| 1. |
- Bergh, Anne-Louise, et al.
(författare)
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How do nurses record pedagogical activities? An investigation of nurses’ documentation inpatients´ records in a cardiac rehabilitation unit for patients following coronary artery bypass surgery.
- 2007
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Ingår i: Journal of Clinical Nursing. - : Wiley-Blackwell Publishing Ltd.. - 0962-1067 .- 1365-2702. ; 16:10, s. 1898-1907
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Tidskriftsartikel (refereegranskat)abstract
- Aims. To describe the use of pedagogically related keywords and the content of notes connected to these keywords, as they appear in nursing records in a coronary artery bypass graft (CABG) surgery rehabilitation unit. Background. Nursing documentation is an important component of clinical practice and is regulated by law in Sweden. Studies have been carried out in order to evaluate the educational and rehabilitative needs of patients following CABG surgery but, as yet, no study has contained an in-depth evaluation of how nurses document pedagogical activities in the records of these patients. Methods. The records of 265 patients admitted to a rehabilitation unit following CABG surgery were analysed. The records were structured in accordance with the VIPS model. Using this model, pedagogically related keywords: communication, cognition/development and information/education were selected. The analysis of the data consisted of three parts: the frequency with which pedagogically related keywords are used, the content and the structure of the notes. Results. Apart from the term 'communication', pedagogically related keywords were seldom used. Communication appeared in all records describing limitations, although no explicit reference was made to pedagogical activities. The notes related to cognition/development were grouped into the following themes: nurses' actions, assessment of knowledge and provision of information, advice and instructions as well as patients' wishes and experiences. The themes related to information were the provision of information and advice in addition to relevant nursing actions. The structure of the documentation was simple. Conclusions. The documentation of pedagogical activities in nursing records was infrequent and inadequate. Relevance to clinical practice. The patients' need for knowledge and the nurses' teaching must be documented in the patient records so as to clearly reflect the frequency and quality of pedagogical activities.
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| 2. |
- Friberg, Febe, et al.
(författare)
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In search in patient teaching in nursing documentation : an analysis of patient records in a medical ward in Sweden
- 2006
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Ingår i: Journal of Clinical Nursing. - : Wiley-Blackwell Publishing Ltd.. - 0962-1067 .- 1365-2702. ; 15:12, s. 1550-1558
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Tidskriftsartikel (refereegranskat)abstract
- Keywords:need for knowledge;nursing;nursing documentation;patient education;patient records;teaching intervention Aim. The aim of this study was to identify terms and expressions indicating patients’ need for knowledge and understanding, as well as nurses’ teaching interventions, as documented in nursing records. Background. Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. Methods. Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients’ need for knowledge and understanding and terms and expressions indicating nurses’ teaching activities were analysed. Results. The results showed that patients’ need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses’ implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. Relevance to clinical practice. Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients’ need for knowledge and nurses’ teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.
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| 3. |
- Friberg, Febe, 1950, et al.
(författare)
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In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden.
- 2006
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Ingår i: Journal of clinical nursing. - : Wiley. - 0962-1067 .- 1365-2702. ; 15:12, s. 1550-8
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Tidskriftsartikel (refereegranskat)abstract
- AIM: The aim of this study was to identify terms and expressions indicating patients' need for knowledge and understanding, as well as nurses' teaching interventions, as documented in nursing records. BACKGROUND: Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. METHODS: Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients' need for knowledge and understanding and terms and expressions indicating nurses' teaching activities were analysed. RESULTS: The results showed that patients' need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses' implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. RELEVANCE TO CLINICAL PRACTICE: Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients' need for knowledge and nurses' teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.
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