什么时候数字文档是最好的? 瑞典外科护士对数字文档的体验及其对工作环境的影响:一项定性研究
Björn Eriksson1, Magnus Svartengren1,2, Camilla Göras3
1Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University Uppsala, Uppsala, Sweden.
BMJ open
|December 23, 2025
概括
电子医疗记录 (EMR) 中的数字文档在系统用户友好且清晰实施时,被外科护士重视. 适应不良的系统和不充分的培训会导致技术压力和负面的情绪反应.
科学领域:
- 护理信息学 护理信息学
- 医疗保健技术 技术 医疗保健 技术
- 人与计算机的交互
背景情况:
- 电子医疗记录 (EMR) 中的数字文档增加了外科护士的工作量和认知压力,导致了技术压力.
- 通常EMR系统不适合用户需求,影响临床实践.
研究的目的:
- 探索术前护士和护士助理在手术期间使用电子文档的经验.
- 检查这些经验对工作环境,情绪反应和适应策略的影响.
主要方法:
- 定性研究设计. 定性研究设计.
- 使用布劳恩和克拉克的方法论进行主题分析.
- 从瑞典三家医院的20名参与者 (护士和护士助理) 收集的数据.
主要成果:
- 两个主要主题:数字系统削弱了没有明确目标的性能,但被自动化和舒适性所拥抱.
- 副主题包括领导力,系统开发影响力和EMR不满足临床需求.
- 积极的体验来自于自动化和用户舒适性; 负面反应来自于不清楚的文档流程和缺乏影响力.
结论:
- 当满足诸如清晰度,培训和用户影响等基本条件时,数字文档是有益的.
- 缺乏清晰度,培训不足和影响有限会引发负面情绪和不适应的应对策略.
- 标准化的数字系统流程和教育努力,包括知识控制,可以提高数字素养和用户体验.
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