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来自前线的声音:护士对文档的经验及其对患者安全的影响的定性研究

Reem Saeed Alghamdi¹, Monirah Albloushi¹, Marwa Alshareef²

¹College of Nursing, King Saud University, Riyadh, Saudi Arabia, ksu.edu.sa.

Journal of nursing management

|March 14, 2026

概括

沙特阿拉伯的护士认为临床文档对于患者安全至关重要,但面临时间限制和培训不足等挑战. 改善文档实践和护士参与对于更好的患者结果至关重要.

科学领域:

护理实践护理实践
患者安全患者安全
医疗保健文档医疗保健文档

背景情况:

护理文档对于患者安全,护理连续性和法律责任至关重要.
尽管采用电子健康记录,但在准确和及时的文档方面仍然存在挑战.
高压的医疗保健环境加剧了记录方面的困难.

研究的目的:

探索护士对沙特阿拉伯临床文档的看法.
用临床文档识别护士面临的挑战.
了解文档对患者安全的影响.

主要方法:

定性描述性设计. 定性描述性设计.
针对来自沙特教学医院的9名经验丰富的护士进行了有目的的抽样.
面对面的半结构面试和使用MAXQDA的感应主题分析.

主要成果:

护士将文档视为关键的法律和临床工具,对患者安全至关重要.
关键的障碍包括时间限制,培训不足,不一致的做法和糟糕的交付.
护士们努力提高文档质量,但觉得自己被排除在机构决策之外.

结论:

需要加强培训和标准化文档实践.
建议增加护士参与政策制定.
解决这些问题可以提高文档准确性,减少工作量,提高患者安全.

关键词:

电子健康记录是电子健康记录.护理文档护理文档护理人员的护理工作人员.患者安全患者安全定性研究是指质量研究.

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