三级医院高年资护士下社区工作实践及效果评价  

Practice and effect of arranging senior nurses from tertiary hospital to serve in communities

作　　者：唐玉侠 于卫华[3] 刘媛媛[4] 牛磊 TANG Yuxia;YU Weihua;LIU Yuanyuan;NIULei(Department of Nursing, the Third Affiliated Hospital of Anhui Medical University, Hefei, 230061, China)

机构地区：[1]安徽医科大学第三附属医院护理部,合肥市230061 [2]合肥市滨湖医院护理部 [3]合肥市第一人民医院护理部 [4]合肥市第一人民医院内分泌科 [5]合肥市庐阳区杏林街道卫生服务中心

出　　处：《中国护理管理》2018年第7期940-943,共4页Chinese Nursing Management

基　　金：安徽省医改办创新城市医联体课题

摘　　要：目的:分析三级医院高年资护士在城市社区医联体建设中的适宜角色并对其工作成效进行评价。方法:依托安徽省医改办创新城市医联体平台以高年资护士为纽带的社区"三人四病"管理工作,以高年资糖尿病护士的工作为例进行评价。高年资糖尿病护士在社区开设糖尿病护理门诊对患者进行个体化干预、建立糖尿病"三段五级四元联动"管理模式并上下转诊患者、参与家庭医生团队为患者建立家庭病床和提供上门服务等,并对患者的就医体验和高年资护士的工作体验进行一对一访谈,比较实践前后患者的满意度、空腹血糖及高年资护士自我价值体验等的变化。结果:社区糖尿病患者的满意度、空腹血糖和糖尿病高年资护士的专业价值感等均较实践前改善。结论:高年资糖尿病护士下社区具有一定的成效,可以为我国分级诊疗制度的落实和我国社区执业护士的发展提供借鉴。Objective： To evaluate the effect of arranging senior nurses from tertiary hospital in communities and their suitable roles to serve in health alliance. Methods： Based on the platform of innovative health alliance of Anhui medical reform office, the effect of senior nurses＇ work was evaluated in the process of the management of ＂three people and four diseases＂ in the community. Individualized interventions were implemented by senior diabetes nurse in the community nursing clinic, and integrated care mode of diabetes ＂treatment-care, three sections, four linkage and five circles combination＂ was established. Home visits were provided by senior nurses together with the family doctor team. And the patients＇ satisfaction, fasting glucose, and senior nurse＇s self-value experience were compared before and after the intervention 3 months later. Results： Patients＇ satisfaction, fasting glucose, and senior nurse＇s self-value experience were significantly improved after intervention. Conclusion： Arranging senior nurses to serve in communities is worth considering in hierarchical diagnosis system and developing the community nurse practitioner.

关 键 词：高年资护士 糖尿病 社区 医联体 

分 类 号：R47[医药卫生—护理学]