School of Information Sciences, University of Tampere, Finland.
Int J Med Inform. 2012 Aug;81(8):507-20. doi: 10.1016/j.ijmedinf.2012.02.003. Epub 2012 Mar 3.
To evaluate the feasibility of the national nursing model and usability of four widely used nursing documentation systems and to study their usefulness in multi-professional collaboration and information exchange.
Qualitative usability study methods were used, including the use of scenario walkthroughs, contextual inquiries, thematic interviews and inspection-based expert reviews in the users' clinical contexts.
The nursing process model was shown to be feasible in nursing practice but the national nursing classification was considered too detailed, multi-layered and difficult to use and understand. The four evaluated nursing documentation systems had many usability problems which resulted in them being difficult to use and produced extra documentation workload. Generally, electronic nursing documentation improves patients' and health professionals' legal protection and makes nursing care more transparent; however, the documentation systems did not provide good support for multi-professional care and information exchange.
Nursing models should comply better with nursing practices and support nurses in patient care and interventions. An essential improvement in practice would be the use of specific templates that are easy to apply in specific situations with homogeneous patient groups. Collaborative care aspects and better utilization of information require that the nursing model is designed to support not just documentation but also information utilization.
评估国家护理模式的可行性和四种广泛使用的护理文件系统的可用性，并研究它们在多专业协作和信息交换中的作用。
采用定性可用性研究方法，包括在用户的临床环境中使用场景遍历、情境查询、主题访谈和基于检查的专家审查。
护理过程模型在护理实践中被证明是可行的，但国家护理分类被认为过于详细、多层次且难以使用和理解。评估的四种护理文件系统存在许多可用性问题，导致难以使用并增加了文件工作量。总的来说，电子护理文件提高了患者和卫生专业人员的法律保护，并使护理更加透明；然而，这些文件系统并没有为多专业护理和信息交换提供良好的支持。
护理模型应更好地符合护理实践，并支持护士进行患者护理和干预。在实践中进行的一项重要改进是使用特定模板，这些模板在同质患者群体的特定情况下易于应用。协作护理方面和更好地利用信息需要设计护理模型不仅支持文件记录，还支持信息利用。
