关键词: 慢性阻塞性肺疾病；延续护理；培训模式；效果评价；社区护士

Abstract: Objective: To develop a training program of the transitional care for patients with chronic obstructive pulmonary disease (COPD) and evaluate the outcomes. Methods: The training model is designed based on the COPD nursing experience in our hospital and real transitional care provided in Xuhui District, Shanghai. Totally 144 nurses from 16 3rd grade hospitals, 2nd grade hospitals and community health centers were recruited to participate in the training program. The training program was offered for 12 months repeatedly. Results: After training, all nurses passed the written test and nursing-procedure performing test. The scores for written test rose from 60.43±12.12 to 94.31±3.28. The scores for nursing-procedure performing test rose from 67.42±5.85 to 89.42±4.63 (P<0.001). The nurses reported that their transitional care competence for COPD patients were enhanced and suggested the training model should be generalized. Conclusion: It can be an effective training model if we combine nursing resources of 3rd grade hospitals with that of community health service centers. This model can not only improve nurses' abilities to provide transitional care for COPD patients but also enhance channels connecting hospitals, communities and families.

Key words: Chronic Obstructive Pulmonary Disease (COPD); transitional care; training model; evaluation; community nurses