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1 Korean of Adult Nursing Vol. 31 No. 4, , August 2019 ORIGINAL ARTICLE eissn X Open Access Pender 의건강증진모형을적용한종양병동간호사의항암화학요법관련호중구감소증관리지침이행영향요인 김경진 1 최자윤 2 화순전남대학교병원간호사 1, 전남대학교간호대학교수 2 Factors associated with Oncology Nurses Adherence to Chemotherapy-Induced Neutropenia Guidelines based on Pender s Health Promotion Model Kim, Gyeong-Jin 1 Choi, Ja Yun 2 1 Nurse, Chonnam National University Hwasun Hospital, Hwasun, Korea 2 Professor, College of Nursing, Chonnam National University, Gwangju, Korea Purpose: This study was conducted to identify factors associated with oncology nurses adherence to Chemotherapy-Induced Neutropenia (CIN) guidelines based on Pender s Health Promotion Model (HPM). Methods: For this cross-sectional descriptive study, 187 nurses who worked at the oncology department of Channam National University Hawsun Hospital responded to self-administered questionnaires. A tool for CIN guideline adherence was developed through systematic search, synthesis, translation, and content validation. Data collection was conducted by a trained research assistant from September 18 to September 26, Data were analyzed using independent t-test, one-way ANOVA, Pearson's correlation coefficient, and stepwise multiple regression. Results: Stepwise multiple regression showed that guideline adherence was associated with CIN education (β=.26, p<.001), self-efficacy (β=.17, p=.018), perceived benefits (β=.16, p=.026), interpersonal factors (β=.16, p=.043), and educational level (β=.14, p=.030). Conclusion: The findings of this study could be used to develop interventions focusing on CIN education and for the strengthening oncology nurses self-efficacy and beliefs to promote adherence to CIN guidelines. In addition, repeated studies would be needed to verify application of Pender s HPM to explain nurses adherence. Key Words: Chemotherapy-induced febrile neutropenia; Evidence-based nursing; Guideline adherence 서론 1. 연구의필요성 항암화학요법은암치료를위해세포독성약물을사용하는치료법으로암진단을받은환자의절반이상이항암화학요법치료를받게된다 [1]. 그런데항암화학요법의가장흔한부작용중하나는골수기능억제이며골수기능억제는약물의용량 과관련되어나타난다 [1]. 고용량항암화학요법이 1주일이상지속되면심한호중구감소증을일으킬수있으며, 호중구감소증이발생하면감염발생위험이매우높다 [2]. 호중구감소증은절대호중구수 (Absolute Neutrophil Count, ANC) 가 500 cells/µl 미만이거나, 1,000 cells/µl 미만이면서 2~3일이내에 500 cells/µl 미만으로감소될것으로예측되는경우를의미한다 [2]. 호중구감소증의심각성에따라감염률에차이가있는데, 호중구수가 101~500/μL 일때감염은약 20%, 100μL 미 주요어 : 항암화학요법관련호중구감소증, 근거기반간호, 지침이행 Corresponding author: Choi, Ja Yun College of Nursing, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju 61469, Korea. Tel: , Fax: , choijy@jnu.ac.kr Received: Mar 27, 2019 / Revised: May 30, 2019 / Accepted: Jul 15, 2019 This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2019 Korean Society of Adult Nursing

2 Kim, G-J Choi, JY 만일때감염은약 40% 가발생한다 [3]. 따라서골수기능장애로유발되는호중구감소증은감염의선행요인이되어암환자의임상결과와삶의질에영향을줌은물론사망에이르게할수있는가장위험한용량제한적독성이다 [2]. 이처럼항암화학요법관련호중구감소증을제대로관리하지못하였을때환자에미치는폐해가심각하므로간호사는감염의시작을나타내는징후와증상을관찰하여적절한조치를시작하는것이중요하다 [4]. 항암화학요법관련호중구감소증관리지침은근거에기반한중재이기때문에관리지침을이행하는것이최선의간호가될수있다. 하지만호중구감소증간호에대한중요성은종종과소평가되고있다 [5]. Kim과 Jeong [6] 의호중구감소증환자의식이에관한연구에서환자보다간호사들이식이섭취허용에대한인식이낮음을알수있어과학적기반을둔식이간호가제대로이루어지지않고있음을보여주었다. 또한대한간호협회에등록된 500병상이상기관대상호중구감소환자식이실태에관한연구에서 51개응답기관중 50% 이하에서호중구감소환자식이에관한관리지침을가지고운영하고있음을보고하였는데, Jeon 등은표준화된항암화학요법관련호중구감소관리지침의필요성을제안하였다 [7]. 의료진이환자와보호자에게건강교육을제공하게되면환자와보호자의반응에민감해져이후환자행동에긍정적인영향을줄수있다. 특히간호사는환자와근접하게업무를수행하기때문에환자의자가관리를변화시킬수있는적합한의료인이다 [5]. 따라서항암화학요법관련호중구감소환자를간호하는간호사가감염발생위험요소확인, 호중구감소증예방교육등임상표준관리지침을지키고수행하는것은항암화학요법관련호중구감소를시기적절하게관리하는데매우중요한부분이다 [8]. 따라서근거기반항암화학요법관련호중구감소증관리지침에포함된권고안이어느정도이행되는지확인할필요가있다고생각된다. 호중구감소증관리지침에관련된문헌을살펴보면국외관리지침으로는식이, 개인위생, 환경등특정영역이나백혈병과같은특정질환자에대한관리로국한되어개발되었고 [3,4,9-11] 국내관리지침으로는노인혈액암환자를위한호중구감소증감염예방가이드라인근거중심개발 [12] 연구가이루어졌다. 국내관리지침의경우국외관리지침을바탕으로관리지침을개발하였지만대상자가노인에국한되어있다. 이처럼지금까지호중구감소증환자관리지침에대한개발은관리지침마다초점을두고있는간호중재를다루고있거나항암화학요법관련호중구감소가발생한특정대상자에게적용할수있는관리지침이개발되고있으나, 포괄적인항암화학요법관련호중구 감소증관리지침의합성이필요하다고생각된다. 종양간호사는자신의호중구감소증환자관리가환자결과에긍정적인영향을미칠수있음을알고있지만, 임상관리지침의내용을제대로사용하고있는지에관해확신하고있지못하고있다 [8]. 따라서항암화학요법관련호중구감소증관리지침이행정도를파악하고이를이행하는데어떤요인이영향을미치는지파악할필요가있다고생각된다. 종양간호사는아니지만본연구주제처럼간호사의행위가환자의건강과직결되는다제내성감염관리수행에관한연구역시간호사의지식과인식과같은간호사요인을중시하고있어 [13], 환자의건강과직결되는간호사행위의경우간호사의행위혹은이행요인을확인하는것이필요하다. 이는근거기반관리지침을간호사가완전하게준수하는것이질적인간호에매우긍정적인공헌을하기때문이다 [14]. 이를위해먼저근거기반연구에준하여포괄적인표준관리지침으로합성하는것이필요하고합성된관리지침을사용하여항암화학요법관련호중구감소관리지침이행정도를확인하고이에영향을미치는요인을파악할필요가있다고생각된다. 건강증진모델인 Pender [15] 의행위관련이론은간호행위에대한관련요인의상호작용을다차원적으로규명할수있고있어환자의건강행위증진요인을파악하는데주로사용되어왔다. 그러나환자의직접적인건강증진행위는아니지만호중구감소증관리나다제내성감염관리수행등환자의건강과직결되는경우간호사요인이중요하기떄문에 Pender의건강증진모델을활용하여영향요인을확인하는것이적절하다고생각되었다. 항암화학요법관련호중구감소증관리지침이행이환자의건강증진을목표로한다는점뿐만아니라, 간호사의임상가이드라인을준수하는가장촉진하는요인을확인한결과간호사의책임감, 전문직가치, 자기효능감, 신념, 조직문화등이영향을미쳤다 [16,17]. 임상가이드라인을준수하는촉진요인에자기효능감이나신념뿐만아니라전문가의책임감이나가치관과같은행위와관련감정이나조직문화를포함하고있기때문에 Pender의행위관련이론에포함된변수를활용하는것이타당하다고생각되었다. 따라서환자의건강증진을위한간호사의행위를 Pender 이론으로설명할수있는지확인하고자하였다. 이에본연구는간호사의항암화학요법관련호중구감소증관리지침이행영향요인을확인하기위해보편적인대상자를위해개발된항암화학요법관련호중구감소증관리지침을종합하여이행정도를측정하고, 호중구감소증관리지침이행을 Pender [15] 건강증진모형의 행위의결과 로확인하고자하였다

3 Factors associated with Guideline Adherence of CIN 2. 연구목적본연구의목적은 Pender [15] 의건강증진모형을적용하여종양병동간호사의항암화학요법관련호중구감소증관리지침이행에영향을미치는요인을파악하기위함이다. 연구방법 1. 연구설계본연구는종양병동간호사의항암화학요법관련호중구감소증관리지침이행에영향을미치는요인을확인하기위한서술적조사연구이다. 2. 연구대상본연구에필요한대상자수는 G*Power 프로그램을사용하여다중회귀분석 (Linear multiple regression: Fixed model, R 2 deviation from zero) 에필요한적정수의표본크기를산출한결과유의수준 ( )=.05, 검정력 (1-β)=90%, 효과크기는 0.15 [18], 예측요인을 16개를감안하여최소 175명이었다. 본연구의대상병원은전라남도에위치한전남대학교화순병원으로연구진행당시 690개병상규모의암전문병원이었으며항암화학요법을활용하여환자를치료하는종양병동에근무하는간호사를대상으로선정하였다. 선정기준은항암화학요법을시행하는병동근무경력이 6개월이상이며, 독립적으로환자를직접간호하는간호사였다. 대상자선정기준에부합한간호사는총 17개병동 197명이었으며, 이중 187명이연구참여에서면동의하였고탈락자는없었다. 따라서회수율은 100% 였고, 탈락률은 0% 였다. 3. 연구도구수정 보완된도구의내용타당도는 2017년 6월 26일부터 7 월 3일까지종양전문간호사 4인과혈액내과임상교수 1인의총 5인전문가를통해내용타당도를검증하였다. 1) 일반적특성및직무관련특성일반적특성및직무관련특성은연령, 최종학력, 직위, 종양병동근무경력, 총근무경력, 호중구감소증관리교육경험, 호중구감소증관리에대한교육횟수, 호중구감소증관리교 육주체, 호중구감소증관리교육내용, 호중구감소증관리지침사용유무, 호중구관리지침개발주체의 11문항으로구성되었다. 2) 지각된유익성항암화학요법관련호중구감소증관리지침이행과관련된지각된유익성을측정하기위해서 Moon [19] 이개발한지각된유익성도구를본연구목적에맞게수정 보안하여사용하였다. 5인전문가를통한내용타당도결과, 12개문항의문항수준내용타당도 (Item level Content Validity Index, I-CVI) 는평균.93으로 12개문항모두.80 이상으로나타나 12개문항전체가선정되었다. 본연구의도구는원저자의승인을받아사용하였다. 지각된유익성도구의각문항은 거의그렇지않다 1점에서 매우그렇다 5점의 5점 Likert 척도로측정되었다. 가능한점수범위는최저 12점에서최고 60점까지로점수가높을수록지각된유익성이높음을의미한다. 개발당시신뢰도 Cronbach s 는.89였으며[19], 본연구에서는.93이었다. 3) 지각된장애성호중구감소증관리지침이행과관련된지각된장애성을측정하기위해서본연구에서는 Moon [19] 이개발한지각된장애성도구를본연구에맞게수정 보안하여사용하였다. 5인전문가를통한내용타당도결과, 11개문항의 I-CVI는 0.90으로 11개문항모두.80 이상으로나타나 11개문항전체가선정되었다. 본연구의도구는원저자의승인을받아사용하였다. 지각된장애성도구의각문항은 거의그렇지않다 1점에서 매우그렇다 5점의 5점 Likert 척도로측정되었다. 가능한점수의범위는최저 11점에서최고 55점까지로, 점수가높을수록지각된장애성이높음을의미한다. 개발당시신뢰도 Cronbach s 는.86[19] 이었으며, 본연구에서는.84였다. 4) 자기효능감호중구감소증관리지침이행과관련된자기효능감을측정하기위해서 Chang과 Crowe [20] 가간호사의근거기반실무에대한자기효능감을평가할목적으로개발한 Self-Efficacy in Evidence Based Practice activities (SE-EBP) 의한국어버전 [21] 을사용하였다. 본연구의도구는원저자와번역저자의승인을받아사용하였다. 문제설정 (5문항), 문헌검색 (9문항), 수행 (14문항) 의 3개영역총 28항목으로각문항은 전혀자신없다 0점부터 매우 Korean J Adult Nurs. 2019;31(4):

4 Kim, G-J Choi, JY 자신있다 10점의 10점 Likert 척도로축정되었다. 가능한점수범위는최저 0점에서최고 280점까지이며점수가높을수록근거기반실무수행에대한자기효능감이높은것을의미한다. 도구개발당시신뢰도는.88이었고, Oh 등 [21] 의연구에서신뢰도 Cronbach s 는.96이었으며, 본연구에서신뢰도 Cronbach s 는.97이었다. 5) 행위와관련감정행위와관련감정은행위와연관된주관적인긍정적, 부정적느낌을말하는것으로 [15], 호중구감소증관리지침이행과관련된행위와관련감정을측정하기위해 Pender [15] 가개발한도구의한국어버전 [21] 을사용하였다. 본연구의도구는원저자와번역저자의승인을받아사용하였다. 총 12개의각문항은 전혀그렇지않다 1점부터 매우그렇다 5점의 5점척도로측정하였으며, 8개의문항은역환산하였다. 가능한점수범위는최저 12점에서최고 60점까지로, 점수가높을수록행위와관련감정이긍정적임을의미한다. 도구개발당시신뢰도 Cronbach s 는.88이었으며, Kim [22] 연구에서는.85였고, 본연구에서는.89였다. 6) 대인관계영향요인대인관계영향요인이란타인의행위, 신념, 태도에대한인지를의미하므로호중구감소증관리지침이행과관련된대인관계영향요인은근거기반실무에대한신념으로측정하였다. Melnyk 등 [23] 이개발한근거기반실무에대한신념측정도구 (Evidence-Based Practice Beliefs Scale, EBPB) 의한국어버전을사용하였다. 본연구의도구는원저자와번역저자의승인을받아사용하였다. 총 16개의각문항은 매우부정 1점에서 매우긍정 5점의 5점 Likert 척도로측정하였으며, 2개의문항은역환산하였다. 가능한점수범위는최저 16점에서최고 80점까지로, 점수가높을수록근거기반실무에대한신념이높음을의미한다. 원도구 [23] 의신뢰도 Cronbach s 는.87, 본연구에서신뢰도는.86이었다. 의도구는원저자와번역저자의승인을받아사용하였다. 총 25개의각문항은 전혀그렇지않다 1점부터 매우그렇다 5점의 5점 Likert 척도로측정하였다. 가능한점수의범위는최저 25점에서최고 125점까지로, 점수가높을수록근거기반실무를위한조직의준비가잘되어있음을의미한다. 원도구 [24] 의신뢰도 Cronbach s 는.85, 본연구에서신뢰도는.92였다. 8) 호중구감소증관리지침이행항암화학요법관련호중구감소증관리지침이행도구는본연구자가기존관리지침을합성한도구를사용하였다. (1) 체계적인검색관리지침합성을위해첫번째단계로체계적인검색을실시하였다. 검색기간은 2017년 7월 1일부터 2017년 7월 20일까지였다. 체계적문헌검색을위해서핵심질문으로연구의대상 (P) 은항암화학요법관련호중구감소증환자, 중재방법 (I) 은간호관리를선택하였다. 문헌의선정기준은 1) 2000년 1월부터검색당시인 2017년 7월까지발표된문헌 2) 언어는영어와한국어 3) 성인대상 4) 항암화학요법관련호중구감소증가이드라인이포함된문헌 5) 원문을확인할수있는문헌 6) 동료평가문헌이었다. 검색데이터베이스는국외의경우 Pubmed, CINAHL 및 EMBASE를사용하였고, 국내의경우한국의학논문데이터베이스와 RISS를사용하였다. MeSH를통해주요단어들의유의어를확인하였고모든검색어를활용하여검색하였다. 검색식을활용하여검색된 1차문헌은총 650편의논문이검색되었다. 중복문헌 478편이제외되어 172편의문헌이선별되었다. 연구자와체계적문헌고찰경험이있는전문가 1 인이독립적으로제목과초록을검토하였고, 의견의일치가되지않은경우두문헌선별자가논의하여 100% 합의하여선별하였다. 연구와관련없는 152편, 선정기준중간호관리에관련된연구가아닌문헌 9편, 연구의원문을찾을수없는문헌 5편, 동료평가가시행되지않은문헌 1편을제외하여최종적으로 5 편의문헌 [3,4,9-11] 이선별되었다 (Figure 1). 7) 상황적영향요인호중구감소증관리지침이행과관련된상황적영향요인을측정하기위해조직문화를측정하였다. Fineout-Overholt와 Melnyk [23] 가개발한 Organizational Culture and Readiness for System-wide Implementation of Evidence-based Practice (OCRSIEP) 의한국어버전을사용하였다. 본연구 (2) 호중구감소증관리지침종합및번역최종선정된 5편의문헌 [3,4,9-11] 의호중구감소증관리지침에제시된권고안을종합하였다. 호중구감소증관리지침권고안을종합한방법은첫째, 5편의관리지침에서한번이라도권고하는권고안을모두채택하였고, 둘째, 관리지침에따라권고안이상충되는경우연구의최신성과연구설계를고려하 392

5 Factors associated with Guideline Adherence of CIN Figure 1. Flow chart of literature selection. 여결정하였고, 셋째, 관리지침에따라권고안이유사하기는하나완전일치하지않은경우에는연구의최신성, 연구설계및효과크기를고려하여종합하였다. 권고안채택은연구자 1인과근거기반연구전문가 1인이각각독립적으로결정한후불일치한경우 100% 합의하였다. 종합된호중구감소증관리지침은영어에능통하며근거기반연구에전문가 1인이종합된권고안의초안을번역하였고, 종양전문간호사 1인이안면타당도검증을하였다. 안면타당도결과, 모두수용되었다. 종합된항암화학요법관련호중구감소증관리지침의하부영역은환경관리, 구강관리, 식이관리, 환자교육및간호실무로구성되었다. (3) 항암화학요법관련호중구감소증권고안내용타당도검증혈액내과전문의 2인, 종양전문간호사 8인총 10인의전문가집단을통하여종합및번역된호중구감소증권고안에대한내용타당도를검증하였다. 각문항에대해전혀적절하지않음, 적절하지않음, 적절함, 매우적절함으로 4점척도로평가하였고, 전체도구의내용타당도 (total CVI, T-CVI) 값은평균.90, 총 37문항의 I-CVI 0.8 이상으로모두채택되었다. (4) 호중구감소증관리지침이행도구최종완성된호중구감소증관리지침이행측정도구는총 5 개영역 37문항으로, 하위영역은환경관리 8문항 ( 최소 4점에서최대 32점 ), 구강간호 6문항 ( 최소 4점에서최대 24점 ), 식이관리 4문항 ( 최소 4점에서최대 16점 ), 환자교육 7문항 ( 최소 4 점에서최대 28점 ), 간호실무 12문항 ( 최소 4점에서최대 48점 ) 으로구성되었다 (Table 1). 이행여부는 4점척도로 항상수행한다 4점, 가끔수행한다 3점, 거의수행하지않는다 2점, 전혀수행하지않는다 1점으로최저 37점에서최고 148점까지분포를보이며, 점수가높을수록호중구감소증관리지침이행정도가높음을의미한다. 본연구에서호중구감소증관리지침이행도구의전체신뢰도 Cronbach s 는.94였고, 하위영역별로는환경관리.81, 구강간호.82, 식이관리.90, 환자교육.80, 간호실무.90이었다. 4. 자료수집자료수집기간은 2017년 9월 18일부터 9월 26일까지이었다. 자료수집전연구대상병원의연구심의위원회심의를거친후제출된계획을준수하여연구가진행되었다. 훈련된연구보조 Korean J Adult Nurs. 2019;31(4):

6 Kim, G-J Choi, JY 원이자발적으로참여에서명동의한간호사에게설문지를배부하도록하였고, 연구보조원이작성된설문지를수거하였다. 설문내용중대상자가이해하지못한단어나문장은없었다. 설문은약 40분정도가소요되었고, 연구참여자에게감사의의미로 1만원상당의사례품을제공하였다. 5. 연구대상자의윤리적고려본연구는전라남도에위치한전남대학교화순병원생명윤리심의위원회 (IRB) 의심의를거쳐시행되었다 ( 연구번호 : CNU HH ). 연구대상자에게는연구참여에대한서면동의를받았으며, 서면동의전에연구의목적, 자료수집방법, 연구대상자의익명성과비밀보장에관한사항과연구를진행하는동안언제든지원하지않경우에는철회할수있음을설명하였다. 수집된대상자의서면자료는연구한논문이발표된후문서파쇄기를이용하여모두폐기할예정이며, 환자의개인정보를포함한전자파일은복원이불가능한방법으로영구적으로파기할예정이다. 6. 자료분석본연구의자료는 SPSS/WIN 24.0 프로그램을이용하여분석하였다. 대상자의일반적특성및직무관련특성, 항암화학요법관련호중구감소증관리지침이행은기술통계를이용하여실수와백분율, 평균및표준편차로분석하였고, 대상자의일반적특성및직무관련특성에따른항암화학요법관련호중구감소증관리이행의차이는 independent t-test, one-way ANOVA로분석하였다. 분산분석시등분산가정을충족하는경우사후검정은 Scheffe test로, 등분산가정을충족하지않는경우에는 Welch s test, 사후검정은 Games-Howell test로분석하였다. 대상자의지각된유익성, 지각된장애성, 자기효능감, 행위와관련된감정, 대인관계영향요인, 상황적영향요인과관련항암화학요법관련호중구감소증관리이행과의상관관계는 Pearson s correlation coefficient를이용하여분석하였다. 대상자의항암화학요법관련호중구감소증관리지침이행에영향을미치는요인은 Stepwise multiple regression 을이용하여분석하였다. 이중불연속변수인대상자의특성변수는가변수 (Dummy variables) 로전환하였다. 연구결과 1. 항암화학요법관련호중구감소증관리지침이행수준 본연구에서전체항암화학요법관련호중구감소증관리지침이행정도는 148점만점중평균 ±16.63점이었다. 이를하부영역별로살펴보면환경관리가 32점만점중평균 25.96±4.46점, 구강관리가 24점만점중평균 17.28±3.98점, 영양관리가 16점만점중평균 13.51±2.79점, 환자교육이 28 점만점중평균 22.97±3.86점및간호실무가 48점만점중평균 43.18±5.29점이었다. 각문항중 침습적시술시무균적으로시행한다. 가 3.78±0.48점으로이행정도가가장높았고, 그다음으로는 정맥주사및중심정맥관부위의감염과염증징후를정기적으로관찰한다. 가 3.72±0.53점, 호중구감소증환자발열시최소한 2가지이상의혈액배양검사를실시해야하며적어도한곳은말초정맥에서실시한다. 가 3.72±0.51 점의순으로나타났다. 호중구감소증관리지침이행정도가가장낮은문항은 Bolus로주입되는 5-FU 투여환자는구강점막염을예방하기위해약물주입시냉동요법 ( 아이스칩 ) 을시행한다. 5-FU의주입 5분전부터주입후 30분까지구강내에아이스칩을물고있도록지시한다. 가 1.65±0.82점으로나타났다 (Table 1). 2. 일반적특성및직무관련특성에따른항암화학요법관련호중구감소증관리지침이행차이본연구의대상자는모두여성이었으며, 연령은평균 ±6.20세였다. 최종학력은 4년제대학졸업자가 144명 (77.0%) 으로가장많았고, 일반간호사가 172명 (92.0%) 으로대부분이었다. 간호사로서총근무경력과종양병동근무경력은각각평균 89.07±72.14 ( 최소 6개월에서최대 294개월 ) 개월과평균 59.16±50.46 ( 최소 6개월에서최대 256) 개월이었다. 호중구감소증관리교육을받은경험이있는간호사는 113명 (60.4%), 교육을받은경험이있는 113명중 86명 (76.1%) 이 1년에 1회교육을받은것으로나타났다. 교육주체는다중응답처리한결과, 병원자체직무교육인경우가 100명 (73.5%) 으로가장많았으며, 교육내용역시다중응답이었는데, 감염예방이 91명 (32.2%) 으로가장많았다. 호중구감소증관리지침사용경험이있는경우는 93명 (49.7%) 이었는데, 지침사용경험이있는 93 명에서사용한지침은대부분 (86명, 92.5%) 병원자체지침이었다

7 Factors associated with Guideline Adherence of CIN Table 1. Level of Items for Guideline Adherence of Chemotherapy Induced Neutropenia Subdomains Items M±SD I. Environmental management 25.96± Healthcare providers should continue to recommend that neutropenic patients avoid or minimize exposure to potentially infectious people. 2 Severely immunocompromised patients, such as patients who receive hematopoietic stem cell transplant, need to be cared in a room with a High-Efficiency Particulate Arresting (HEPA) filter. 3 Patients with neutropenia need to maintain high standards of hygiene quality. 4 During building construction or maintenance work, containment barriers need to be deployed to protect from harmful dust and airborne particles. V V 3.57±0.60 V 2.63±1.07 V 3.20±0.80 V 3.19± Do not open the windows of the patient room. V 3.16± The patients room for patient with neutropenia limits natural flowers, dry flowers and plants. 7 Visitors should be screened for symptoms indicating potential respiratory infection and instructed not to visit patients if an infection is found. 8 Patients with neutropenia avoid contact for 48 hours with people who have recently received live vaccine or attenuated vaccine. V V V V V 3.60±0.74 V V V V 3.50±0.74 V 3.11±1.03 II. Oral care 17.28± Patients who receive bolus 5-fluorouracil (5-FU) therapy perform cryotherapy (ice chips) to prevent oral mucositis. 10 If possible, the patients have an oral examination from dentists prior to the start of treatment, and if dental treatment is necessary, begin dental treatment before chemotherapy begins. 11 Apply the oral care protocol, including regular brushing and patient education, to reduce oral mucositis of the patient with neutropenia. 12 Educate the patients about frequent oral care including toothbrushing and gentle flossing as tolerated. 13 Complications from oral mucositis can be minimized by keeping the mouth and lips moisturized, drinking enough water, avoiding spicy foods, very hot or cold foods, alcohol and smoking. 14 Before beginning chemotherapy, the nurses perform oral assessments more than once a day after an initial assessment and encourage patients with neutropenia to participate actively in their oral assessment. V 1.65±0.82 V 3.08±0.98 V 3.07±0.96 V V 3.16±0.87 V 3.40±0.78 V 2.92±1.02 III. Diet 13.51± Diet education for neutorpenia patient is to avoid uncooked meats, seafood, and eggs and unwashed fruits and vegetables. 16 Neutropenia patients should avoid eating non-pasteurized milk or beer, yogurt and cheeses made from unpasteurized milk. 17 If cooked poorly or improperly cooked, the processed meat, a sandwich, and chilled cooked pies should be avoided because of the high risk infection. 18 If visitors bring favorite food for neutropenic patients during hospitalization, the food has to be checked with a staff nurse. V V V 3.56±0.71 V 3.45±0.76 V 3.41±0.78 V 3.10±0.93 1=Nursing care, education and support for patients with neutropenia; 2=Neutropenia: state of the knowledge part II; 3=Evidence-based care for the neutropenic patient with leukemia; 4=Evidence-based nursing practice to prevent infection in hospitalized neutropenic patients with cancer; 5=Putting evidence into practice: prevention of infection. Korean J Adult Nurs. 2019;31(4):

8 Kim, G-J Choi, JY Table 1. Level of Items for Guideline Adherence of Chemotherapy Induced Neutropenia (Continued) Subdomains Items IV. Patient education 22.97± M±SD 19 Healthcare providers should educate patients and families about the importance of proper method and time period for hand washing. 20 To wear a high-efficiency mask to prevent the infection of the Aspergillus infections. 21 Neutropenic patients should avoid contact with animal feces, saliva, urine, or solid litter box material and direct or indirect contact with reptiles. 22 Daily showers or baths can help to lower the risk of infection by reducing the number of bacteria on patients' skin. 23 Educate patients to avoid any activities that can harm the skin; use an electronic shaver and keep nails short. 24 Patient instructions to report the following signs and symptoms of infection: temperature of F or higher, chills and sweating, sore throat, cough and shortness of breath, burning on urination, diarrhea, and redness or swelling at a site of injury. 25 To prevent injury to the mucous membrane, educate the use of water-soluble lubricant during sexual intercourse, and women to refrain from using tampons. V V V V 3.48±0.69 V V 2.70±1.11 V 3.49±0.72 V 3.20±0.82 V V 3.41±0.75 V 3.68±0.62 V 3.01±0.95 V. Nursing management 43.18± It is essential that clinical observations, with a special emphasis on temperature, are recorded at least every four hours and more frequently as necessary. 27 Check the number of luekocytes, in particular the number of Absolute Neutrophil Count (ANC) per day. 28 Invasive procedures, such as the insertion of central catheters or foley catheter, should be avoided if possible when the patient is neutropenic nadir. 29 Access sites for intravenous (IV) and central catheters are checked regularly for signs of inflammation and infection. 30 If an invasive procedure has to be undertaken, strict aseptic techniques must be used to prevent pathogens gaining access to the tissues. 31 The infusion lines injected with blood lipids, or parenteral nutrition are exchanged daily, and the other infusion lines change once a week. 32 Fever in the setting of neutropenia is considered an oncologic emergency, which worthy of initiation of empiric antimicrobial therapy within 60 minutes. 33 Fever evaluation is including at least two blood cultures, with at least one drawn peripherally. 34 If a central catheter is removed due to infection or suspected infection, best practice suggests that the catheter tips should be cultured for bacterial growth. 35 Fever evaluation should include cultures of the urine and any open lesions or wounds. 36 Constipation needs to be proactively by using active measures such as prophylactic stool softeners. V 3.44±0.72 V 3.68±0.59 V V 3.56±0.66 V 3.72±0.53 V 3.78±0.48 V 3.53±0.79 V 3.44±0.73 V 3.72±0.51 V 3.65±0.59 V 3.63±0.60 V 3.44± Restrict invasive treatment, such as enema or suppositories. V 3.58±0.60 Total ± =Nursing care, education and support for patients with neutropenia; 2=Neutropenia: state of the knowledge part II; 3=Evidence-based care for the neutropenic patient with leukemia; 4=Evidence-based nursing practice to prevent infection in hospitalized neutropenic patients with cancer; 5=Putting evidence into practice: prevention of infection

9 Factors associated with Guideline Adherence of CIN Table 2. Performance according to General and Job related Characteristics (N=187) Characteristics Categories n(%) M±SD Total (37~148) ±16.63 Environmental care (8~32) 25.96±4.46 Oral care (6~24) 17.28±3.98 Nutritional care (4~16) 13.51±2.79 Patient education (7~28) 22.97±3.86 Nursing practice (12~48) 43.18±5.29 Performance t or F (p) Scheffe Age (year) 29 a 30~39 b 40~49 c 100 (53.5) 62 (33.1) 25 (13.4) 31.18± ± ± ± (.003) c>a Education College a Bachelor b Master c 15 (8.0) 144 (77.0) 28 (15.0) ± ± ± (<.001) c>a, b Position General Charge 172 (92.0) 15 (8.0) ± ± (.020) Whole Career for a nurse (year) <1 a 1~3 b 4~5 c 6~9 d 10 e 11 (5.9) 39 (20.9) 33 (17.6) 53 (28.3) 51 (27.3) ± ± ± ± ± (.003) e>c Career for a oncology nurse (year) <1 a 1~3 b 4~5 c 6~9 d 10 e 21 (11.2) 56 (30.0) 38 (20.3) 49 (26.2) 23 (12.3) ± ± ± ± ± (.009) e>a Experience of CIN education Yes No 113 (60.4) 74 (39.6) ± ± (<.001) Frequency of experience of CIN education per a year (n=113) (76.1) 27 (23.9) Institute for CIN education Hospital Nursing association Nursing academy Graduate school 100 (73.5) 18 (13.3) 9 (6.6) 9 (6.6) Contents of CIN education Prevention for infection Intervention Assessment Mechanism 91 (32.2) 86 (30.4) 55 (19.4) 51 (18.0) Experience of performing guideline for CIN Yes No 93 (49.7) 94 (50.3) ± ± (<.001) Sources of guideline for CIN (n=93) Hospital itself Academy 86 (92.5) 7 (7.5) CIN=Chemotherapy Induced Neutropenia; Scheffe test; Games-Howell test; Multiple response. Korean J Adult Nurs. 2019;31(4):

10 Kim, G-J Choi, JY 본연구에서종양병동간호사의항암화학요법관련호중구감소증관리지침이행정도는평균 ±16.63점, 4점만점에평균평점 3.32±0.45점이었다. 종양병동간호사의특성에따른항암화학요법관련호중구감소증관리지침이행정도는연령 (F=6.15, p=.003), 최종학력 (F=12.39, p<.001), 직위 (t= -2.35, p=.020), 간호사로서근무경력 (F=4.25, p=.003), 종양병동근무경력 (F=3.47, p=.009), 호중구감소증관리교육경험 (t=5.91, p<.001), 호중구감소증관리지침사용경험 (t=4.16, p<.001) 에따라통계적으로유의한차이가있었다. 연령은사후검정결과 40-49세집단이 29세미만집단보다호중구감소증관리지침이행정도가높았고, 최종학력은사후검정결과석사이상학위자가전문학사와학사학위자에비해높았다. 간호사로서근무경력은사후검정결과 10년이상근무경력자가 3-5년미만근무경력자보다, 종양병동근무경력은사후검정결과 10년이상근무경력자가 1년미만근무경력자에보다호중구감소증관리지침이행정도가더높았다. 직위는책임간호사가일반간호사보다호중구감소증관리지침이행정도가더높았고, 호중구감소증관리교육경험이있는경우가없는경우에비해, 호중구감소증관리지침사용경험이있는경우가없는경우에비해호중구감소증관리지침이행정도가더높았다 (Table 2). 3. 호중구감소증관리지침이행과각변수들간의상관관계종양병동간호사의호중구감소증관리지침이행정도와 Pender [15] 의건강증진모형에포함되어있는변수인지각된유익성, 지각된장애성, 자기효능감, 행위에대한감정, 대인관련영향요인및상황적영향요인간상관관계분석을실시한결 과는 Table 3과같다. 호중구감소증관리지침이행정도는지각된유익성 (r=.37, p<.001), 자기효능감 (r=.36, p<.001), 행위에대한감정 (r=.16, p=.031), 대인관련영향요인 (r=.41, p<.001), 상황적영향요인 (r=.16, p=.025) 과는유의한순상관관계를, 지각된장애성 (r=-.23, p=.002) 과는유의한역상관관계가있는것으로나타났다. 4. 종양병동간호사의호중구감소증관리지침이행영향요인종양병동간호사의호중구감소증관리지침이행정도에영향을미치는요인을파악하기위하여단변량검증에서유의한변인들을회귀분석식에투입한후단계적다중회귀분석을실시하였다. 독립변수간의상관관계를분석한결과연령과간호사로서총근무경력의상관계수가.98로나타났고, 나머지변수들은.80 미만으로나타나연령을제외하고나머지변수를분석에투입하였다. 케이스진단시절대값 3보다큰이상점은없었으며, 단계선택방식을이용하여분석하였다. 독립변수에대한회귀분석의가정을검증한결과오차의자기상관 ( 독립성 ) 검증에서는 Durbin-Wastson 통계량이 2.01로 2에가까웠기때문에자기상관이없었고, 다중공선성의문제는공차한계가.62~.92로 0.1 이상으로나타났으며, 분산팽창지수 (Variance Inflation Factor, VIF) 도 1.09~1.61로 10을넘지않아문제가없었다. 잔차의가정을충족하기위한선형성, 정규성, 등분산성의가정도만족하였고, 특이값을검토하기위한 Cook s distance 값은 1.0을초과하는값이없어특이값도없는것으로확인되었다. 모형의설명력을나타내는수정된결정계수 (Adj. R 2 ) 는.31로설명력은약 31% 였다 (Table 4). 종양병동간호사의호중구감소증관리지침이행정도의가장 Table 3. Correlation among Main Variables associated with Guideline Adherence of Chemotherapy Induced Neutropenia (N=187) Perceived benefits Perceived barriers Affects related behavior Interpersonal influences Situational influences Self-efficacy Variables r(p) r(p) r(p) r(p) r(p) r(p) Perceived barriers -.21 (.005) 1 Self-efficacy.28 (<.001) -.21 (.005) 1 Affects related behavior.23 (.001) -.47 (<.001).18 (.014) 1 Interpersonal influences.47 (<.001) -.33 (<.001).49 (<.001).30 (<.001) 1 Situational influences.20 (.007) -.19 (.008).32 (<.001).22 (.002).38 (<.001) 1 Guideline adherence.37 (<.001) -.23 (.002).36 (<.001).16 (.031).41 (<.001).16 (.025) 398

11 Factors associated with Guideline Adherence of CIN Table 4. Factors associated with Guideline Adherence of Chemotherapy Induced Neutropenia for Oncology Nurses (N=187) Variables B SE β t p 95% CI (Constant) < ~83.95 Experience of CIN education (ref. yes) < ~13.29 Self-efficacy ~2.12 Perceived benefits ~2.72 Interpersonal influences ~2.83 Education (ref. master) ~12.31 R 2 =.33, Adjusted R 2 =.31, F=17.76, p<.001 Durbin-Wastson=2.01, Tolerance=.62~.92, VIF=1.09~1.61 CIN=Chemotherapy Induced Neutropenia; CI=confidence interval; VIF=Variance Inflation Factor. 주요한예측요인은호중구감소증관리에대한교육경험 (β=.26, p<.001) 이었고, 그다음으로는자기효능감 (β=.17, p=.018), 지각된유익성 (β=.16, p=.026), 대인관계영향요인 (β=.16, p=.043), 최종학력 (β=.14, p=.030) 인것으로나타났다 (Table 4). 논의 본연구는종양간호사를대상으로항암화학요법관련호중구감소증관리지침이행을파악하고, 이에영향을미치는요인을 Pender [15] 의건강증진모형의변수로분석하고자하였다. 종양병동간호사의항암화학요법관련호중구감소증관리지침이행정도는 148점만점에평균 122.9점 ( 만점대비 80% 이상 ) 이었다. Nirenberg 등 [8] 의선행연구에서도간호사의 80% 이상이항암화학요법관련호중구감소증관리를위해임상진료지침을사용하였다. 항암화학요법관련호중구감소증환자는근거기반관리지침을준수하지않을경우치명적인위험에노출될가능성이매우높기때문에항암화학요법관련호중구감소증환자관리지침이행이상대적으로잘된것으로생각된다. 하부영역별로이행정도를살펴보면구강관리의경우 24점만점중평균 17.2점으로가장낮은이행영역이었다. 구강관리영역에서구강사정이나냉동요법과같이준수가잘되지않는항목들도있었기때문에근거기반관리지침을지금보다더잘준수하기위해영향을미치는요인에관한논의가필요하다고판단된다. 본연구에서는종양간호사의항암화학요법관련호중구감소증관리지침이행에영향을미친요인으로호중구감소증관리교육경험, 자기효능감, 지각된유익성, 신념및최종학력이영향요인으로나타났다. 이중에항암화학요법관련호중구감소증관리교육경험유무가가장영향이컸다. 본연구는 Pender [15] 의건강증진모형에근거하여간호사의이전개인적경험이변수로선택되었다. 따라서간호사의현재근거기반지식수준을평가하는대신항암화학요법관련호중구감소증관리에관한교육경험유무를측정하였다. 교육과지식간의상관관계에관한연구결과는다양하다. 따라서교육을받았다고지식이반드시향상되는것은아니지만, 근거기반지침은최신연구결과를체계적으로종합하고있기때문에교육을통해최신연구결과를접하는것이매우중요하다고생각된다. 매일의업무가많은간호사들이최신의연구결과를체계적으로검색하여확인하는일은근거기반실무를저해하는요인으로보고되고있다 [25]. 물론본연구와전체선택변수는달랐지만, 요양병원에근무하는간호사를대상으로신체억제대지침이행에영향을미치는요인에관한연구에서도간호사의지식을변수로선택하지않고교육경험을선택하였는데, 교육경험이단변량에서는의미가있었으나다변량분석에서는의의를보이지못했다 [26]. 반면, 상급종합병원간호사를대상으로근거기반실무역량에영향을미치는요인에관한연구에서는학회참석유무와정보검색능력이다변량분석에서의의가있었다 [25]. 따라서간호사들이최신의연구결과를체계적으로검색하여확인하는일이쉽지않기때문에병원이나학회차원의교육을통해최신의연구결과를교육하고최신의근거를실천하도록독려하는일은매우중요하다고생각된다. 본연구에서간호사의지식을확인하지않았기때문에간호사의교육경험이간호사의지식으로연결되었는지는확실하지않으며, 새롭게알아야하는지식과근거기반지침에대한이해처럼이미형성된지식에새로운지식을추가하거나새로운지식으로대체하는경우교육이간호사의지식형성에중요한것인가에대한추후연구가필요하다. 다음으로종양간호사의항암화학요법관련호중구감소증 Korean J Adult Nurs. 2019;31(4):

12 Kim, G-J Choi, JY 관리지침이행에영향을미친요인은자기효능감이었는데, 자기효능감이높을수록항암화학요법관련호중구감소증관리지침이행이높았다. 기존연구에서항암화학요법관련호중구감소증관리지침은아니지만, 근거기반지침이행에관한간호사의인식및준수에관한연구에서자기효능감이관련요인으로나타났다 [27]. 간호사대상은아니지만, 임상현장교육자가인식하는근거기반실무교육의장애요인및촉진요인에대한탐색연구 [21] 에서자기효능감이교육자의대학원과정중근거기반실무교육을받은경우높은것으로나타났다. 항암화학요법관련호중구감소증은다빈도발생하는증상이며발생자체만으로도환자에게미치는영향이크므로종양간호사는이에대해자기효능감을가지고대처하는일은매우중요하다. 암환자의면역력이매우낮아진상태에서호중구감소증관리는매우복잡하고어려운과제이기때문에종양간호사의자기효능감을강화할수있는전략개발이필요하다고판단된다. 본연구에서다음으로종양간호사의항암화학요법관련호중구감소증관리지침이행에영향을미친요인은지각된유익성으로지각된유익성이높을수록호중구감소증관리지침이행이높았다. 이는감염예방을위한간호사의손씻기수행과지각된유익성이상관관계가있는것으로나타난것과비슷한결과를보였다 [28]. 비록간호사의수행은아니지만 Pender의건강증진이론을적용하여당뇨환자의영양행위 [29], 고혈압환자의수축기혈압 [30] 등다양한대상자의건강증진행위에서지각된유익성은공통적으로건강증진행위와상관성이있었거나영향요인이었거나직접적인경로를보여주었다. 따라서대상자의직접적인건강증진행위는아니었지만, 간호사의항암화학요법관련호중구감소증관리지침이행을통해대상자가감염으로부터보호될수있다는지각된유익성이영향을미친것으로해석된다. 따라서항암화학요법관련호중구감소증관리지침교육시간호사의호중구감소증관리지침이행을통해대상자가얻을수있는이익에관한내용을포함하는것이중요하다고여겨진다. 본연구에서종양병동간호사의항암화학요법관련호중구감소증관리지침이행에영향을미친요인은대인관계영향요인이었는데, 본연구에서는대인관계영향요인을근거기반실무에대한신념으로측정하였다. Jang과 Park [31] 의연구결과간호사의신념이근거기반의사결정에유의한정적영향을미치는것으로나타나본연구와비슷한결과를나타냈다. 그러므로지속적인교육프로그램을통해간호사의대인관련영향요인을높이면호중구감소증관리지침이행을높일수있을것으로판단된다. 본연구에서마지막으로종양간호사의항암화학요법관련호중구감소증관리지침이행에영향을미친요인은최종학력이었다. 석사학위이상의학력을가진간호사가전문학사나학사소지자에비해항암화학요법관련호중구감소증관리지침이행을더잘하는이유는대학원교육과정이대부분근거기반간호실무를강조하고있기때문으로생각된다. 임상현장교육자가인식하는근거기반실무교육의장애요인및촉진요인에대한탐색연구가이루어졌는데 [21], 자기효능감이교육자의대학원과정중근거기반실무교육을받은경우높은것으로나타났다. 따라서석 박사학위과정에서배운근거기반실무교육을통해지침수행에대한자기효능감이높아졌고이로인해지침이행이높아진것으로생각된다. 따라서추후연구에서는자기효능감이매개변수로서근거기반실무지침이행에영향을미치는지여부를확인하는연구가필요하다고판단된다. 본연구결과를종합해볼때개인의건강증진행위를설명하기위해개발된 Pender [15] 의건강증진모델은대상자에게질적간호를제공하고자하는간호사의지침수행을설명하는데도적절함을알수있었다. 다만본연구에서는행위에대한감정과상황적영향요인변수가항암화학요법관련호중구감소증관리지침이행에영향을미치지못했다. 또한대상자의직접적인건강증진행위영향요인을살핀연구에서설명력이 50% 이상 [32,33] 으로본연구결과에비해높은것을감안했을때간호사의행위가환자의건강과직결되는상황일지라도행위에대한감정과상황적영향요인변수가관리지침이행을설명하지못한이유와나머지 68.9% 의이행을설명하는다른변수에대해추후연구가필요하다고생각된다. 따라서추후연구에서는개인의건강증진행위와대상자의건강증진을위한간호사의질적간호행위간에차이가있는지에대한고찰이생각된다. 따라서교육적측면에서환자의건강과직결되는간호사의행위를설명하는데 Pender의건강증진모델이적합하다는점에서의의가있으며환자의건강과직결되는건강증진행위에관한내용을교육과정에서다룰필요가있고, 연구적측면에서는간호사의건강증진행위를어떤경로를통해설명을하는지에관한추후반복연구가필요하며, 임상실무적인측면에서는간호사의자기효능감, 신념등을증진할수있는전략개발의근거자료로활용될수있을것으로여겨진다. 그러나본연구는일개병원의간호사를대상으로하였기에연구결과를일반화하는데주의해야하며, 항암화학요법관련호중구감소관리지침이행도구를본연구자가개발하였지만이행정도에따라준수정도를파악할수없기때문에대상자의이행정도가높은지낮은지에대한기준마련이필요하다고판 400

13 Factors associated with Guideline Adherence of CIN 단된다. 또한 Pender의건강증진모형을적용한종양간호사의항암화학요법관련호중구감소관리지침이행영향요인을확인하였는데, 대상자자신과간호사의건강증진행위간차이정도를확인하지못한채이론검증을하였다는점에서본연구의제한점이있다. 결론및제언 본연구는 Pender [15] 건강증진모델을적용하여종양병동간호사의항암화학요법관련호중구감소증관리지침이행을파악하였는데, 종양간호사가호중구감소증관리교육경험있고, 지각된유익성, 자기효능감및대인관계영향요인, 최종학력이높을수록호중구감소증관리지침이행정도가높았다. 따라서환자에게제공될유익성을강조하며근거기반관리지침실천에대한자기효능감과신념을높일수있는병원, 학교혹은학회차원의프로그램개발및교육이필요하다고생각된다. 또한환자의건강증진과직결되는간호사의행위를설명하는데 Pender 건강증진모델적용이타당한지에관한추후반복연구가필요하다. CONFLICTS OF INTEREST The authors declared no conflict of interest. AUTHORSHIP Study conception and design acquisition - KG-J and CJY ; Data collection - KG-J; Analysis and interpretation of the data - KG-J and CJY; Drafting and critical revision of the manuscript - KG-J and CJY. ACKNOWLEDGEMENT This article is a revision of the first author's master's thesis from Chonnam National University. REFERENCES 1. Korean Oncology Nursing Society. Oncology nursing: treatment and care. 3rd ed. Seoul: Fornurse; p Baden LR, Swaminathan S, Angarone M, Blouin G, Camins BC, Casper C, et al. Prevention and treatment of cancer-related infections, Version , NCCN clinical practice guidelines in oncology. of the National Comprehensive Cancer Network. 2016;14(7): Nirenberg A, Bush AP, Davis A, Friese CR, Gillespie TW, Rice RD. Neutropenia: state of the knowledge part II. Oncology Nursing Forum. 2006;33(6): Coughlan M, Healy C. Nursing care, education and support for patients with neutropenia. Nursing Standard. 2008;22(46): Methven C. Effects of chemotherapy-induced neutropenia on quality of life. Cancer Nursing Practice. 2010;9(1): Kim MA, Jeong IS. Comparison of perception of the neutropenic diet between nurses and patients. Asian Oncology Nursing. 2012;12(4): Jeon OK, Yim SE, Jeong IS, Yun EY, Kim MH, Park YS, et al. Survey on dietary restrictions for neutropenic patients. Asian Oncology Nursing. 2010;10(2): Nirenberg A, Reame NK, Cato KD, Larson EL. Oncology nurses' use of National Comprehensive Cancer Network clinical practice guidelines for chemotherapy-induced and febrile neutropenia. Oncology Nursing Forum. 2010;37(6): Shelton BK. Evidence-based care for the neutropenic patient with leukemia. Seminars in Oncology Nursing. 2003;19(2): Larson E, Nirenberg A. Evidence-based nursing practice to prevent infection in hospitalized neutropenic patients with cancer. Oncology Nursing Forum. 2004;31(4): Zitella LJ, Friese CR, Hauser J, Gobel BH, Woolery M, O'Leary C, et al. Putting evidence into practice: prevention of infection. Clinical of Oncology Nursing. 2006;10(6): Bae KH. Development of the evidence-based nursing guideline for neutropenia induced infection in elderly patients with hematologic malignancy [master's thesis]. Seoul: Yonsei University; Kim JH, Lim KH. The factors influencing compliance of multidrug-resistant organism infection control in intensive care units nurses. Korean of Adult Nursing. 2015;27(3): Miller M, Kearney N. Guidelines for clinical practice: development, dissemination and implementation. International of Nursing Studies. 2004;41(7): Pender NJ. Health promotion in nursing practice. 7th ed. Pearson; Boston; p Ismaile S. Nursing Studies: promoters and barriers for adherence to clinical practice guidelines among nurses [dissertation]. Durhan: Durham University; Jun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review. Korean J Adult Nurs. 2019;31(4):

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