護理人員交班內容一致性改善專案

Improvement Project of Consistency for Nursing Handover Content

陳怡潓(Chen, Yi-Hui) ； 李明珠(Lee, Ming-Ju) ； 陳秀敏(Chen, Shiow Miin) ； 蔡惠婷(Tsai, Huei-Ting) ； 陳萃婷(Chen, Tsuei-Ting)

《健康與建築雜誌》 4卷1期 (2017/02) Pp. 42-50

https://doi.org/10.6299/JHA.2017.4.1.R5.42

摘要

背景：交班是護理人員每日例行且非常重要的工作，本單位因屬內科綜合病房病人科別屬性多病情複雜，檢驗項目繁瑣，曾因交班遺漏而延遲病人檢查與治療，再加上新進人員多，難掌握病人交班重點，以致交班內容一致性僅57％。目的：本專案旨在提升護理人員交班內容一致性。方法：利用結構式問卷及實地交班查核方式，確立問題為: 護理資訊交班作業系統排列不一致、病人住院天數長、病情複雜嚴重度高、檢驗結果項目多未統整內容、健康問題無交班重點、未按一定流程交班。擬定解決方案：以ISBAR(Introduction 介紹，Situation 情境，Background 背景，Assessment 評估，Recommendation 建議) 模式設定交班項目順序、製作疾病診斷交班內容、依據健康問題交班內容、交班內容教育訓練指導等。結果：對策實施後，交班內容一致性由57％提升至82%，藉此以ISBAR 配合護理資訊交班系統達到交班一致性。結論/實務應用：護理人員每日例行且重要的交班工作，當交班內容繁瑣或項目過多難掌握病人交班重點，專案實施後以ISBAR 方式配合護理資訊交班系統，可以有效提升交班內容一致性提升照護品質。

關鍵字

交班 ； 交班內容 ； 一致性

並列摘要

Background: The nurse-to-nurse handover is a routine and crucial part of clinical nursing, especially in a general medical unit. The characteristics of our unit include complicated health problems and examination. It's hard to new staffs to transfer patients' condition, and lead to the consistency of handover content only 57%. Lack of the consistency of handover content had caused omissions and delay patients' examination and treatment. Purposes: The main purpose of this project is to improve the consistency of handover content. Methods: This is a structured questionnaire study. Through interview to collect the consistency of handover content and nursing problems identified including : inconsistent arrangement of nursing information handover system, high patient acuity, long length of hospitalization, no organization of patients' examination, nursing care plans without the key point, and the handover without properly process. Proposed solution: setting the order of the handover items according to ISBAR(Introduction, Situation, Background, Assessment, Recommendation) model, redesign the handover content of the disease diagnosis, the handover content base on health problems, and hold the lectures talking about handover content. Results: After implementing interventions, the consistency of handover content had increased from 57% to 82%. Using ISBAR model and nursing information handover system had improved the consistency of handover content. Conclusion/Implications for practice: The nurse-to-nurse handover is a routine and important part in clinical nursing. However, the complicated handover content or too many examinations caused us hardly to catch patients' condition. After implementing the project, the researchers found using ISBAR model and nursing information handover system could improve the consistency of handover content effectively.

並列關鍵字

handover ； content of handover ； consistency