贡献，以及在生死轨迹中发展“完全疼痛”方法的贡献是显而易见的。

ANP 的角色为护理提供了大量新机会，包括在卫生政策中建立新模式以及在专科和全科姑息治疗组织内实施新的战略领导者。现在需要的是一个证据基础，以告知未来的方向并为临床实践以及患者和家庭的结果做出贡献。