我国分级诊疗政策效力与政策效果评估

背景　自新医改以来，我国制定了一系列分级诊疗政策，但十余年来，我国离全面实现分级诊疗的目标仍存在较大差距，因此，对国家出台的分级诊疗相关政策进行系统的量化分析显得尤为重要。目的　评估我国推动分级诊疗所发布的政策文件效力和实施效果。方法　2020年9月，在北大法宝、中国知网、万方数据知识服务平台、百度搜索引擎和政府部门相关网站等以“分级诊疗”“分级医疗”“双向转诊”“基层首诊”为检索词检索2009-2019年国家及各部委颁布的政策文件，经筛选后获得236项有助于分级诊疗制度推进的政策文件。效力分为政策措施、政策目标、政策反馈、政策力度4 个维度，效果用基层医疗卫生机构急诊就诊人次数指标表示，通过构建多元回归模型对三类不同政策工具分级诊疗实施效果进行回归分析。结果　2009-2019年的政策数量变化趋势与政策整体效力变化趋势基本一致，政策平均效力较平稳波动，政策措施得分在3.00分左右（除外2013年），政策目标得分均≤2.50分（除外2019年），政策反馈的平均得分在2.25分，政策力度平均得分<2.44分。供给、需求、环境型三类政策工具的政策数量变化趋势基本一致，供给型和环境型政策数量基本高于需求型政策。供给型政策中，医疗卫生机构建设类占比最多（36.67%），资金投入与资源分配类的平均效力值最高（20.00分）；需求型政策中，医保类最多（61.70%）且平均效力值最高（15.07分）；环境型政策中，目标规划类最多（49.25%）且平均效力值最高（20.25分）；供给型、需求型、环境型这三类政策工具对政策实施效果影响的回归系数分别为1.271 9、2.013 8和1.937 8（P均<0.10），滞后期在1~3年。结论　我国分级诊疗政策效力的提高主要得益于政策颁布数量的累计效应；4个评价维度中，政策措施平均得分较高，政策目标的量化度低，政策反馈要求模糊，政策力度缺乏高层级部门的推动；供给型和环境型政策的数量基本都高于需求型政策，政策效力的得分主要取决于政策措施，特别是供给型和环境型政策；三类政策工具均对我国分级诊疗的开展起到正向作用，且需求型政策无论从滞后期还是政策效果指向来看都最具优势。如何充分发挥需求型政策引导国民理性就医选择的促进作用，应引起政府部门的高度重视。     

Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences

Background

Medical student interest in general surgery has declined, and the lack of adequate accommodation for pregnancy and parenting during residency training may be a deterrent. We explored resident and program director experiences with these issues in general surgery programs across Canada.

Methods

Using a web-based tool, residents and program directors from 16 Canadian general surgery programs were surveyed regarding their attitudes toward and experiences with pregnancy during residency.

Results

One hundred seventy-six of 600 residents and 8 of 16 program directors completed the survey (30% and 50% response rate, respectively). Multiple issues pertaining to pregnancy during surgical residency were reported including the lack of adequate policies for maternity/parenting, the major obstacles to breast-feeding, and the increased workload for fellow resident colleagues. All program directors reported the lack of a program-specific maternity/parenting policy.

Conclusions

General surgery programs lack program-specific maternity/parenting policies. Several issues have been highlighted in this study emphasizing the importance of creating and implementing such a policy.     

Self-Reported Reasons for Abstinence from Illicit Drugs

Objective: To provide a more balanced understanding of the initiation and restraint of substance use, educators, clinicians, and researchers would benefit from a review of research assessing the reasons nonusers report for having abstained from drugs. Method: Based on searches of computerized databases and the reference sections of relevant articles, we identified 15 relevant studies that assessed and quantified participants’ expressed reasons for having abstained from (a) one or more named substances or (b) drugs (or alcohol and drugs) with little or no further specification. We defined as more salient those 25% of reasons in each study that were endorsed most frequently, ranked highest, or rated most influential. Results: Five reasons – concerns about physical health, lack of interest, harmful psychological consequences, personal beliefs/morals, and peer/family disapproval – were most frequently identified as salient across studies and substances. Conclusion: These salient reasons are consistent with outcome expectancy and social learning models that have been proposed to explain drug initiation. To enhance the value of future research, we recommend testing whether importance ratings differ across contexts; repeatedly assessing within-subject variability of reasons across time; evaluating the association of psychological characteristics with reasons for abstaining; and continuing to evaluate which reasons for abstaining vary by type of drug, gender, ethnicity, and religiosity. We also recommend additional research comparing which reasons predict continued abstinence and which predict initiation of use during follow-up.     

政策工具视角下国内护理卫生政策的文本分析

目的 研究1978年—2020年护理卫生政策中政策工具使用情况,探讨现有政策工具的分布情况及框架结构,为后续政策的制定及落实提供参考。方法 基于Rothwell&Zegveld构建的政策工具分析框架,采用内容分析法,构建X维度（基本政策工具）及Y维度（政策发展阶段）的二维分析框架,对现有护理卫生政策文本进行编码整理和量化分析。结果 最终纳入24篇政策文件,共整理378条政策分析条目。X维度中,供给型、需求型、环境型政策工具所占比例分别为24.60%、14.02%、61.38%。Y维度中,萌芽探索期、补充完善期、成熟提升期政策工具占比分别为23.02%、31.75%、45.24%。结论 目前国内护理卫生政策工具总体使用不协调,供给型政策工具较关注人才培养,科技研究和信息化建设有待增加;需求型政策工具应用较少,缺乏有效拉动作用;环境型政策工具使用过于频繁,内部工具比例有待调整。建议可进一步把握护理卫生政策演化的规律性,提升政策实施的实效性,强化政策组合的整体性。     

Nurse educators' perceived challenges in mandatory continuing nursing education

AIM: This paper reports a study that leads to understanding challenges facing nurse educators implementing mandatory continuing nursing education in The People's Republic of China. BACKGROUND: Mandatory continuing nursing education was instituted to maintain and develop registered nurses' competence in the context of healthcare reform in China in 1996. However, there is an increasing complaint of credit-focused and teacher-centred learning in Chinese literature. Despite an increasing appeal to improve the learning situation, little consensus has been reached. By examining nurse educators' perceived challenges and their coping strategies in implementing mandatory continuing nursing education, this study illuminates the possibilities for reform in mandatory continuing nursing education. METHODS: Data were collected through in-depth interactive dialogues between the researcher and five nurse educators in five healthcare organizations in China, utilizing Gadamer's philosophical hermeneutics. FINDINGS: Three themes were found in this study described as finding a way to support nurses' competence within a constrained situation, reconciling credit requirements and representing all stakeholders' interests. CONCLUSIONS: A tension between the mandatory continuing nursing education policy and the context of implementing the policy can contribute to credit-focused and teacher-centred learning. Regular policy review and educational support for nurse educators are crucial aspects to improve mandatory continuing nursing education.     

当艾滋病遭遇流动人口——我国流动人口管理的政策与法律浅析

人口流动是艾滋病传播的重要促进因素,流动人口的管理与艾滋病防治息息相关。本文分析了我国流动人口管理的政策与法律,从艾滋病防治的视角提出了改进我国流动人口管理的措施与方法。     

百草枯中毒患者家属对预后不满的原因分析与对策

目的分析百草枯中毒患者家属对预后不满的原因及护理对策。方法回顾分析106例某科收治百草枯中毒过程中患者家属对预后不满原因。结果护理人员的没有主动服务,工作责任心不强,缺乏与患者家属的有效沟通,医护缺乏沟通和配合,相关疾病理论知识缺乏;医疗费用大,效果差;患者家属医学知识缺乏等患者对预后不满是主要原因。结论通过建立良好的护患沟通;加强培训,提高护理人员的素质修养,开展主动服务活动等措施是对减少患者家属对预后不满的有效措施。     

CHARTS项目对四川省艾滋病防治政策环境的影响分析

目的 了解中英艾滋病策略支持项目(CHARTS)对四川省艾滋病防治政策环境变化的作用和影响,为改进艾滋病防治工作提供参考.方法 采用问卷调查与关键人物访谈相结合的方法.结果 省级多部门艾滋病战略规划数量显著增加,规划针对的目标人群明显扩大;政府部门的关注度和社会力量参与度不断提高,并呈现出合作的趋势;艾滋病预防政策和策略更加完善,受益人群面不断扩大;对艾滋病受害者的治疗、关怀和支持的政策和策略进一步完善,尤其是对艾滋病孤儿和脆弱儿童的关怀支持力度进一步加大;项目督导评估系列工作基本实现了从无到有.结论 在CHARTS项目支持下,四川省艾滋病防治政策环境得到显著改善,但仍然面临诸多挑战.