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电子健康记录能力在研究生护士中的应用:扎根理论研究。

Electronic health record competency in graduate nurses: A grounded theory study.

机构信息

University at Buffalo, graduated Fall 22, Saint John Fisher University, School of Nursing, Director of Experiential Learning, 3690 East Ave, Rochester, NY 14618, United States of America.

University at Buffalo, State University of New York, 323 Baldy Hall, Buffalo, NY 14260-1020, United States of America.

出版信息

Nurse Educ Today. 2024 Jan;132:105987. doi: 10.1016/j.nedt.2023.105987. Epub 2023 Oct 11.

Abstract

BACKGROUND

The use of electronic health records is ubiquitous in healthcare settings, yet newly graduated nurses struggle with developing electronic health record competency prior to entry into nursing practice. Insufficient electronic health record knowledge, skills, and attitudes among newly graduated nurses are contributing to patient harm, clinical burn-out, and unsafe practices. In this study, we interviewed electronic health record educators to identify how newly graduated nurses develop electronic health record competency characteristics and to learn about their educational approaches for teaching electronic health record proficiency.

METHOD

This study used a constructive grounded theory approach to develop a theoretical model to make sense of electronic health record educators' experiences working with newly graduated nurses during electronic health record education and training sessions.

FINDINGS

Electronic health record educators found that in the newly graduated nurse population, practicing builds competency in electronic health record knowledge, skills, and attitudes. The research revealed that it is the combination of teaching through modeling, working hard as a new graduate, and understanding charting to standards requirements that impacts the development of electronic health record competency characteristics.

CONCLUSION

Electronic health record competency characteristics are developed when an educator is modeling documentation knowledge, skills, and attitudes, the newly graduated nurse is working hard to learn, and there is clarity by nursing leadership related to charting to standards requirements. It is the success or failure in these core areas that impacts a newly graduated nurse's ability to achieve electronic health record competency. A level of competency and proficiency in electronic health record is required to provide care that is safe and patient centered.

摘要

背景

电子健康记录在医疗保健环境中无处不在,但新毕业的护士在进入护理实践之前,在发展电子健康记录能力方面存在困难。新毕业护士电子健康记录知识、技能和态度不足,导致患者受到伤害、临床倦怠和不安全的操作。在这项研究中,我们采访了电子健康记录教育者,以确定新毕业护士如何发展电子健康记录能力特征,并了解他们教授电子健康记录熟练程度的教育方法。

方法

本研究采用建构主义扎根理论方法,构建了一个理论模型,以理解电子健康记录教育者在电子健康记录教育和培训期间与新毕业护士合作的经验。

结果

电子健康记录教育者发现,在新毕业护士群体中,实践可以建立电子健康记录知识、技能和态度的能力。研究表明,通过模拟教学、作为新毕业生努力工作以及理解图表到标准要求,这三个因素的结合,影响了电子健康记录能力特征的发展。

结论

当教育者对记录知识、技能和态度进行示范,新毕业护士努力学习,护理领导层对图表到标准要求有明确的要求时,电子健康记录能力特征就会得到发展。这些核心领域的成功或失败,会影响新毕业护士实现电子健康记录能力的能力。需要具备一定水平的电子健康记录能力和熟练度,才能提供安全和以患者为中心的护理。

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