【作者】 赵光红；

【导师】 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 研究目的有关对护理质量及其评价体系的研究,已有众多报道。但目前所应用的评价体系忽略了护理的非技术性服务属性因素,偏重于基础护理质量和终末质量的评价,使之与护理专业发展不平衡。护理评价若以“量的测量”为标准,忽视“质的考核”,则缺乏约束机制,患者获得的服务质量难以保证;护理评价若以“质的评价”为标准,忽视“量的测量”,则存在公平性问题,从而影响护理人员的工作积极性。因此,本研究的目的是用科学的方法建立一套能权衡“护理工作量”和“护理质量”的综合评价体系,在保障患者安全和提高护理质量的同时,能够体现护理管理的公平性,以激发护理人员工作热情和提高工作效率。研究方法1.文献回顾法:通过查阅文献、书籍和各类数据库,归纳出国内外护理质量管理的相关理论和研究现况,找出当今护理评价的特点,提出本课题要解决的问题。2.专家咨询法:主要以专题小组讨论、专家咨询和头脑风暴法等方式确定课题的相关项目、研究框架和权重系数。3.问卷调查法:依据研究的目的和内容,设计合理的调查问卷收集资料。4.统计分析法:主要运用Excel和SPSS13.0统计软件包对各类研究数据进行分析。本研究涉及到的统计分析方法主要有多元线性回归、卡方检验、t检验、方差分析、Pearson秩相关和离差法。主要研究结果1进一步明确了护理的概念和相关理论在护理评价中的应用从护理的实践出发,结合文献资料分析了护理服务的内涵、特征,对护理的概念进行了新的界定:护理是指具有执业资格的护理人员向有健康需求的人群提供专业帮助,使其恢复健康或从事有益于健康的活动,是一种无形的服务。由此可见,护理包括两个方面的内容:第一为技术性活动,如遵医嘱执行静脉给药、提供床上擦浴等技术性护理活动;第二为服务属性的护理内容,如护士要具有良好的服务态度,给予心理护理等。同时,运用文献研究的方法明确了相关理论在构建护理评价中的应用。护理工作量与质量综合评价体系的构建依据系统理论内涵的指导,护理工作量的测量与护理质量标准的重新构建依据持续质量改进理论、绩效管理理论等的启示和指导。2现行护理质量管理评价的实证状况通过对某三甲综合医院护理质量检查结果的回顾性分析发现,现行的以终末质量评价为主的护理质量评价有一定的专业价值,主要表现在规范护理操作行为、提高专业性技术操作水平两方面,但也存在其评价不能体现护理服务内涵,忽视全员、全过程管理,不重视经济性和不能达到“零缺陷”、等问题。应用问卷调查了患者对现行护理服务的满意状况。患者对护理人员服务态度的满意度较高,但对护理人员主动服务意识满意度不高;影响总体满意度的单项指标为护士进行护理操作前后的解释工作、护士巡视病房的次数等。通过分析,护理工作量大可能是上述结果的重要影响因素。对护理人员的职业态度和工作满意度的调查发现,护理人员有较高的职业态度,但工作满意度处于中等偏低水平。护理人员最不满意的是福利待遇、工作与家庭的平衡。职业态度与工作满意度呈显著正相关,说明外界因素可能影响护理人员的工作满意度,需查找原因进行对症性处理。运用问卷调查护了理人员对护理质量管理的看法。结果显示,护理人员均愿意积极参与护理质量管理,并且从临床一线的角度对护理质量管理提出了有价值的建议。由此表明,只要建立科学、公平的护理质量管理体系,就能真正提高护理服务质量。3护理工作范畴的界定及工作量的测量对收集到的47个临床科室的护理工作项目进行分类、界定,得出基础护理中直接护理47项,间接护理28项;专科护理中直接护理125项,间接护理26项;其中基椿だ碇屑浣踊だ?0项为非护理专业性工作,专科护理中间接护理7项为非护理专业性工作。将所有收集到的护理工作项目进行工时测量,统计3年每日人均工作时间,即每日人均工作量,结果显示,内科系统、外科系统、妇产科、儿科、急诊、肿瘤科、综合科系统、ICU每日人均工作量差异无统计学意义(P＞0.05)。4构建以结构-过程-结果为纵线,以环境、护理人员、患者、服务质量4个维度横向考查的护理质量标准基于护理具有技术性和服务性双重属性的理念,以结构-过程-结果框架模式为基础,借鉴持续质量改进理论建立了新的护理质量评价标准。新的评价标准包括环境、护理人员、患者、服务质量四个维度。每个维度均从结构、过程、结果三方面制定了评价标准。标准建立后,通过专家调查法确定了各级评价指标的权重系数。环境、护理人员、服务质量、患者四个维度的权重分别是0.11,0.18,0.48,0.23。5构建了护理工作量和质量综合评价体系将动态护理工作量采用中位数平移法确定标准值,结合专业特点,设定评分等级,转换成标准分。再运用统计学方法将专家咨询结果进行分析,得出护理工作量与护理质量对总体护理评价的权重系数为0.4:0.6,构建出综合评价体系模型。建议1.应正确认识护理服务的内涵,提供高品质护理服务。对护理服务的界定直接影响护理服务质量管理,因此,只有充分认识到护理的内涵,才能真正转变护理质量管理理念,适应“以患者为中心”的新医学模式,提供高品质的护理服务。2.护理质量评价需以患者为中心,实行以人为本的管理。由于护理人员编制的限制,护理工作量是护士主要的压力源,护士没有多余的精力完成治疗操作以外的、患者真正期望的服务。因此,建议医院领导在限制人力成本带来经济效益的同时,也应考虑护理人员的编制问题。3.护理质量标准应从护理的全过程、多维度进行构架。护理质量受诸多因素的影响,如制度、人员、环境、基础设施、人力配置结构等。因此,要想达到全方位的护理质量管理,首先必须从护理的全过程、多维度构建护理质量标准。4.护理评价应以护理工作量和质量综合评价体系进行,以体现护理管理的公平性。新的评价体系引入“量”的测量,其作用以权重体现在体系中。新的评价体系兼顾了公平原则,对所谓的“少做事,少出错;不做事,不出错”的世俗观点提出挑战,由此可见“量”的引入能极大地提高护理人员工作效率和工作积极性。创新之处1.确定了护理工作的范围,并科学地赋分,解决了当今护理工作范围不易量化的难点。2.构建了一套符合现行护理管理模式下新的护理质量标准。3.构建了护理工作量与质量综合评价体系,其评价体系所得出的综合量化指标,一是护理部可以此来考核护理单元和个人护理工作绩效状况;二是可作为护理人员晋升、评先和发放奖金的参考指标;三是为管理者科学地配备护理人力资源提供重要的参考依据。不足之处1.本研究资料的收集局限于一所医院,需扩大样本来源进一步了解现行护理质量评价的真实状况。2.本研究建立的评价体系需在临床实践运用中进行检验并不断修正。更多还原

【Abstract】 AimThere are many research reports about nursing quality evaluation system.Howver,the nursing evaluation system at present mainly focuses on evaluation of basic nursing quanlity and outcome of nursing quality while ignores the non-technical aspects of nursing care, which does not match the development of nursing profession.With the development of nursing science,the connotat ion and denotation of nurs ing has developed,as well as the nursing workload has been increasing.In the hospital, nursing workload varies in different departments.It is easy to know that heavier the workload is,the less qualified the nursing quality is likely to be.If nurses’ performance at a ward is evaluated completely by nursing quality,it is unfair to the nurses who work at the departments with heavy workload.But if nurses’ performance is evaluated completely by nursing workload,the nurses will be misguided to perform more nursing tasks,while the nursing quality is ignored,and it leads to low level patient satisfaction.Therefore,in order to comprehensively evaluate nurses’ work,it is necessary to establish a comprehensive evaluation system considering both nursing workload and nursing quality.The aim of this research is to establish a comprehensive evaluation system which can guarantee patients’ safety and improve nursing quality.Meawhile,it can embody the fairness in the management so as to motivate nurses to maintain high working efficency.MethodsMain methods used in this research are as following:1.Literature review.Extensive literature study was done by searching articles and books on different databases.The researcher have analized the relevant information about nursing quality management nationally and abroad,and thus make clear the problem to be solved in this study.2.Expert consultation.The baseline survey was shaped through panel discussion, expert consultation and brain storming method.3.Questionnaire.Three questionaires were designed by the researcher and used in this study.They were Nurses’ Professional Attitudes toward Profession,Nurses’ job satisfaction, Patient satisfaction with Nursing Care,4.Statistic analysis.The data collected were analysed in Excel and SPSS 13.0 statistical package.The statistical methods used in this research are multiple linear regression, Chi-square test,t test,one way ANOVA,and Pearson correlation.Main results1.The concept of nursing was redefined and role of some theories in the nursing evaluation was clarified.Based on the nursing practice and literature review,the connotation and the charatcteristics of nursing were analysed.The definition of nursing at present was reconsidered.The nursing is redefined as following:nursing is that nurses who have nurse license provide professional help to people to recover from disease or to take part in activities good for health,and it is a kind of invisible service.According to this definition,nursing contains two attributes:one is the technical attribute,the technique activities provided by nurses,such as delivering medication according to the physician’s order,assiting physicians to carry out tests,etc;The other is the service attribute,for example,nurses having good attitudes toward patient.Meanwhile,roles of relevant theories in quality evaluation were analized based on literature reivew.The establishment of comprehensive evaluation system was based on the system theories.Continuous quality improvement theory and performance management theory were applied in the measurement of nursing workload and the re-establishment of nursing quality evaluation system.2.The results of the empirical study on nursing quality management. Through retrospective analysis on the nursing quality control results in a Level 3 hospital,it showed that the current outcome-oriented nursing quality evaluation has advantages on standardizing nursing operation behaviors and improving nursing skills.But it also has some disadvantages,such as not reflecting the service attribute of nursing,ignoring total staff,total process management,iadequate attention to economics and not encouraging staffs to achieve zero defects.Questionnaires were used to measure patients’ satisfaction with nurses’ performance.It was found that patients were satisfied with nurses’ etiquette and their attitudes,but they were not satisfied with their initial service awareness.Results also indicated that the explanation before and after nursing activities and the frequency of nurses’ ward rounds are the factors influencing patients’ satisfaction.The reason for the results above may be the heavy nursing workload for nurses,leading to the lack of time and energy to do explanation to patients.The investigation on nurses’ professional attitudes and their job satisfaction showed that nurses had good professional attitudes while their job satisfaction was relatively at low level. The most unsatisfied aspects were about welfare and the balance between family and job. Nursing professional attitude is positively related to their job satisfaction.Questionnares were sent to nurse to collect their opinions abour present nursing quality management.The result showed that nurses were willing to take part in the nursing quality management,and they really have valuable suggestions about quality management.It indicates that the nursing quality can be improved ultimately as long as nursing management system is scientific and fair.3.Setting scope of nursing care activity and measurement of nursing workload. All nursing activity items collected from 47 clinical units were categorized.There were 75 basic nursing items,in which there were 47 direct nursing care items and 28 indirect nursing items.There were 151 specialized care items,in which there were 125 direct nursing care items and 26 indirect care ones.Among indirect nursing care items,10 items in basic nursing care and 7 items in specialized nursing care belong to nonprofessional nursing care.The nursing workload per nurse day has been measured for the past 3 years.The results showed that there were no significances statistically in nursing workdload per nurse day among the medical,surgical,gynaecology and obstetrics,pediatric,emengency,oncology departments(P＞0.05).4.The nursing quality evaluation stardard has been established based on the "structure-process-outcome" theorectical framework.With the concept that nursing has both technique attribute and service attribute,a new nursing quality evaluation stardard has been established based on the "structure-process-outcome" theorectical framework with the reference of continuous quality improvement theory.The new standard has 4 domains:environment,nurses,nursing quality, and patients.Each domain contains structure,process,outcome standards.With experts consultation,the weight factors of the 4 domains are 0.1100,0.1180,0.4800,0.2300 respectively.The whole nursing quality standard system was established.5.The comprehensive evaluation system has been established.Nursing workload was calculated in hours,and is a dynamic data.The standard value of it was set down by median parallel moving method.With the consideration of nursing profession,nursing workload was graded at different levels,and has a standardized score accordingly.With experts consultation,the weight factors of nursing workload and nursing quality in the nursing evaluation system are 0.4 and 0.6.Finally,a comprehensive evaluation system considering both nursing workload and nursing quality was established on the basis of nursing workload score,the nursing quality score and their weight factors.Suggestions1.Nurses and their managers should acknowledge the service attribute of nursing so as to provide a high quality service to patients.The acknowledgement of the service attribute of nursing affects the nursing management. As long as the connotation of nursing is recognized,the ideas of nursing quality management can be matched to the development of nursing,adapting to the "patientcentered" healthcare.2.Nursing quality evaluation should be patient-centered and nursing management should be nurse-oriented.Heavy nursing workload is a main stressor for nurses.Nurses can’t provide the expected knight service to patients due to limited time and energy caused by inadequate staffing.Therefore,it is strongly suggested that hospital administrator take enough considertion on nurse staffing level instead of considering too much on decreasing hospital cost by restricting the recruition of nurses.3.Nursing quality evaluation system should be established in the viewpoint of_different angles with the consideration of the whole nursing service process.Nursing quality is influenced by different factors,such as hospital system,staffs,environment,infrastructures, manpower allocation,etc.In order to achieve the goal of comprehensive nursing quality management,nursing quality evaluation system should be established in the viewpoint of different angles with the consideration of the whole nursing service process.4.Nursing evaluation should be carried out on the basis of comprehensive evaluation, considering both nursing workload and nursing quality so that it can reflect the fairness in the management.The new comprehensive evaluation system takes into account of nursing workload,the impact of which is showed as its weight factor in the system.The comprehensive evaluation system shows up the fairness in the management which denies the opinion that the less work it is done,the less mistakes it is likely to be made.Taking consideration of nursing workload into the evaluation system can encourage nurses to work initiatively and to improve their working efficency.Innovations of this study1.This study has ascertained the scope of nurses work and quantified nursing workload, so it has solved the problem that nursing workload is hard to meaure;2.A new nursing quality evaluation system fitting for the nursing management at present has been established in this study;3.A comprehensive evaluation system considering both nursing workload and nursing quality has been established.The results got from the comprehensive evaluation system can serve as reference to evaluate performance of individual nurse and care unit;it can also serve as a criteria for nurses’ promotion,awarding and nurses’ bonus.Furthermore,it provides important evidence for reasonable nursing manpower allocation.Deficiencies of this study1.The samples used in this study were collected in only one hospital.Samples should be collected in more hospitals to explore the status of nursing quality evaluation.2.The comprehensive evaluation system established in this study needs to be tested and improved in the clinical nursing management.更多还原