社区护理的发展：核心服务与实践困境分析

Timpka T, Svensson B, Molin B

Department of Community Medicine, Linköping University, Sweden.

Int J Nurs Stud. 1996 Jun;33(3):297-308. doi: 10.1016/0020-7489(95)00067-4.

As examples of nurse practitioners in primary care, Swedish district nurses have been shown, in several studies, to respond well to the general pressure to achieve higher productivity in health care. Yet they have less frequently been involved in studies of the detailed content of the service they provide. To maintain total service quality, change should not be brought about only for the sake of efficacy. This study is divided into an analysis of the basic service provided in district nursing by identifying a typical interaction with a patient; and an analysis of the daily dilemmas district nurses experience, their consequences, and possible measures for change. For the consultation study, data were collected from 40 videorecordings of office-hour consultations by a rural district nurse. Regarding the dilemma situations, a critical incident questionnaire was returned by 153 district nurses in a Swedish country. The analyses showed that the district nurse practises in an area between self-care on the one hand, and the intersection of the different specialties in health care, on the other. Both the consultation study and the study of dilemmas in practice showed that the district nurse has to approach the health care organisation from a viewpoint close to that of the patient, which implies that she can, and has to, maintain an overview of the patient's total interaction with social institutions. This focal localisation of the shared care and co-ordination aspects constitutes a critical target for change and development efforts. The conclusions are that, first, the role of the district nurse/nurse practitioner as co-ordinator and advocate in patient-centred care could be considered in central health services policies and planning. Second, the content of the district nurses' daily work could be taken into account in the implementation of quality programs. These measures together can lead to an integration between today's theoretical nursing models and the dynamically changing structures of health care organisations.

作为初级保健领域执业护士的例子，瑞典地区护士在多项研究中表明，他们能很好地应对医疗保健领域提高生产率的总体压力。然而，他们较少参与对其提供服务详细内容的研究。为了维持整体服务质量，变革不应仅为了效率而进行。本研究分为两部分，一是通过识别与患者的典型互动来分析地区护理所提供的基本服务；二是分析地区护士日常遇到的困境、其后果以及可能的变革措施。对于咨询研究，从一名农村地区护士办公时间咨询的40段视频记录中收集数据。关于困境情况，瑞典一个乡村的153名地区护士返回了一份关键事件问卷。分析表明，地区护士一方面在自我护理领域开展工作，另一方面处于医疗保健不同专业的交叉领域。咨询研究和实践困境研究均表明，地区护士必须从接近患者的视角来接触医疗保健机构，这意味着她能够且必须全面了解患者与社会机构的总体互动情况。共享护理和协调方面的这种重点定位构成了变革与发展努力的关键目标。结论如下：第一，地区护士/执业护士在以患者为中心的护理中作为协调者和倡导者的角色可在中央卫生服务政策和规划中予以考虑。第二，在质量计划的实施中可考虑地区护士日常工作的内容。这些措施共同作用可促使当今的理论护理模式与动态变化的医疗保健组织架构实现整合。