Dahm Marie Fogelberg, Wadensten Barbro
Project and Development Department, Uppsala University Hospital, Uppsala, Sweden.
J Clin Nurs. 2008 Aug;17(16):2137-45. doi: 10.1111/j.1365-2702.2008.02377.x.
The aim of the present study was to investigate nurses' opinions about using standardised care plans in electronic health record and quality standards for clinical practice.
Following introduction of an electronic health record, use of standardised care plans and quality standards has increased among nurses at two hospitals in Sweden. Understanding nurses' opinions is important to continued development in this area. There are few previous studies on nurses' opinions about standardised care plans.
Survey.
The study was quantitative, descriptive and based on a questionnaire. The questionnaire included items on nurses' knowledge of and opinions about standardised care plans and quality standards.
The majority of the nurses were of the opinion that standardised care plans increase their ability to provide the same high-quality basic care for all patients. They also thought that a common standardised care plan across several professions would improve conditions for provision of high-quality care. The majority of the nurses also felt that the quality standards are a prerequisite of maintaining standardised care plans of high quality. There was no consensus on whether standardised care plans increase the risk of failing to notice patients' individual problems. Most agreed that standardised care plans decrease documentation time as well as redundant documentation. The study showed that training is needed to teach nurses how to use standardised care plans in care provision.
The nurses in the study had positive attitudes towards use of standardised care plans and felt that they could facilitate nursing practice.
Use of standardised care plans can improve nursing documentation and facilitate work for nurses. Moreover, it can support nurses in their use of evidence-based nursing methods. The present study shows that nurses have positive attitudes, which could facilitate continued use of standardised care plans.
本研究旨在调查护士对于在电子健康记录中使用标准化护理计划以及临床实践质量标准的看法。
在引入电子健康记录后，瑞典两家医院的护士对标准化护理计划和质量标准的使用有所增加。了解护士的看法对于该领域的持续发展很重要。此前关于护士对标准化护理计划看法的研究较少。
调查。
本研究为定量、描述性研究，基于一份问卷。问卷包括关于护士对标准化护理计划和质量标准的知识及看法的项目。
大多数护士认为标准化护理计划提高了他们为所有患者提供同等高质量基础护理的能力。他们还认为跨多个专业的通用标准化护理计划将改善提供高质量护理的条件。大多数护士也觉得质量标准是维持高质量标准化护理计划的先决条件。对于标准化护理计划是否会增加忽视患者个体问题的风险，没有达成共识。大多数人同意标准化护理计划减少了记录时间以及重复记录。研究表明需要进行培训，以教导护士如何在护理工作中使用标准化护理计划。
研究中的护士对使用标准化护理计划持积极态度，并认为它们可以促进护理实践。
使用标准化护理计划可以改善护理记录，方便护士工作。此外，它可以支持护士使用循证护理方法。本研究表明护士持积极态度，这可能有助于标准化护理计划的持续使用。
