河南省表格式护理文书书写用时现状及影响因素分析  

Status quo and influencing factors of writing time of nursing forms in Henan province

作　　者：时红梅 陈翠屏 王园园 张国增[3] Shi Hongmei;Chen Cuiping;Wang Yuanyuan;Zhang Guozeng(Department of Nursing,the First Affiliated Hospital of Henan University,Kaifeng 475001,China;Henan University Minsheng College,Kaifeng 475000,China;Nursing and Health Research Institute,Henan University,Kaifeng 475000,China)

机构地区：[1]河南大学第一附属医院护理部,开封475001 [2]河南大学民生学院,开封475000 [3]河南大学护理与健康研究所,开封475000

出　　处：《中华现代护理杂志》2020年第12期1555-1561,共7页Chinese Journal of Modern Nursing

基　　金：河南省医学科技攻关计划项目(201702135);河南省高等学校重点科研项目(19B330001)。

摘　　要：目的了解河南省表格式护理文书书写用时现状并分析其影响因素,旨在减轻护士护理文书书写负担,提高书写效率。方法本研究为横断面研究,采用方便抽样法,于2017年6-9月对河南省18家医院的护士进行问卷调查。利用自行设计的一般资料调查表和表格式护理文书书写调查问卷进行调查,采用单因素分析和Logistic回归分析护理文书书写用时影响因素。共发放问卷3586份,回收有效问卷3387份,有效回收率为94.5%。结果3387名护士中,37.8%(1280/3387)的护士每天书写护理文书的时间在1~2 h,>2 h的占25.9%(877/3387)。书写一份入院护理文书用时6~10 min的最多,占28.3%(960/3387)。单因素分析显示,护士的年龄、护龄、职称和入院护理文书书写时间以及医院级别、医院性质、科室、开放床位数、护士分管床位数、科室每天新入患者影响护理文书书写时间(χ^2值分别为27.837、40.289、49.562、442.159、9.378、23.742、165.649、48.927、328.491、55.941;P<0.05)。Logistic回归分析显示科室、护士分管床位数和入院护理文书书写时间是影响护理文书书写用时的主要因素(P<0.05)。结论河南省表格式护理文书书写用时较长,护理文书书写内容较多是造成护士耗时较长的主要原因。为了有效降低护士间接护理时间,增加患者的直接护理时间,建议在符合国家要求的基础上适当简化入院护理文书书写内容,将入院护理文书中有些条目分解到后续护理文书中。Objective To explore the status quo and influencing factors of the time spent in writing nursing forms in Henan province,in order to reduce the burden of writing nursing documents and improve the writing efficiency.Methods In this cross-sectional study,nurses from 18 hospitals in Henan province were selected by convenient sampling for a questionnaire survey between June and September 2017.They were investigated with the self-designed general information questionnaire and nursing document writing questionnaire.Univariate analysis and Logistic regression analysis were used to analyze the influencing factors of the time spent in writing nursing documents.Totally 3586 questionnaires were distributed,and 3387 valid ones were recovered,with an effective recovery rate of 94.5%.Results In the 3387 nurses,37.8%(1280/3387)wrote nursing documents for 1 to 2 hours every day,and 25.9%(877/3387)did so for>2 hours.The proportion of nurses writing an admission nursing document in 6-10 minutes was the highest,accounting for 28.3%(960/3387).Univariate analysis showed that age,nursing year,job title,time of writing an admission nursing document,hospital level,nature of hospitals,departments,number of open beds,number of beds managed by nurses,and the number of newly admitted patients in the department affected the time of writing nursing documents(χ^2=27.837,40.289,49.562,442.159,9.378,23.742,165.649,48.927,328.491,55.941;P<0.05).Logistic regression analysis revealed that departments,number of beds managed by nurses,and the time spent in writing an admission nursing document were the main factors affecting the time spent in writing nursing documents(P<0.05).Conclusions It takes a long time to write the nursing documents in Henan province.The considerable content of nursing documents is the main reason for the longer writing time.In order to effectively reduce the indirect nursing time of nurses and increase the direct nursing time for patients,it is recommended to appropriately simplify the content of admission nursing documents o

关 键 词：护士 护理文书 书写时间 影响因素 

分 类 号：R47[医药卫生—护理学]