Changes in nursing professions' scope of practice: A pilot study using electronic nursing records

Abstract

Objectives: This study aims to identify and evaluate comprehensive nursing service as a new nursing care service in Korea. To this end, we performed comparison analyses between the comprehensive nursing service and non-comprehensive nursing service wards' nursing practices through nursing documentation. Methods: The hospital in this study was a general hospital in South Korea with 750 beds. The research wards were selected randomly from among the total wards, and the nursing records of inpatients staying in the hospital in the two weeks from September 1 to 14, 2015, were analyzed. Among 198 inpatients whose admissions to the hospital were confirmed, 10 inpatients were randomly selected, using a table of random numbers, and a total of 7340 of their nursing records were analyzed. Both quantitative and qualitative analyses of the contents of nursing records were conducted, on the basis of individual nursing statements. Result: Through the electronic nursing records, it can be found that comprehensive nursing service varied in the records of "fall prevention activities" and "check of the patients condition." The difference between the nursing records of the non-comprehensive and comprehensive nursing service wards for "check of the patients condition, were 188 versus 524 respectively. In addition, there were variances found in checking and recording the overall condition of a patient, such as food intake, sleep, and transfer. Conclusion: Through the electronic nursing record, the application of comprehensive nursing service enables a nurse to attend to an inpatient directly, without any support for daily activities by family or a paid caregiver. (C) 2018 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.