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Title:Kakovost negovalne dokumentacije z vidika osredotočenosti na osebo in vpeljave elektronskega zdravstvenega zapisa
Authors:ID Klančnik Gruden, Maja (Author)
ID Štiglic, Gregor (Mentor) More about this mentor... New window
ID Pajnkihar, Majda (Comentor)
ID Kenda, Rajko (Comentor)
Files:.pdf DOK_Klancnik_Gruden_Maja_2024.pdf (5,73 MB)
MD5: B419F174C7397596444D0182F458CD6B
 
Language:Slovenian
Work type:Doctoral dissertation
Typology:2.08 - Doctoral Dissertation
Organization:FZV - Faculty of Health Sciences
Abstract:Uvod: Dokumentacija zdravstvene nege podpira medicinske sestre pri sprejemanju kliničnih odločitev, zato je pomembno, da je kakovostna in ustreza strokovnim zahtevam ter odseva načela osredotočenosti na osebo, česar raziskave ne potrjujejo. Uvedba elektronskega zapisa zdravstvene nege (EZZN) kaže pozitivne učinke, ki niso enoznačni in zanesljivi. Namen doktorske disertacije je izdelati predlog izboljšav obstoječega kliničnega informacijskega sistema zdravstvene nege, ki bi medicinske sestre spodbujal k izvajanju bolj na osebo osredotočene zdravstvene nege. Metode: Raziskava je temeljila na paradigmi pragmatizma in uporabi mešanih metode. Kot raziskovalni pristop je bilo uporabljeno akcijsko raziskovanje. Izveden je bil en cikel, ki je potekal v petih korakih: identifikacija problema, načrtovanje, intervencija, evalvacija in integracija.V okviru identifikacije problema sta bili konvergentno izvedeni kvantitativna in kvalitativna raziskava. V kvantitativno raziskavo je bilo vključenih 207 dokumentacij otrok z akutno okužbo spodnjih dihal s treh oddelkov. Izvedena je bila opazovalna presečna raziskava s pomočjo merskega instrumenta Q-DIO. V kvalitativno raziskavo je bilo vključenih 60 dokumentacij otrok, ki so bili zbrani s pomočjo kategorizacijske matrike, izdelane na osnovi teorije Na osebo osredotočena zdravstvena nega ter analizirani po metodi direktivne analize vsebine. V fazi intervencije je bila izvedena učna delavnica, priprava pa v fazi načrtovanja. Učne delavnice se je udeležilo 47 članov tima zdravstvene nege iz oddelka, kjer so uporabljali EZZN. Ti so bili v fazi evalvacije povabljeni k sodelovanju v drugi kvalitativni raziskavi, izvedeni s pomočjo fokusnih skupin. Teh se je udeležilo 28 oseb. Zbrani podatki so bili analizirani s pomočjo orodja tematska mreža. V zadnji fazi so bili za izdelavo priporočil integrirani rezultati raziskav, analiza literature in načela teorije Na osebo osredotočena zdravstvena nega. Rezultati: Kakovost zapisov zdravstvene nege je bila pomembno višja na oddelku, kjer so uporabljali EZZN in standardiziran jezik za poimenovanje negovalnih diagnoz (p < 0,05). Najbolje so bile podprte faze procesa zdravstvene nege: izvajanje (100 %), postavljanje negovalnih diagnoz (98 %) in ocenjevanje (87 %); najslabše je bilo podprto načrtovanje (51 %). Frekvenca in raznolikost pojavljanja negovalnih diagnoz sta bili največji v fiziološki in psihološki dimenziji, pri tem je imel oddelek, ki je uporabljal EZZN in standardiziran jezik, največjo raznolikost v vseh treh dimenzijah, kjer so se diagnoze pojavljale. Pri kvalitativni analizi zapisov zdravstvene nege je bilo ugotovljeno, da ti le delno pokrivajo pet procesov osredotočenosti na osebo. Na podlagi kvalitativne analize zapisov intervjujev fokusnih skupin sta bili oblikovani dve tematski mreži: uporabnost kliničnega informacijskega sistema zdravstvene nege in na osebo osredotočeni zapisi zdravstvene nege. Razprava in sklep: Dokumentacija zdravstvene nege je pomembno orodje pri odločanju medicinskih sester. Zagotavljanje in preverjanje njene kakovosti s standardiziranimi orodji sta zato pomembni. Uporaba elektronske dokumentacije prispeva k večji kakovosti in bolj celostni obravnavi, vendar še ni zagotovilo kakovosti. Na osnovi integracije rezultatov raziskave, analize literature in teorije Na osebo osredotočena zdravstvena nega je bilo izpostavljenih pet tematskih sklopov: kompetence uporabnikov, podporno okolje, uporabniku prijazen in na procesu zdravstvene nege zasnovan informacijski sistem, pristno delovanje in izidi zdravstvene nege.
Keywords:na osebo osredotočena zdravstvena nega, elektronski zapis zdravstvene nege, klinični informacijski sistem zdravstvene nege, akutna bolnišnična obravnava
Place of publishing:Maribor
Publisher:[M. Klančnik Gruden]
Year of publishing:2024
PID:20.500.12556/DKUM-85966 New window
UDC:616-083:659.2:004(043.3)
COBISS.SI-ID:194869763 New window
Publication date in DKUM:09.05.2024
Views:160
Downloads:22
Metadata:XML RDF-CHPDL DC-XML DC-RDF
Categories:FZV
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Licences

License:CC BY-NC-ND 4.0, Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Link:http://creativecommons.org/licenses/by-nc-nd/4.0/
Description:The most restrictive Creative Commons license. This only allows people to download and share the work for no commercial gain and for no other purposes.
Licensing start date:22.09.2023

Secondary language

Language:English
Title:Quality of nursing documentation from the aspect of person-centredness and introduction of electronic health record
Abstract:Introduction: Quality of nursing documentation is important, because it supports nurses in clinical decision-making. It is also important that it meets professional requirements and reflects person-centred principles. The literature does not support these requirements. The introduction of the electronic nursing record (ENR) has shown positive effects, but these are not uniform and reliable. The aim of the doctoral thesis is to propose improvements to the existing clinical nursing information system that would encourage nurses to provide more person-centred care. Methods: The research was based on the paradigm of pragmatism and the use of mixed methods. Action research was used as the research approach. One cycle was carried out in five steps: problem identification, planning, intervention, evaluation, and integration. In the context of problem identification, quantitative and qualitative research were carried out in a convergent design. The sample for the quantitative study consisted of 207 records of children with acute lower respiratory tract infection from three wards. An observational cross-sectional study was conducted using the Q-DIO measurement instrument. The sample for the qualitative study consisted of 60 records of children, which were collected using a categorisation matrix based on the Person-Centred Nursing Framework. The data were analysed using the directed qualitative content analysis. During the intervention phase, a workshop was conducted that had been prepared during the planning phase. The workshop was attended by 47 members of the nursing team from the ward where the ENR was used. Twenty-eight people took part in focus group interviews during the evaluation phase. The data collected were analysed using an analytic tool called thematic networks. In the final phase, the research findings, the literature analysis and the principles of the Person-Centred Nursing Framework were integrated to make recommendations. Results: The quality of nursing records was significantly higher in the ward where ENRs and standardised language for nursing diagnoses were used (p < 0.05). Implementation (100%), nursing diagnosis (98%) and assessment (87%) were the best supported phases of the nursing process in the documentation; the worst was planning (51%). The frequency and the variety of nursing diagnoses were the highest in the physiological and psychological dimensions. The ward that was using the ENR and standardised nursing language had the highest variety in all three dimensions where diagnoses occurred. The qualitative analysis of the nursing documentation found that person-centred processes were only partially captured in the documentation. Based on the qualitative analysis of the focus group interview transcripts, two thematic networks were summarised: the usability of the clinical nursing information system and person-centred nursing records. Discussion and conclusion: Nursing documentation is an important tool that supports nurses' decision-making. Ensuring and verifying its quality with standardised tools is therefore important. The use of electronic documentation contributes to higher quality and more integrated care, but is not a guarantee of quality. Based on the integration of the survey results, the literature analysis, and the Person-Centred Nursing Framework, five themes were summarised: user prerequisites, supportive environment, user-friendly and nursing process-based information system, authentic engagement, and nursing outcomes.
Keywords:person-centred nursing, electronic nursing record, clinical information system in nursing, acute care setting


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