Daskein Robyn, Moyle Wendy, Creedy Debra
Research Centre for Clinical and Community Practice Innovation, Griffith University, Nathan, Brisbane, Qld, Australia.
J Clin Nurs. 2009 Jul;18(14):2087-95. doi: 10.1111/j.1365-2702.2008.02670.x. Epub 2009 Apr 3.
This study investigated registered nurses' knowledge of documentation used in aged-care nursing home facilities in Queensland, Australia.
The purpose of nursing documentation is to communicate health information, facilitate quality assurance and research, demonstrate nurses' accountability and, within Australia, to support funding of residents' care. Little is known about the relationship between RNs' knowledge of nursing documentation, the documentation process within residential aged care and the outcomes of the documentation.
Cross-sectional, retrospective design.
The study was conducted with a large sample of RNs (n = 360) located in 162 Queensland aged-care facilities. Participants completed a postage-return questionnaire in which they identified factors that influence their knowledge and understanding of documentation.
Participants reported that they have considerable knowledge of nursing documentation. They also indicated that they were most knowledgeable about policies on documentation and writing discharge instructions. However, their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading reports each shift.
The modified version of Edelstein's questionnaire provided a valid and reliable instrument for measuring RNs' knowledge of nursing documentation. A factor analysis of the 16 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in aged-care facilities have high levels of knowledge about documentation. Specific recommendations relate to the implementation of comprehensive documentation education programs that reflect the needs of organisations and the level of RNs' skills and knowledge concerning documentation.
Accurate nursing documentation is relevant to residents' care outcomes and to government funding allocations. Measuring RNs' knowledge of nursing documentation can identify factors that impede and facilitate their documentation of care.
本研究调查了澳大利亚昆士兰州老年护理院设施中注册护士对护理文件记录的知识掌握情况。
护理文件记录的目的是传达健康信息、促进质量保证和研究、证明护士的责任，并且在澳大利亚，支持居民护理的资金投入。关于注册护士对护理文件记录的知识、老年护理机构内的文件记录过程以及文件记录的结果之间的关系，人们了解甚少。
横断面回顾性设计。
该研究对昆士兰州162家老年护理机构中的大量注册护士（n = 360）进行。参与者完成了一份回邮问卷，在问卷中他们确定了影响其对文件记录的知识和理解的因素。
参与者报告称他们对护理文件记录有相当多的了解。他们还表示，他们对文件记录政策和撰写出院指导最为了解。然而，他们对护理评估的知识排名第五，对每班阅读报告的了解最少。
埃德尔斯坦问卷的修改版为测量注册护士对护理文件记录的知识提供了一种有效且可靠的工具。知识量表中16个条目的因素分析显示出极佳的信度。数据表明，老年护理机构中的注册护士对文件记录有较高水平的了解。具体建议涉及实施全面的文件记录教育计划，该计划应反映组织的需求以及注册护士关于文件记录的技能和知识水平。
准确的护理文件记录与居民的护理结果和政府资金分配相关。测量注册护士对护理文件记录的知识可以识别阻碍和促进他们护理文件记录的因素。
