Kim Mihui, Kim Yesol, Choi Mona
College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea; Department of Nursing Science, Jeonju University, Jeonju, Republic of Korea.
College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea; College of Nursing, Gyeongsang National University, Jinju, Republic of Korea.
Aust Crit Care. 2025 Mar;38(2):101126. doi: 10.1016/j.aucc.2024.09.011. Epub 2024 Nov 16.
Although prognosis prediction models using nursing documentation have good predictive performance, the experiences of intensive care unit nurses related to nursing activities and documentation when a patient's condition deteriorates are yet to be explored.
The aim of this study was to explore nurses' experiences of nursing activities and documentation in intensive care units when a patient's condition deteriorates.
This was a descriptive qualitative study using focus-group interviews with intensive care unit nurses in tertiary or university-affiliated hospitals. In total, 19 registered nurses with at least 1 year of clinical experience in the adult intensive care unit were recruited using a purposive sampling method. Five focus-group interviews were conducted, and the data were analysed through a qualitative content analysis.
Intensive care unit nurses' experiences with patient deterioration were classified into four main categories-perceived patient deterioration; endeavours to verify nurses' concerns; nursing activities to improve a patient's condition; and optimising documentation practices-which comprised 12 subcategories. Intensive care unit nurses recognise patient deterioration through nursing activities and documentation, and the two processes influence each other. However, nursing activities related to nurses' concerns were mainly handed over verbally rather than documented due to the inflexibility of the available standardised forms and the potential uncertainty of those concerns.
The findings reveal how intensive care unit nurses perceive, intervene, and document the condition of a deteriorating patient. Nurses' concerns may be the first sign of a patient's deteriorating condition and are therefore crucial for minimising patient risk. Therefore, efforts to systematically document nurses' concerns may contribute to improving patient outcomes.
尽管使用护理记录的预后预测模型具有良好的预测性能，但重症监护病房护士在患者病情恶化时与护理活动和记录相关的经历仍有待探索。
本研究旨在探讨重症监护病房护士在患者病情恶化时的护理活动和记录经历。
这是一项描述性定性研究，采用焦点小组访谈法对三级医院或大学附属医院的重症监护病房护士进行调查。采用目的抽样法，共招募了19名在成人重症监护病房至少有1年临床经验的注册护士。进行了5次焦点小组访谈，并通过定性内容分析法对数据进行了分析。
重症监护病房护士对患者病情恶化的经历分为四个主要类别——感知到的患者病情恶化；努力核实护士的担忧；改善患者病情的护理活动；以及优化记录做法——其中包括12个子类别。重症监护病房护士通过护理活动和记录来识别患者病情恶化，这两个过程相互影响。然而，由于现有标准化表格的灵活性不足以及这些担忧的潜在不确定性，与护士担忧相关的护理活动主要通过口头交接而非记录下来。
研究结果揭示了重症监护病房护士如何感知、干预和记录病情恶化患者的状况。护士的担忧可能是患者病情恶化的第一个迹象，因此对于将患者风险降至最低至关重要。因此，系统记录护士担忧的努力可能有助于改善患者预后。
