國際護理作業系統臨床適用性評估與驗證.

國際護理作業系統臨床適用性評估與驗證.

Evaluating the β Version of ICNP(superscript ?) for the

Adequacy of the Items in Clinical Practice:

ICNP(superscript ?) Validation Project in Taiwan

方亞芸;邱艷芬 摘要 本研究在驗證國際護理作業分類系統(ICNP)在我國護理紀錄之應用性及適用 性。以回溯性研究方式於 2004 年 9 月至 12 月在 12 家醫學中心共 25 科進行施測， 25 科包含內外科、小兒科、急診、加護病房及精神科，共 3,996 篇護理交班記錄， 針對護理記錄中的每一句使用台灣護理學會所發展之國際護理作業系統中文版 瀏覽器進行適用性分析，其適用性判別依據四個等級做分類：Level 1：可以完全 以 ICNP 字彙轉譯原護理記錄的字句；Level 2：可以以相似的 ICNP 字彙轉譯原 護理記錄的字句；Level 3：以 ICNP 字彙轉譯外，需要再輸入數據以完成原護理 記錄的字句；Level 4：無法以 ICNP 字彙轉譯原護理記錄的字句。在 4,243 篇護 理交班記錄共 24,722 句中，護理現象為 8,585 句(34.7%)、護理行動 16,137 句 (65.3%)，其適用性分析 Level 1 共 9,753 句(39.5%)；Level2 共 3,703 句(15.0%)；

Level 3 共 10,189 句(41.2%)；Level 4 共 l,077 句(4.4%)；無法以 ICNP 字彙轉譯 原護理記錄的字句為病人主觀感受、護士對病人行為及經驗之描述及手術過程。 將 Level 3 及 4 的字句經由國內專家進行評估及討論，建議加入字彙護理現象共 33 個字彙及護理行動共 29 個字彙，同時完成字彙之中英文定義及歸屬與編碼，

向 ICN 提出加入 ICNP 之建議。 Abstract

The project's goals were to evaluate the adequacy of the items in the International Classification for Nursing Practice (ICNP(superscript ?)) terminology for describing nursing practice in Taiwan. Taiwan Nurses Association (TWNA) conducted a

nationwide project to validate its comprehensiveness and congruency in coding the nursing records of current clinical practice. The research was a

retrospective research. Data were collected from 29 units of 25 nursing words of 12 medical centers distributed in the Taiwan area from September to December of 2004. The 25 wards included surgical-medical wards, pediatric wards, emergency, intensive care units and psychiatric departments. The shift reports were divided into many individual sentences and each sentence was mapped to terms in ICNP(superscript ?)

by the Chinese ICNP(superscript ?) browser developed by the TWNA. The criteria to assess congruency of the coding results were: level 1, the same terms were found; level 2, similar terms were found; level 3, extra words, such as "laboratory data," "educational context," or "result of physical assessment," were needed to complete the record; level 4, no term could be found. There were 12 medical centers

participating in this project. A total of 24,722 sentences from 3,996 shifts reports from 27 wards were processed by the research team. Among them, 8,585 sentences (34.7%) were nursing phenomena and 16,137 sentences (65.3%) were nursing interventions made. In mapping, 9,753 sentences (39.5%) completely found the same terms (level 1); 3,703 sentences (15.0%) found similar terms (level 2); 10,189 sentence (41.2%) needed to type in extra words (level 3); 1,077 sentences (4.4%) were unable to find any term to fit them (level 4). Sentences categorized into level 4 were about patient's subjective expressions, nurses' descriptions of patient's behaviors, experiences, and the procedures of surgery. Sentences of level 3 and 4 were evaluated further by a group of experts for their significance in describing nursing practice. There were 33 terms in nursing phenomena and 29 terms in nursing intervention concluded. Their definitions were also developed. We recommend these 62 terms to the ICN for adding the ICNP terminology system.