对护士医嘱执行记录知识、态度、行为的调查分析

Investigation on Knowledge, Attitude, and Practice of Nursing Records in Their Executing of Medical Orders

目的了解护士对书写医嘱执行记录规范要求所持态度、行为及相关知识掌握情况,为护理管理者实施有效管理提供依据。方法采用自行设计的问卷,随机对本院不同学历、职称、工作年限的100名护士进行问卷调查。结果①知识得分最高,态度得分次之,行为得分最低,形成知与行相互分离的特点;②不同学历、职称护士在知识、态度得分上有显著性差异;而行为得分无显著性差异;③不同工作年限的护士在知识得分上有显著性差异,而在态度、行为得分上无显著性差异。④护士医嘱执行记录行为不符合规范要求发生率高。结论护士在医嘱执行记录问题上知而不信,信而不行,不利于履行举证责任的法定义务。提示护理管理者应及时采取措施,使护士医嘱执行记录真正成为法律的依据和提高护理质量的有效资源。

Objective To identify the knowledge, attitude, and practice about nursing records when nurses execute the medical orders and to provide the basic information for nursing managers. Methods Self- developed questionnaire was applied; the subjects were 100 different leveled nursing staffs in our hospital. Results Findings of KAP investigation showed that the score about knowledge was the highest among them; but the attitude and the lowest score were related to the practice. The disparted character between knowledge and behaviors is obvious. The indicators of knowledge and attitude had significant differences among the nurses with different education levels and professional title levels, but practices were the same among them. Nurses with longer working experience had higher scores in knowledge and showed significant difference, but had no significant difference in attitude and practice among them. Most nurses had their practices not met the requirements of the standard. Conclusions The nurses know the knowledge about the records, but not to believe and not to adopt in practice, these are problems in carrying out their duties for providing evidence in medical dispute. Therefore, it is suggested that the nursing managers should take active countermeasures to enhance quality of records of executing medical orders and protect clients and nurses; and good use of information of nursing documents also promotes nursing quality.