Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation

Aims and objectives. To describe the change in documentation of the nursing process in all inpatient wards in a 900‐bed university hospital. Major research question was what are the differences between before and after implementation of documentation policy related to the steps of the nursing process? Background. Implementation of standardized languages has been shown to be difficult to accomplish in clinical practice. Patients are the source of data and their conditions, responses and well‐being should be reflected in the nursing record. As such, nursing documentation can create the premises for the development of new knowledge in nursing and the improvement of nursing performance and can provide data and information necessary for nursing researchers to evaluate the quality of interventions and participate in the formulation of healthcare policy. This study is part of longitudinal project to prepare nurses for electronic documentation within the interdisciplinary health record and to improve documentation of nursing using standardized languages. Design and method. A cross‐sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post‐test (n = 349 nursing records) to obtain data on nursing documentation. The year‐long intervention comprised planned work in groups, and educational and supporting efforts. Results. A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for inpatients. Conclusion. At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages. Relevance to clinical practice. Nurses need to use standardized language to document patient care data in the electronic health record and to demonstrate contributions to nursing care.     

Structure and content in Norwegian nursing care documentation.

In 1994, the Norwegian Board of Health (NBH) published recommendations for nursing care documentation. The two-fold purpose of the present study was to see if 5 wards in 2 Norwegian hospitals fulfilled the proposed NBH recommendations and guidelines regarding documentation, and to evaluate them in terms of the proposed structure and key words of the VIPS model. Results showed that all nursing records (n = 55) had an admission assessment. A nursing care plan was present in 62% of the records. Nursing goals were lacking in the remaining 38%, diagnosis and planned interventions were absent in 18%, and 45% of the diagnoses lacked information concerning patient progress or outcome. The nursing care plans were updated in only 40% of the records and discharge notes were present in 35%, confirming that NBH recommendations were not met in this sample. The key words of the VIPS model covered all information present in the records, and high interrater reliability was obtained for the majority of key words categorized by two independent researchers. It is suggested that the VIPS model components and key words can contribute to a reliable and uniform model for nursing care documentation and enhance comprehensive and systematic documentation, which is presently lacking in Norwegian records.     

Research and the configuration of nursing services

• ? This paper is concerned with the way in which nursing research has influenced changes in the organization of nursing services, particularly the shift from so-called traditional nursing to new nursing. To this end published research and professional literature are selectively reviewed.
• ? The case is made to support the view that change in nursing has been driven forward by the evangelical zeal of opinion leaders rather than evidence.
• ? It is suggested that holistic care as embodied in new nursing is no longer affordable. Market pressures have precipitated a revisiting of the task basis of nursing. An effective anchor would have been a solid body of research evidence pointing up the value new nursing may have. Regrettably not enough research was done prior to the diffusion of new nursing. What was done was not always adequate, and what was adequate was not effectively deployed by nurse leaders.
• ? Nursing is the largest workforce in the NHS and has attracted a great deal of policy interest. It is suggested that it will become increasingly important for nursing to be more strategic, and develop its own professionally driven research agenda.
• ? The future of the nursing profession is uncertain. It is clear that evidence-based practice is centre stage, and there is a need for nursing to re-negotiate its professional boundaries and to develop intellectual partnerships in order to move the knowledge base of practice forward.

     

Towards an aesthetics of nursing

Towards an aesthetics of nursing This paper re-appraises the work of Barbara Carper on aesthetics and the art of nursing. It identifies serious flaws in Carper's original arguments and the way in which she and subsequent authors have conflated the concepts of art and aesthetics in nursing. The paper explores a broader approach to aesthetics and proposes a way in which a theoretical approach to nursing aesthetics could be developed. The paper concludes that nursing is a fit object of aesthetic appreciation and that aesthetic quality is a necessary attribute of good nursing practice.     

提升护理服务综合价值的研究

目的:研究护理综合价值的提升。方法:分析护理价值研究背景,阐述护理价值研究进展结果:提出护理价值研究途径。结论:有利于达成一种共识,使广大护理人员认识护理价值、研究护理价值、开发护理价值,重视护理综合价值研究和提升。 护理服务价值是护理服务劳动产品的价值和服务本身所创造的价值的总和,即使用价值与价值的统一。目前日本、美国、德国和中国都在加强护理价值研究的探索,但仍存在使用价值与价值研究分离问题。因此,我们应不断加强护理综合价值研究,以适应卫生事业改革对护理管理的挑战。本研究主要在分析国内外护理价值研究的基础上,提出综合护理价值研究途径,以达到合理评价护理价值的目的。     

基层医院整体护理的实施与对策

目的:总结实施整体护理的经验,提高护理质量。方法:全面综合分析实施整体护理的对策和措施。结果:经验:领导的高度重视和大力支持,是实现整体护理模式转变的坚实基础;提高人员整体素质,确保整体护理的有效开展;多做少写,以点带面,实行非模式病房开展整体护理工作;积极开展健康教育,巩固整体护理效果;实施整体护理质量管理的措施。体会:领导的重视和支持,是开展整体护理工作的根本保证;提高了社会公众对护理工作的认可程度和护士的社会地位;显示了护士的自身价值;改善了护患关系,提高了病人满意度,同时也密切了医护关系;护理队伍整体素质提高,敬业精神增强。结论:实施整体护理,促进了护理学科的发展。     

我国护理行业的改革与发展

从我国护理行业的现状、卫生体制改革以及基本国情出发 ,着重探讨护理管理、护理教育、护理环境、护理经济与管理体系、护理立法等方面的发展途径     

Innovations in United States genetics nursing: Practice and research

Aim: Clinical and research applications from human genome discoveries are growing and creating both opportunities and challenges to the integration of genetic concepts into practice and research. Nurses have a long history of caring for individuals, families, and groups with genetic conditions. In the past two decades, a small group of nurses in the USA have used a variety of strategies to further develop the field of genetics nursing. In this paper we identify innovative approaches to identifying genetics‐related nursing roles and opportunities, as well as successful collaborative efforts beyond nursing to address the emerging health and societal challenges related to human genetics discoveries. Methods: The information presented here comes from a variety of sources where the authors or genetics nurses directly participated, including: (i) a systematic literature review of genetics nursing; (ii) a comprehensive research study of models of delivering clinical genetics services and the roles of health professionals; and (iii) participation in numerous national research, planning, programmatic, and advisory groups involved with clinical genetics‐related health services, research, education, and public policy. Results: Genetics nurses in the US have developed innovative responses to genetics‐related challenges within and beyond the profession of nursing. These include: (i) establishing an organization for nurses in genetics and gaining formal recognition of genetics as a specialty of nursing; (ii) defining the scope of genetics nursing practice and developing a new genetics nursing credential; (iii) establishing a multiprofessional genetics education coalition and defining genetic competency for health‐care practice; (iv) creating new clinical practice roles for nurses that integrate emerging genetics concepts and skills into diverse clinical practice areas; (v) expanding nursing involvement in genetics‐related research; and (vi) participation in high‐level genetics advisory groups. Conclusions: The US experience shows that nurses have made substantial progress in expanding their involvement in genetic services through visionary leadership, innovative approaches to challenges, establishing support with nurse colleagues, and engaging in multiprofessional efforts. The most important first step is developing a supportive environment for nurse advancement. In the US, the genetics nurses’ organization known as the International Society of Nurses in Genetics (ISONG) has provided this base.     

整体护理病房三级护理查房的体会

我院自1999年7月开始在整体护理模式病房中实施三级护理查房。1年多来,对800例危重病人进行了护理查房,查房的形式为责任护士每天查,主管护师或护士长每周查,副主任护师以上或科护士长每月抽查,护理部主任每季抽查。通过查房,明显提高了危重病人的护理质量,病人得到了更为优质的服务,护理服务满意率提高;对护理人员来说,提高了业务水平,锻炼了口头表达能力;对护理管理来说,及时了解护士对护理程序的应用情况,掌握危重病人的护理质量,对护理中存在的不足及时提出指导意见。     

晨间护理缺陷分析及对策

目的提高晨间护理质量。方法通过向住院病人和护士发放问卷调查及每周不定期检查各病区晨间护理质量,了解晨间护理工作中存在的缺陷,提出整改的措施。结果晨间护理工作中存在的主要缺陷:51.8%的病人认为护士与病人的沟通少,进病房时未向病人问好,整理病房时未向病人解释,口腔清洁率70.3%,头发清洁率45.3%,皮肤清洁率69.5%,病房安静整洁率67.3%,床单位整洁率86.5%,病情关注情况67.9%,健康教育执行情况48.6%,协助生活不能自理的病人进食、入厕、更衣、床上排便等占75.4%,时间安排满意度75.6%,护士认为晨间护理重要的占30%,晨间护理内容知晓率占60.9%,认为工作量大来不及做的占56.7%。结论提高护士对晨间护理的认识,规范晨间护理内容和程序,加强与病人的沟通,提供符合个体化需要的晨间护理,合理安排护理人员、工作重点和时间,持续质量改进,有助于提高晨间护理质量。     

本院护理人员论文发表情况的调查分析

目的了解中医院护理人员护理论文发表的现状,分析存在的问题并寻求对策。方法对本院2008~2012年护理人员发表护理论文的期刊级别及作者学历、职称、工龄、年龄等情况进行回顾性分析。结果本院2008~2012年发表护理论文在数量呈上升趋势,护理论文内容以中医护理技术所占比例最大(29.12%),药械监控方面的护理论文较少。发表在不同期刊级别的作者年龄、职称、工龄及学历比较,差异具有统计学意义(均P0.05)。结论护理人员撰写论文的意识、能力需要培训和提高。实施激励政策,调动护理人员科研积极性,对提高护理人员科研意识和水平具有积极的意义。     

我院专科护理门诊的实施与体会

目的探讨专科护理门诊的实施方法与体会。方法确定专科项目及服务内容、选拔护理门诊人员并明确工作职责、设置合理的诊室、制订相关制度,规范就诊流程,建立门诊护理日志,拓展服务功能。结果开设专科护理门诊以来,已接待门诊患者27000余人次,得到了患者、家属、医生及护士的认可。护理门诊就诊综合满意率为96．54％。结论开设专科护理门诊有利于提高护理专业地位,满足不同患者的健康需求,促进专科护士成长。     

临床护理成本与效益分析

笔者根据临床护理服务价格偏离成本的事实,提出关注护理成本,改革现行的医疗护理服务收费制度和医疗费用结构比,提升护士的劳务价值,以期深入发展护理经济研究形成系统的护理成本核算体系,以低成本、高效益的优质护理服务来赢得市场。     

影响护理质量持续提高的因素及对策

目的探讨影响护理质量持续提高的因素,并提出对策。方法分析总结影响护理质量持续提高的因素。结果影响护理质量持续提高的因素主要为护理人员职业道德教育不够、护理职业得不到社会的尊重和理解、奖惩制度不明确和病房护理人员短缺等。结论加强教育引导,进一步提高护理人员的敬业精神;改革分配制度,改善护理工作环境和激发护理人员工作积极性对确保护理质量管理持续提高具有重要的作用。     

社区护理中存在的问题及对策

3年的社区护理实践,发现社区护理中存在的问题有：受社会经济环境影响,护理工作量日益增加;护理人员严重不足,护理工作超负荷运转;社区护理仪器设备不配套,护理整体水平与医疗发展不适应;工作量与奖金分配不成比例。采用相应的对策：护理人员角色转换;加强对护理人员的时间管理;提高社区护理人员的政治觉悟,树立无私奉献的思想;加强护理业务技术及其质量管理;加强科室间协调工作,保证仪器设备到位。收到了明显的效果,提高了社区护理质量。     

我国护理成本研究中的问题与思考

论述我国护理成本研究中存在的方法单一、体系缺乏、病人分类系统不能满足需要等问题，提出护理成本管理要注重预算，提高人力生产力，进行成本效益分析和开发计算机综合信息系统等措施，指出现阶段进行护理成本研究的实际意义。     

护理记录书写中存在的问题及对策

目的了解护理记录书写中存在的问题，并提出相对应的对策。方法以《广东省病历书写规范》为标准对本院1300份入院和出院病历进行质量检查，找出护理记录书写存在的问题。结果1300份入院和出院病历存在护理缺陷的病历的有433份。护理记录书写存在的问题分别为记录治疗性措施多（91．9％），护理记录字迹不清、涂改（82．2％），病情描述含糊不清（59．6％），记录不及时（43．6％）和医护记录不一致（28．6％）。结论转变观念，加强医护间的密切配合，实施临床护士层级管理和设计护理记录表格对提高护理记录书写质量具有重要的意义。     

Nursing documentation in nursing homes--state-of-the-art and implications for quality improvement

This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients' (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients' needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n=332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients' independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients' functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.     

传承护理专业发展进程 开展“优质护理服务示范工程”

通过对近30年来护理专业发展进程的思考,剖析护理工作的内涵,从20世纪80年代初李士鸾引入责任制护理,到20世纪90年代中期推行整体护理,一直到今年开展"优质护理服务示范工程"。这一切变化充分体现了具有中国特色的护理专业发展的延续性,阐述了在医药卫生体制改革的形势下如何开展"优质护理服务示范工程"活动,促进整体护理进一步深化。