Wimmer Elke Irlinger, Glaus Agnes, Spreeuwenberg Cor
WE'G Hochschule Gesundheit, Careum Institut Zürich.
Pflege. 2008 Aug;21(4):215-23. doi: 10.1024/1012-5302.21.4.215.
In order to explore the status quo of the assessment of nursing care needs in newly admitted inpatients on oncology wards a survey in a German university hospital was carried out. Research questions included: Do the nurses collect data regarding nursing care needs of admitted cancer patients? When are the data collected? What data are collected? What is documented, when is it documented, and is the patient involved in the documentation? What, if any, factors on the part of nurses have an impact on the way in which these data are collected? Two methods were used to collect research data: nursing documents of hospitalised cancer patients were analysed (n = 68), followed by an interview with the nurses (n = 81). Beforehand, an instrument was developed and tested for both investigative methods. The main result was: the nurses' perception of the needs' assessment was incongruent with data in the patients' documentation files. The study showed that nurses consider their documentation of nursing care needs to be more comprehensive with regard to the time and content/areas of documentation than it actually is. With regard to the psychological, social, and spiritual care needs, for example, this means: in the nurses' own opinion, they had taken into account these needs far more strongly than they actually had. According to the analysis of the care documents, patients were involved in the documentation in 15% of the cases. According to the nurses, general communication skills, the use of assessment instruments, and the standardisation of the documentation need to be improved. The review of international literature confirms the deficiency recorded by this survey. The oncology patients' perspective should be included more strongly in the assessment of nursing care needs. In this way, individual nursing care needs are assumed to be understood more appropriately. Self-assessment instruments could be a suitable resource in this context. The instruments have to be introduced by education, and their validity, reliability, practical relevancy, and applicability need to be checked continuously.
为了探究肿瘤病房新入院患者护理需求评估的现状，在一家德国大学医院开展了一项调查。研究问题包括：护士是否收集入院癌症患者护理需求的数据？何时收集数据？收集哪些数据？记录了什么、何时记录，以及患者是否参与记录？护士方面的哪些因素会对这些数据的收集方式产生影响？采用两种方法收集研究数据：分析住院癌症患者的护理文件（n = 68），随后对护士进行访谈（n = 81）。事先，针对这两种调查方法开发并测试了一种工具。主要结果是：护士对需求评估的认知与患者文件记录中的数据不一致。该研究表明，护士认为他们对护理需求的记录在记录时间和内容/领域方面比实际情况更全面。例如，在心理、社会和精神护理需求方面，这意味着：在护士自己看来，他们对这些需求的考虑远比实际情况强烈得多。根据护理文件分析，15%的病例中患者参与了记录。护士认为，一般沟通技巧、评估工具的使用以及记录的标准化需要改进。对国际文献的综述证实了本次调查所记录的不足之处。在护理需求评估中应更加强调肿瘤患者的观点。通过这种方式，有望更恰当地理解个体护理需求。在这种情况下，自我评估工具可能是一种合适的资源。这些工具必须通过教育引入，并且需要持续检查其有效性、可靠性、实际相关性和适用性。
