重症监护病房护理记录质量影响因素研究

The influencing factors on the quality of nursing records in ICU

目的探讨影响重症监护病房(ICU)护理记录质量的因素,为ICU的护理文件管理提供参考。方法纳入2019年3~6月ICU护理记录200例作为研究对象,将其按照质量不同分为合格组174例与不合格组26例。比较2组人员因素、管理因素以及环境因素,并进行Logistic回归分析。结果合格组护士主观能动性高、年资≥5年、工作能力优人数占比均高于不合格组,而患者病情复杂人数占比低于不合格组(P<0.05)。合格组护理记录标准制定、护理记录质控力度大、护理记录与护士评价奖罚相关占比显著高于不合格组,而医辅人员配置不足占比低于不合格组(P<0.05)。合格组工作时间≥10 h/d、护理信息设备及系统障碍、媒体不良舆论占比均高于不合格组(P<0.05)。经Logistic回归分析可得:护士主观能动性低、护士年资<5年、护士工作能力差、患者病情复杂、护理记录质控力度小、护理记录与护士评价奖罚不相关、医辅人员配置不足、工作时间≥10 h/d、护理信息设备及系统障碍、媒体不良舆论均是ICU护理记录质量的独立危险因素(均P<0.05)。结论ICU进行护理记录的质量管理时,应综合考虑各方面因素,通过多方面努力,提高其质量。

Objective To investigate the influencing factors on the quality of nursing records in ICU,so as to provide reference for nursing document management.Methods A total of 200 cases of ICU nursing records in our hospital from March 2019 to June 2019 were enrolled as research objects,which were divided into qualification group(n=174)and non-qualification group(n=26)according to their quality.The personnel factors,management factors and environmental factors were compared between the two groups,and Logistic regression analysis was performed.Results The proportion of nurses with high subjective initiative,seniority≥5 years and excellent working ability in qualification group was significantly higher than that in non-qualification group,however,the proportion of patients with complicated conditions in qualification group was significantly lower than that in non-qualification group(P<0.05).The proportion of nursing records related to reward and punishment of nurses in qualification group was significantly higher than that in non-qualification group,however,the proportion of medical auxiliary personnel insufficient was significantly lower than that in non-qualification group(P<0.05).The working time in qualification group was≥10h/d,the proportion of nursing information equipment and system obstacles,and the proportion of media adverse opinions in qualification group were significantly higher than those in non-qualification group(P<0.05).Logistic regression analysis showed that the nurses subjective initiative was lower,and the proportion of nurses with qualification work<5 years was lower,patient’s condition was complex,poor ability of nursing record quality,nursing and nurse assessment rewards and punishment were not relevant,paramedical personnel configuration was insufficient,working hours≥10h/d,nursing information equipment and system obstacles,bad publicity media were independent risk factors affecting ICU nursing records quality(P<0.05).Conclusion It is necessary to consider all the factors for the quality management of nursing records in ICU,so as to improve its quality through various efforts.