Title Problem evidentiranja sestrinskog rada u primarnoj zdravstvenoj zaštiti Title (english) Problems of keeping records of nurses' working hours in primary health care Author Goranka Rafaj Mentor Josipa Kern (mentor)Committee member Đurđica Kašuba Lazić (predsjednik povjerenstva)Committee member Zlata Ožvačić Adžić (član povjerenstva)Committee member Josipa Kern (član povjerenstva)Granter University of Zagreb Defense date and country 2014-07-10, Croatia Scientific / art field, BIOMEDICINE AND HEALTHCARE Abstract Prema Zakonu o sestrinstvu medicinska sestra je dužna evidentirati provedene postupke u sestrinskoj dokumentaciji na svim razinama zdravstvene zaštite. Zakonskom legislativom za većinu radnih mjesta medicinskih sestara u primarnoj zdravstvenoj zaštiti (PZZ) predviđena je srednja stručna sprema (SSS), što znači da s jedne strane postoji zakonska obveza dokumentiranja sestrinskog rada, a s druge strane nedostatna educiranost za određene poslove. Stoga se ukazuje potreba da se ocijeni postojeće stanje sestrinstva u PZZ s obzirom na obrazovnu strukturu i na upućenost medicinskih sestara u važnost evidentiranja sestrinskog rada i vođenja sestrinske dokumentacije, te s obzirom na stavove i znanja o sestrinskoj dokumentaciji u PZZ u eri informatizacije zdravstvenog sustava. S tim je ciljem provedeno istraživanje u kojemu su ispitanici bile medicinske sestre zaposlene u PZZ u DZ Bjelovarsko–bilogorske županije. Od ukupno sto medicinskih sestara njih 98 ispunilo je anketni upitnik čime je postignut odaziv od 98%. Obrada podataka je pokazala da u PZZ prevladava zapošljavanje medicinskih sestara srednje
stručne spreme (70 SSS prema 28 VŠS). Informatička je educiranost niska (7 ispitanika završilo je informatički tečaj, a 9 ih je prošlo obuku prije početka rada s aplikacijom u ambulanti), dok 26,5% sestara ne zna koju aplikaciju koriste u radu. Sestre s VŠS su upućenije u važnost evidentiranja sestrinskog rada i vođenja sestrinske dokumentacije u PZZ nego sestre sa SSS. Važnost sestrinske dokumentacije u PZZ medicinske sestre vide prvenstveno u pravnoj zaštiti (74,5%), zakonskim obvezama (70,4%) i utvrđivanju profesionalne odgovornosti (71,4%), dok 22,4% sestara ocjenjuje dokumentiranje sestrinskog rada u PZZ nepotrebnim. U ocjeni vođenja sestrinske dokumentacije u PZZ sestre ističu pregledniji uvid u kronologiju pacijentovih potreba (79,6%) i mišljenje da vođenje sestrinske dokumentacije sestrinski rad čini „vidljivim“ (74,5%), dok 32,7% smatra da vođenje sestrinske dokumentacije neće poboljšati kvalitetu sestrinskog rada. Medicinske sestre sa SSS pozitivnije ocjenjuju svrhovitost elektroničke sestrinske dokumentacije za direktnu praksu (direktni rad s pacijentima, ocjena kvalitete, lakši rad sestre). Sestre s VŠS pozitivnije ocjenjuju svrhovitost elektroničke dokumentacije kroz sustav i struku (reorganizacija zdravstvenog sustava i unapređenje sestrinstva kao istraživačke discipline). Temeljem dobivenih rezultata kao zaključak se nameće sljedeće: potrebno je uskladiti zakonsku regulativu (je li za rad u PZZ dovoljna SSS?) i obrazovanje medicinskih sestara (o sestrinskoj dokumentaciji već u srednjoj školi – važnost, vođenje, svrhovitost/korisnost). Sestrinskim obrazovnim sadržajima treba dodati informatičko obrazovanje. Prije početka korištenja informatičke aplikacije sestre treba primjereno upoznati s aplikacijom – načinom korištenja i dometima aplikacije, te uključiti medicinske sestre u kreiranje, odnosno unapređivanje aplikacija za potrebe sestrinstva u PZZ.
Abstract (english) According to the Nursing Act, a medical nurse is required to keep records of the performed procedures in the nursing documentation at all levels of health care. For most nursing positions in primary health care (PHC), the legal provisions stipulate medium level of education (secondary school level – SSL), which indicates on one hand, there is a legal obligation of nursing documentation and, on the other hand, there is insufficient educational capacity for certain work tasks. The aim of this study was to evaluate the current nursing situation in PHC from the perspective of educational structure and medical nurses' awareness of the importance of record keeping and nursing documentation, but also from the perspective of their attitudes and knowledge on nursing documentation in PHC in the era of informatization of the health care system. The study included PHC medical nurses employed in Bjelovar-Bilogora County Health Centre. Out of 100 medical nurses approached, 98 completed the study questionnaire, yielding a 98% response rate. Data analysis showed that educational level of PHC medical nurses was dominantly secondary school level (70 with SSL vs. 28 with college education). Informatics education level was low (7 respondents completed a course in informatics, and 9 had some training before starting their work with the nursing computer program/system in their practice), and 26.5% did not know which computer program they were using. Nurses with college degree were more aware of the importance of record keeping and nursing documentation in PHC than nurses with SSL only. The importance of nursing documentation in PHC was seen by medical nurses primarily in the legal protection (74.5%), legal obligation (70.4%), and establishing professional responsibility (71.4%), while 22.4% considered nursing documentation in PHC unnecessary. When assessing nursing documentation in PHC, medical nurses pointed out to an easier insight into the chronology of patient needs (79.6%) and more 'visible' actual work of nurses (74.5%), while 32.7% did not consider that nursing documentation would improve the quality of work in the nursing practice. Nurses with SSL assessed more positively the purposefulness of electronic nursing documentation for direct practice (direct work with patients, quality assessment, easier work for nurses), and nurses with college degree through the system and profession (reorganization of the health care system, and promotion of nursing profession as a research discipline). Results of this study indicate the following: it is necessary to harmonize the legal provisions (Is SSL education enough for work in PHC?) with the education of medical nurses (on nursing documentation already at secondary school level – importance, record keeping, purposefulness/usefulness). Training in informatics should be part of the nursing education. Before starting to use a nursing computer program/system, the nurses should be adequately made familiar with the program – its usage and scope; and they should be involved in the development and upgrading of programs to suit the nursing needs in PHC.
Keywords
medicinske sestre u PZZ
evidentiranje sestrinskog rada
sestrinska dokumentacija
informatizacija u sestrinstvu
Keywords (english)
medical nurses in PHC
record keeping for nurses
nursing documentation
nursing informatization
Language croatian URN:NBN urn:nbn:hr:105:481332 Study programme Title: Studies in Nursing Type of resource Text File origin Born digital Access conditions Open access Terms of use Created on 2016-03-01 09:43:34
