PERCEPTION OF RECORDING MISSION OF OCCUPATIONAL HEALTH NURSES AND EVALUATION OF HEALTH RECORDS IN THEIR WORKPLACES

Öz

AIM:This study aimed to evaluate occupational health nurse’s perception of their professional roles in documenting health records and their recorded forms contents.METHODOLOGY:This study is conducted as a qualitative manner using a purposive sample. Qualitative data were collected by the way of structered interviews.These interviews were established inAnkara city between February and June 2005. 16 occupational health nurses were participated in thisstudy. Before study, researchers were taken formal permission and interviews were informed aboutstudy aim, were participated voluntary. Participation continued until no new content appeared.Each interview was conducted in their enterprises in one time and repeat interviews with in it. İnterviews takes about approximately one hour.All interviews were recorded. İnterviews notes were analyzed byusing thematic content analyzing method. And also all documented health records content in these enterprises were evaluated by the researchers. FINDINGS AND RESULTS:At the end of this research results shows that the OHN couldn’t aware of their recording roles and their records forms content was not related to the nursing activities . Thisresearch suggets in service training program and also certificational training program should be conducted to the these groups especially emphasized to this topics to promoting efficiency in these nursing activities

Anahtar Kelimeler

• occupational health,nurse,recording,perception

İŞYERİ HEMŞİRELERİNİN KAYIT TUTMA GÖREVLERİNE İLİŞKİN ALGILAMALARI İLE İŞYERİNDE TUTULAN SAĞLIK KAYITLARININ DEĞERLENDİRİLMESİ

Öz

AMAÇ: Bu çalışma, iş sağlığı hemşirelerinin kayıt tutmada kendi mesleki rollerine ilişkin algılamalarını belirlemek ve işyerlerinde tutulan kayıtları değerlendirmek amacıyla yapılmıştır.YÖNTEM: Bu çalışma, amaca uygun örnekleme yöntemi ile katılımcıların belirlendiği ve kalitatifyaklaşımın kullanıldığı bir çalışmadır. Veriler yapılandırılmış görüşme tekniği kullanılarak Şubat-Haziran 2005 tarihleri arasında Ankara’da gerçekleştirilmiştir. İşyerlerinde çalışan 16 işyeri hemşiresi vesağlık memuru araştırma kapsamında yer almıştır. İşyerlerinden yazılı izin alınmış ve çalışmaya katılmayı kabul edenlerle görüşme yapılmıştır. Her bir görüşme yaklaşık bir saat sürmüştür. Görüşmeden elde edilen veriler- görüşme içeriği- araştırmacılar tarafından kaydedilmiş ve veriler ”tematik içerik analizi ” yöntemi kullanılarak değerlendirilmiştir. Ayrıca her bir işyerinde kullanılan kayıt formları toplanmış ve formların içeriği araştırmacılar tarafından değerlendirilmiştir.BULGULAR VE SONUÇ:Bu araştırmanın sonucunda işyeri hemşirelerin kayıt tutma rollerininfarkında olmadıkları ve tuttukları kayıt içeriğinin hemşirelik eylemleri ile ilişkili olmadığı saptanmıştır.Araştırmanın sonuçları, hizmet içi eğitim programı ve sertifika programlarında işyeri hemşirelerinin kayıt tutma rollerini ayrıntılı olarak ele alınmasının özellikle hemşirelik eylemlerinin etkinliğini artırmakiçin gerekliliğine işaret etmektedir

Anahtar Kelimeler

• iş sağlığı,hemşire,kayıt tutma,algılama

Kaynakça

1. Abbey HM, Treacy PAS, Buttler M and at all. (2005) Modes of rationality in nursing documen- tation: biology, biograpy and the “voice of nur- sing”. Nursing Inquiry.12(2):66-77.
2. Allen D. (1998) Record-keeping and routine nursing practice. the view from the wards. Jour- nal of Advanced Nursing. 27(6):1223-30.
3. Baker SK. (2000) Minimizing litigation risk:documentation strategies in the occupational health setting. Journal of the American Associati- on of Occupational Health Nurses . 48(2):100.
4. Beyers M. (1997) Documentation system changes. Nursing Management. 27(10).64.
5. Björvell C, Wredling R, Thorell-Ekstrand I. (2003a) Improving documentation using a nursing model. Journal of Advanced Nursing. 43(4):402- 410.
6. Björvell C,Wredling R,Thorell-Ekstrand I. (2003b) Prerequisites and consequences of nur- sing documentation in patient records as percei- ved by a group of registered nurses. Journal of Clinical Nursing.12(2):206-14.
7. Catton H, Naish J. (2006) Making nursing vi- sible. Nursing Standard. 20(44):14-6.
8. Currell R, Urquhart C. (2007) Nursing record system: effects on nursing practice and health ca- re outcomes. The Cochrane Database of Syste- maticReviews. (3) Art. No.: CD002099. DOI: 10.1002/14651858.CD002099 (Electronic versi- on) http://www.mrw.interscience.wiley.com/coc- hrane/clsysrev/articles/CD002099/frame.html

9. Diamond B. (2005a) Abbreviations: the need for legibility and accuracy in documentation. Bri- tish Journal of Nursing.14(12):665-6.
10. Diamond B. (2005b) Exploring principles of good record keeping in nursing. British Journal of Nursing. 14(8).460-62.
11. Don Cliff B. (2000) Making nursing visible and valuable. New Zelland Nursing Journal .
12. Donabedian A. (1988) The quality of care. how can it be assessed?. The Journal of the Ame- rican Medical Association; 260: 1743-60.
13. Edwards SD. (1999) The idea of nursing scien- ce. Journal of Advanced Nursing. 29(3):563-569.
14. Ehrenberg A, Ehnfors M, Semedby B. (2001) Auditing nursing content in patient records. Scan- dinavian Journal of Caring Sciences.15:133-41.
15. Evers G. (2003) Developing nursing science in Europe. Journal of Nursing Scholarship. 35(1):9.
16. Frank-Stromborg M, Christensen A. (2001a) Nurse documentation: not done or worse, done the wrong way. Part I. Oncology Nursing Forum. 28(4):697-702.
17. Frank-Stromborg M, Christensen A. (2001b) Nurse documentation: not done or worse, done the wrong way-Part II. Oncology Nursing Fo- rum.;28(5):841-45.
18. Gruber M,GruberJM. (1990) Nursing malprac- tice: the importance of documentation or saved by the Pen1. Gastroenterology Nursing. 12(4):255-9.
19. Gruber M. (1995) Documentation is commu- nication. Gastroenterology Nursing.;18(3):07-8.
20. Hale CA, Thomas LH, BondS, Todd C. (1997) The nursing records as a research tool to identify nursing interventions. Journal of Clinical Nur- sing. 6:207-14.
21. Heartfield M. (1996) Nursing documentation and nursing practice: a discourse analysis. Journal of Advanced Nursing. 24(1):98-103.
22. Huffman MH, Cowan JA. (2004) Redefine ca- re delivery and documentation. Nursing Manage- ment. 35(2):34-8.
23. Karkkainen O, Eriksson K. (2003) Evaluation of patient records as part of developing a nursing care classification. Journal of Clinical Nur- sing.12(2):198-205.
24. Karkkainen O, Eriksson K. (2004a) A theore- tical approach to documentation of care. Nursing Science Quarterly.17839:268-72.
25. Karkkainen O, Eriksson K. (2004b) Structu- ring the documentation of nursing care on the ba- sis of a theoretical process model. Scandinavian Journal of Caring Sciences. 18(2);229-36.
26. Karkkainen O, Eriksson K. (2005) Recording the content of a caring process. Journal of Nur- sing Management. 13(3):202-8.
27. Langowski C. (2005) The times they are chan- ging: effects of online nursing documentation systems. Quality Management in Health Ca- re.;14(29).121-5.
28. Lee T-T,Chang PC. (2004) Standardized care plans: experiences of nurses in Taiwan. Journal of Clinical Nursing. 13:33-40.
29. LeeT-T. (2005a) Nurses’ concerns about using information systems: analysis of comments on a computerized nursing care plan system in Taiwan. Journal of Clinical Nursing. 14.344-353.
30. Lee T-T. (2005 b) Nursing diagnoses:factors affecting their use in charting standardized care plans. Journal of Clinical Nursing. 14:640-647.
31. Levy BS, Wegman DH. (2000) Occupational health: recognizing and preventing work-related disease and injury. Lippincott Williams and Wil- kins. Philadelphia.
32. Mackey TA, Cole FL, ParnellS. (2003) Occu- pational health nurses’ educational needs: what do they want?. Journal of the American Association of Occupational Health Nurses. 51(12):514-20.
33. McHugh J. (2003) Confidentialy of employee health records: ethical and legal dilemmas for oc- cupational health nurses. Journal of the American Association of Occupational Health Nurses. 51():378-83.
34. Moloney R, Maggs C. (1999) A systematic re- view of the relationships between written manual nursing care planning, record keeping and patient outcomes. Journal of Advanced Nursing.
35. Mrayyan MT. (2005) The influence of standar- dized languages on nurses’ autonomy. Journal of Nursing Management. 13(3):238-41.
36. Owen K. (2005) Documentation in nursing practice. Nursing Standard.19(32):48-49.
37. Parse RR. (1999) Nursing science: the trans- formation of practice. Journal of Advanced Nur- sing. 30(6):1383-1387
38. Pearson A. (2003) The role of documentation in making nursing work visible. International Jo- urnal of Nursing Practice.;9(5):271.
39. Perry SE. (1984) Evaluating nursing care thro- ugh medical record review, Journal of the Ameri- can Medical Record Assocciation.55(12):28-31.
40. Rasmor M,Brown CM. (2003) Pyhsical exa- mination for the occupational health nurse: skills update. Journal of the American Association of Occupational Health Nurses. 51(9):390-401.
41. Roberts C, Smith R. (1993) Improving nursing records with audit. Nursing Standard. 7(51):37-9.
42. Rogers B. (1994) Occupational health nursing concepts and practice. W:B Saunders Company. Philadelphia.
43. Saba VK. (2001) Nursing informatics: yester- day, today and tomorrow. International Nursing Review. 48(3):177-87.
44. Strasser PB. (2004) Ensuring confidentiality of employee health information-developing poli- cies and procedures. Journal of the American As- sociation of Occupational Health Nurses. 52(4):149-53.
45. Tapp A. (2000) Occupational health transfer of records. Canadian Nurse. 6(3):39-40.
46. Toth D, DiBenedetto DV. (2003) A standardi- zed language for occupational health nursing-the minimum data set. Journal of the American Asso- ciation of Occupational Health Nurses.;51(/):283- 6.
47. Vaugt W, Paranzino GK. (2000) Confidentia- lity in occupational health care: a matter of advo- cacy. Journal of the American Association of Occupational Health Nurses. 48 (5):243-52.
48. Whittemore R. (2005) Analysis of integration in nursing science and practice. Journal of Nur- sing Scholarship. 42(4):695-701.
49. Whyte M. (2005) Computerized versus hand- written records. Paediatric Nursing.17(7):15-8.
50. Winters J,Ballou KA. (2004) The idea of nur- sing science. Journal of Advanced Nursing. 45(5):533-535.
51. Wood C. (2003) The importance of good re- cord–keeping for nurses. Nursing Times. 99(2):26-7.