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간호일지와 간호사의 면담자료에 나타난 간호활동 내용의 비교분석

 Comparison of Nursing Activities Reflected in Nursing Notes and In-depth Interviews of Nurses in an Acute Hospital

Journal of Korean Academy of Nursing 2003년 33권 6호 p.802 ~ 811
KMID : 0806120030330060802
송미순/Song MS
김매자/박영숙/이은옥/하양숙/한경자/류세앙/강혜영/김경남/조문숙/Kim MJ/Park YS/Lee EO/Hah YS/Han KJ/Ryu SA/Kang HY/Kim KN/Cho MS

Abstract

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.
KeyWords
간호일지, 간호활동(Nursing notes, Nursing activities, Interview)
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SCI(E) MEDLINE 학술진흥재단(KCI) KoreaMed