Turkiye Klinikleri Journal of Medical Ethics-Law and History

.: RESEARCH
Opinions of Nurses and Nursing Students About Nursing Documentation: Comparative Study
Hemşirelerin ve Hemşirelik Öğrencilerinin Hemşirelik Kayıtlarına İlişkin Görüşleri: Karşılaştırmalı Bir Çalışma
Şenay UZUNa, Filiz ARSLANb, Ayşe Sevim ÜNALc, Tümay GEÇERd, Fahriye OFLAZe
aFundamentals of Nursing, bPediatric Nursing, ePsychiatric Nursing, Gülhane Military Medical Academy, School of ursing, Ankara cM. Cakmak Military Hospital, Erzurum dSiirt Military Hospital, Siirt
Turkiye Klinikleri J Med Ethics. 2009;17(2):63-70
Article Language: EN
Full Text
ABSTRACT
Objective The nursing documentation is essential because it provides the continuity and evaluation of care, it is the main source of communication among the health care providers and provides data from the aspect of legal issues for both the care giver and care taker. Although the importance of the nursing documentation is emphasized during the nursing education, it is seen that the nursing documentations are held in a different quality. The understanding of the reason of this difference is important for practice and education. The aim of this study was to compare the opinions of nurses and nursing students about the documentation. The results are expected to take the necessary precautions for unfavorable factors of nursing documentation and to contribute to preparing undergraduate and postgraduate educational programs. Material and Methods: The study was descriptively planned. All the participants were recruited from the same nursing school and affiliated training hospital. The data were acquired by a data-collecting form, which included 10 questions followed by multiple choices. The forms were replied by the nurses (n= 168) and the nursing students (n= 72). Results: The study has shown that: (1) nurses regard the documentation as a protector against legal issues while the students think that consistency of the patient care is more important; (2) both groups reported the excessive workload as the reason of not documenting; (3) for improving the documentation, the nurses think that clinics-specific forms are necessary while the students lay emphasis on the computer-based documentation; (4) opinions about the content of the forms were similar. Conclusion: The nursing students, unlike the nurses, reported that the first aim of the documentation is to provide the continuity of the care. Taking the reasons of not documenting listed by the nurses into consideration from the aspects of practice, management and education is thought to increase the quality of care.

Keywords: Documentation; nursing; nurses; students, nursing
ÖZET
Amaç: Hemşirelik kayıtları; bakımın sürekliliğini ve değerlendirmesini sağlaması, sağlık ekibi arasında bakım konusunda temel iletişim kaynağı olması, hem bakım veren hem de alan için yasal açıdan veri sağlaması gibi nedenlerle oldukça önemlidir. Hemşirelik kayıtlarının önemi hemşirelik eğitimi sırasında vurgulanmasına rağmen, mezuniyet sonrası hemşirelik kayıtlarının farklı nitelikte tutulduğu görülmektedir. Bu farklılığın nedenlerinin anlaşılması uygulama ve eğitim açısından önemlidir. Bu çalışmanın amacı hemşirelerin ve hemşirelik öğrencilerinin hemşirelik kayıt konusundaki görüşlerini karşılaştırmaktır. Sonuçların hemşirelikte kayıt tutmayı olumsuz etkileyen faktörlere ilişkin önlemlerin alınmasını sağlayacağı ve mezuniyet öncesi ve sonrası eğitimlere katkıda bulunacağı düşünülmektedir. Gereç ve Yöntemler: Çalışma tanımlayıcı olarak planlanmıştır. Bütün katılımcılar aynı hemşirelik okulundan ve bu okulu destekleyen aynı eğitim hastaneden alınmışlardır. Veriler, çoktan seçmeli yanıtları bulunan 10 soru içeren bir veri toplama formu ile elde edilmiştir. Formlar hemşireler (n= 168) ve hemşirelik öğrencileri (n= 72) tarafından yanıtlanmıştır. Bulgular: Çalışma sonuçları göstermiştir ki; (1) hemşireler kayıt tutmayı, yasal konularda bir koruyucu olarak görürken, öğrencilere gore hasta bakımının devamlılığını sağlamak daha önemlidir; (2) her iki grup da kayıt tutmamanın en önemli nedeni olarak işyükü fazlalığını bildirmişlerdir.; (2) kayıt tutmayı geliştirmek için hemşireler kliniklere özel formların gerekli olduğunu belirtirken, öğrenciler bilgisayar tabanlı kayıt tutmanın gerekli olduğunu belirtmişlerdir; (4) formların içeriği konusunda her iki grup da benzer görüş bildirmişlerdir. Sonuç: Hemşirelik öğrencileri,hemşirelerden farklı olarak kayıt tutmanın ilk amacının hasta bakımının devamlılığını sağlamak olduğunu bildirmişlerdir. Hemşirelerin kayıt tutmama nedenleri olarak sıraladıkları nedenlerin, uygulama, yönetim ve eğitim alanları açısından dikkate alınarak giderilmesinin hasta bakımı kalitesini arttıracağı düşünülmektedir.

Anahtar Kelimeler: Kayıt tutma; hemşirelik; hemşire, hemşirelik öğrencisi

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