• Journal of Korean Clinical Nursing Research
• /
• v.15 no.3
• /
• pp.107-116
• /
• 2009

Purpose: This study was conducted to evaluate the record completeness of the nursing process in the Electronic Nursing Record(ENR) in a university hospital. Methods: We compared nursing statements documented in 2004 with those from the year 2007, given the fact that the ENR system had been utilized since 2004. The ENRs of 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. Results: The number of nursing records which documented the whole nursing process completely was 4,010 (48.3%) in 2007, whereas 513 (5.9%) in 2004 (p<.001). The number of incomplete records in 2004 was 8,142 (94.1%), while 4,300 (51.7%) in 2007 (p<.001). The number of nursing diagnoses was 846 in 2004 and 4,313 in 2007, which increased in number more than 5 times. The most frequently used diagnoses were 'pain', 'risk for infection' and 'risk for ileus' in both years. Conclusion: There was a significant increase in the record completeness on nursing process in 2007 compared to the records in 2004. The reasons for this increase are attributed to nurse training for encouraging to complete recording and nursing record auditing.

• Journal of Korean Academy of Nursing
• /
• v.22 no.4
• /
• pp.454-463
• /
• 1992

세계가 일일 생활권화 됨과 더불어 국제교류가 활발해지므로써 횡문화 간호 연구는 전문직 간호(Professional Nursing)에 있어서 매우 중요한 부분을 차지하고 있음을 많은 문헌을 통해서 알 수 있다(Brink, 1976 : Leininger, 1977 : Roberston & Boyle, 1987). 횡문화 간호연구는 서로 다른 문화적 배경을 가진 사람들을 잘 이해하고 그들의 건강을 돌봄에 있어서 더욱 효과적이고, 안전한 간호를 할 수 있을 뿐만 아니라 간호이론 개발, 간호모형(Model) 개발에 있어서도 매우 중요한 역할을 한다고 믿는다. 본 연구는 1984년에서 1987년 사이에 전문적 간호연구지에 실린 10편의 횡문화 간호연구와 관련된 논문들을 발췌하여 간호지식체의 본질적인 과정인 비판적 문헌고찰을 통해 각 논문들을 비교 분석 한 것으로써, 미래의 간호연구를 위한 간호실무, 간호교육, 간호연구 방법 및 간호 행정면에서 그 적용성을 높여줄 것이다. 비판적 문헌고찰을 위한 기준은 Burns와 Grove(1987)의 방법을 참고하여 아래와 같이 선정하였다. 1. 분석대상 : 목적, 가설 진술, 문헌고찰, 표본조사, 방법론적 논점, 결과 해석 2. 이론적 틀의 유도 흑은 통합 3. 발전적인 간호수행을 위한 중요성, 적용성 및 제언 이상의 내용으로 비교 분석을 해본 결과 1984년에서 1987년 사이에 발표된 횡문화 간호에 관한 논문들의 주제는 주로 여성을 대상으로 한 건강돌봄, 자가간호, 건강신념, 수유, 임신 그리고 간호사와 소수민족 노인과의 의사소통 양상 등으로 나누어 볼 수 있었다. 이론적 틀은 주로 사회학, 정신심리학, 인류학 이론으로부터 도출되었고, 오직 두 편만이 간호 이른에 틀을 둔 것으로 나타났다. 1. 10개의 논문의 가설과 목적의 분석에 있어서 4편의 논문은 목적과 가설이 구체적으로 진술되어 있었고, 나머지 6편은 목적이 전반적으로 진술되어 있었으며 가설도 구체적이지 않았다. 이러한 제한점은 각 논문의 연구자가 문헌고찰을 충분히 하지 못하고 단지 수편의 논문만을 제시 한 데서 비롯되었다고 분석 해 볼 수 있겠다. 2. 문헌고찰 부분에서는 각각의 연구주제를 지지해줄 수 있는 문헌들이 충분히 고찰되지 못하였고, 이론적배경 또한 횡문화 이론과의 관련성이 적었다. 또한 횡 문화 연구에 기초가 되는 연구대상자의 사회 인구학적 특성과 역사적 배경은 잘 나타났으나, 이론적 연구와 경험적 연구 간에 괴리가 있었다. 3. 표본추출방법은 문화에 기반을 둔 대상자를 선정한다는 점에서 한계성 이 있었다. 4. 방법론적 이유로는 대상자와의 면담시간이 구체적으로 기술되지 않았으며, 고유한 언어를 통역하는 과정에서 의미론적 문제에 대한 고려가 부족하였다. 면접과 기록과정에서 보면 자료의 기록과정과 분류 및 분석과정이 명시되어 있지 않았다. 참여관찰과 면접방법을 사용시 이에 대한 자세한 기술이 되어 있지 않았다. 5. 연구결과의 적용 및 이에 대한 논의는 상당히 제한되어 있었는데, 수편의 연구만이 방법론 문제점과 앞으로의 연구분야에 대한 전망을 제시하였으며, 특이한 것은 어 떤 연구자도 이른 개발을 위한 적용 및 임상실무적 차원에서 간호에 대한 제언을 하지 않았다.

• Journal of the Korea Academia-Industrial cooperation Society
• /
• v.10 no.5
• /
• pp.1126-1132
• /
• 2009

We carried out this study to reduce the gaps between medical institutes and between medical personnels and help to improve medical service quality, by classifying diagnoses and related intervention through the development of standard nursing intervention and by computerizing protocols. We considered two processes: one is the development process of home nursing standard intervention, and the other is the process of computerizing its related protocols. For the former, research covered analysis of home health care practices, development of client assessment protocol, of patients diagnosis protocols, and of patients intervention protocol. For the latter, strategies for home health care information systems should be set up and it constituted four research contents of analysis, design, management and evaluation of the systems. We also trained and educated home nurses who work at home health service center, by making them use the manual of home health care information systems at a certain city of P. In this study, therefore, we developed elements of standard home health care mediation so that they could be included in the forms of home health information note, home health progress note, and home health progress summary, home health discharge summary. Because standard home health care intervention has been developed, it became easier to exchange information between different home heath service center offices, can prevent from missing or redundant information, and contribute to standardization of hospital terminologies when EMR and HMR are developed.

• The Journal of Korean Academic Society of Nursing Education
• /
• v.22 no.3
• /
• pp.396-407
• /
• 2016

Purpose: This study aimed to identify the effectiveness of educational Electronic Nursing Record System in terms of nursing process preparation ability and satisfaction about the system itself. Methods: A one group pre-post experimental study design was utilized in this study. The effectiveness of the system was examined through quality of nursing diagnoses, interventions, and outcomes and electronic nursing record system satisfaction inventory. Junior and senior nursing students were the potential study respondents and evaluation instruments were applied only for the one who agreed to participated in the study. Education about nursing process and electronic nursing record system was carried out as part of regular classes and students were guided to prepare nursing process upon the scenarios developed earlier. Results: 29 juniors and 33 seniors prepare nursing process documentation related to each scenario and both groups showed significant improvement upon nursing process documentation (t=7.53, p<.001, t=3.23, p=.003, respectively) compared to paper based nursing process preparation. Satisfaction about system itself was 2.78(0.81). Conclusion: Educational electronic nursing record system seems to be effective to train nursing students for nursing process preparation ability. Effort to enhance its utility are called in the area of education and system itself.

• Korean Journal of Occupational Health Nursing
• /
• v.2
• /
• pp.13-25
• /
• 1992

본 연구는 업종별 산업간호사의 보건관리업무의 내용과 수행정도를 측정하고 업종별 보건관리업무 수행정도를 비교 분석코저 한다. 연구방법은 산업간호사회에 등록된 산업장중 서울, 인천, 마산, 창원, 부산, 울산 지역에 있는 130개 산업장을 임의로 선정하여 산업간호사를 대상으로 설문조사하였다. 자료분석은 반도와 백분율, 업종간의 보건관리업무 내용별 수행정도는 일원분산분석과 다중검증 비교로 유의성을 검증하였다. 연구결과는 다음과 같다. 1) 업종별로 산업간호사의 업무수행에 유의한 차이를 보인 보건관리내용은 서비스업에 있어서 근로자의 건강사정에 대한 수행정도가 제조업과 기타제조업에서 보다 높게 나타났다.(F=4.23, P=.0167) 반면에 근로자의 건강진단과 계속관리, 작업환경 관리업무 수행정도는 제조업과 기타제조업에서 서비스업보다 높게 나타났다.(F=9.78, P=.0001 ; F=5.366. P=.005) 2) 업종간에 유의한 차이가 없는 보건관리내용은 산업장진단 또는 건강문제분석, 보건교육, 통상증상에 대한 투약, 기록과 보고, 건강관리실 운영 등이었으며 업무수행정도는 가끔 또는 필요시하는 정도로 나타났다. 반면에 조사, 연구 참여에 대한 수행정도는 세 업종 모두 가장 낮은 것으로 나타났다. 이러한 연구결과들은 산업장 간호사의 신규교육이나 직무교육과정운영이 업종별로 운영되어야 함을 시사해 준다고 볼 수 있으며 또한 산업간호사의 직무 중 보건 교육, 통상질환에 대한 투약, 기록 및 보고, 건강관리실운영등은 업종간에 유의한 차이가 없으나, 수행정도는 낮은것으로 나타나 이에 대한 실제적인 직무교육이 강화되어야 할 것으로 생각된다. 특히 보건교육도 업종별로 차이가 있으므로 다양한 보건교육교재의 개발이 필요하다고 생각된다.

• Journal of Korean Critical Care Nursing
• /
• v.1 no.1
• /
• pp.73-83
• /
• 2008

Purpose: Purpose of this study was to analyze the nursing focuses for standardization of ICU nursing records. Methods: The data were collected from 1,000days'nursing records of 197 ICU patients at a tertiary hospital in Seoul. Nursing focuses were unified at the consulting group meeting and they were cross-mapped with the NANDA nursing diagnoses. Results: The 62 nursing focuses in 7 NANDA categories were extracted from nursing record. Among total nursing focuses 41 correspond to the NANDA nursing diagnoses and 21 were added to ICU nursing focuses. The 10 most frequently used nursing focuses are 'Ineffective airway clearance', 'Impaired gas exchange', 'Ineffective tissue perfusion: cardiopulmonary', 'Ineffective breathing pattern', 'Ineffective tissue perfusion: renal', 'Ineffective infant feeding pattern', 'Risk for impaired skin integrity', 'Hyperthermia', 'Impaired skin integrity', 'Decreased cardiac output', Conclusion: Nursing focuses list of ICU was extracted from the result of this study. These nursing focuses might form a framework for development of research-based assessment guideline and care plans for ICU patients through standardization of nursing records.

• Journal of Korean Academic Society of Home Health Care Nursing
• /
• v.11 no.1
• /
• pp.14-22
• /
• 2004

The purpose of this study was to establish the basic-data set for the electronic nursing records system by analysis of nursing phenomenas and nursing actions described in nursing records of orthopedic patients using the ICNP. Nursing notes for 1.421 days of 97 orthopedics patients who were discharged from a tertiary teaching hospital in Daegu were used. Narrative data from the nursing notes were collected. decomposed. and cross mapped with the concepts of the ICNP beta version. In total 11.442 statements were found in the process of decomposing the narrative data into single statement. These statements consist of 3.970(34.70%) nursing phenomena statements. 6.996(61.14%) nursing action statements, and 476(4.16%) other statements. Finally 312 unique statements were collected by integrating same or similar statements. These statements consist of 120 (38.46%) nursing phenomena statements. 154 (49.36%) nursing action statements. and 38 (12.18%) other statements. When this result was cross mapped with ICNP beta version. 77.0% of nursing statements were completely expressed. 17.0% of them were partially expressed. and 0.3% of them were not able to expressed at all. The findings of this study showed the usability of ICNP as terminology of electronic nursing records system. And the result of this study can be utilized for an ICNP-based electronic nursing records system and can help clinical nurses to spend more time on direct nursing.

• The Korean Nurse
• /
• v.17 no.1 s.93
• /
• pp.51-60
• /
• 1978

본 조사를 1977년 7월부터 11월까지 전국 52개교 간호교육기관을 대상으로 질문지에 의하여 간호교육기관의 교육 실태를 분석 검토한 결과 다음과 같은 결과를 얻었다. 1. 전국의 간호교육기관 수는 대학과정 14개교(대학 2개교, 간호학과 12개교), 전문학교 37개교, 간호학교 1개교 이었다. 설립별로 분류하여 보면 국립은 9개교, 공립은 16개교, 사립은 27개교이었다. 2. 전국 간호교육기관의 재학생 수는 10,882명이었고 대학과정에 2908명, 전문학교과정에 7,974명이었다. 총 재학생중 남학생 수는 53명이었다. 3. 1977년도 졸업생 수는 총 3,097명으로 11월 현재 취업율은 78.8$\%$ 미취업율은 21.2$\%$을 나타내고 있다. 4. 전국의 총 간호교수는 603명으로 전임강사 이상 간호학 교수는 74%이었다. 대학과정의 학(과)장중 85.7%가 간호학 전공교수 이었으나 전문학교의 경우 기관장중 35.1%가 간호학 전공교수이었다. 5. 교수의 주당 강의시간 수는 대학과정의 경우 1$\~$3시간을 담당하는 교수가 52.6$\%$를 차지함에 비해, 전문학교의 경우 1$\~$3시간 담당교수는 11.0$\%$에 불과 하였으며 7$\~$9시간 담당교수가 28.0$\%$를 차지하고 16시간 이상 강의하는 교수도 2.6$\%$나 있었다. 교수의 정원을 질문 하였으나 자료 수집된 대부분의 학교에서 기록하지 않아 집계할 수 없었음을 밝히며, 끝으로 협조해주신 전국 간호교육 기관에 진심으로 감사드리면서 앞으로도 계속적인 지원과 협조를 바랍니다.

• Journal of Korean Academy of Nursing
• /
• v.7 no.1
• /
• pp.1-9
• /
• 1977

Primary function of health record is that as tool of communication between the health processionals with the mutual goal, the promotion of health care standard. Studies have been carried out world over oil tile subject, among those, Weed's Problem-Oriented Health Record is considered a paramount achievement. This study was designed to assess tile possibility of implementing tile problem-oriented health record system through ail experiment in order to provide data for nurse administrators infiltrating reformation of recording system and format. Record of 29 patients admitted at Korea University Hospital, Seoul, from March through June, 1976 for 4 to 14 days were sampled. Nursing notes were recorded by research assistants; senior nursing student trailed extensively by the researcher oil Problem-Oriented Records, oil Problem Oriented Nursing Record format (experimental group) and analysis were carried out comparative, with that of traditional nursing records noted by other nursing personnel (control group) on the same patient. Attitude towards Problem Oriented Nursing Record system and format were attained through questionaries responded by the 51 research assistants. Results are as fellows: Comparative analysis revealed that: 1. Assessment of patients' health problems recorded significantly more in traditional records. 2. Focus of health Problem differed; traditional records slowed significantly higher frequency in medical and procedure as focus while problem oriented records on nursing focus problems. 3. Problem- Oriented records were better organized, Mean value scores of attitude towards Problem- Oriented Records revealed that: Positive value scores on all 4 categories: 1) Assessment of nursing needs, 2) Nursing care planning 3) Patient progress assessment and 4) Tool of teaching and learning revealed that the Problem-Oriented Nursing Record is positively accepted by tile respondents. Recommendation Further experiments on implementation of Problem- Oriented Health Record are recommended: experiment involving all health professionals, in larger scope and longitudinal.

• Journal of Korean Clinical Nursing Research
• /
• v.19 no.3
• /
• pp.369-382
• /
• 2013

Purpose: This study aimed to develop an educational program on nursing records especially focused on legal issues, and to test the effects of the educational program on nurses' knowledge, performance, and behavior. Methods: A textbook on legal issue-focused nursing records and an instrument with 36 items rated on a 5-point scale (1-5) for measuring the nurses' charting-related performance and behavior were developed from November 2007 through March 2008. A nonequivalent control group pretest-posttest design was employed to test the effects of the education program. Knowledge was self-reported by the Nurse Charting Knowledge Scale, while performance and behavior were measured by their nurse managers. The pretest and posttest were conducted from March through May in 2008. A total of 226 Korean nurses participated in this study. Data were analyzed with descriptive statistics, t-test, Chi-square, paired t-test, Spearman's coefficient, and multiple regression. Results: Nurses who received the intervention showed greater levels of knowledge (t=10.28, p<.001), performance (t=2.53, p=.013), and behavior scores (t=3.07, p=.002) than those of the control group. The factors influencing the improvement of knowledge were 'job attitude' (t=-3.32, p=.001) and 'career in present unit' (t=2.95, p=.004). The factor influencing the improvement of performance was 'career in present unit' (t=-3.39, p=.001). The factor influencing the improvement of behavior was 'job attitude' (t=-3.46, p=.001). Conclusion: The educational program on legal issue-focused nursing records was effective in improving nurse charting-related knowledge, performance, and behavior.