影響護理人員使用護理紀錄標準化範本之相關因素

The Influential Factors of Nurses Using the Standardized Nursing Record

王曼蒂(Man-Ti Wang) ； 楊淑慧(Sue-Hwa Yang) ； 宋佳穎(Chia-Yin Sung) ； 劉淑芳(Shwu-Fang Liou) ； 陳碧蓮(Bi-Lian Chen)

《榮總護理》 28卷3期 (2011/09) Pp. 241-248

https://doi.org/10.6142/VGHN.28.3.241

摘要

本研究目的在於探討影響護理人員使用護理記錄標準化範本之相關因素。以橫斷式調查研究法，依自擬結構性問卷採立意取樣選取中部某醫學中心，自2008年10月6日至13日期間，調查355位護理人員使用護理紀錄標準化範本情形。研究結果顯示92%護理人員知道有護理紀錄標準化範本，71%曾使用護理紀錄標準化範本，45%覺得使用範本可讓護理紀錄內容完整，30%認為它是護理工作的依據，78%感受使用範本快速省時，39%認為節省時間達11-30%；82%使用護理紀錄標準化範本者匯入護理紀錄後會再修改。不使用護理紀錄標準化範本原因包括4%護理人員不知道此項功能，7%不清楚操作程序，22%認為系統運作緩慢，25%覺得操作時切換多個螢幕，19%認為自己輸入的速度較快，43%認為內容不符合需求，37%認為須重新編輯較麻煩，11%認為耗費時間多，62%認為自行輸入的護理紀錄內容較護理紀錄標準化範本完整。使用護理紀錄標準化範本與否與護理人員的能力進階有關，與性別、年資、工作單位無相關。建議依各專科特性整合護理記錄標準化範本內容，及建立護理紀錄用語之標準化，以作為新進人員書寫護理紀錄及檢核護理工作完整參考，及提供護理教學有關護理紀錄書寫之範例參考。

關鍵字

護理資訊 ； 護理紀錄 ； 標準紀錄範本

並列摘要

The purpose of this study was to explore the use of standardized nursing record by nurses. A cross-sectional survey design and purposive sampling were used to recruit 355 nurses who were employed at a medical center in Taichung, Taiwan. These nurses used the standardized nursing record during October 6 to 13, 2008. The results showed that 92% of the nursing staff knew about the record and 71% had used it; 45% of the nurses felt that the content was complete while 30% thought that the record could be used as the basis for nursing care; 78% of the nurses felt that to use the standardized nursing record would be quicker and save much time; 39% said that the record helped save 11-30% of time and 82% of them after using standardized nursing record need to modify. The reasons for not using standardized nursing record included: 4% of the nurses did not know it's existence, 7% did not know the procedures involved, 22% thought that operation of the system was slow, 25% felt that the operation was complicated, 19% believed that self-typing was faster, 43% thought that the content did not meet the demand, 37% felt the need to revise was inconvenient while 11% of the nurses thought that the whole process was time-consuming. The results showed that using standardized nursing record was correlated to the clinical leader (p= .006) and not correlated to gender (p= .08), unit (p= .38), and occupational experience (p= .69). We suggested that the standardized nursing record could be used as a reference for different clinical services and units. In research, we recommend a terminology for the nursing record to be established. In teaching, the record should be used as a reference for new nurses.

並列關鍵字

nursing informatics ； nursing record ； standardized nursing record