上海市慢性病社区护理模式的构建及应用  

Construction and application of community nursing model for chronic diseases in Shanghai

作　　者：刘薇群 张娴 范恩芳 褚丽萍 王娜 江长缨[6] 陆梅 LIU Weiqun;ZHANG Xian;FAN Enfang;CHU Liping;WANG Na;JIANG Changying;LU Mei(Nursing Department,Shanghai University of Medicine&Health Sciences affiliated Zhoupu Hospital,Shanghai,201318,China)

机构地区：[1]上海健康医学院附属周浦医院护理部,上海市201318 [2]上海市徐汇区漕河泾街道社区卫生服务中心护理部 [3]上海市浦东新区泥城社区卫生服务中心护理部 [4]上海市松江区车墩镇社区卫生服务中心护理部 [5]上海市浦东新区金杨社区卫生服务中心护理部 [6]上海市浦东新区南码头社区卫生服务中心护理部 [7]上海市普陀区宜川街道社区卫生服务中心护理部

出　　处：《中国护理管理》2024年第11期1617-1621,共5页Chinese Nursing Management

基　　金：上海市社区卫生协会社区科研项目(SWX19M09)。

摘　　要：目的:构建上海市慢性病社区护理模式,探索上海市社区卫生服务中心护理同质化发展路径,以提升社区慢性病护理质量。方法:构建“三维联动集成共享”平台,通过平台培养社区“一专多能”护士;采用质性研究等方法明确慢性病社区延续护理角色定位;评价“一专多能”护士培养结果和社区护理实践效果。结果:社区卫生服务中心与上级医疗机构长期有序联结,截至2023年年底,累计培养多类别“一专多能”护士4435人次,已有137家(55.5%)社区卫生服务中心开设了337个专科护理门诊;社区护理人员慢性病护理能力提升,2023年1月—12月上海市151.2万人次患者在社区卫生服务中心享受到同质的专科护理服务,社区慢性病患者的延续护理需求得到一定满足。结论:上海市慢性病社区护理模式的应用提升了社区护理人员的专科护理能力,促进了社区慢性病护理实践的规范化,让社区居民享受到有效、便捷、优质的延续护理服务。Objective:To construct a chronic disease community nursing model in Shanghai,explore the development path of homogeneous nursing in Shanghai community health service centers,in order to improve the nursing quality of chronic disease in the community.Methods:A three-dimensional linkage integrated sharing platform was constructed to train the community nurses with multi-skills.The role of community nurse for chronic diseases was clarified by qualitative research and other methods.The training results of nurses with multi-skills and the effectiveness of community nursing practice for chronic diseases were evaluated.Results:Community health service centers have been in long-term and orderly connection with higher-level medical institutions.By the end of 2023,a total of 4435 multi-skilled community nurses have been trained,and 137(55.5%)community health service centers have opened 337 specialized nursing clinics.The ability of community nurses to care for chronic diseases has been improved.From January to December 2023,1.512 million patients in Shanghai received homogeneous specialized nursing services at community health service centers,and the continuous care needs of chronic disease patients have been met to a certain extent.Conclusion:The application of community nursing model for chronic disease in Shanghai has enhanced the specialized nursing abilities of community nurses,promoted the standardization of chronic disease nursing practices,and enabled community residents to enjoy effective,convenient,and high-quality continuous nursing.

关 键 词：慢性病管理 社区护理 居家护理 能力提升 护理门诊 

分 类 号：R47[医药卫生—护理学] R197[医药卫生—临床医学]