Promoting patient safety using electronic medical records in nursing/midwifery undergraduate curricula: Discussion paper

This discussion paper highlights the importance of Australian nursing and midwifery students’ lack of exposure to electronic medical records during their undergraduate programs. There is pressure on universities offering nursing and midwifery programs to provide students with opportunities to learn to use patient electronic medical records. This will provide authentic rehearsal with the digital technology prior to clinical placements and increase graduate work readiness.Informed by contemporary literature, we describe the benefits of implementing electronic medical records (eMR) in health organisations and identify the challenges and barriers to implementing and integrating the education of electronic records into undergraduate nursing and midwifery programs. Undergraduate students who had not experienced eMR as part of on-campus learning felt unprepared and lacked confidence when commencing clinical practice. Some international nursing and midwifery programs have found that student’s skills improve in decision-making and documenting patient observations when eMR is integrated into their university education program. Successful integration of an eMR program should consider academic/teaching staff skills and confidence in technology use, initial and ongoing costs and technical support required to deliver the program.In conclusion, Australian universities need to embed eMR learning experiences into the nursing and midwifery undergraduate curricula to increase students work-readiness with a focus on patient safety.     

电子护理记录与手写护理记录临床效果比较

目的 总结电子护理记录的优越性.方法 电子护理记录组50份,手写护理记录组50份,比较两组记录书写时间、书写质量及存在的问题.结果 电子护理记录组在书写时间及整体效果方面,明显优于手写护理记录组(P ＜ 0.05).结论 电子护理记录书写时间短,操作简单快捷,病历整洁,提高了工作效率及护理文书质量.     

Psychiatric electronic health records privacy in Jordan: A policy brief

Psychiatric health records are highly sensitive data which requires special policy to maintain its privacy, without affecting data accessibility. The current authors reviewed social, ethical and legal underpinnings for psychiatric electronic health records (EHR), and suggests a policy to maintain privacy and confidentiality of the psychiatric data, without affecting data accessibility. The purpose of this policy brief is to discuss and provide alternatives regarding psychiatric electronic health records privacy and information access. The current policy applied in Jordan still immature to ensure high levels of reliability, as the psychiatric data is openly accessed to the non-specialized personnel. Sensitive personal data policy is recommended in this paper with developing overriding mechanisms to counteract obstacles to data accessibility.     

护理专业学生生命认知现状的调查分析

目的调查分析护理专业学生生命认知现状，为有效开展生命教育提供依据。方法采用生命意义量表和生命态度剖面图量表作为调查工具，对527名高职护理专业学生进行生命认知现状调查。结果护理专业学生的生命意义感普遍偏低；不同年级护理专业学生的生命意义量表总分、对生命的热忱、生命目的、生命控制及对死亡的接纳等方面比较差异均具有统计学意义。结论在护理专业学生中开展生命教育迫在眉睫，对不同年级学生需给予针对性的生命教育内容。     

Modelling nursing activities: electronic patient records and their discontents

A fully integrated and operating EPR in a clinical setting is hard to find: most applications can be found in outpatient or general practice settings or in isolated hospital wards. In clinical work practice problems with the electronic patient record (EPR) are frequent. These problems are at least partially due to the models of health care work embedded in EPRs. In this paper we will argue that these problems are at least partially due to the models of health care work embedded in current EPRs. We suggest that these models often contain projections of nurses' and doctors' work as it should be performed on the ward, rather than depicting how work is actually performed. We draw upon sociological insights to elucidate the fluid and pragmatic nature of healthcare work and give recommendations for the development of an empirically based EPR, which can support the work of nurses and other health care providers. We argue that these issues are of great importance to the nursing profession, since the EPR will help define the worksettings of the future. Since it is a tool that will impact the development of the nursing profession, nurses have and should have a stake in its development.     

Evaluation of patient records as part of developing a nursing care classification

The aim of the study was to evaluate the content of nursing care records and the usefulness of the instrument used for their evaluation. The evaluation involved 70 patient records from seven acute special care inpatient units. The evaluation instrument used was based on Phaneuf's Nursing Audit as further developed by Lukander. The nursing records in all the care units evaluated was very good or good. However, some deficiencies were found, for instance, regarding patient teaching and recording patients' own opinions. The method proved adequate for evaluating the content of patient records.     

脑血管病急性期护理病案记录单的设计及内容管理

目的 探讨脑血管病急性期患者护理病案记录单设计及内容管理.方法 对护理记录单进行设计,采用填空式的记录方式,减少文字重复书写及记录时间,将患者生命体征的变化,反映神经科专科特点的神志、瞳孔、瘫痪肌力的变化记录体现时间性;并对其记录的内容包括新患者入院时的记录、住院期间记录、出院记录等进行管理.结果新患者入院时的记录,住院期间的记录,出院记录均根据专科的特点记录.结论 脑血管病急性期住院期间护理病案记录单设计与内容管理,对提高护理质量有深远的意义.     

电子护理文书在临床护理工作中的应用

目的:探讨电子护理文书在临床护理工作中的应用效果。方法:随机选取100份在临床护理工作中使用电子护理文书的护理记录(观察组)和100份使用手写护理文书的护理记录(对照组),对其护理记录中的书写质量、时间及相关存在问题进行统计分析、比较。结果:观察组在书写质量、书写时间等整体效果上均优于对照组(P<0.05,P<0.01)。结论:在临床护理工作中使用电子护理文书,其书写时间短、操作简单、速度快、质量高,对提高护理工作效率有重要意义。     

Undergraduate nursing students' attitudes towards organ donation: a survey in an Italian university

ZAMPIERON A., CORSO M. & FRIGO A.C. (2010) Undergraduate nursing students' attitudes towards organ donation: a survey in an Italian university. International Nursing Review 57 , 370–376 Aims: To examine undergraduate nursing students' attitudes towards organ donation and to determine whether or not attitudes were related to the students' education and training. Background: Nurses' knowledge and personal opinion can influence patient's willingness to donate organs or to hold an organ donor card. It is unclear how Italy's future nurses view organ donation. Methods: The study's source population consisted of third‐year undergraduate nursing students enrolled in seven nursing schools from an Italian university during 2008. Respondents completed self‐administered quantitative questionnaire with 61 questions, including the Organ Donation Attitude Scale. Findings: Of the 378 students contacted, 183 (48%) completed all survey questions; 140 were females (76.5%) and the mean age of students was 25. The median score of students' attitude scores towards organ donation was 151 (the attitude is positive when the score is higher than 161). No significant correlations were found to exist between organ‐donation attitude and sex, age, clinical practice in hospitals with a transplant unit, nursing care to patients waiting for a transplant or dialysis patients. Only 16% of the students had previously signed a donor card consenting to their own organ donation. The study revealed that doubts about transplantable organs still exist within the student body. Conclusions: This study highlighted that students' awareness of organ donation was not adequate and that attitude levels were lower than in other countries. If these future workers would receive adequate training, they could promote organ donation to the general public and to other hospital personnel.     

In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden

Aim. The aim of this study was to identify terms and expressions indicating patients’ need for knowledge and understanding, as well as nurses’ teaching interventions, as documented in nursing records. Background. Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. Methods. Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients’ need for knowledge and understanding and terms and expressions indicating nurses’ teaching activities were analysed. Results. The results showed that patients’ need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses’ implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. Relevance to clinical practice. Efforts must be directed towards elaborating upon the above‐mentioned terms and expressions as indications of patients’ need for knowledge and nurses’ teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.     

医护人员对癌症终末治疗和死亡的态度及其影响因素的研究

目的探讨医护人员对癌症终末治疗和死亡的态度及其影响因素。方法采用自行设计的问卷对571名医护人员进行调查。结果住院经历和处置死亡经历是医护人员赞同“减轻痛苦和提供尊严”的危险因素;处置死亡经历是赞同“建立治疗遗愿”的危险因素;危重患者接触经历是赞同“患者应坚强活下来”的保护因素;男性是赞同“想到死亡很平静”的危险因素,差异均有显著性意义（P〈O．05或P〈0．01）。结论开展病人角色扮演等方式的教育,建立临终关怀病房和重症监护病房的常规培训制度,因人而异、因势利导地开展科学的死亡教育是增强医护人员对生死观认识的可探索途径。