【作者】 江会；

【导师】 叶文琴；

【作者基本信息】 第二军医大学 ， 护理学， 2013， 博士

【摘要】 研究目的“依据护理工作量和患者病情配置护士，实行分层管理，体现能级对应”是当前医改背景下护理人力管理的改革和努力方向。本课题以三级综合医院神经内科病房患者所需的实际护理工作量为研究切入点，通过现况研究、工时测算、患者分类、岗位设置的系列课题研究，以探索神经内科病房护理人力数量和结构的合理配置方法。建立一套科学、合理、规范的神经内科病房各岗位护理人力配置的测算计算公式，以实现从数量和结构两方面合理、有效地配置和使用护理人力、节约医院人力成本、推进优质护理服务和岗位管理工作顺利开展的研究目的。研究方法①采用质性访谈法和问卷调查法对上海市三级综合医院神经内科护理人员进行质性访谈和现况调查，了解神经内科护理人员对当前护理人力配置现状的认识和看法，分析了解神经内科病房护理人力的配置现状，对比分析不同工作年限、不同学历、不同职称护理人员直接护理项目、间接护理项目的实施和参与现状。②采用便利抽样法，以某三级综合医院神经内科病房为研究对象，运用动作时间测定法，采用体育专用秒表测算神经内科住院患者每日所需要的直接护理、间接护理工时数。建立以患者自理能力、病情严重程度、护理操作治疗量、护理评估和健康教育为综合评分指标的患者分类方法，将患者分为ABCD四类，并测算每类患者每日的直接护理时数和间接护理时数。③采用专家会议法，将卫生部岗位管理文件与临床护理工作的实施现状相结合，构建神经内科提供直接护理服务的岗位即临床护理岗位的分层框架和各岗位人员的准入标准、岗位职责、工作内容以及各岗位参与直接护理项目的专家建议工时构成比，以此工时构成比为基础，测算每日责任护士岗、助理护士岗和护理辅助岗的人员配置比例。采用文献分析法引用宽放率和机动系数，建立以护理工作量工时测算为基础的神经内科各岗位护理人力配置的测算模型。结果①目前神经内科护理人力配置数量总体不足，中夜班护理人力配置更加薄弱，临床护理人员的床护比、护患比均未达到所要求的护理人力配置标准。护理工作内容除护理管理、护理教学、护理科研等少数项目外，不同工作经验、不同学历、不同职称护理人员虽然能力不等，但工作内容相同，临床一线护理人员以低年资、低工作经验、低职称的大专学历护理人员为主体。②不同自理能力组、不同等级护理组患者直接护理工时的ANOVA单因素方差分析结果表明：单独采用患者自理能力分类或等级护理分类均不能完全反应临床的护理工作量、不能满足护理人力配置所需的患者分类需求。以专业照顾、护理评估和病情观察、治疗处置、心理护理和健康教育为护理工作内容设计患者分类的评分标准，结合自理能力、等级护理、医嘱治疗量、护理评估和健康宣教对患者进行评分分类，ABCD四类患者每日的直接护理时数分别为：120.11、111.21、99.99和37.13min，平均间接护理时间为12.21min。③将临床护理岗岗位细化为责任护士岗位、助理护士岗位和护理辅助岗位，所构建的护理人力配置公式模型为：[（120.11×NA+111.21×NB+99.99×NC+37.13×ND）/480]×1.2×1.46，责任护士岗、助理护士岗、护理辅助岗的配置比例分别为50%、15%、35%。非临床护理岗位其配置公式模型为：[（12.21min×NABCD）/480]×1.2×1.46。NA、NB、 NC、ND为A、B、C、D各分类患者的病人数，NABCD为ABCD四类患者的总病人数。结论护理人力配置应综合考虑影响护理工作量的各类因素，以患者实际所需的护理工作量为基础测算护理工时数，科学地设定护理岗位,优化护理队伍结构，以各岗位所需的护理工时数测算护理人力的配置数量，实现从数量和结构上合理配置护理人力的目标，以促进长效深入地开展岗位管理和优质护理服务，提高护理质量和患者对护理工作的满意度。更多还原

【Abstract】 Objective：The size and mix of nursing teams are critical elements of efficient healthservice management and workforce planning. The staffing level and skill mix arerecognized as central elements of the current nursing reforms in China. Thesereforms aim at supplying proper nursing staff on the basis of daily nursing workloadand patient’s acuity measurement. The objective of this project was to establish a setof methods to calculate the numbers of different layers of nursing staff. This was adescriptive study, of nursing hour measurement, patient classification and front-linenursing staff configuration study to achieve an overall goal of the effectiveness,flexible and cost-effective use of nursing resources in the neurological ward in atertiary general hospital in China.Methods：①Qualitative interview and questionnaires were used to explore thenurses perception of the nurse staffing and skill mix and to analyze the direct andindirect nursing care delivery status by comparing the nursing care delivery groupedaccording to different years of working experience, educational background andprofessional titles.②Measuring the direct and indirect nursing hours per patient perday in a neurological ward in a tertiary general hospital by convenience sampling.Establishing a patient classification tool based on the daily nursing workload andclassifies the patients into four groups (ABCD).③Expert meeting method was usedto define the qualification criteria, responsibilities, nursing care scope,proper ratiosfor different layers of nursing staff for the purpose of devising a formula of nursingresource allocation in the neurological ward in the tertiary general hospital.Results：①Nursing staff was inadequate when measured by both nurse-bed andnurse-patient ratios. There was no significant difference in the frequency ofimplementing direct nursing work by the nursing staff with different years ofexperience, education background nor professional titles.②The ANOVA analysisshowed that both the patient dependency and acuity classification cannot reflect thenursing workload adequately. Patient classification tool that combined patientdependency, acuity, number of treatment procedures, nursing assessment andnursing education was created and used to classify the patients into four (ABCD)groups. The nursing hours per patient per day for group A is120.11min,group B is111.21min, group C is99.99min and group D is37.13min.③Nursing configurationwas set as the combination of three categories: registered nurse, assistant nurse and health care workers. The staffing formula for direct nursing care is:[（120.11×NA+111.21×NB+99.99×NC+37.13×ND）/480]×1.2×1.46，The percentageof registered nurse, assistant nurse and health care workers was set at50%,15%and35%respectively. The staffing formula for indirect nursing care is:[（12.21min×NABCD）/480]×1.2×1.46. NA, NB, NC,and NDstand for the number ofpatients in each group (ABCD). NABCDis for the total number of patients in allgroups.Conclusions：It is essential to distribute nursing resource reasonably for qualitynursing care and management. The nurse allocation should consider all the factorsinfluencing nursing workload. By doing so we can calculate the needed nursinghours for patient care and configure the nurses properly to improve the quality ofnursing care thus patients satisfaction, while at the same time meet the goals of costcontainment in the hospital.更多还原