• Journal of Korean Academy of Nursing
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• v.33 no.6
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• pp.802-811
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• 2003

Purpose: The purpose of this study was to compare the nursing activities delineated by interview of nurses with those on nursing notes. Method: The participants of interview were 18 nurses working in medical and surgical units of a large hospital in Seoul. Each nurse was asked to choose one patient who demand most nursing care among her patients. The nurse was then interviewed to describe what her nursing activities for the patient was that day. The audio-taped interview was transcribed and the content was analyzed by researchers. Nursing notes of each nurses' patients were copied and the content analyzed by researchers. Finally, themes from the interview data and those from nursing notes were compared. Result: Activities related to emotional or psychological nursing, education for patient and families, and problem solving related to treatment or nursing procedure were most often omitted in nursing notes. Most of the documentation in nursing notes were related to physical condition of patients or physician's orders. Nurses described that they will do better recording if they were given less patient care responsibility, had better nursing knowledge, had better recording system, and received more training on nursing record. Conclusion: Nursing notes did not reflect nursing activities properly. Few independent nursing roles were documented in the nursing notes. Development of nursing education program and nursing record system is needed for improvement of nursing record.

• Journal of Korean Academy of Nursing
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• v.35 no.3
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• pp.441-450
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• 2005

Purpose: The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done. Method: Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test. Results: The most frequent nursing intervention was 'nausea management' in the nursing note and was 'medication administration: oral' in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice. Conclusion: This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.

• Journal of Home Health Care Nursing
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• v.2
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• pp.35-51
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• 1995

This study was done to define nursing diagnose and to test the validity of the characteristics for patients with cerebrovascular accidents being seen at home by home health care nurses. This study was a descriptive study. The sample consisted of 10 experts(professors and home health care nurses) who had had a variety of experience using nursing diagnoses in clinical practice, and 336 nurse progress notes for 18 patients with cerebrovascular accidents. First, 32 nursing diagnoses were defined by the analysis of 336 nurse progress notes, and ten nursing diagnoses were selected according to a criteria of frequency and four nursing diagnoses from home health care clinical practice. Second, content validity was examined by an expert group which considered the sign / symtoms of the fourteen nursing diagnoses. The instrument used for this was a checklist for sign / symtoms based on the nurse progress notes and literature : Carpenito(1993), Kim Cho Ja et al (1994), Lee Sun Ok et al.(1994), Kim Mae Ja et al. (1992), Seoul University Hospital (1993) , Kim Mi Ja et al. (1991). The data were collected from March 1995 to April 1995. Data were analyzed using Content Validity Incidence where if 80% or more of the expert group agreed, characteristics were defined as a major sign/symtoms, if between 50% and 79% of the expert group agreed with the characteristic it was defined as a minor sign / symtoms. The results of this study are summarized as follows : 1. Thirty-two nursing diagnoses related to patients with cerebrovascular accidents were defined. There was a high frequency for the following : 'Potential for disuse syndrome (61%)', 'Impaired physical mobility(50%)', 'Impaired skin integrity (44.4%)', Potential for aspiration(33.3%)', 'Potential for infection: respiration(33.3%)', 'Self-care deficit : bathing /hygine(27.8%)', 'Ineffective family coping(22.2%)', 'Potential for trauma(22.2%)', 'Alteration in nutrition: less than body requirements(22.2%)'. The following diagnoses were also used in home health care clinical practice : 'Anxiety in family (50%)', 'Caregiver fatigue(27.8%)', 'Ineffective treatment behavior (22.2%)', 'Ineffective Levin tube management and Levin tube feeding(22.2%)'. Fourteen nursing diagnoses were selected. 2. Ten of the nursing diagnoses for patients with cerebrovascular accident were listed as nursing diagnoses by NANDA but four nursing diagnoses were new nursing diagnoses used in home health care clinical practice. 3. Characteristics of the ten Nursing Diagnoses from NANDA were developed from the sign /symtoms in the literature and in the nurse progress notes. These characteristics was verified as major or minor sign / symtoms by the expert group. 4. Characteristics of the four nursing diagnoses used in home health care were not defined by the literature but only by the nurse progress notes and verified as major or minor signs /symtoms by the expert group. On the basis of the findings of this study, the following recommendations are made : 1. Continual study is necessary to identify other signs /symtoms not verified in this study. 2. It is necessary to use verified signs /symtoms in home health care clinical practice. 3. It is necessary to define related factors which define each diagnoses in this study. 4. It is necessary to develop of standardized nursing are plans which include defined signs and symtoms. 5. It is necessary to study the outcomes of the standardized nursing care plans.

• Journal of East-West Nursing Research
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• v.16 no.2
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• pp.147-155
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• 2010

Purpose: The purpose of this study is to identify the simulation experiences of nursing baccalaureate students in their pediatric rotation. Methods: Fifty-three students responded to open-ended questions after three sessions of pediatric simulation experiences. The practice reflection notes of the students were also analyzed to identify educational outcomes coming from nursing simulation experiences. Results: The open-ended questions and practice reflection notes showed that simulated pediatric practice provided a virtual experience within safe environment. It also increased learning motivation, clinical decision making, and overall self-confidence of the nursing students. Conclusion: The findings of this study suggest that simulation can enhance the quality of nursing education through positive clinical experiences.

• Journal of Korean Academy of Nursing
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• v.29 no.5
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• pp.1113-1122
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• 1999

The author investigated pain experiences of 90 cancer patients and the adequacy of pain treatment they have received during their stay at a large medical center in T city between October 1994 and August 1995. Pain was assessed by the Shortened BPQ and results are summarized as follows: As for ratings of “worst pain” during the 24 hour period, 70% of the patients reported they had “severe” pain. As for ratings on “pain now,” 43% of the cancer patients reported “moderate to severe” pain. Over 46% of the patients reported a pain relief score of 0(not at all) or 1(somewhat) even after receiving pain medication. Adequacy of analgesic treatment was evaluated by comparing the patient's reported level of pain and the analgesic use, namely, the pain management index(PMI). The PMI indicated that 58% of the patients were undertreated for the pain control. In review of nurse's notes. systematic pain assessment was scarcely recorded, although pain documentation appeared in 70% of the notes; and the contents were mostly simple description. In conclusion, the results of patient's pain ratings, the PMI and poor pain documentation in the nurse's notes implied poor pain assessment and management.

• Journal of the Korea Convergence Society
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• v.11 no.8
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• pp.351-360
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• 2020

This study is mixed design to measure the effects of case-based learning and the Cornell notes-taking system in human anatomy course, the basic course in nursing, on self-directed learning ability, critical thinking dispositon, and teamwork of nursing students. Among those who completed anatomy course, 34 underachieving students were targeted and surveyed before and after classes, and interviewed on case-based learning and Cornell notes-taking system. For quantitative analysis, SPSS/WIN 21.0 was used for frequency analysis, paired t-test, and Pearson's correlation coefficients. For qualitative research, content analysis was performed. The results showed significant increases in self-directed learning ability(t=-9.69, p<.001), critical thinking dispositon(t=-7.75, p<.001), and teamwork (t=-12.43, p<.001) in underachieving nursing students. In addition, there was a significant correlation between self-directed learning ability, critical thinking dispositon, and teamwork. In conclusion, case-based and Cornell notes learning methods were effective in helping underachieving students enrolled in human anatomy course. There is a need for continuous research on the use of case-based and Cornell notes in other courses.

• The Journal of Korean Academic Society of Nursing Education
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• v.24 no.2
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• pp.168-180
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• 2018

Purpose: The purpose of this study was to explore preceptees' experience among nursing students in the Clinical Nursing Practice program as integral practice. Specific aims were to identify problems students face as preceptees at a clinical practice and how they interact with preceptors and others. Methods: Grounded theory methodology was utilized. Data were collected from interactive field notes and transcribed notes with individual in-depth interview from 12 senior nursing students who had experiences as a preceptee in the Clinical Nursing Practice. Results: Through constant comparative analysis, a core category emerged as "Being refined while taking a firm stand with lack." The process of "Being refined while taking a firm stand with lack" consisted of four phases: sailing phase, adaptation phase, achievement phase and wistful returning phase. Conclusion: The findings of the study indicate that there is a need for nursing students to understand the limitations and strengths to learning experiences in preceptorship. In addition, the Clinical Nursing Practice as an integral practice program is needed to improve nursing capacity and for proper adaptation to real clinical environment among graduating students.

• Journal of Korean Academy of Nursing
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• v.36 no.2
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• pp.227-235
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• 2006

Purpose: This study aimed to: 1) determine the core nursing interventions, and 2) compare acute interventions with subacute interventions recorded in the nursing notes of patients with cerebrovascular accidents (CVA). Methods: The nursing records covering the first 10 days of 30 patients with a CVA who were admitted from January to December 2004 at C University Hospital in Korea were examined. Data was collected using the nursing interventions classification (NIC) from January to April 2005. Finally, data analysis was carried out using mean, SD, and paired t-test according to domains, classes, and interventions. Results: The most frequent nursing intervention at both stage was 'Neurologic monitoring'. There were differences in interventions belonging to the 'Physiological: complex,' 'Behavioral,' 'Safety,' and 'Health system' domains between the acute and subacute stages. The frequency of interventions belonging to the 'Immobility management,' 'Neurological management,' 'Tissue perfusion management,' 'Patient education,' 'Risk management,' 'Health system mediation,' and 'Information management' classes at the acute stage was higher compared to the subacute stage. Conclusions: This study found out that nurses relatively recorded more nursing interventions during the acute stage hence the unsuccessful documentation of the subacute stage particularly in describing the specific nursing interventions at this stage.

• Journal of Home Health Care Nursing
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• v.11 no.1
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• pp.14-22
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• 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.

• Journal of Korean Academy of Nursing
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• v.37 no.1
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• pp.114-124
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• 2007

Purpose: The purpose of this study was to describe the experiences of job satisfaction in clinical nurses. Methods: Data was collected from three focus groups composed of 17 hospital nurses. Each focus group had an interview for an average of two and a half hours with the guidance of researchers. The main question was 'how do you describe your lived experience of job satisfaction as a clinical nurse?' Qualitative data from the field notes and transcribed notes were analyzed using a grounded theory methodology developed by Strauss and Corbin. Results: The core category of experience of job satisfaction in clinical nurses was identified as 'Finding success.' Supportive interpersonal relationships and environment affected this category. In the process of attaining job satisfaction through finding success, the participants were using four interactional strategies such as giving meaning, finding self-esteem, extending the horizon of life, and strengthening self-capability. The dimensions of job satisfaction in clinical nurses were the sense of achievement, stability, and pride. Conclusion: The results of this study yields very useful information for nursing mangers to design a program which enhances job satisfaction of clinical nurses based on interactional strategies.