三级医院护理术语体系架构和使用现状的质性研究
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摘要
[目的]分析国内临床医院护理术语的体系架构和使用情况,为护理术语的发展和完善提供科学的研究基础。[方法]采用目的抽样方法选取国内9所三级医院作为研究单位,采用半结构式访谈和临床护理文件分析的方法,对三级医院的护理管理者和临床护理资料进行调查。[结果]各医院护理术语的架构和使用存在较大差异,尚未形成护理术语的规范化、同质化;护理表单基本涵盖护理程序的各环节,但尚未形成完整的体系。[结论]目前的护理术语体系和架构难以成为专业交流和信息共享的有效平台,不能充分发挥有效的决策支持作用,建议基于护理程序构建我国的护理术语框架体系。
引文
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[5]杜艳丽,石兰萍.国际护理实践分类系统的研究与应用现状[J].中国护理管理,2010,10(5):8-10.
[6]刘辉,张燕舞,高妍,等.我国护理术语标准化问题分析及发展策略[J].中国护理管理,2014,14(5):556-560.
[7]刘霖,COENEN A M Y,陶红,等.国际护理术语分类体系发展概况及其对我国护理的启示[J].中华护理杂志,2015,52(5):593-597.
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[10]FLANAGAN J,WEIR-HUGHES D.NANDA-I NIC and NOC,the EHR,and meaningful use[J].Int J Nurs Knowl,2016,27(4):183.
[11]SMITH K J,CRAFT-ROSENBERG M.Using NANDA,NIC,and NOC in an undergraduate nursing practicum[J].Nurse Educ,2010,35(4):162-166.
[12]VON KROGH G,DALE C,NADEN D.A framework for integrating NANDA,NIC,and NOC terminology in electronic patient records[J].J Nurs Scholarsh,2005,37(3):275-281.
[13]MOORHEAD S,JOHNSON M,MAAS M.Nursing outcomes classification(NOC)[M].fifth edition.Atlanta:Mosby,2013:1.
[14]BEHRENBECK J G.Nursing-sensitive outcome implementation and reliability testing in a tertiary care setting[J].Int J Nurs Knowl,2003,14(4s):1.
[15]SEGANFREDO D H,ALMEIDA M A.Nursing outcomes content validation according to Nursing Outcomes Classification(NOC)for clinical,surgical and critical patients[J].Rev Lat Am Enfermagem,2011,19(1):34-41.櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅
[16]MELLO B S,MASSUTTI T M,LONGARAY V K,et al.Applicability of the Nursing Outcomes Classification(NOC)to the evaluation of cancer patients with acute or chronic pain in palliative care[J].Appl Nurs Res,2016,29:12-18.
[2]李玉恩.术语与术语标准化[J].术语标准化与信息技术,2005,3:12-13;15.
[3]郝德慧,林秋子,盧小珏,等.台湾护理词条标准值现况与发展[J].护理杂志,2009,56(3):12-17.
[4]程渝,刘玉馥,刘小莉,等.护理语言的研究进展[J].国外医学:护理学分册,2003,22(3):105-107.
[5]杜艳丽,石兰萍.国际护理实践分类系统的研究与应用现状[J].中国护理管理,2010,10(5):8-10.
[6]刘辉,张燕舞,高妍,等.我国护理术语标准化问题分析及发展策略[J].中国护理管理,2014,14(5):556-560.
[7]刘霖,COENEN A M Y,陶红,等.国际护理术语分类体系发展概况及其对我国护理的启示[J].中华护理杂志,2015,52(5):593-597.
[8]American Nurses Association(ANA).Standardized terminologies supporting nursing practice[EB/OL].(2012-06-10)[2015-10-19].http://www.nursingworld.org/Terminologies.
[9]GRAZIELE-RIBEIRO B.Philosophical fundamentals and concept of outcomes classification:contributions in nursing assessment[J].J Nurs UFPE on Line,2016,10(Suppl.5):4336-4342.
[10]FLANAGAN J,WEIR-HUGHES D.NANDA-I NIC and NOC,the EHR,and meaningful use[J].Int J Nurs Knowl,2016,27(4):183.
[11]SMITH K J,CRAFT-ROSENBERG M.Using NANDA,NIC,and NOC in an undergraduate nursing practicum[J].Nurse Educ,2010,35(4):162-166.
[12]VON KROGH G,DALE C,NADEN D.A framework for integrating NANDA,NIC,and NOC terminology in electronic patient records[J].J Nurs Scholarsh,2005,37(3):275-281.
[13]MOORHEAD S,JOHNSON M,MAAS M.Nursing outcomes classification(NOC)[M].fifth edition.Atlanta:Mosby,2013:1.
[14]BEHRENBECK J G.Nursing-sensitive outcome implementation and reliability testing in a tertiary care setting[J].Int J Nurs Knowl,2003,14(4s):1.
[15]SEGANFREDO D H,ALMEIDA M A.Nursing outcomes content validation according to Nursing Outcomes Classification(NOC)for clinical,surgical and critical patients[J].Rev Lat Am Enfermagem,2011,19(1):34-41.櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅櫅
[16]MELLO B S,MASSUTTI T M,LONGARAY V K,et al.Applicability of the Nursing Outcomes Classification(NOC)to the evaluation of cancer patients with acute or chronic pain in palliative care[J].Appl Nurs Res,2016,29:12-18.