行动研究法在提高护理文书质量中的应用效果评价  

Application effect evaluation of action research method in improving the quality of nursing documentation

作　　者：聂伟琳 方弘 蓝晓英 陈舒萍 陈佩兰 廖美兰 戴流芳 NIE Weilin;FANG Hong;LAN Xiaoying;CHEN Shuping;CHEN Peilan;LIAO Meilan;DAI Liufang(The First Heart Ward,Department of Cardiology,Xiamen Cardiovascular Hospital of Xiamen University,School of Medicine,Xiamen University,Xiamen,China,Fujian Province,Xiamen361006,China)

机构地区：[1]厦门大学附属心血管病医院心内一病区,福建厦门361006

出　　处：《中国当代医药》2022年第12期140-143,共4页China Modern Medicine

摘　　要：目的采用行动研究法解决护理文书书写问题,优化护理文书质控流程,提高护理文书书写质量。方法选取2020年6月至2021年6月厦门大学附属心血管病医院心内一病区的27名护士作为研究对象,采用行动研究法,通过3轮计划、行动、观察和反思不断与护士探索影响护理文书书写质量的原因,逐步改进并完善护理文书书写及质控流程中存在的问题。比较行动研究前(2020年6月)、第1轮行动研究后(2020年10月)及第3轮行动研究后(2021年6月)护理文书质控总分及体温单、评估单、护理记录单质控分数。结果第3轮行动研究后护理文书质控总分,体温单、评估单、护理记录单质控分数均高于行动研究前和第一轮行动研究后,差异有统计学意义(P<0.01)。结论行动研究法具有解决问题、促进变革的优势,基于行动研究的文书质量整改和质控流程再造,提高了护理文书质量,值得推广。Objective To solve the problem of nursing document writing by action research method,optimize the quality control process of nursing document,and improve the quality of nursing document writing.Methods From June 2020 to June 2021,27 nurses in The First Heart Ward of Department of Cardiology,Xiamen Cardiovascular Hospital of Xiamen University were selected as the research subjects.The action research method was used to continuously explore with nurses to influence the writing of nursing documents through three rounds of planning,action,observation and reflection.The total score of nursing document quality control and the score of temperature sheet,evaluation sheet and nursing record sheet were compared before the action study(June 2020),after the first round of action study(October 2020)and after the third round of action study(June 2021).Results After the third round of action research,the total scores and the scores of nursing documents,temperature charts,assessment sheets,and nursing record sheets were higher than those before and after the first round of action research,and the differences were statistically significant(P<0.01).Conclusion The action research method has the advantages of solving problems and promoting changes.The nursing documentation quality improved by action research,it is worthy promoting.

关 键 词：护理文书 质量控制 护理记录质量 行动研究 电子护理记录 

分 类 号：R473[医药卫生—护理学]