일 지역 병원간호사의 안전간호활동과 간호기록 수행도

Abstract

The purpose of this study was to identify the relationship between safety care activity and charting performance among nurses working in hospitals and to provide basic data for the development of hospital policy for charting performance. By using a self reported questionnaire, data were collected from 225 nurses who worked in general hospitals in Jeju province from November, 2015. The questionnaire consists of safety care activities on a 5-point Likert scale, Of the 225 nurses who had received the questionnaire, 212(94%) responded. Collected data were analyzed using frequencies, means, T-test, ANOVA with SAS WIN 9.2 program version. The results of the study were as follows:

1. The mean score of safety activity care was 4.22. Among sub-factors of safety activity care, blood transfusion related safety care was highest followed by patient transfer related safety care, adult assessment tool, identification of patient related safety care, medication related safety care, bed sore related safety care, pain related safety care, communication related safety care.

2. The mean score of nursing documentation was 4.10. Among sub-factors of practice in nursing documentation was the highest followed by blood transfusion ,adult assessment tool, identification of patient, fall assessment, nursing intervention, bed sore, medication, communication, discharge summary, infection, pain, nursing process, standardized terminology to the nursing documentation.

3. Level of safety care activity was significantly different by age, year of employment in present hospital, type of hospital of nurses.

4. Level of documentation performance was significantly different by age, year of employment in present hospital, type of hospital, working department, nursing delivery system, experience of charting education, monitoring committee in the nursing division, monitoring committee in the ward.