[Clinical pathways: a way to integrate a standardized treatment and patient-orientation?]. / Klinische Behandlungspfade: Ein Weg zur Integration von standardisierter Behandlungsplanung und Patientenorientierung?

The implementation of Diagnosis Related Groups (DRGs) as the payment system for hospital work requires to optimise the processes and the use of resources while maintaining the quality of care. To achieve these goals hospitals implement clinical pathways. The systematic structure of these pathways was developed in the industrial context during the 1950s. This history led to the assumption that a process begins and ends in a previously-planned most linear motion. This assumption creates various problems. First of all, the conditions of the situation and the individual's personal needs are ignored. Both aspects are relevant for the quality of care as well as for the calculation of the expenditures. Another problem is the disregard of communicative understanding, the core of nursing. As a result of these problems, the contradictory goals satisfying the rationale and communicative needs conflict. This situation creates the risk of the functional-orientated orders of the clinical pathways determining the relationship between the nurse and the patient. The next risk is that the patient will only be a marginal part of the process. In addition, the nurses may loose their caring competence. Despite these arguments, the use of clinical pathways can be well supported. For the pathway to be successful, the stipulation that remains important is for the system to allow flexibility. To achieve this flexibility, one must utilize assessment instruments. The steps of the intervention process have to be guided by the results of the assessment along with the outcome. The art of professional nursing should successfully combine the clinical pathway with the patient's individual needs.

[Living with a chronic progressive form of multiple sclerosis--a balance act]. / Leben mit einer chronisch progredienten Verlaufsform der Multiplen Sklerose--ein Balanceakt.

There are only a few studies in the German speaking countries available which address the subject of the experience of chronically ill people during the course of their illness. Therefore it was the intent of this present study to find answers for central nurse science issues: How do people who suffer from a chronically progressive course of multiple sclerosis experience the downward trajectory? Which strategies do they develop in order to integrate the disease into their lives? In what ways does the scientific paradigm of medicine influence the perceptions of the illness and the life with it? After an analysis of the national and international state of nursing research follows a description of the methodology of the Grounded Theory and the individual examination steps of the study. The second part examines some essentials of the study. The results show that the trajectory is characterized by four phases. At first the ill person concentrates on the social discussion of the pathogenesis and the medical paradigma. But with physical experiences, exchange with other affected people and acquired information, those concerned develop a very case-specific knowledge. Often disillusioned by the medication strategies, based on the experience that their subjectivity and their individuality are not taken into account, they increasingly disapprove the deficit-oriented perspective of the professionals. They develop distinctly self-caring potentialities. To identify and support this self-care potentialities should be the very core of nursing.