재활간호학회지제21권제2호, 2018년 12월 Korean J Rehabil Nurs Vol. 21 No. 2, 110-120, December 2018 ISSN 1229-294X (Print), ISSN 2288-3002 (Online) https://doi.org/10.7587/kjrehn.2018.110 문선숙 1 서연옥 2 이경우 1 구자성 3 혜전대학교간호학과 1, 순천향대학교간호학과 2, 강릉영동대학교간호학과 3 The Level of Performance, Frequency and Educational Needs of Nursing Activities in Long-term Care Hospital Moon, Sun-Sook 1 Suh, Yeon Ok 2 Lee, Kyung-Woo 1 Gu, Jasung 3 1 Department of Nursing, Hyejeon College, Hongseong 2 College of Nursing, Soonchunhyang University, Asan 3 Department of Nursing, Gangneung Yeongdong University, Gangneung, Korea Purpose: This study was to explore the level of core nursing activities performed by long-term care hospital nurses and to investigate the frequency and educational needs of major nursing activities. Methods: A cross-sectional descriptive research design was used. The subjects were 155 nurses working at seven long-term care hospitals in Korea. Data were collected in 2018 from September 15 to October 16 using a structured questionnaire. Data were analyzed using the SPSS program. Results: The mean age of nurses was 45.19±10.99 years and the mean career of long-term care hospital was 49.84±40.52 months. Monitoring activity was shown as the highest score in the performance level and frequency, whereas infection control received the highest score in educational needs. A scatter plot revealed that physical examination, respiratory care, wound care, communication and education showed overall high scores in the performance level, frequency, and educational needs. Emergency care and infection control were the activities that were performed less frequently but had high performance level and educational needs. Conclusion: It is important to establish rules for requisite and delegable activities considering the performance level and frequency of nursing activities in long-term care hospitals in order to improve the quality of patient care. Key Words: Long-term care hospitals, Core nursing activities, Duties 서론 1. 연구의필요성 우리나라요양병원은노인인구의증가와함께해마다증가 되는추세로최근약 1,500여개가운영되고있으며, 요양급여인원은연간 80만명을넘어서고있다 (Korean Statistics Information Service; KOSIS, 2018). 요양대상자의증가로인하여요양병원간호인력에대한요구도한층증가되었다. 그러나간호인력확보수준에따른차등수가제도입으로인하여간 주요어 : 요양병원, 간호사, 간호, 교육 Corresponding author: Suh, Yeonok College of Nursing, Soonchunhyang University, 31 Soonchunhyang 6 gil, Dongnamgu, Cheonan 31151, Korea. Tel: +82-41-570-2497, Fax: +82-41-570-2498, E-mail: yeonok@sch.ac.kr - 이논문은 2018년도순천향대학교연구비지원을받은논문임. - This work was supported by Soonchunhyang University Research Fund. Received: Nov 11, 2018 / Revised: Dec 4, 2018 / Accepted: Dec 11, 2018 c 2018 Korean Academic Society of Rehabilitation Nursing http://www.kasren.or.kr
호인력등급은높아졌지만간호사수에비하여간호보조인력의수가증가되면서 (Kim & Jeong, 2014) 간호사대비환자수는더많아져업무량이늘어나면서간호의질도저하되고있는실정이다. 최근의연구에서사용되는간호활동조사도구는간호과정과간호행위를적용한간호활동기술서 (Korean Nurses Association, 2003) 와한국표준간호행위분류 (Park, Sung, Song, Cho, & Sim, 2000) 를토대로구성된것이며, 이는신규간호사에서부터전문간호사가수행하는간호활동까지포함되어있다 (Jang & Kim, 2017). 또한임상간호사직무분석에서도출된간호활동 (Park et al., 2012) 을조사도구로사용한연구들 (Park, 2016; Kim, Jeong, Lee, & Kim, 2017) 이보고되어있다. 선행연구들에서사용한간호활동도구들은장기입원노인이대다수인요양병원의상황에적용하기어렵고, 불필요한조사항목이많아요양병원에서주로수행하는간호활동에초점을두어야할필요가있다. 요양병원에서의간호활동은급성기간호에비하여새로운간호기술이적용되지않고기본간호활동이반복적으로수행되면서시간이많이소요되는활동 (Kim & Kim, 2016) 들이다. 장기요양대상자에게제공되는간호행위에는기관절개관간호, 흡인, 산소요법외에도욕창간호, 도뇨관리및장루간호, 당뇨발간호가있고, 배뇨배변관리및일상생활수행능력과같은재활간호서비스 (Lee & Kwak, 2016; Jang & Kim, 2017) 가포함되어있으나개인위생과같은단순한간호업무를모두포함하고있었다. 우리나라요양병원에서는외국과비교해볼때간호사와간호조무사의업무표준에대한명확한규정이없고간호사에게더높은수준의간호를요구하는실정이다 (Lee, Shin, & Harrington, 2015). 요양병원간호활동에대한최근연구들은간호사의활동과간호조무사에게위임하는활동 (Jang & Kim, 2017; Park, 2016), 요양병원간호인력의간호행위수행실태 (Kim & Jeong, 2014; Kim & Kim, 2014), 간호인력확보수준과환자의간호결과 (Kim & Lee, 2015) 들이보고되어있으나, 조사항목들이연구마다차이가있으며간호사가해야할간호와보조인력에게해야할간호에대한정보가명확하게드러나지않고있다. 외국에서는전문성있는교육과훈련을받은간호사가최대한의능력을발휘하여실무를해야한다는주요권고사항이발표되었으며 (Institute of Medicine, 2010a), 적절한간호제공자 가 적절한장소와시간 에 적절한수준 의간호를제공해야하는것을의미하는 Top of License (TOL) practice 라는개념을적용하고있다 (Russell-Babin & Wurmser, 2016). 이 러한개념을적용하는이유는건강제공자를값싼인력으로대체하지않아야함을의미하며, TOL을적용함으로써보다효율적이고효과적인간호를제공하게되어대상자에게좋은결과를주고궁극적으로는간호의질을높일수있도록하기위함이다 (Hlahol, 2016). TOL을위한핵심간호내용을확인한연구를살펴보면, 핵심간호활동으로전문간호 ( 환자사정, 기록, 사회심리적간호등 ), 비판적사고, 환자교육, 의사소통등을제시하여교육및훈련의수준에따라간호활동의차이가있음을확인하였고, 결과적으로대상자간호에영향을미치는것으로보고되고있다 (Buck et al., 2018; Loversidge et al., 2018). 우리나라요양병원처럼간호사수가부족하고, 대신간호보조인력에게간호활동을위임하여역할이혼합된상황에서는간호사의핵심간호활동을파악하고이를중점적으로수행한다면간호업무의효율성을높일수있을것이다. 요양병원간호사의간호수행과관련된국내연구들은주로위임되는간호활동을조사한것이대부분이었다 (Jang & Kim, 2017; Park, 2016). 간호사가해야할간호활동에대한명확한규정이마련되어있지않은상태에서일부간호활동을간호보조인력에위임함으로인하여대상자간호의질적보장이이루어지지않고있다 (Paek, Zhang, Wan, Unruh, & Meemon, 2016; Shin & Hyun, 2015). 노인병원이나요양병원에서근무하는간호사들은심리사회적영역이나자기개발영역을제외한대부분의간호활동에서교육요구도가높은상태이며 (Suh, Yee, & Kim, 2017), 중요도는높지만수행도가이에미치지못한간호활동이많았고특히수행도와중요도의요구수준이높은직접간호활동에대한교육이필요하다고하였다 (Kim et al., 2017). 이러한결과들은간호사들이해야할간호활동의범위를결정하는근거자료가될수있으며, 중요도나교육요구도가높은간호활동에중점을두어야함을시사하지만보다더보편화된연구들이수행되어야한다. 따라서요양병원간호사가점점증가되고있는우리나라의현상황에서요양병원의표준화된간호활동을파악하기위해서는주요간호활동에대한지속적인연구가필요하다. 이에본연구에서는요양병원핵심간호활동수행수준에대한간호사의인식과수행빈도를파악하고, 핵심간호활동별교육요구도를분석하여요양병원간호사의질적관리를위한근거자료를마련하고자한다. 2. 연구목적본연구의목적은요양병원간호사가수행하는핵심간호활 Vol. 21 No. 2, 2018 111
문선숙 서연옥 이경우등 동수준을파악하고주요간호활동의수행빈도및교육요구도를조사하기위함이며구체적인목적은다음과같다. 요양병원간호사가수행하는핵심간호활동의수행수준, 수행빈도, 및교육요구도정도를파악한다. 일반적특성에따른핵심간호활동의수행수준, 수행빈도, 및교육요구도의차이를분석한다. 핵심간호활동의수행수준과수행빈도, 교육요구도별간호활동임무의상대적관계를분석한다. 연구방법 1. 연구설계 본연구는요양병원간호사가수행하는핵심간호활동에대한수행수준을파악하고수행빈도및교육요구도와의관계를조사하는서술적조사연구이다. 호활동수준, 수행빈도, 교육요구도가포함된질문지를구성하였다. 70개의세부간호활동은 14개간호임무인기본간호, 안위간호, 신체사정, 모니터링, 호흡기간호, 응급간호, 안전관리, 감염관리, 상처간호, 기동성돕기, 투약및검사, 영양과배설, 의사소통및교육, 간호관리로분류하였다. 14개간호임무는선행연구에서제시된직무와임무 (Park et al., 2012) 에근거하여분류되었다. 핵심간호활동수행수준은간호사가수행하기에어느정도의수준이필요한지를 1 하, 2 중, 3 상 으로 3점척도로측정하여점수가높을수록수준이높은간호활동임을의미한다. 간호활동수행빈도는 1 시행하지않음, 2가끔, 3 월 1회이상, 4 주 1회이상, 5 매일 의 5점 Likert 척도로측정하여점수가높을수록수행빈도가많은것을의미한다. 교육요구도는 1 전혀필요하지않다 에서 5 매우필요하다 로측정하여점수가높을수록교육요구도가높다고인식하고있음을의미한다. 2. 연구대상 4. 자료수집 본연구는서울, 충청, 경북지역의요양병원에서근무하는일반간호사를편의표집하였으며구체적인대상자선정기준은 1) 150병상이상요양병원에서근무하는간호사, 2) 본연구에대한설명을듣고연구에자발적으로참여하기로서면동의한간호사이다. 주요간호활동의빈도를조사하므로수행빈도의일관성을유지하기위하여주임간호사, 수간호사또는팀장과같은관리자급간호사는연구대상자에서제외하였다. 연구대상자수는 G*Power 3.0.10 프로그램을이용하여 independent t-test에서효과크기.3, 유의수준.05, 검정력.95로계산한결과 134명이산출되었다. 탈락률을고려하여총 160명에게자료수집을하였고, 이중부적절한응답을제외한 155명의자료를분석하였다. 자료수집기간은 2018년 9월 15일부터 10월 16일까지였으며, 연구자들이서울, 경북, 충청지역의 7개요양병원간호부에연구목적과내용에대해설명하고자료수집에대한승인을받았다. 연구참여를희망하는간호사를대상으로설문조사를하기전에연구자들이개인정보보호, 동의서작성방법및설문지회수방법에대해설명을한후동의서를받았으며, 설명문과동의서사본은대상자에게지급하고, 완성한설문지와동의서는개별봉투에넣어밀봉한후회수하여개인정보가노출되지않도록하였다. 설문지조사에소요되는시간은 20분내외이며이에대한보상으로생활용품을제공하였다. 5. 자료분석 3. 연구도구핵심간호활동도구는대한간호협회간호표준개발보고서 (Korean Nurses Association, 2003) 와간호사직무분석 (Park et al., 2012) 을참고하여총 98개의간호활동을선정한후선행연구결과 (Jang & Kim, 2017; Park, 2016) 에서수행빈도가높은항목을연구자들이선정하여세부간호활동항목을구성하였다. 이항목에대해서는요양병원근무간호사와노인간호전공교수의타당성검토를한후 70개의간호활동에대한핵심간 수집된자료는 Korea plus statistics (SPSS statistics 25) 를이용하여분석하였다. 대상자의일반적특성과핵심간호활동수행수준, 수행빈도, 교육요구도정도는빈도, 백분율, 평균, 표준편차로분석하였다. 일반적특성에따른핵심간호활동수행수준, 수행빈도, 교육요구도의차이는 independent t-test, one-way ANOVA analysis로분석하였다. 핵심간호활동의수행수준과수행빈도, 교육요구도별임무의상대적관계는산점도로확인하였다. 112 The Korean Journal of Rehabilitation Nursing
6. 윤리적고려 Table 1. General Characteristics (N=155) 본연구는 S대학교생명윤리심의위원회의심의를거쳐승인 (1040875-201808-SB-029) 을받은후자료수집을시행하였다. 자료수집전연구대상자에게연구목적과결과활용에대해설명한후연구참여에대한서면동의를받았으며설문내용은연구목적으로만사용되고익명으로처리하여철저히비밀이보장됨을설명하였다. 응답도중연구참여를철회할수있으며설문을중단할경우어떠한불이익도없고수집된모든자료는추후폐기하는것에대해설명하였다. 연구결과 1. 일반적특성 본대상자의평균연령은 45.9±10.99세이고 40대와 50대가각각 46명 (29.7%) 으로가장많았으며, 결혼한대상자가 125명 (80.6%) 이었다. 전문대학졸업자가 95명 (61.3%) 으로 4년제대학 60명 (38.7%) 보다많았으며, 전체임상경력은평균 155.2 ±107.76개월로 10년이상의경력자가 50% 이상을차지하였다. 요양병원에서의근무기간은평균 49.84±40.52개월로 1~5 년사이가 71명 (45.8%) 로가장많았다. 간호사대비환자의비율은평균 9.37±4.80명이며, 간호조무사대비환자의비율은 7.53±6.13명이었다. 자료수집병원의특성은 150병상이상의요양병원을편의표집하였으며, 건강보험심사평가원의평가결과 1등급 2개, 2등급 2개, 3등급 2개병원이며, 4등급병원이 1개로총 7개병원이었다 (Table 1). 2. 핵심간호활동수행수준, 수행빈도및교육요구도정도대상자들이수행하는간호활동중에서수행수준이가장높은임무는모니터링 (2.58±0.40), 투약및검사 (2.57±0.48) 이었으며, 수행수준이가장낮은항목은개인위생 (2.09±0.55) 항목이었다. 수행빈도가높은임무도모니터링 (4.25±0.81), 신체사정 (4.17±0.82), 호흡기간호 (3.88±0.99) 였으며, 수행빈도가낮은임무는영양및배설 (2.73±1.07) 이었다. 대상자들의교육요구도가가장높은임무는감염관리 (4.08±0.97), 응급간호 (4.04 ±0.95) 항목이며, 교육요구도가낮은것은개인위생 (3.45±0.82) 이었다 (Table 2). Variables Categories n(%) or M±SD Age (year) <29 30~39 40~49 50~59 >60 16 (10.3) 32 (20.6) 46 (29.7) 46 (29.7) 15 (9.7) 45.2±10.99 Marital status Education Clinical experience (year) Career of long-term care facility (year) Single Married College graduate Bachelor <5 5~10 11~15 16~20 >20 <1 1~5 >5 29 (18.7) 125 (80.6) 95 (61.3) 60 (38.7) 30 (19.4) 44 (28.4) 33 (21.3) 20 (12.9) 28 (18.1) 12.92±8.98 32 (20.6) 71 (45.8) 52 (33.5) 4.15±3.38 Nurses to patients ratio 9.37±4.80 Nurse aid to patients ratio 7.53±6.13 3. 일반적특성에따른핵심간호활동수행수준, 수행빈도, 교육요구도의차이 대상자의일반적특성에따른세변수들간의차이를분석한결과, 연령, 결혼상태, 교육수준, 임상경력은수행수준, 수행빈도, 교육요구도와유의한차이를보이지않았다 (Table 3). 요양병원근무경력에따른수행수준, 수행빈도는통계적인차이가없었으나교육요구도에서는유의한차이가있어요양병원근무경력이많은대상자가교육요구도가더높은것으로나타났다 (F=5.15, p=.007). 4. 핵심간호활동수행수준, 수행빈도, 교육요구도별간호활동임무의상대적관계 핵심간호활동에서간호임무들의수행수준과수행빈도, 교육요구도의상대적관계를확인하기위하여임무들의산점도로확인하였다. 산점도에서높고낮음을표기하는기준은평균값을이용하였다. 1) 수행수준과수행빈도핵심간호활동임무의수행수준과수행빈도가모두높은임 Vol. 21 No. 2, 2018 113
문선숙 서연옥 이경우등 Table 2. The Level, Frequency and Educational Needs of Core Activity Duty Personal care Comfort care Physical examination Monitoring Respiratory care Emergency care Safety Infection control Wound care Core activity Oral care Eye care Perineal care Bed bath Bed shampoo Back care Tooth management Meal support Position change Sheet change after incontinence Pain management Sleep assist Hot and cold application Physical assessment Consciousness assessment Cognitive assessment Vital sign Blood glucose Intake and output EKG, O 2 saturation Complication Airway tube/maintenance Endotracheal tube care Trachostomy care Suctioning Oxygen therapy Deep breathing & coughing Inspection, auscultation, percussion, palpation. Cardiopulmonary resuscitation Emergency kit/equipment management Use of ambu Preparation and use of equipment in emergency Consciousness monitor Management of convulsion Environmental management Fire prevention and disaster management Accident surveillance Monitoring of compliance with infection control guidelines Implementation of isolation Management of infectious diseases Wound dressing Prevention of skin integrity (N=155) Level Frequency Educational needs M±SD M±SD M±SD 1.98±0.68 2.07±0.71 2.13±0.68 2.11±0.72 1.79±0.73 2.06±0.73 1.95±0.72 2.27±0.75 2.41±0.62 2.09±0.71 2.09±0.55 2.64±0.50 2.30±0.61 2.01±0.64 2.32±0.47 2.34±0.66 2.52±0.55 2.60±0.53 2.54±0.45 2.53±0.62 2.53±0.62 2.50±0.65 2.67±0.54 2.70±0.50 2.58±0.40 2.65±0.50 2.54±0.60 2.44±0.65 2.63±0.55 2.65±0.52 2.38±0.64 2.55±0.42 2.54±0.71 2.65±0.59 2.38±0.68 2.64±0.52 2.47±0.59 2.51±0.63 2.53±0.49 2.27±0.60 2.49±0.60 2.48±0.58 2.42±0.47 2.57±0.58 2.45±0.68 2.51±0.69 2.51±0.57 2.60±0.57 2.50±0.61 2.55±0.56 3.35±1.70 3.69±1.61 3.27±1.66 2.49±1.08 2.12±1.10 3.38±1.65 3.18±1.80 3.95±1.43 4.17±1.35 3.27±1.78 3.29±1.21 4.49±0.97 3.96±1.34 3.05±1.44 3.83±0.98 3.44±1.40 4.60±1.17 4.48±1.08 4.17±0.82 4.18±1.44 4.08±1.39 4.44±1.19 4.46±0.89 4.11±1.17 4.25±0.81 3.93±1.39 3.52±1.70 3.42±1.71 4.26±1.23 4.27±1.15 3.90±1.26 3.88±0.99 2.26±1.19 2.79±1.37 3.03±1.49 2.79±1.32 3.49±1.42 2.73±1.30 2.84±0.95 3.95±1.30 3.36±1.42 3.75±1.36 3.69±1.14 3.29±1.44 2.52±1.36 2.95±1.52 2.92±1.16 3.77±1.59 3.94±1.39 3.86±1.35 3.27±0.99 3.30±0.98 3.49±0.93 3.37±0.89 3.27±0.92 3.50±1.01 3.51±0.97 3.37±1.15 3.72±1.16 3.37±1.06 3.45±0.82 3.84±1.12 3.57±0.98 3.39±0.96 3.60±0.91 3.75±1.00 3.90±1.02 3.77±1.06 3.79±0.90 3.51±1.24 3.40±1.23 3.49±1.18 3.89±1.09 3.80±1.19 3.62±1.03 3.97±1.16 3.97±1.06 3.95±1.07 3.95±1.13 3.77±1.13 3.63±1.03 3.86±0.99 4.17±1.01 4.12±1.09 3.90±1.00 4.08±1.06 3.91±1.09 4.01±1.06 4.04±0.95 3.52±1.03 3.95±1.04 3.86±1.08 3.78±0.96 4.08±1.04 4.02±1.06 4.14±1.01 4.08±0.97 3.91±1.10 3.87±1.04 3.88±1.04 114 The Korean Journal of Rehabilitation Nursing
Table 2. The Level, Frequency and Educational Needs of Core Activity (Continued) (N=155) Duty Mobility support Core activity Performing ROM exercise Providing support to walk Helping to use assistive device Level Frequency Educational needs M±SD M±SD M±SD 2.21±0.62 2.16±0.69 2.15±0.62 2.17±0.55 3.24±1.55 3.25±1.52 3.45±1.52 3.31±1.33 3.68±0.98 3.50±0.91 3.43±0.98 3.54±0.87 Medication & test Preparedness for prescription medication Administration of oral medication Administration of intravenous medication Administration of intramuscular medication Administration of subcutaneous medication Suppository administration Transfusion of blood and blood products Specimen collection 2.61±0.59 2.56±0.63 2.68±0.54 2.62±0.59 2.57±0.62 2.25±0.78 2.61±0.67 2.54±0.59 2.57±0.48 4.13±1.41 4.25±1.33 3.97±1.37 3.74±1.48 3.56±1.52 3.07±1.67 2.16±1.25 3.53±1.40 3.52±1.11 3.68±1.19 3.62±1.21 3.74±1.20 3.70±1.20 3.63±1.19 3.36±1.14 3.82±1.31 3.64±1.16 3.66±1.08 Nutrition & elimination Tube feeding Gastrostomy feeding Urinary catheterization Encouraging natural bladder and bowel movement Enema Removing fecal impaction Colostomy care 2.46±0.59 2.36±0.64 2.50±0.59 2.31±0.63 2.29±0.64 2.10±0.67 2.39±0.65 2.35±0.46 3.43±1.70 2.68±1.70 2.91±1.40 2.78±1.44 2.64±1.31 2.17±1.24 2.43±1.49 2.73±1.07 3.66±1.14 3.68±1.10 3.71±1.08 3.53±1.08 3.48±1.04 3.52±1.06 3.85±1.04 3.65±0.93 Communication & education Establishing therapeutic relationship & communication Patient and family counseling Health education and self-care 2.42±0.58 2.55±0.51 2.42±0.58 2.47±0.41 3.27±1.11 2.83±1.27 2.49±1.41 3.86±0.96 3.78±1.01 3.78±1.02 3.78±0.94 3.79±0.87 Nursing management Recording nursing activity Organizing document Admission and discharge care Transitional care Management of disinfectants Management of equipment & device Medication management Drug management 2.70±0.46 2.51±0.60 2.47±0.56 2.39±0.60 2.43±0.60 2.39±0.60 2.52±0.59 2.73±0.54 2.52±0.41 4.72±0.76 4.44±1.08 3.39±1.31 3.22±1.33 3.41±1.65 3.52±1.53 4.01±1.42 3.59±1.59 3.82±0.80 3.85±1.18 3.71±1.09 3.58±0.96 3.51±1.03 3.61±1.08 3.63±1.05 3.70±1.11 3.93±1.25 3.69±0.93 무는모니터링, 신체사정, 호흡기간호, 상처간호, 간호관리, 의사소통및교육이며, 수행수준은높지만수행빈도가낮은임무는응급간호, 감염관리였다 (Figure 1). 2) 수행수준과교육요구도핵심간호활동임무의수행수준과교육요구도가모두높은임무는응급간호, 감염관리, 상처간호, 호흡기간호, 신체사정, 의사소통및교육이었으며, 수행수준이낮고, 교육요구도도낮은임무는개인위생, 기동성지지, 안위간호, 영양과배설이었다 (Figure 2). 3) 수행빈도와교육요구도핵심간호활동임무의수행빈도가높고교육요구도가높은임무는신체사정, 호흡기간호, 의사소통및교육, 안전관리였으며, 수행빈도는낮지만교육요구도가높은임무는감염관리와응급간호였다 (Figure 3). 논의 본연구는요양병원에서간호사가수행하는핵심간호활동에대해수행수준과수행빈도및교육요구도를확인하여중점을두어야할간호활동을파악함으로써간호의전문성을유지 Vol. 21 No. 2, 2018 115
문선숙 서연옥 이경우등 Table 3. Difference of the Level, Frequency and Educational Needs according to General Characteristics (N=155) Variables Categories n(%) Level Frequency Educational needs M±SD t or F (p) M±SD t or F (p) M±SD t or F (p) Age (year) 29 30~39 40~49 50~59 60 16 (10.3) 32 (20.6) 46 (29.7) 46 (29.7) 15 (9.7) 2.60±0.36 2.43±0.30 2.37±0.31 2.41±0.31 2.45±0.24 1.73 (.147) 2.50±0.88 2.46±0.61 2.45±0.64 2.45±0.54 2.49±0.49 0.03 (.998) 3.81±0.88 3.80±0.75 3.70±0.82 3.68±0.83 4.09±0.43 0.61 (.659) Marital status Single Married 29 (18.8) 125 (81.2) 2.43±0.33 2.42±0.30 0.10 (.921) 2.50±0.68 2.45±0.60 0.35 (.724) 3.77±0.98 3.76±0.74 0.03 (.977) Education College graduate Bachelor 95 (61.3) 60 (38.7) 2.43±0.29 2.42±0.34 0.24 (.812) 2.48±0.58 2.42±0.67 0.59 (.555) 3.73±0.83 3.79±0.75 -.46 (.650) Clinical experience (year) <5 5~10 11~15 16~20 20 30 (19.4) 44 (28.4) 33 (21.3) 20 (12.9) 28 (18.1) 2.45±0.34 2.42±0.29 2.36±0.30 2.49±0.36 2.43±0.29 0.70 (.595) 2.59±0.74 2.33±0.60 2.50±0.52 2.67±0.49 2.34±0.64 1.79 (.134) 3.70±0.88 3.76±0.80 3.94±0.61 3.69±0.83 3.65±0.88 0.46 (.764) Career of long-term care facility (year) <1 a 1~5 b >5 c 32 (20.6) 71 (45.8) 52 (33.5) 2.38±0.28 2.39±0.30 2.50±0.33 2.30 (.104) 2.36±0.65 2.44±0.62 2.56±0.58 1.17 (.313) 3.34±1.03 3.82±0.62 3.93±0.77 5.15 (.007) a<b<c Nurses to patients ratio 9.37±4.80 Nurse aid to patients ratio 7.53±6.13 Scheffe test. Figure 1. Scatterplot of Duties in the Level and Frequency. 하기위한간호활동항목과규정을마련하기위한근거자료를제시하고자하였다. 연구결과에서수행수준과수행빈도가높은임무는모니터 링, 수행수준과교육요구도가낮은임무는개인위생, 수행빈도가높은항목은신체사정, 호흡기간호이며, 영양과배설의수행빈도가낮은것으로나타났다. 모니터링은활력징후, 혈당 116 The Korean Journal of Rehabilitation Nursing
Figure 2. Scatterplot of duties in the level and educational needs. Figure 3. Scatterplot of duties in the frequency and educational needs. 등을측정하고심전도나산소포화도등을모니터하거나합병증을관찰하는간호들로써수행수준이가장높고가장많이수행하는간호활동이지만교육요구도는중간정도였다. 이는요양병원간호사가 90% 이상수행하는간호활동이며간호보조인력에게위임하지않는다는결과 (Park, 2016) 를볼때간호사가해야할필수적인간호이며자주수행하는활동이기에본 연구에서교육요구도가수행수준과빈도만큼높지않게나타난것이라고해석된다. 반면위임업무를제시한선행연구들 (Jang & Kim, 2017; Park, 2016) 에서활력징후측정과같은간호활동은보조인력에게약 80% 이상위임하는것으로보고되었다. 그러나본연구의대상자들은합병증관찰이나환자상태모니터링과함께활력징후를측정하는것도어느정도의수준 Vol. 21 No. 2, 2018 117
문선숙 서연옥 이경우등 이필요한간호활동이라고인식하고있음을알수있다. 개인위생간호활동은선행연구들에서도보조인력에게위임하는간호활동에포함되어있었는데 (Kim & Jeong, 2014; Kim & Kim, 2016) 본연구에서도수행수준과교육요구도가가장낮았다. 개인위생은장기요양환자에게매일수차례반복적으로수행되는단순한간호활동으로간호사의지도, 감독하에보조인력이수행할수있어높은수준이필요하다고생각하지않음을알수있다. 이러한간호활동에대해서는향후위임을위한기준과절차가마련되어수행된다면효율적인간호업무를제공할수있을것이다. 핵심간호활동의임무별수행수준과수행빈도, 교육요구도에대한상대적관계를분석한결과에서는수행수준과수행빈도, 교육요구도가모두높은간호임무는신체사정, 호흡기간호, 상처간호, 의사소통과교육으로나타나, 간호사의사고와판단이요구되는전문적간호활동임을알수있다. 신체사정과호흡기간호는요양병원에입원한환자에게가장많이발생하는폐렴예방과도관련이있는간호활동으로 (Chae, Song, Kang, & Lee, 2015), 호흡재활에대한중요성과교육요구도가높았던결과 (Suh et al., 2017) 를고려할때요양병원간호사가수행하는중요한간호업무중의하나임을알수있다. 그러나몇몇연구보고에서는전문성이요구되는이러한간호활동들이간호사들인력부족으로인하여일부보조인력에게위임하고있는것으로나타나 (Jang & Kim, 2017; Lim, 2015), 환자의생명과관련된문제가발생될수있음을우려하고있다. 이는요양병원의간호인력기준이간호사정원의 2/3범위내에서간호조무사를고용하도록의료법시행규칙이시행되면서보조인력에게위임하는업무가많아지게된요인이되었을것이다. 다음으로수행수준과수행빈도, 교육요구도가모두높은간호임무인상처간호는욕창예방과관련된간호활동으로요양병원에서간호사가가장많이수행하는간호활동이다 (Kim et al., 2017). 우리나라의경우욕창발생률이요양기관평가항목에포함되어있으며, 간호인력의산정에도반영되어 (Lee et al., 2015), 간호사에의해집중적으로관리되는필수적인간호임을다시한번확인하였다. 또한의사소통및교육과같은간호활동역시수행수준과수행빈도, 교육요구도가모두높은것으로나타나고도의전문성이요구되는업무임을알수있었다. 그러나요양병원간호사들스스로가교육과상담에대한간호역량이낮다고인식하고있어 (Kim & Gu, 2015) 본연구대상자들의교육에대한높은요구도를고려할때, 이들에게의사소통기술이나환자및보호자교육에대한역량을강화시킬수있는지원이필요한것으로보인다. 이러한결과에근거하여 간호사의수행빈도가높은간호활동중에서높은수준의간호가필요한임무에대해서는반드시간호사에의해수행될수있도록전문적교육과지원이필요하며환자의생명과직결된간호문제를해결할수있도록간호인력의비율을확대할필요가있다. 우리나라보다앞서노인요양제도를시행하고있는미국의경우, 너싱홈에서근무하는간호사와간호보조인력의비율을적절하게유지하는것이환자간호의질을높이는중요한요인이며, 효율적인비율에대한비용효과적측면에서의연구가더필요함을제시한바있다 (Kim, Harrington, & Greene, 2009). 우리나라도현행요양병원간호인력의등급산정비율을조정하기위한노력이필요하며, 근거자료를마련하기위하여간호활동수준에대한대단위연구가필요하다고본다. 본연구에서수행빈도는낮지만수행수준과교육요구도가높은임무에포함된것은응급간호와감염관리로나타났다. 이러한결과는요양병원간호사들이응급간호를수행하는빈도는낮지만응급상황에대한대처능력과이를위한계속교육이필요하다는것을간호사들이인식하고있음을유추할수있다. Kim과 Gu (2015) 는응급상황이나안전사고발생시신속하고정확하게대처할수있는역량의중요성을요양병원간호사들이인식하고있다고보고하였으며, 실제응급상황이나안전사고대처의 96% 정도는간호사에의해수행되고있어 (Kim et al., 2017), 응급간호에대한주기적인훈련이필요함을시사한다. 감염관리는본연구대상자들의교육요구도가가장높았던간호임무로나타났다. 이는면역력이저하된노인입원환자가많은요양병원에서무엇보다중요한간호활동이지만전반적으로는감염관리체계가제대로갖추어져있지않은상황에서감염관리에대한전문적인정보를얻기위한것이라고볼수있다. Kim, Jeong, Kim과 So (2018) 는 17.4% 의요양병원만이감염관리담당부서를운영하고있으며, 요양병원인증평가항목인손위생, 소독, 멸균등에대한교육요구도는낮은반면감염관리교육프로그램에서접할기회가적은공기와수질관리, 건축과감염관리, 지표관리등에대한교육요구도가높다고보고하였다. 한편, 본연구대상자들에서일반적특성에따른핵심간호활동의수행수준과수행빈도에대한차이는없었으나, 교육요구도는전체임상경력보다요양병원근무기간과관련이있고요양병원경력이높을수록교육요구도가높았다. 요양병원에서의경력이간호역량에더중요한요인이라고본다면 (Kim & Gu, 2015) 경력이쌓일수록역량을증가시키기위한지원이필요할것이다. 특히교육요구도가높았던감염관리와응급간호항목에서필수항목을선정하여주기적으로실무교육이나재교육을받을수있는기회를제공해야할것이다. 118 The Korean Journal of Rehabilitation Nursing
핵심간호활동중에서수행수준과교육요구도가낮은간호임무는개인위생과기동성지지, 영양및배설이었다. 선행연구에서도개인위생, 배변관리, 활동돕기는간호사도수행하지만보조인력이더많이수행하는간호 (Kim & Jeong, 2014) 였으며, 특히개인위생은수행수준이가장낮고, 대부분보조인력에게위임하는일상생활보조업무 (Jang & Kim, 2017; Kim et al., 2017) 였고, 배뇨관리와관장도수행수준이낮았다 (Kim et al., 2017). 이와같이고도의간호수준이요구되지않는간호활동이지만대상자를관찰하고건강상태를파악하여조기에문제를발견할수있는기회가되므로보조인력에게위임을하더라도간호사가책임의식을가지고사정하고감시해야할것이다. 본연구에서안전관리임무는수행빈도와교육요구도가높고수행수준도비교적높은편이었다. 환자의안전관리는점차강조되는추세이며이는요양병원의환자의특성상주로인지기능과감각기능에손상이있는노인들임을고려할때특히중요성을두어야할부분이다. 최근요양병원인증평가로환자안전에중점을두고있어서요양병원간호사들이환자안전관리에대한간호활동을급성병원보다더많이하는것으로보고되었으며 (Moon & Yoon, 2018), 앞으로도환자안전관리에대해지속적으로관심을가지고안전간호활동을증진시키기위해노력해야할것이다. 이상의결과를종합하여보면요양병원간호사가수행하는간호활동을수행수준에따라분류하고, 핵심간호를규정하여기준을제시한다면위임여부를결정하는근거자료로활용될수있을것이다. 본연구의제한점은핵심간호활동으로구성된항목들이요양병원의규모나지역적특성에따른간호활동의차이를반영하지못한것이며, 요양병원을편의표집하여연구결과를일반화하기에주의를기울여야한다. 그러나본연구에서는요양병원간호사들이수행하는주요간호활동을위주로조사도구를구성하였으며, 간호임무로분류하여수행수준과수행빈도, 교육요구도를상대적으로분석함으로서간호사에의해반드시수행되어야할간호활동과간호임무, 교육요구도가높은간호활동을파악한것에연구의의의가있다. 또한수행수준과수행빈도를고려하여위임할수있는간호활동을규정할수있는근거자료를제공한것에연구의의의가있다. 결론및제언 요양병원간호사가수행하는간호활동에대해수행수준, 수행빈도, 교육요구도의상대적관계를분석한결과에서수행수 준, 수행빈도, 교육요구도가모두높은간호임무는신체사정, 호흡기간호, 상처간호, 의사소통과교육이었고, 간호사가반드시수행해야할핵심간호활동이었다. 수행빈도는낮지만수행수준과교육요구도가높은응급간호와감염관리는요양병원간호사에게실무교육이필요한간호임무임을알수있었다. 또한수행수준과교육요구도가낮은개인위생, 기동성지지, 영양및배설은대부분보조인력에게위임이가능하지만간호사의감시감독하에수행되어야하는간호라고볼수있다. 따라서요양병원간호사가수행해야할핵심간호활동은간호사의전문적인지식과판단이요구되는간호활동을중심으로구성되어야할것이다. 또한, 간호수준이높고전문성이요구되는간호활동에대해서는적절한교육의기회를제공하여준다면환자간호의질향상에도움이될것이다. 이상의연구결과를토대로하여요양병원간호사가수행해야할주요간호활동이파악되고, 핵심간호활동을규정하기위한대단위수준의반복연구가필요하며, 간호사와간호보조인력의업무기준을마련하기위한연구를제안한다. REFERENCES Buck, J., Loversidge, J., Chipps, E., Gallagher-Ford, L., Genter, L., & Yen, P. Y. (2018). Top-of-license nursing practice: Describing common nursing activities and nurses' experiences that hinder Top-of-License Practice, Part 1. Journal of Nursing Administration, 48(5), 266-271. https://doi.org/10.1097/nna.0000000000000611 Chae, J. M., Song, H., Kang, G., & Lee, J. Y. (2015). Impact of nurse staffing level and oral care on hospital acquired pneumonia in long-term care hospitals. Journal of Korean Academy of Nursing Administration, 21(2), 174-183. https://doi.org/10.11111/jkana.2015.21.2.174 Hlahol, M. (2016). Registered nurses' perception of top of license practice activities. Unpublished doctoral dissertation, The Ohio State University, Columbus, OH, USA. http://hdl.handle.net/1811/76699 Institute of Medicine. The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press; 2010. Jang, E. J., & Kim, S. H. (2017). Delegation of nursing activities in long-term care hospitals. Journal of Korean Gerontology Nursing, 19(2), 101-112. https://doi.org/10.17079/jkgn.2017.19.2.101 Kim, E. H., & Lee, E. (2015). Nursing outcomes of inpatient on level of nursing staffing in long term care hospitals. Journal of Korean Data & Information Science Society, 28(3), 715-727. https://doi.org/10.5392/jkca.2016.16.07.368 Kim, E. J., & Gu, M. O. (2015). Recognition for nursing competency importance, nursing competency level, and their influencing Vol. 21 No. 2, 2018 119
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