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1 J Korean Acad Nurs Adm ( 간호행정학회지 ) Vol , , September 2017 ISSN (Print) ISSN (Online) 국내근거기반간호연구의동향 류세앙 1 윤순원 1 김윤숙 2 목포대학교간호학과 1, 목포기독병원 2 Trends in Evidence-based Nursing Research in South Korea Ryu, Seang 1 Yun, Sun Weon 1 Kim, Yun Sook 2 1 Department of Nursing, Mokpo National University 2 Mokpo Christian Hospital Purpose: The purpose of this study was to analyze the current status of research related to evidence-based nursing and to suggest directions for the future of evidence-based nursing practice, education and research. Methods: A search was done of 20 research publications, including domestic nursing journals, nursing master's theses and doctoral dissertations before vember Finally, 183 studies were selected. The selected papers were analyzed using descriptive statistics and x 2 test with the SPSS/WIN 18.0 program. Results: Most of papers examined in this study were journal articles (80.9%). Meta-analysis (35.0%) was the most common study design. Methodological characteristics were as follows: before 2010 about 5% were documents that suggested Priori design, generation of PICO, search strategy, quality assessment and description of quality assessment outcome, but after 2011, these designs increased to 30.8%, 73.1%, 41.0%, 91.0% and 65.4%, respectively. The most frequent topics for evidence-based nursing implementation were evidence-based nursing readiness (16 papers). Highest frequency topics in systematic reviews and meta-analysis were studies that confirmed the intervention effect of exercise programs. The highest frequency topics in guideline were temperature control. Conclusion: Researchers' perceptions to improve research methodological quality and education to strengthen the research capability are necessary. Key Words: Evidence-based nursing, Nursing research, Trends 서론 1. 연구의필요성 과학적근거에기반한간호실무에대한연구가활발해지면서세계적으로근거기반간호가간호과학의한분야로자리잡고있다 [1]. 근거기반간호는보건의료실무의기반이되는중요한원리로임상실무와교육에서커다란패러다임의변화이며, 근거기반간호실무는 21세기간호사들이지녀야할핵심역량 중의하나이다 [1,2]. 간호사는임상실무에서발생하는임상질문에대한외적근거를얻기위해최상의연구들을검색하고, 이러한과학적근거를바탕으로임상적전문성, 환자의선호도, 사회적가치를통합하여근거기반간호를수행해야한다 [3]. 임상실무의질관리에서가장중요한것은 잘하는것보다올바른것을하는것 이다. 근거기반간호를통해최상의환자관리와환자결과를이끌어낼수있으며, 최소의비용으로최선의간호를제공함으로써간호의질을향상시킬수있다 [4]. 국내간호학계에서는 2004년대한간호학회주관으로근거 주요어 : 근거기반간호, 간호연구, 동향 Corresponding author: Yun, Sun Weon Department of Nursing, Mokpo National University, 1666 Yeongsan-ro, Cheonggye-myeon, Muan 58554, Korea. Tel: , Fax: , sunoen02@naver.com Received: Jun 2, 2017 Revised: Jul 26, 2017 Accepted: Aug 25, 2017 This is an open access article distributed under the terms of the Creative Commons Attribution n-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 2017 Korean Academy of Nursing Administration

2 류세앙 윤순원 김윤숙 기반간호의활용에대한학술대회가개최된이후, 다양한학술대회에서근거기반간호를발전시키기위한노력이전개되고있다 [5,6]. 간호연구수행으로도출된근거가표준화된실무로자리잡기위해서는연구결과의탐색과비평적분석및근거의통합이라는일련의과정을거쳐실무지침에반영되어야한다 [4,7]. 이러한근거의활용을통해간호실무의질적수준을향상시킬수있으므로간호학연구자들은근거를생성하고활용을촉진하는방안에대한연구를지속적으로수행해야한다. 국내에서는 2000년대이후임상과학계가힘을합하여근거기반간호의확산을위한연구들을수행해오고있다 [7]. 근거기반간호에서일차연구들의 2차합성을통해최상의근거를생성하려는체계적고찰과메타분석은임상적의사결정과간호수행에필요한과학적근거를제공해주는중요한연구이다 [8]. 국내에서도의학, 한의학, 치의학, 약학, 간호학등의보건의료분야에서체계적고찰연구가꾸준히증가하고있다. 보건의료분야의학술지별로체계적고찰연구에대한국내동향을살펴보면간호학분야의연구가 33% 로가장많았다 [9]. 하지만보건의료분야의국내학술지와국외학술지및기관보고서에출판된체계적고찰연구의질을비교했을때, 국내간호학술지연구의질이전반적으로낮았다 [9]. 또한국내간호학분야메타분석논문의질평가결과, 11점만점에평균 5.61점이었고, 9점에서 11점에해당하는높은수준의메타분석논문은 4.8% 에불과했다 [10]. 근거기반실무에대한연구결과들이높은근거수준으로활용되기위해서는양적증가뿐만아니라연구방법이나결과에대한신뢰성과타당성이우선전제되어야한다 [8]. 이를통해임상실무자들은높은수준의근거를간호에적용하여대상자의건강결과를향상시키고, 간호의질과신뢰를강화시킬수있다 [11]. 간호학의지식체확장을위해서는새로운지식체의개발뿐만아니라그동안축적된지식체의동향을파악하고이를바탕으로추후지식체의생성방향을조망해보는것이필요하다 [12]. 근거기반간호와관련된지식체의경향을분석하기위해수행된국내연구를살펴보면, 2008년부터 2010년까지대한간호학회지 (Journal of Korean Academy of Nursing, JKAN) 에게재된실험연구의분석을통해연구의현황을파악하고근거기반교육과실무에대한상황을검토한논문이한편있다 [8]. 하지만 Choe 등 [7] 의연구는출판연도별로제한된기간에하나의간호학회지에게재된실험연구의일반적인특성과중재영역에대한분석을시행하였으므로, 국내간호학계전반에걸친근거기반간호연구동향전체를파악하는데는한계가있다. 따라서좀더범위를넓혀, 국내간호학계에서근거기반간호의개념이도입된이후근거기반간호에대한연구가어떻게 이루어지고있는지그현황을살펴볼필요가있다. 이에본연구에서는국내 20개간호학회지에게재된논문과간호학석사및박사학위논문을대상으로근거기반간호를주제로다룬조사연구와실험연구, 일차연구들을 2차합성한체계적고찰과메타분석, 그리고임상실무지침개발또는수용개작연구의내용과경향을분석해보고자한다. 국내근거기반간호연구의일반적인특성과최상의근거를생성하기위해일차연구들을 2차합성하는연구방법론적특성및연구주제에대한동향분석은불필요한반복연구를시행하지않도록이끌어줄것이며, 근거기반간호연구의발전과간호실무의질적수준향상에도움이될것으로보인다. 2. 연구목적근거기반간호연구의동향을분석하여근거기반간호연구의방향을제시하기위함이다. 연구목적을위한연구수행과정은다음과같다. 국내근거기반간호연구의일반적특성을조사한다. 국내근거기반간호연구중일차연구들을 2차합성한체계적고찰과메타분석그리고임상실무지침개발연구의방법론적특성을파악한다. 근거기반간호실행과관련된주요주제를분석한다. 근거기반간호실무를위한근거유형별주제를분석한다. 3. 용어정의 : 조작적정의 1) 근거기반간호연구본연구에서정의하는근거기반간호연구는근거기반간호를주제로다룬조사연구와실험연구, 일차연구들을 2차합성하여근거를생성한체계적고찰과메타분석, 그리고임상실무지침개발또는수용개작연구를말한다. 근거기반간호를주제로다루지않은일차조사연구와실험연구및일차연구들의 2 차합성과정이없는문헌고찰논문은본연구의범위에서제외함을의미한다. 국내근거기반간호연구는국내에서출판된근거기반간호연구를말한다. 연구방법 1. 연구설계 본연구는근거기반간호와관련된연구의동향을분석하여 386 Journal of Korean Academy of Nursing Administration

3 국내근거기반간호연구의동향 근거기반간호연구의방향을제시하기위한문헌조사연구이다. 2. 연구대상본연구에서분석할문헌의선정과정은다음과같다. 먼저, 국내의간호와관련된 20개학회, 즉간호과학회, 성인간호학회, 기본간호학회, 여성건강간호학회, 정신간호학회, 지역사회간호학회, 간호행정학회, 간호교육학회, 노인간호학회, 근거기반간호학회, 임상간호연구, 대한근관절건강학회, 대한종양간호학회, 한국아동간호학회, 한국직업건강간호학회, 한국가정간호학회, 한국보건간호학회, 한국재활간호학회, 한국기초간호학회, 한국농촌간호학회의홈페이지를통해학술지문헌을검색하였다. 추가로간호학석사및박사학위논문을검색하기위해학술연구정보서비스 (RISS) 와국가과학기술정보센터 (NDSL) 를이용하였다. 20개간호학회지의문헌검색범위는각학회지의창간호부터 2016년 11월까지발표된연구의전수를조사하였고, 간호학석사및박사학위논문의경우는 RISS와 NDSL의데이터베이스구축이후부터 2016년 11월까지수록된논문의전수를조사하였다. 검색어는국내 DB검색기능을고려하여간단한용어를사용하였다. 검색어는근거기반, 근거중심, 증거기반, 증거중심, 메타분석, 가이드라인, 체계적고찰, 문헌고찰, 문헌검색, 문헌분 석, 실무지침이었다. 검색된문헌중근거기반간호를주제로다룬조사연구와실험연구, 임상실무지침개발또는수용개작, 체계적고찰과메타분석연구및근거기반간호의확산에대한논평을포함한간호학논문은선택되었다. 배제된논문은중복논문, 간호학외의타분야논문, 근거기반간호를주제로다루지않은조사연구와실험연구, 포스터나학술대회자료와같이전문 (full text) 을볼수없는논문그리고일차연구들의 2차합성과정이없는문헌고찰논문이었다. 앞에서제시된 11개의검색어를사용하여검색된문헌은학술지 397편, 학위논문 193편으로총 590편이었다. 일차로 590 편문헌의목록을프린트하여대조한결과 199편문헌이중복되었고간호학논문이아닌문헌은 15편이었으며본연구에서정의한근거기반간호연구의범주가아닌문헌은 88편이었다. 이를제외한후총 288편의문헌은우선초록을검토하였다. 288편의초록을검토한결과, 근거기반간호연구의범주가아닌문헌 63편, 학술대회문헌 5편, 포스터자료 2편이제외되었다. 초록을검토후선정된 218편은전문을찾아서재검토하였다. 전문재검토결과, 근거기반간호연구의범주가아닌문헌 35편을제외후 183편의문헌이최종선정되었다. 문헌추출과정은정확성을기하기위해선택및배제기준에따라 3명의연구자에의해독립적으로수행되었다 (Figure 1). Figure 1. Study flow diagram. Vol ,

4 류세앙 윤순원 김윤숙 3. 연구도구본연구에서사용한분석틀은근거기반간호와관련된논문의일반적특성과연구방법론적특성및연구주제의 3개범주로구성하였다. 먼저논문의일반적인특성인출판상황, 발표연도및연구설계는논문분석연구를수행한선행문헌 [12,13] 의고찰을통해도출되었다. 연구설계유형은실험연구와비실험연구로분류하였고조사연구, 체계적고찰과메타분석, 임상실무지침개발과수용개작은비실험연구에포함시켰다. 논문의윤리성분석을위해기관윤리심의위원회 (Institutional Review Board, IRB) 승인여부를확인하였다. 다음으로일차연구들의 2차합성과정을파악하기위한연구방법론적특성은체계적고찰과메타분석의질평가도구인 AMSTAR (Assessment of Multiple Systematic Reviews) 와보고지침 (Reporting guidance) 인 PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) 및임상실무지침평가도구인 AGREEII의체크리스트항목을참고하여도출하였다 [14]. 연구방법론적특성은사전계획, PICO (Patient/ Problem, Intervention, Comparison, Outcome) 생성, 체계적문헌검색, 문헌선정, 질평가이다. 연구방법론적특성중체계적문헌검색은미국국립의학도서관 (America national library of medicine, NLM) 이제시한 COSI (Core, Standard, Ideal) 모델을참고하였다 [14]. 분석할문헌의일반적특성과연구방법론적특성을발표시기별로분석하기위해 2004년이전과 2005 년에서 2010년, 2011년에서 2016년으로분류하였으며범주화기준은다음과같다. 2004년대한간호학회주관으로근거기반간호의활용에대한학술대회가개최된이후전문가단체를중심으로한학술대회에서근거기반간호가소개되었으며, 간호부차원에서도근거기반간호를위한노력이전개되고있어 2004년이전의문헌을첫번째범주화기준으로하였다 [5]. 2010년에근거기반간호연구를지원하고발전시키기위해발족된한국근거기반간호연구회를중심으로근거기반간호연구방법론에대한교육이본격화되었고, 2011년에는한국주최로개최된아시아 8개국의간호학자와대학원생이참여한동아시아간호포럼을통해근거기반간호연구에대한관심이동아시아로확장공유되었다 [7]. 이를근거로 2011년전후를두번째와세번째범주화기준으로하였다. 마지막으로연구주제는근거기반간호의실행과근거기반간호실무를위한근거유형별주제로나누어서구성하였다. 근거기반간호의실행은근거기반간호를주제로다룬조사연구와실험연구를중심으로근거기반간호실행을위한준비도, 근 거기반간호교육, 임상실무지침의이행그리고기타의 4개영역으로나누어분류하였다. 근거기반간호실무를위한근거유형별주제를파악하기위해먼저근거의유형을임상실무지침개발또는수용개작, 체계적고찰과메타분석연구로나누어분류하였고, 체계적고찰과메타분석은간호중재의효과를확인한연구와관련변인의효과크기를확인한연구로재분류하였다. 근거유형별주제는성인간호학회의 4개분야, 11영역분류기준을참고하였고, 간호관리, 모아간호, 교육, 대체요법및기타를추가하여임상실무분야의주요주제로구성하였다. 최종분석틀은공동연구자 3인의합의하에완성되었다. 4. 자료수집자료수집기간은목포대학교의임상윤리심의위원회의승인 (IRB SB ) 을받은후 2016년 11월 3일부터 11월 14일까지이루어졌다. 연구분석을위한자료수집은인터넷기반전자데이터베이스 (DB) 를활용하였다. 분석대상논문은분석틀에맞추어 Excel program에입력하여정리하였고공동연구자 3인이검토후최종확인하였다. 5. 자료분석수집된자료는 SPSS/WIN 18.0을사용하여분석하였다. 일반적특성은빈도와백분율로산출하였고, 방법론적특성은 x 2 test로분석하였다. 연구방법론적특성의분석에체계적고찰 26편, 메타분석 64편, 임상실무지침개발 20편, 그리고임상실무지침개발후효과검증 4편으로총 114편이포함되었다. 그리고근거기반간호연구의주제분석은자료수집도구의틀에따라분류한후수기로빈도를산출하였다. 연구결과 1. 근거기반간호연구의일반적특성 근거기반간호연구문헌의출판상황은학회지출판논문이 148편 (80.9%) 으로대부분을차지하였다. 학회지별출판상황을살펴보면, 간호과학회지에출판된논문이 41편 (22.4%) 으로가장많았고그다음으로성인간호학회지 29편 (15.8%), 임상간호연구 20편 (10.9%) 순이었다. 근거기반간호관련연구는 2011년이후가장많았다. 연구설계는메타분석연구가 64편 (35.0%) 으로가장많았고임상실무지침수용개작과실험연구 388 Journal of Korean Academy of Nursing Administration

5 국내근거기반간호연구의동향 가 16편 (8.7%) 으로가장적었다. 실험연구논문을실험유형별로살펴보면유사실험이 14편 (7.7%) 이었다. 메타분석연구의수는발표시기별로각각 16편 (88.9%), 12편 (52.2%), 36편 (25.4%) 으로가장많았다. 체계적고찰은 2005년이후에 2편 (8.7%) 의연구가시작되었고 2011년이후 24편 (16.9%) 으로증가된양상을보이며메타분석은 2004년이전에비해 2005년에서 2010년사이에는감소하는추세를보였다. IRB 승인을받은논문은 59편 (32.2%) 이었다. 2011년에서 2016년사이에 IRB승인을받은논문은 57편 (40.1%) 으로발표시기별로증가하였다 (Table 1). 2. 근거기반간호연구의연구방법론적특성사전계획을수립한논문은 25편 (21.9%) 이었고 PICO를수행한논문은 58편 (50.9%) 이었다. DB명과검색어를기술한논문은각각 104편 (91.2%), 101편 (88.5%) 으로대부분을차지하였다. 검색범위를나타낸논문은 94편 (82.5%) 이었고, 81편 (71.1%) 의논문에서검색전략을수립하여검색을수행하지않았으며, 97편 (85.1%) 의논문은문헌선정과정을제시했다. 75 편 (65.8%) 의논문은문헌의질평가를하였고, 53편 (46.5%) 의 논문만이질평가결과를기술하였다. 발표시기별사전계획 (x 2 =11.42, p=.003), PICO 생성 (x 2 = 48.81, p<.001), 검색어제시 (x 2 =45.76, p<.001), DB명제시 (x 2 =21.58, p<.001), 검색전략제시 (x 2 =17.64, p<.001), 문헌선정과정제시 (x 2 =28.85, p<.001), 질평가유무 (x 2 =70.28, p<.001), 질평가결과기술유무 (x 2 =35.44, p<.001) 는유의한차이가있었다 (Table 2). 3. 근거기반간호의실행과관련된연구주제근거기반간호실행과관련된주제는근거기반간호역량및수행의장애요인과활용요인을포함한근거기반간호의준비도에대한연구가 16편으로가장많았다. 다음으로근거기반간호관련교육과임상실무지침의이행에대한연구가각각 12편이었다 (Table 3). 4. 근거기반간호실무를위한근거유형별연구주제근거유형별주제는체계적고찰과메타분석을통한간호중재프로그램의효과를확인한연구가 81편으로가장많았는데, Table 1. General Characteristics of Evidence-based Nursing Research (N=183) Characteristics Categories n(%) Publication Journal* Subtotal Korean Academy of Nursing Korean Society of Adult Nursing Korean Clinical Nursing Research t published Subtotal Master's thesis Doctoral dissertations IRB approval Study design Experiment Subtotal Pre-experiment Quasi-experiment RCT n-experiment Subtotal Survey SR Meta-analysis Guideline development Guideline adaptation Others 148 (80.9) 41 (22.4) 29 (15.8) 20 (10.9) 35 (19.1) 20 (10.9) 15 (8.2) 124 (67.8) 59 (32.2) 16 (8.7) 1 (0.5) 14 (7.7) 1 (1.1) 167 (91.3) 36 (19.7) 26 (14.2) 64 (35.0) 20 (10.9) 16 (8.7) 5 (2.8) 2004 (N=18) Year of publicatuin 2005~2010 (N=23) 2011~2016 (N=142) n(%) n(%) n(%) 14 (77.8) 10 (55.6) 4 (22.2) 4 (22.2) 18 (100.0) 18 (100.0) 16 (88.8) 1 (5.6) 1 (5.6) 17 (73.9) 4(17.4) 4(17.4) 2 (8.7) 6(26.1) 2 (8.7) 4(17.4) 21 (91.3) 2 (8.7) 23 (100.0) 2 (8.7) 2 (8.7) 12 (52.2) 4(17.4) 2 (8.7) 1 (4.3) *Only the top three were shown; IRB=Institutional review board; SR=Systematic review; RCT=Randomized controlled trial. 117 (82.4) 27 (19.0) 25 (17.6) 18 (12.7) 25 (17.6) 14 (9.9) 11 (7.7) 85 (59.9) 57 (40.1) 16 (11.3) 1 (0.7) 14 (9.9) 1 (0.7) 126 (88.7) 34 (23.9) 24 (16.9) 36 (25.4) 15 (10.6) 13 (9.2) 4 (2.7) Vol ,

6 류세앙 윤순원 김윤숙 Table 2. Methodological Characteristics of Evidence-based Nursing Research Characteristics Categories n(%) Priori' design PICO Systematic search Literature selection Quality assessment Data base Core search COSI search Search range Search words Search strategy Process of literature selection Criterion for literature selection Quality assessment Description of quality assessment outcome 89 (78.1) 25 (21.9) 56 (49.1) 58 (50.9) 10 (8.8) 104 (91.2) 30 (26.3) 84 (73.7) 93 (81.6) 21 (18.4) 20 (17.5) 94 (82.5) 13 (11.4) 101 (88.5) 81 (71.1) 33 (28.9) 17 (14.9) 97 (85.1) 14 (12.3) 100 (87.7) 39 (34.2) 75 (65.8) 61 (53.5) 53 (46.5) 2004 (N=17) Year of publicatuin 2005~2010 (N=19) 2011~2016 (N=78) n(%) n(%) n(%) 17 (100.0) 17 (100.0) 6(35.3) 11 (64.7) 12 (70.6) 5(29.4) 14 (82.4) 3(17.6) 4(23.5) 13 (76.5) 10 (58.8) 7(41.2) 17 (100.0) 9(52.9) 8(47.1) 2(11.8) 15 (88.2) 16 (94.1) 1 (5.9) 16 (94.1) 1 (5.9) PICO=Patient/problem, intervention, comparison, outcome; COSI=Core+standard+ideal. 18 (94.7) 1 (5.3) 18 (94.7) 1 (5.3) 3(15.8) 16 (84.2) 11 (57.9) 8(42.1) 17 (89.5) 2(10.5) 5(26.3) 14 (73.7) 2(10.5) 17 (89.5) 18 (94.7) 1 (5.3) 5(26.3) 14 (73.7) 5(26.3) 14 (73.7) 16 (84.2) 3(15.8) 18 (94.7) 1 (5.3) 54 (69.2) 24 (30.8) 21 (26.9) 57 (73.1) 1 (1.3) 77 (98.7) 7 (9.0) 71 (91.0) 62 (79.5) 16 (20.5) 11 (14.1) 67 (85.9) 1 (1.3) 77 (98.7) 46 (59.0) 32 (41.0) 3 (3.8) 75 (96.2) 7 (9.0) 71 (91.0) 7 (9.0) 71 (91.0) 27 (34.6) 51 (65.4) (N=114) x 2 (p) (.003) (<.001) (<.001) (<.001) 1.00 (.600) 2.07 (.355) (<.001) (<.001) (<.001) 4.27 (.118) (<.001) (<.001) Table 3. Topics related to Evidence-based Nursing Implementation Domain Topics EBN readiness (16)* Prioritizing for guideline development (1), Guideline topic selection (1), Competency (7), Facilitators and barriers (7) EBN education (12) Guideline adherence (12) Readiness for preceptors and instructors (2), Nurse education (4), EBN competency enhancement (2), Linkage between specific practice and EBN (2), Nursing student education (6), EBN competency enhancement (3), Linkage between clinical practicum and EBN (2), EBN attitude (1) Intravenous infusion control (3), Hemodialysis nursing (2), Fall control (2), Pain control (2), Infection control (1), Heat application (1), Cold application (1) Others (3) EBN decision making (2), Structural model of evidence-based practice implementation (1) *The number in parentheses indicates the number of each domain; EBN=Evidence-based nursing. 그중활동과휴식영역의운동중재효과 12편, 안전과안위영역의불안완화중재효과 5편, 오심과구토중재효과 4편으로확인되었다. 다음으로임상실무지침개발과수용개작을통해근거를생성한연구는 40편이었으며, 그중체온관리 4편, 심부정맥 혈전증예방관리 3편, 섬망관리 3편이었다. 체계적고찰과메타분석을통해관련변인의효과크기를파악한연구는 20편이었고, 그중인지손상, 감정노동및직무만족과관련된변인의효과크기를파악한논문이각각 2편으로나타났다 (Table 4). 390 Journal of Korean Academy of Nursing Administration

7 국내근거기반간호연구의동향 Table 4. Topics by Evidence Type for Evidence-Based Nursing Practice Domain Safety/ comfort (43) Nutrition/ metabolism/ excretion (13) Activity/ rest (28) Cognition/ regulation/ sense (24) Immunity/ body damage (2) Comfort change (41) Intake/ absorption/ metabolic disorder (7) Fluid imbalance/ voiding dysfunction (6) Activity/ self-care (16) Cardiovascular/ blood disorder (7) Respiratory dysfunction (5) Cognition/ nerve dysfunction (17) Dysregulation (5) Sensory dysfunction (2) Nursing management (8) Maternal-child nursing (9) Education (7) Alternative therapy (10) Others (7) Guideline development & adaptation (40) Temperature control (ASPAN's hypothermia 1, Web-based 1, adult fever 1, children fever 1), Pain (assessment 1, control 2), Well-dying (1) Enteral feeding (2), Oral care (2), Nutrition control (1), ysphagia (1), Constipation control (1) Intravenous infusion (2), Incontinence (1), Dehydration prevention (1), Urinary catheterization (1), Prompted voiding, therapy (1) Deep vein thrombosis prevention (3), Blood culture (1), Acute stroke care (1), Blood transfusion control (1) Systematic review & meta analysis* Intervention effect (81) Related factor (20) Pressure ulcer prevention (1), Fall prevention (1) Anxiety relief (5), Fatigue relief (4), Nausea and vomiting (4), Psychosocial support (3), Stress relief (2), Relaxation therapy (2), Depression relief (2), Spiritual intervention (1), Dignity intervention (1), Primary insomnia (1), Suicide prevention (1), Pain relief (1), Upright position of labor (1) Exercise (12), Diet and exercise (2) Coronary artery disease (1) Oxygen therapy (1) Ventilation therapy (1), Hypoxemia (1), Pulmonary rehabilitation (1), Pneumonia (1) Delirium care (3), Acute confusion control (1), EVD care (1), Post-lumbar puncture care (1), Post-intracranial aneurysm clipping care (1) Hemodialysis control (Dialyzing water 1, Catheter dysfunction 1, Hemodialysis patient 1), Diabetic foot care (1) Cognitive behavior (3), Dementia cognitive rehabilitation (1), Dementia stimulation program (1), Social cognition (1), Reality therapy (1), Self-efficacy promotion (1) Eye care (1) Sensory stimulation program (1) Smoking prevention (2), Maternal adaptation (1), ADHD intervention (1), Married immigrant women (1), Child nursing (1), Ego-resilience (1) Hardiness (1), Suicidal ideation (1), Death anxiety (1), Depression (1), Psychological distress (1) Health promotion behavior (1), Dementia agitation (1) Cognitive impairment (Rheumatic disease 1, Breast cancer 1) Raloxifene and lipid profiles (1) Emotional labor (2), Job satisfaction (2), empowerment (1), Workplace bullying (1), Job stress (1), Transformational leadership (1) Maternal adaptation (1), ADHD (1) Nurse education (Simulation 2, Wed-based 1), Oncology patients (Education intervention 2, Posttraumatic growth intervention 1), Dementia family support program (1) Aroma therapy (3), Music therapy (2), Stimulation-oriented intervention (1), Acupressure (1), Laughter therapy (1), Imagery therapy (1), Foot massage (1) Tool validity (Braden scale 1, Stratify 1), Quality assessment of meta-analyses (1), Systematic searching (Urinary Tract Infections 2), eliability and accuracy of infrared temperature (2) *Duplicate count, The number in parentheses indicates the number of each domain; EVD=External ventricular drainage, ADHD=Attention deficit hyperactivity disorder. Vol ,

8 류세앙 윤순원 김윤숙 논의 본연구는근거기반간호연구의동향을파악하기위한문헌조사연구이며, 근거기반간호의질적향상을위해추후수행되어야할연구과제의방향을제시하고자시도되었다. 1. 일반적특성 2016년 11월까지출판된근거기반간호관련논문은총 183 편이었으며, 학회지에발표된논문이대다수로그중간호과학회에게재된논문이 22.4% 로가장많았다. 근거기반간호연구는발표시기별로증가추세를보였으며 2011년이후의논문이과반수이상이었다. 2004년에대한간호학회주관으로근거기반간호활용에대한학술대회가개최된이후, 여러학회나병원간호사회등전문가단체를중심으로한학술대회에서근거기반간호가소개됨과더불어근거기반간호실행을가이드할저서들이출판되었다 [5,6]. 2010년에근거기반간호연구를지원하고발전시키기위해발족된한국근거기반간호연구회를중심으로근거기반간호연구방법론에대한교육이본격화되었고, 2011년에는한국주최로개최된동아시아간호포럼등을계기로 [7], 근거기반실무의중요성에대한공감대가형성되면서 2012년근거기반간호학회가설립되었다. 그외에도다양한집단의노력들이합해지면서국내근거기반간호관련연구논문이증가한것이라볼수있다. 근거기반간호연구중임상실무지침개발또는수용개작및체계적고찰은 2011년이후 6~13% 증가하였다. 임상실무지침은과학적근거를실무에도입함으로써, 간호사에게효과가검증된중재에대한인식을증진시키고, 비효율적인중재를시행하지않게함으로써근거와실무사이의갭을줄이는역할을한다. 2011에서 2012년사이에병원간호사협회주도로국내근거기반임상간호실무지침의주제선정및우선순위결정에대한연구가이루어진후 [2,5] 임상실무지침개발연구의필요성에따라 2011년이후가이드라인개발과수용개작연구가증가된것으로보인다. 체계적고찰은특정연구질문에대한답을얻기위해질높은문헌을체계적으로확인, 평가, 합성하는연구로, 우리나라의경우체계적고찰에대한연구방법이미흡하다는각성하에, 2011년한국보건의료연구원에서표준화된체계적고찰매뉴얼개발이후연구가증가된것으로여겨진다 [14]. 본연구에서 IRB 승인을받은논문은 2011년이후증가하였으나여전히 60% 는 IRB 승인없이연구를진행하였다. 국내의연구동향분석에서보고된 IRB 승인비율은 2010년 Shin 등의 [12] 연구에서 8.4%, 2011년 Choe 등의 [7] 연구에서 44.3%, 2015년 Choi 등의 [13] 연구에서 11.8% 였다. 본연구에서는비실험연구가 91% 였고, Choe 등의 [7] 연구는 94% 가인간을대상으로한실험연구를분석하였으므로본연구결과보다 IRB 승인비율이높게나타난것이라해석할여지가있다. IRB는연구계획서의윤리적타당성검토와연구참여대상자의권리, 안전, 복지를보호하는역할을한다. 또한연구의질평가시사전계획여부를확인할수있는지표가될수있다 [15]. 연구윤리준수와연구의질적향상을위해실험연구뿐만아니라비실험연구의 IRB 승인비율을높일필요가있다고생각된다. 2. 방법론임상실무에있어서연구활용의증가는필수적이며나아가개별연구의통합적고찰은근거기반간호를발전시키는데중요한역할을한다. 이러한이유로간호연구자들은좀더엄격하고체계적으로간호연구를통합하는데집중해야한다 [16]. 본연구에서임상실무지침개발, 체계적고찰및메타분석연구의통합적수행을위한연구방법론적특성을살펴보면, 발표시기별 PICO생성문헌은증가하였으나 2011년이후에도 26.9% 의문헌이 PICO생성없이연구를진행하였다. 임상문제를연구개념으로만들기위해서는핵심질문을 PICO 형식으로구조화시켜야한다. 이러한방법을통해검색의목적을명확히하고, 검색에소요되는시간을절약할수있으며, 검색전략을개발하여타당한근거를검색하기위한기초가될수있다 [17,18]. 본연구결과, 대다수의문헌이검색어는제시했지만검색범위를제시하지않은문헌은 17.5% 였다. 발표시기별로검색전략을제시하는문헌이증가되고있지만 2011년이후에발표된문헌의 59% 는여전히검색전략을제시하지않았다. 새로운연구들이발표되면해당주제에대한결론이달라질수도있으므로일정기간이지나면다시검색을해야한다. 이러한이유로문헌의검색범위를명시할필요가있다 [14]. 또한적절한근거를찾기위해서는최상의검색전략을수립해야한다. 검색전략을통해적절한근거를찾을수있는민감도 (sensitivity) 와부적절한근거를배제할정확도 (precision) 를향상시켜타당하고포괄적인연구를찾을수있고, 이는최선의실무를위한필수적인수단이된다 [14,18]. 국내상급종합병원간호사를대상으로문헌검색능력을조사한결과, 5점만점에 2.81점이었고특히데이터베이스의기능에대한이해능력이낮았다 [19]. 이는근거기반간호를실행하기위해서는무엇보다도최신의타당한연구결과를빠르고효과적으로검색하기위한체계적인 392 Journal of Korean Academy of Nursing Administration

9 국내근거기반간호연구의동향 문헌검색전략이필요함을나타내므로 [18], 검색의재현가능성과객관성을확보하기위해검색전략을향상시킬수있는교육이필요하다. 연구문헌의검색시빈번하게지적되는한계는포괄적문헌검색이잘수행되지않는다는점이다 [20]. 근거기반간호관련연구동향을분석한선행연구는찾아보기어려워직접비교는한계가있지만, 국내여러분야의체계적고찰을분석한 Son [10] 은간호학분야의포괄적문헌검색비율이 AMSTAR를기준으로 14.8% 라고보고하였고, 국외의경우 2003년부터 10년간건병증 (tendinopathy) 의중재효과에대한체계적고찰에서는 [21] 58.6% 라고보고하였다. 하지만본연구결과포괄적문헌검색을위한 COSI 검색과검색전략이수립된문헌은각각 18.4%, 28.9% 의비율로낮은결과를보였다. 추후근거기반간호연구의질적향상을위해서는이에대한보완이필요할것으로보인다. 본연구에서 65.8% 의문헌에서연구방법의질평가를수행했다고보고한것에비해질평가의결과를기술한문헌은 46.5% 였다. 이는 Kim과 Kim이 [10] 보고한 31% 보다는높았고, Long 등의 [21] 연구 86.2% 보다는낮은것을확인할수있어, 국내의연구자들이연구과정에서질평가의수행은물론이고질평가의결과와활용에대한정확한보고를하는것이필요하다. 임상실무지침개발, 체계적고찰및메타분석연구를통해도출된근거가실무에서활용되기위해서는연구의재료가되는개별문헌의연구방법이나결과에대한신뢰성과타당성이우선전제되어야한다 [10]. 개별문헌의신뢰성과타당성확보를위해서는연구가적절하게수행되었는지에대한방법론적검증을위한문헌의질평가가필수적이며, 아울러질평가결과기술을통해개별문헌의질이결론을도출하는데적절히사용되었는지확인해야한다 [10,18]. 이러한과정없이연구결과를합성하고의미를해석하는것은연구결과에대한올바른해석을이끄는데제한점이있다 [8]. 문헌의질평가와질평가의결과기술을통해신뢰성과타당성있는연구결과를확보해야할것으로판단된다. 본연구결과최근연구일수록질평가를수행한문헌은확연하게증가추세를보였으며질평가의결과를제시한비율또한증가되는양상으로나타났다. 최근개별문헌을통합하는연구에서저조한질평가비율과질낮은데이터를활용하는문제에대한비판이계속제기되고있었다 [8,10,20]. 이에대한각성하에한국보건의료연구원의표준화된체계적고찰매뉴얼개발및간호학회차원에서근거를생성하기위한연구방법론에대한교육프로그램운영등의결과로질평가및질평가결과를제시한비율이증가한것으로보인다 [7,14] 3. 연구주제근거기반간호실행과관련된주제는근거기반간호역량및수행의장애요인과활용요인을포함한근거기반간호수행의준비도에대한연구가많았다. 근거기반간호역량은연구결과나표준화된지침을정확하게해석하여최상의근거를찾는간호제공자의능력으로, 대상자의건강결과개선뿐만아니라재원기간단축, 비용절감등에도영향을미치는근거기반간호활성화의필수요소이므로이에대한기초연구가다수이루어진것으로해석된다 [22]. 우리나라에서는 2009년부터국내일부대학병원과상급종합병원을중심으로개인적, 조직적차원의 근거기반간호프로젝트 를통해근거기반간호활성화에노력을기울여왔다 [23]. 근거기반간호가대상자의건강결과를향상시키고간호의질과신뢰를강화시키는이점이있음에도불구하고임상실무자들은일관되게근거기반간호를수행하고있지않다 [11]. 미국간호사들을대상으로근거기반간호에대한인식을조사한연구에서간호사들은근거에기반한최선의실무를일관되게수행하지않고있었으며, 간호지도자와관리자들의근거기반간호에대한저항이만연한것으로밝혀졌고 [24], 근거기반간호수행의주요장애요인은근거기반간호에대한기관의인식수준이었다 [25]. 본연구에서근거기반간호의활용과장애요인을조사한연구가 7편있었지만, 주로상급종합병원과대학병원간호사대상의연구였고, 간호관리자와지도자의인식에관한연구와기관의지원현황에대한연구는각각 1편정도확인되었다. 실무현장에서근거기반간호가정착되기위해서는근거기반실무를수행할간호사들의인식변화와역량강화가우선되어야한다 [23]. 그러므로상급종합병원과대학병원은물론중소종합병원에근무하는간호사와간호관리자의근거기반간호에대한인식과기관의지원방안에관한연구가확대되어야할것으로판단된다. 최근전통적인간호교육의한계에대한비판과더불어새로운교육과정도입의필요성에따라근거기반간호교육의요구도가높아지고있으며, 근거기반간호는대학뿐만아니라임상실무현장까지연계되어교육되어야한다 [7]. 간호사가근거에기반한간호를수행하려면학부과정에서근거를검색하고이를비평적으로분석하여실무에적용할수있는능력을갖추어야한다 [26]. 본연구결과국내학부과정에근거기반간호교육이전반적으로적용된사례는없었고, 근거기반간호교육방법론개발을위해일부실습교과목에근거기반간호를적용하여근거기반간호역량을파악한연구가소수있었다. 국내에서는일부대학원교육과정에근거기반간호가개별교과목으로개 Vol ,

10 류세앙 윤순원 김윤숙 설되어운영되고있는추세이다 [5,27]. 근거기반간호와관련된교육프로그램을통해근거기반간호실무에대한준비가강화되었고실제실무지식이향상되었으므로 [28] 학부과정의근거기반간호교육및이에대한연구가계속되어야할것이다. 마지막으로근거기반간호실무를위한근거유형별주제를살펴보면, 개별연구의합성을통해근거를생성하려는체계적고찰과메타분석은간호중재프로그램의효과에대한연구가많았는데, 그중공통적으로많이수행된연구는활동과휴식영역의운동중재효과에관한연구였다. 이는국내간호연구동향분석에서조사연구다음으로간호중재관련실험연구의비율이높았고특히운동요법관련간호중재연구가많이시행되었다는것과같은맥락이다 [12,13]. 근거의강도에따른근거의위계 (hierachy) 에서최상의근거는무작위대조군실험연구 (Randomized Controlled Trial, RCT) 에대한체계적고찰이므로 RCT는근거기반간호의기초가되는문헌이다 [17] 년에서 2011까지미국, 아프리카, 유럽, 아시아지역간호연구에서수행된무작위대조군실험연구의경향을분석한것을보면 [29], 전세계적으로 RCT가증가하고있고특히아시아지역의 RCT연구가주목할만큼증가된것으로나타났다, 하지만여전히국내의 RCT연구는 4% 미만이었다 [7]. 본연구에서근거기반간호를주제로다룬실험연구를분석한결과역시 RCT 는 1편뿐이었고유사실험연구가주를이루었다. 근거기반간호실무향상을위해서는잘설계된무작위대조군실험연구를더많이시도할필요가있다. 그렇지만인간을대상으로하는무작위대조군실험은연구설계시고려해야할표본의무작위화, 실험상황의통제, 눈가림적용등을충족시킬수없는실무적한계가있다. 따라서무작위대조군실험에대한연구자의인지와같은개인적요인뿐만아니라조직이나국가의자원과기금의활용에대한연대를이끌어내야한다 [29,30]. 더불어간호연구자들은 RCT만이모든상황에서 최고의표준 이라고받아들일것이아니라, 유사실험연구라하더라도연구설계와수행절차의보완이이루어진반복연구는과학적으로입증된연구결과를축적하여명확한결론을도출하는데기여한다는점을인식해야한다 [12,30]. 이는과학적근거에기반한간호실무를정착시키는데한걸음더다가갈수있는길이다. 근거유형별주제중임상실무지침개발및수용개작에서주로다루어진주제는배설, 영양, 체온과같은임상간호수행을위한기본적인간호중재개발이많았다. 이에비해임상실무지침의주제선정과지침개발우선순위의최상위에있는투약간호, 피부반응검사및주요검사전과후의간호에대한임상실무지침개발연구는 [2,5] 많이이루어지지않았으므로, 임상실 무지침개발의요구도와필요성에따른지침개발, 다양한주제및기존임상실무지침의업데이트에관한연구가수반되어야할것이다. 결론 본연구는근거기반간호에대한기초연구로서국내 20개간호학회지게재논문과간호학석사및박사학위논문중근거기반간호를주제로다룬조사연구, 실험연구, 임상실무지침개발또는수용개작, 체계적고찰및메타분석연구를분석하였다. 이를통해근거기반간호에대한연구방향을제시할수있었다. 첫째, 높은수준의근거를생성하기위한체계적고찰, 메타분석및임상실무지침개발의연구방법론적특성을살펴보았을때, PICO생성, 검색어, 검색데이터베이스, 문헌선정과정, 질평가및질평가결과의제시는발표연도별유의한차이와함께제시빈도가증가하는추세를보여근거기반간호연구의질적향상이이루어지고있음을확인하였다. 하지만여전히 2011 년이후에도 PICO생성, 검색전략수립및질평가결과의기술에대한명확한제시가이루어지지않은문헌이상당수있었으므로이에대한연구자의인식과역량강화교육이필요하다고생각된다. 둘째, 근거기반간호의장애요인과간호사의역량등을포함한근거기반간호수행의준비도에대한연구는주로상급종합병원이나대학병원을중심으로진행되었으므로중소병원이나노인요양병원대상의연구가필요할것으로판단된다. 셋째, 임상실무지침의주제선정과지침개발우선순위의최상위에있는투약간호, 피부반응검사, 주요검사전후의간호에대한실무지침개발연구가필요한것으로판단된다. 더불어일관성있는주제와잘설계된반복적인실험연구의확대를통해최상의근거를생성하려는노력을기울여야할것이다. 본연구결과는근거기반간호의질적향상을위하여향후수행되어야할연구과제의기초자료로활용이가능할것으로판단된다. REFERENCES 1. Oh EG, Kim SA, Kim SS, Kim S, Cho EY, Yoo JS, et al. Integrating evidence-based practice into RN-to-BSN clinical nursing education. Journal of Nursing Education. 2010;49(7): Gu MO, Cho MS, Cho YA, Jeong JS, Jeong IS, Park JS, et al. Topics for evidence-based clinical nursing practice guidelines 394 Journal of Korean Academy of Nursing Administration

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