The Journal of Korean Academic Society of Nursing Education (한국간호교육학회지)

The Korean Academic Society of Nursing Education (한국간호교육학회)
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Effects of nursing record education focused on legal aspects at small and medium sized hospitals

  • Do, Taehee (Daegu Catholic University) ;
  • Kim, Heejung (College of Nursing․Institute of Nursing Science, Daegu Catholic University)
  • Received : 2021.03.11
  • Accepted : 2021.05.07
  • Published : 2021.05.31
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Abstract

Purpose: The purpose of this study was to examine the effect of nursing record education on the knowledge and performance of nursing record of nurses at small- and medium-sized hospitals. Methods: The participants were 62 nurses working in two small- and medium-sized hospitals. Thirty-two nurses comprised the experimental group, and 30 nurses comprised the control group. Nursing record education was provided for the experimental group. Data were analyzed by x2-test and t-test analysis using the IBM SPSS statistics 25.0 Program. Results: After education, the knowledge (t=2.43, p=.019), performance (t=2.19, p=.033) and behavior scores (t=2.42, p=.018) on nursing record were significantly higher in the experimental group than in the control group. Based on this result, nursing record education is an effective intervention to improve nurses' knowledge and performance in writing nursing records in small- and medium-sized hospitals. Conclusion: We suggest the development of a systematic and standardized education program on nursing record including its legal aspects, for nurses in small- and medium-sized hospitals. The results of this study can be used as basic data for developing a nursing record education program for small- and medium-sized hospitals.

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References

  1. Griffith R. What to include in a nursing record. British Journal of Nursing. 2016;25(9):520-521. https://doi.org/10.12968/bjon.2016.25.9.520
  2. Cho IS, Choi WJ, Choi WH, Kim MK. The adoptions and use of electronic nursing records in Korean hospitals: findings of a nationwide survey. Journal of Korean Clinical Nursing Research. 2013;19(3):345-356. https://doi.org/10.22650/JKCNR.2013.19.3.345
  3. Whittenburg L, Meetim A. Electronic nursing documentation: patient care continuity using the clinical care classification system (CCC). Studies in Health Technology and Informatics. 2016;225:13-17. https://doi.org/10.3233/978-1-61499-658-3-13
  4. Inan NK, Dinc L. Evaluation of nursing documentation on patient hygienic care. International Journal of Nursing Practice. 2013;19(1):81-87. https://doi.org/10.1111/ijn.12030
  5. Vankipuram M, Kahol K, Cohen T, Patel VL. Toward automated workflow analysis and visualization in clinical environments. Journal of Biomedical Informatics. 2011;44(3):432-440. https://doi.org/10.1016/j.jbi.2010.05.015
  6. Lee JY. Analysis of factors to complete nursing documentation through initial nursing assessment record [master's thesis]. Seoul: Yonsei University; 2017. p. 1-50.
  7. Kang MM. Comparison of the performance and the record of nursing behaviors using the INCP in ICU [master's thesis]. Gyeonggi-do: Dankook University; 2006. p. 1-65.
  8. Gomes DC, Cubas MR, Pleis LE, Shmeil MA, Peluci AP. Terms used by nurses in the documentation of patient progress. Revista Gaucha de Enfermagem. 2016;37(1):e53927. https://doi.org/10.1590/1983-1447.2016.01.53927
  9. Ehrenberg A, Ehnfors M. The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions. Scandinavian Journal of Caring Science. 2001;15(4):303-310. https://doi.org/10.1046/j.1471-6712.2001.00044.x
  10. Hwang ES, Lee SJ, Kim SJ, Heo IH. A study on knowledge, importance and performance in nursing records of university hospital nurses. Journal of Korean Critical Care Nursing. 2019;12(1):71-81. https://doi.org/10.34250/jkccn.2019.12.1.71
  11. Selvi ST. Documentation in nursing practice. International Journal of Nursing Education. 2017;9(4):121-123. https://doi.org/10.5958/0974-9357.2017.00108.8
  12. Lee SM, Yoon SY, Kwon SY. A study on the knowledge level of nursing documentation among nurse officers in military hospitals: focusing on the legal aspects. Journal of Military Nursing Research. 2013;31(2):118-128.
  13. Jung EY, Yang SH. A study on the knowledge level of nursing records among nursing students-focusing on legal aspects. Journal of East-West Nursing Research. 2017;23(2):150-159. https://doi.org/10.14370/jewnr.2017.23.2.54
  14. Kim YM. Development and evaluation of an educational program on legal issue-focused nursing records. Journal of Korean Clinical Nursing Research. 2013;19(3):369-382. https://doi.org/10.22650/JKCNR.2013.19.3.369
  15. Korea Medical Dispute Mediation and Arbitration Agency. Medical dispute mediation and arbitration statistical yearbook 2019. Seoul: Korea Medical Dispute Mediation and Arbitration Agency; 2020.
  16. National Health Insurance Service. National health insurance service statistical year book 2019 [Internet]. Gangwon: National Health Insurance Service; 2020 [cited 2021 Feb 14]. Available from: https://www.nhis.or.kr/nhis/together/wbhaec06300m01.do?mode=view&articleNo=10802543&article.offset=0&articleLimit=10
  17. Kang HS, Song HJ. The association between safety care activity and documentation of nursing records among nurses in general hospitals. Journal of Korean Critical Care Nursing. 2018;11(3):85-94.
  18. Jung MJ. Study on the needs, accommodation and satisfaction toward the nursing practice program of the nurses in small to medium sized hospitals [master's thesis]. Gwangju: Nambu University; 2012. p. 1-59.
  19. Kim EY, Yi YJ. Effects on knowledge and performance in clinical nursing of education on nursing recording focusing on legal aspects. Journal of Korean Academic Nursing Administration. 2011;17(3):277-283. https://doi.org/10.11111/jkana.2011.17.3.277
  20. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007;39(2):175-191. https://doi.org/10.3758/bf03193146
  21. Kim YM, Park SA. A nurse charting knowledge scale: focusing on legal aspects. Journal of Korean Clinical Nursing Research. 2007;13(2):27-38.
  22. Kim YM. Development and evaluation of an educational program on legal issue-focused nursing records. Journal of Korean Clinical Nursing Research. 2013;19(3):369-382. https://doi.org/10.22650/JKCNR.2013.19.3.369
  23. Goo KH. The level of clinical nurses' knowledge about how to write nursing records [master's thesis]. Daegu: Kyungpook National University; 2012. p. 1-38.
  24. Kim N, Park Y, Lee Y, Yang Y. Effects of nursing recording education focusing the legal aspects on the nurses' knowledge, confidence and education satisfaction in a local hospital. Asian Pacific Journal of Multimedia Services Convergent with Art Humanities and Sociology. 2019; 9(12):509-522. https://doi.org/10.35873/ajmahs.2019.9.12.046
  25. Eun Y, Kang HS, Jeon MY. Survey on online continuing education requirements according to practical experience of nurses at small and medium sized hospitals. Journal of Muscle Joint Health. 2016;23(3):197-205. https://doi.org/10.5953/jmjh.2016.23.3.197
  26. Linch GFDC, Lima AAA, Souza EN, Nauderer TM, Paz AA, da Costa C. An educational intervention impact on the quality of nursing records. Revista Latino-Americana de Enfermagem. 2017;30(25):e2938. https://doi.org/10.1590/1518-8345.1986.2938
  27. Ahn JO, Jung YM, Cha JH, Lee HJ, Lee SY. Nurses' perception on EMR and standardized nursing statements in Korea armed forces hospitals. Journal of Military Nursing Research. 2018;36(1):71-83. https://doi.org/10.31148/kjmnr.2018.36.1.71
  28. Mykkanen M, Miettinen M, Saranto K. Standardized nursing documentation supports evidence-based nursing management. Studies in Health Technology and Informatics. 2016;225:466-470.
  29. Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice. 2010;16:112-124. https://doi.org/10.1111/j.1440-172x.2009.01815.x
  30. Jang SJ, Lee HO, Kwon JH, Lee SH. The effects of safe handling education of antineoplastic drug on knowledge and performance of clinical nurses. Journal of Korean Clinical Nursing Research. 2016;22(2):217-224. https://doi.org/10.22650/JKCNR.2016.22.2.217