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1、Excellence in Nursing卓越的护理Art or Science艺术或科学Definition of Nursing定义Nursing is an art which is supported by science and practiced for the enhancement of human health护理是一门以提高人们的健康为目的的科学与实践结合的艺术Core value and Meaning核心价值和含义Nursing involves a somewhat mystical Nursing involves a somewhat mystical abili
2、ty to communicate and have a ability to communicate and have a relationship with people for the relationship with people for the purpose of improving their health and purpose of improving their health and is supported by scienceis supported by science护理需要一种独特的能力护理需要一种独特的能力, ,这种能力即为这种能力即为改进人们健康为目的改进人
3、们健康为目的, ,在科学的指导下与在科学的指导下与人进行交流和建立关系的能力人进行交流和建立关系的能力Dictionary Meaning of Art艺术的定义A skill acquired by experience, study or observation; for example, the art of making friends”通过经验学习或观察而获得的一种技术如交朋友的艺术An art implies a personal unanalyable creative power, such as the art of choosing the right word艺术意味着个
4、体无需分析的创新能力如选择合适字的艺术On-the-Level同等水平Performance Communication that Works有效的工作交流Definition-On the Level同等的定义Regardless of our position in life, we all have more similarities than differences在生活中无论我们的地位如何,我们之间相同多于不同Single economy and ecology 同一经济,同一人类Single family同一家庭Increasing interdependence 不断增加相互依赖
5、Single boat on level sea 在大海里的同一条船上Hypothesis of “On the Level”假识This approach is rooted in the notion that effective person to person communication is a cornerstone of excellent performance and a good work climate and that is it also a key to deep personal satisfaction and success in todays very co
6、mplex, changing and often crazy work environment. 这种方式植根于这样的含义”有效的人与人之间的交流是卓越工作的核心,良好的工作氛围也是当前复杂,不断变化,充满压力下工作的人们深层的个人满意度和成功的钥匙Directness直接Person to person 个体对个体Descriptive language 描述性的语言Honest 诚实Rich in information 足够的信息 No hidden agenda 无言外之意Humble 谦卑Intends to create trust 意在产生信任Illustration # 1,
7、 nurse starting IVMr. Wu, I am your nurse for today. My name is Miss Lu. Your doctor has ordered a special medicine to treat the infection in your gall bladder that must be given directly into your vein. This will require putting a needle in the vein of your hand or arm. Have you ever had an IV befo
8、re?吴先生，今天我是你的护士， 我叫刘小姐，你的医生开了一种药来控制你胆囊里的炎症，这种药需要直接进入你的静脉，因而我要在你的手上或前臂的静脉里放一根针，你以前打过吗？Yes, I had one several years ago when I was sick. It was a little painful, but if it will help me get well it is OK. Where will you put it?是的，几年前我生病时曾打过一次，有点痛，但如果能帮我好起来，那没关系，你要打在哪里？I will try to put it here on your
9、left hand, but if that doesnt work I may need to put it in your arm further up.我会先试一下你的左手，但如果不行，就打在你的手臂上。Illustration # 2Illustration # 2Getting patient up after surgeryGetting patient up after surgery病例病例 2 ,2 ,术后让病人起床术后让病人起床Mr. Wu, I am Xiao Lin and I will be your nurse today. I know you just got
10、back from surgery about an hour ago and your surgeon removed your gall bladder this morning. How are you feeling now?吴先生，叫小林，我是你今天的责任护士，我知道1小时前，你刚手术回来，今天早上你的医生把你的胆囊切除了，现在你觉得如何？I am a little sleepy and I hurt some in my abdomen right here. It is also a little painful if I take a deep breath.我有点想睡，腹部这
11、里有点痛，深呼吸时也有点痛。Yes it is always a little painful right after surgery but we will help you and your doctors have given you medicine for pain. This will make it easier to breathe deeply and get out of bed. I will help you sit up and take a deep breath right now. This may be a little painful but it will
12、 help prevent your getting pneumonia.是的，刚手术后总是会有点痛，但我们可以帮你，医生已为你开了一些止痛药，这会使你更容易深呼吸和起床，现在我要帮你坐起来做深呼吸，这可能会有些痛，但能帮助你防止肺炎的发生。Respect尊重Earned, not assumed赢得而不是假定的Built on honest direct communication基于诚实的直接交流Equal rights of expression of views同等表达观点的权力Does not allow intimidation, denigration and abuse of
13、all kinds不允许有威逼, 破坏名声,滥用权利Assumes every human being has value and their own unique contribution假定每个人都是有价值的，有他们独特的贡献Illustration # 3, cant start IVDr. Zhong, your staff ordered TPN for Mr. Wu, bed three, room 6, Tomorrow, patient is going to have the surgery,the physician suggest to put a central lin
14、e, but our APN nurse feel it is the difficulty case for her to do this procedure because the patients short. Could one of your staff help us?钟医生，外科医生为吴先生，6号房间3号病床，开了TPN医嘱，病人后天要手术，医生说今天就要给病人深静脉留置进行TPN治疗，但我的护士觉得这一病人头颈短，在病区内做深静脉置管较危险，因而，你能否请你的麻醉师帮我们一下Thank you for mentioning the problem. I will ask our
15、 anesthesiologist to deal with the issue. Please ask your nurse staff send the patient to the operating room in a few minutes.谢谢你提出这个问题，我会叫我的麻醉师帮助你们，请马上把病人送到手术室。Illustration # 4, cant start IVDr.Li, Your staff ordered intravenous antibiotics for Mr.Wu,bed three, room 6, for his cholecystitis, but ou
16、r staff has not been able to start an IV.Actually we tried several times and we were thinking a central line might be preferable in this patient anyway. Our advanced practice nurse who usually would put in a central line is away this week with the Gobi March. Could one of your staff help us?护士长护士长:
17、李医师,你医生为6号房间3号床病人开了静脉内抗菌素治疗，但我的员工无法开通静脉，事实上我们已试了几次。但我想对这个病人来说做深静脉置管更好，我们的临床高级护士通常能置深静脉，但这次她不在医院，你们的医生能帮我们一下吗？I heard about the problem. Could one of your staff help us?李医生李医生: 我已听到了这个问题，我们能到办公室去谈一下吗？Yes, of course护士长护士长:当然可以例4 不能开通静脉Dr. Li speaking: I just came from the patients room and the family
18、is quite unhappy with the new nurse who could not start the IV. Do you know why none of our more experienced nurses were available to able to help here after her first attempt when the family began complaining?李医师：我刚从病房里出来，对我们新护士不能开通静脉，家属很不开心，你知道为什么新护士一针不成功时，在家属开始抱怨前，没有老护士去帮那位新护士。Nurse Manager: Actu
19、ally, I was there and did try to help but the patients veins are very small and we just could do it. The family did say they were upset while I was there.护士长：事实上，我在那儿，也尝试过尽可能的开通静脉，但病人的静脉实在太细，我们无法开通，我在那里的时候，家属已经不高兴了。Doctor: Sounds like I may not have gotten the story straight. Let me see if I can get
20、 one of the anesthesiologist to start a central line 李医师: 听起来我得到的信息有所偏差，我看我能否叫我们的一名医生来做深静脉穿刺Illustration # 4, missed insulin order漏打胰岛素医嘱 Xiao Lin, Mrs. Wu in bed 4, room 5 should have gotten her insulin at 3 pm, what happened?小李：5号房间4号床的吴女士在3PM应当注射胰岛素了，为什么没打？出了什么事？Dr. Li, the endocrinologist was he
21、re just before three pm and recommended we change her control to oral medicine only. Here is their note on the chart. The diabetic education nurse was here too and she feels it is probably unrealistic to expect this family to give insulin at home. Actually here blood sugars have not been very high e
22、xcept twice when they were drawn from the dame arm she was getting her IV which had glucose in it小李：三点之前内分泌科医生李医生在这里，建议我们只用口服降糖药，这是病人病历上的记录，刚才我们的糖尿病APN护士也在这里，她觉得病人回家后让病人家属注射胰岛素不现实，事实上，她的血糖除了二次因为手臂上挂葡萄糖而抽得的血结果血糖比较高外，其他几次都不太高， 。Sure enough . Hmmm, I will need to call Dr .Li and get this cleared up .I
23、told the family she would need insulin. I would appreciate it if the nurse would call me if there is an apparent 好，我会打电话给李医师澄清这一事情，我已告诉病人家属病人需要打胰岛素，当医生对病人的医嘱分歧较大时，你们护士应当打电话通知我，我将非常感激。I agree that would have been helpful. We will keep that in mind我同意这样会更有益一些。我们会记住的Shared Responsibility分享责任Shared comm
24、itment for implementation of decision分享努力实施决策Assumes both parties to the communication have shared in the planning假定双方在计划时分享交流Expecting people in authority to have all the answers is irresponsible期望权威人有所有的答案是不负责任Expecting to have all the answers yourself is demagoguery期望你自己有所有的答案是非理性的On the Level co
25、mmunication does not allow, “The committee met and I decided”平等的交流不允许“委员会开会，我决定”Shared Responsibility, cont.On the Level communication does not allow, “It is a bad plan, but I didnt want to say anything”“平等交流不允许”那时一个坏计划，但我不想说任何事Failure as well as success is almost always collective, not singular失败成功
26、几乎总是集体的，而非个体的。We need to stop blaming the people “down there” for lack of motivation and the people “up there” for the abuse of power and get on with building a workplace based on shared responsibility我们需要停止埋怨那些 在我们 “下面 ” 人们缺乏工作主动性和那些在我们“上面”高高在上乱用权力，开始以分享责任为基础来建设我们的工作环境。Illustration # 5, Misundersta
27、nding例五：误解Nurse unit manager: Xiao Lin, would you get Mr. Wu up today and be sure he breathes deeply and coughs?病房护士长：小林，你能否叫吴先生起床，让他做深呼吸和深咳嗽吗？Xiao Lin: But Mr. Wu is not my patient today.小林：但是吴先生今天不是我的病人Unit manager: I know he isnt, but three of your patients are going home and Mr. Wus nurse has mo
28、re than she can handle today, so I thought you could help with Mr. Wu.病房护士长：我知道他不是，但是你的三个病人就要出院了，吴先生的护士今天忙不过来，因此，我想你可以帮帮吴先生。Illustration # 6, new directive新的目标Xiao Lin, this means you have to make a nutritional assessment on every patient you admit and if there is a problem place your report form on
29、 the front of the chart before you finish your shift.小林，这意味着对每一位入院病人要做营养评估，如果有问题，在你下班前就把报告放在病历的前页。I can see this is important and I will do my best to do it but I think the doctors should be the one to do this, we are already too busy.我能理解这很重要，我会尽我最大的努力做的，但我想这应当是医生做的事，我们已经太忙了Yes, the nurses are ofte
30、n short handed, but the doctors are also busy and we have agreed to help in this way. Since this is a new requirement I will try to remind all of the nurses and help you as much as I can.是的，我的护士总是那么忙，但是医生也很忙，我们已经同意这样做了，由于这是一个新要求，我会努力提醒所有的护士，我会尽我所能帮你。PurposeCommunication is focused and purposeful交流应当
31、是集中,有目的的Oriented to a specific result围绕特定的结果 Purpose not so rigid as to prevent change if new information indicates the need目的不是僵硬一成不变的Final solution to question or problem not always necessary, merely a better understanding of the issues could be an adequate purpose对问题的最终解决或答案并不总是需要的，只是对事物的更好理解也是一种
32、恰当的目的。Illustration # 7, adverse event例7不良事件Nursing director: Xiao Lin, as you know, your patient, Mr. Wu was taken to ICU during the night. This was necessary because he was having trouble breathing and required a respirator. The nursing record shows you were aware of and recorded a rapid respirator
33、y rate at the end of your shift but there is no record you informed either the doctor or the nurse manager. Can you tell me what happened from your point of view?护理部主任：小林，你知道，你的病人吴先生在晚上被转到ICU，因为病人有呼吸困难，要用呼吸机，护理记录单上显示下班前你意识到这种变化,并记录病人呼吸频率很快，但没有记录你通知了医生或护士长，从你的角度你能告诉我发生什么。Illustration # 7, cont.Xiao L
34、in: That is correct. I did notice his respiratory rate had gone up to 24 per minute so I wrote it down. I was going to call the resident but then I got a phone call from my friend and I forgot to call or tell anyone before I left. But other nurses knew he was breathing fast too. 小林：是这样的，我注意到病人的呼吸上升到
35、24次/分，因此我就把它记录下来了，我正要传呼或告诉其他人的时候，我接了一个朋友来的电话,当我下班前,我忘记叫医生或其他人了,但其他护士也应当知道病人呼吸很快。Nursing director: Xiao Lin, you know it was your responsibility to pass on this information. Is it not true you and the nurse manager have had two similar discussions in the past three months?护理部主任：小林，你知道这是你的责任将这些信息告诉别人，
36、在过去三个月里，类似的问题护士长曾与你讨论过 Xiao Lin: Yes, and I am really very sorry.小林：是的，我很抱歉。Illustration # 8,compliance problem?例8遵从问题Nursing Director: I understand we are having a problem with the new policy on nutritional assessment, is that why you wanted to see me?护理部主任：我了解到对营养评估新制度实施方面有些问题，这是你想见我的原因吗？Illustrat
37、ion # 8, cont.Nurse Manager: I am not sure whether it is a compliance problem or a lack of staffing. The dieticians say they are willing to come and consult but the reality is they are not coming to consult on all the patients with nutritional problems. And so far I havent figured out exactly why. T
38、he nurses are putting the assessment report on the front of the chart when there is a problem, but the doctors rarely ask for the dietary consult. They just write they have taken care of it or it isnt needed and sometimes they forget to deal with it altogether unless I push them.护士长：我不知道这是遵守制度的问题，还是
39、人力不足的问题，营养师说他们愿意来会诊，但事实上他们没有来会诊所有营养问题的病人，目前我还不知道究竟为什么，护士把有营养问题的筛选评估单放在医生病历的首页，但医生很少请营养师会诊，他只是说已处理了或者不需要，有时医生忘记去处理它，除非我催他们。Illustration # 8, cont.Director: Sounds to me like we need more information. Why dont we ask for a meeting with the director for graduate medical education, he is the one most fa
40、miliar with the residents and most of these orders for dietary consultation would be written by the residents.护理部主任：听起来我们需要更多的信息，为什么你不问一下医务科科长在行政会议上强调一下，让医生今后更关注这一问题。Summary, On-The-Level总结Guide lines and goals, not policy是指导和目标，而不是制度Best done one on one, face to face最好一对一、面对面的做Anticipate need for change预测改变的需要Anticipate a positive experience预测积极的体验Anticipate improvement in skill 预测技能上的改进Anticipate gratification预测满意
