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[通过电子护理文档系统(UEPD)支持护理程序——一种工具的初步验证]

[Support of the nursing process through electronic nursing documentation systems (UEPD) – Initial validation of an instrument].

作者信息

Hediger Hannele, Müller-Staub Maria, Petry Heidi

机构信息

1 Zürcher Hochschule für Angewandte Wissenschaften, Schweiz.

2 Pflege PBS, Wil, Schweiz.

出版信息

Pflege. 2016;29(3):125-35. doi: 10.1024/1012-5302/a000484.

Abstract

BACKGROUND

Electronic nursing documentation systems, with standardized nursing terminology, are IT-based systems for recording the nursing processes. These systems have the potential to improve the documentation of the nursing process and to support nurses in care delivery.

AIM

This article describes the development and initial validation of an instrument (known by its German acronym UEPD) to measure the subjectively-perceived benefits of an electronic nursing documentation system in care delivery.

METHOD

The validity of the UEPD was examined by means of an evaluation study carried out in an acute care hospital (n = 94 nurses) in German-speaking Switzerland. Construct validity was analyzed by principal components analysis.

RESULTS

Initial references of validity of the UEPD could be verified. The analysis showed a stable four factor model (FS = 0.89) scoring in 25 items. All factors loaded ≥ 0.50 and the scales demonstrated high internal consistency (Cronbach's α = 0.73 – 0.90). Principal component analysis revealed four dimensions of support: establishing nursing diagnosis and goals; recording a case history/an assessment and documenting the nursing process; implementation and evaluation as well as information exchange.

CONCLUSIONS

Further testing with larger control samples and with different electronic documentation systems are needed. Another potential direction would be to employ the UEPD in a comparison of various electronic documentation systems.

摘要

背景

电子护理文档系统采用标准化护理术语,是基于信息技术的护理过程记录系统。这些系统有潜力改善护理过程的文档记录,并在护理提供过程中支持护士工作。

目的

本文描述了一种工具(其德文缩写为UEPD)的开发及初步验证,该工具用于衡量电子护理文档系统在护理提供过程中主观感知到的益处。

方法

通过在瑞士德语区一家急症医院(n = 94名护士)开展的一项评估研究,检验UEPD的有效性。通过主成分分析来分析结构效度。

结果

UEPD有效性的初步参考得以验证。分析显示出一个稳定的四因素模型(FS = 0.89),包含25个项目的评分。所有因素的载荷≥ 0.50,各量表显示出较高的内部一致性(克朗巴哈α系数 = 0.73 - 0.90)。主成分分析揭示了支持的四个维度:确立护理诊断和目标;记录病史/进行评估以及记录护理过程;实施与评估以及信息交流。

结论

需要使用更大的对照样本并结合不同的电子文档系统进行进一步测试。另一个潜在方向是在各种电子文档系统的比较中使用UEPD。

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