1、vBrown应用整体的观念应用整体的观念与患者建立伙伴关系与患者建立伙伴关系专家型的临床思维过程和技术操作专家型的临床思维过程和技术操作运用科研指导实践运用科研指导实践运用不同方法进行疾病和健康管理运用不同方法进行疾病和健康管理v清楚自身专业角色和功能清楚自身专业角色和功能v区分不同层次护理实践区分不同层次护理实践v帮助帮助APN提供全面和整体的护理提供全面和整体的护理v提供护理研究框架提供护理研究框架v开展课程设计开展课程设计vBrowns framework of APN(1998)vHamrics model of APN(2005)Browns Framework of advance
2、d practice nursing(1998)vPrimary criteriaGraduate educationCertificationPractice focused on patient/familyvCore competencies Direct clinical practice(Central competencies)Expert coaching and guidanceconsultationResearch skillsClinical and professional leadershipcollaborationEthical decision making s
3、killsvCritical environmental elements affecting APNRegulatory and credentialing requirements认证监管Business aspects业务评价Policy making consideration健康政策Reimbursement/payment mechanisms薪酬Outcome evaluation and performance improvementMarketing and contracting市场和合同Organizational structure and culturevCalkin
4、s model of APN Population responsesKnowledge levelSkill levelPatient responses correlated with the knowledge and skill of beginning practitioners,experienced nurses and APN.Knowledge and skills of the nurses needed are based on the patient needs.3 curves were overlaid on a normal distribution chartv
5、Shulers model of APN:a theoretical framework 1993 Holistic patient needsNP-patient interactionSelf-careHealth preventionHealth promotionwellness病人特点病人特点：恢复力恢复力易感性易感性稳定性稳定性复杂性复杂性资源资源预测性预测性参与护理参与护理参与决策参与决策护士能力护士能力：判断判断支持和代言支持和代言护理实践护理实践合作合作系统思维系统思维合适的反应合适的反应临床研究临床研究促进学习促进学习Strong Memorial Hospitals mo
6、del of APN (Ackerman,MH et.1996)vEmpowerment赋能赋能 Giving power to another,encouraging,or giving authority 人们获得自己控制、决定及行动去影响自人们获得自己控制、决定及行动去影响自己健康的过程（己健康的过程（WHO，1986）赋能过程：共同参与、主动聆听、共同获赋能过程：共同参与、主动聆听、共同获得个体化知识得个体化知识 应用：慢性病管理应用：慢性病管理vThe Transtheoretical Model TTM 跨理论模式跨理论模式is a model of intentional cha
7、nge developed by Prochaska and Diclemente in the 1980s.It focuses on the decision making of the individual.vThe core constructs of the TTM the processes of change 改变阶段 decisional balance 权衡决定 self-efficacy 自我效能 Temptation 改变方法无意图期无意图期意图期意图期准备期准备期终止期终止期行动期行动期维持期维持期vPRECONTEMPLATION(Not ready to chang
8、e)vThe individual is not currently considering change:“Ignorance is bliss”难得糊涂vPeople are not intending to take action in the foreseeable future,usually in the next six months.vTechniques:Validate lack of readiness Encourage re-evaluation of current behavior Encourage self-exploration,not action Exp
9、lain and personalize the risk vTraditional health promotion programs are often not designed for such individuals and are not matched to their needs.(Velicer,1998)vCONTEMPLATION(Thinking of changing)vAmbivalent about change:“Sitting on the fence”左右为难vNot considering change within the next month.vTech
10、niques:Encourage evaluation of pros and cons of behavior change.Re-evaluation of group image through group activities.Identify and promote new positive outcome expectations vPREPARATION(Ready to change)vTesting the waters vPlanning to act within 1month.vTechniques:encouragement to evaluate pros and
11、cons of behavior change.identify and promote new positive outcome expectations.Encourage small initial steps.have taken some actions in the past year Suitable for action-oriented programs for smoking cessation,weight loss,or exercise programs.vACTION(Making change)vThe active work toward desired beh
12、avioral change including modification of environment,experiences,or behavior have been taken.vAt this stage people have made specific overt modifications in their life-styles within the past six months.vAt this stage measures should be taken against relapse.vTechniques:Help the individual on restruc
13、turing cues and social support.Enhance self-efficacy for dealing with obstacles.Help to guard against feelings of loss and frustration.vMAITANANCE(Staying on track)von ongoing,active work to maintain changes made and relapse prevention.vAt this stage people are less tempted to relapse and increasing
14、ly more confident that they can continue their change.vTechniques:follow-up support reinforce internal rewards discuss coping with relapsevRELAPSE(Fall from grace)vIt is a form of regression to previous stages.vIt refers to falling back to the old behaviors after going through other stages.vRegressi
15、on occurs when individuals revert to an earlier stage of change.vTechniques:Evaluate trigger for relapse Reassess motivation and barriers Plan stronger coping strategies vDecisional Balanceweighing of the pros and cons of changing.weighting the importance of the Pros and Cons.vSelf-efficacy specific
16、 confidence that people have that they can cope with high-risk situations without relapsing to their unhealthy or high-risk habit.This concept was adapted from Banduras self-efficacy theory.vTemptation reflects the intensity of urges to engage in a specific behavior when in the midst of difficult si
17、tuations.Temptation is the converse of self-efficacy.The most common types of tempting situations are;vnegative affect or emotional distress vpositive social situationsvcravingvsmoking cessation vexercise vlow fat diet vradon testing valcohol abuse vweight control vcondom use for HIV protection vorg
18、anizational change vuse of sunscreens to prevent skin cancer vdrug abuse vmedical compliance vmammography screening,and vstress managementv基本概念基本概念社会网络向个体提供的援助社会网络向个体提供的援助缓冲理论：社会支持缓冲压力缓冲理论：社会支持缓冲压力依附理论：童年形成的安全依附感对以后依附理论：童年形成的安全依附感对以后建立互相支持的关系有很大影响建立互相支持的关系有很大影响v内容的构成内容的构成House 1981v价值观上的支持价值观上的支持v信息
19、上的支持信息上的支持v物质上的支持物质上的支持v情感上的支持情感上的支持v应用应用Stewart 1989v个人层面个人层面v两人层面两人层面v小组层面小组层面v社区层面社区层面v社会系统层面社会系统层面v先决条件（先决条件（Langford，1997）社会网络社会网络 提供社会支持的载体提供社会支持的载体社会植入社会植入 个体在网络中与重要人物的联系个体在网络中与重要人物的联系社会风气社会风气 环境风格环境风格 乐于助人乐于助人v结果结果正面正面负面负面 v理论模型理论模型压力缓冲模型压力缓冲模型主要作用模型主要作用模型 直接影响健康，不论是否经历充直接影响健康，不论是否经历充满压力的环境满压力的环境 理论在理论在APN发展中的作用。发展中的作用。选取一个概念或理论，讨论如何将其应用于选取一个概念或理论，讨论如何将其应用于APN护理实践。护理实践。
