Registered Nurses’ Decision-making Regarding Documentation in Patients’ Progress Notes

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Title Registered Nurses’ Decision-making Regarding Documentation in Patients’ Progress Notes
Author Tower, Marion; Chaboyer, Wendy; Green, Quentine; Dyer, Kirsten; Wallis, Marianne
Journal Name Journal of Clinical Nursing
Year Published 2012
Place of publication United Kingdom
Publisher Wiley-Blackwell Publishing
Abstract Aims and objectives. To examine registered nurses’ decision-making when documenting care in patients’ progress notes. Background. What constitutes effective nursing documentation is supported by available guidelines. However, ineffective documentation continues to be cited as a major cause of adverse events for patients. Decision-making in clinical practice is a complex process. To make an effective decision, the decision-maker must be situationally aware. The concept of situation awareness and its implications for making safe decisions has been examined extensively in air safety and more recently is being applied to health. Design and methods. The study was situated in a naturalistic paradigm. Purposive sampling was used to recruit 17 registered nurses who used think-aloud research methods when making decisions about documenting information in patients’ progress notes. Follow-up interviews were conducted to validate interpretations. Data were analysed systematically for evidence of cues that demonstrated situation awareness as nurses made decisions about documentation. Results. Three distinct decision-making scenarios were illuminated from the analysis: the newly admitted patient, the patient whose condition was as expected and the discharging patient. Nurses used mental models for decision-making in documenting in progress notes, and the cues nurses used to direct their assessment of patients’ needs demonstrated situation awareness at different levels. Conclusions. Nurses demonstrate situation awareness at different levels in their decision-making processes. While situation awareness is important, it is also important to use an appropriate decision-making framework. Cognitive continuum theory is suggested as a decision-making model that could support situation awareness when nurses made decisions about documenting patient care. Relevance to clinical practice. Because nurses are key decision-makers, it is imperative that effective decisions are made that translate into safe clinical care. Including situation awareness training, combined with employing cognitive continuum theory as a decision-making framework, provides a powerful means of guiding nurses’ decision-making.
Peer Reviewed Yes
Published Yes
Alternative URI
Volume 21
Issue Number 19-20
Page from 2917
Page to 2929
ISSN 1365-2702
Date Accessioned 2012-09-19
Language en_US
Research Centre Centre for Health Practice Innovation; Menzies Health Institute Qld
Faculty Griffith Health Faculty
Subject Clinical Nursing: Secondary (Acute Care)
Publication Type Journal Articles (Refereed Article)
Publication Type Code c1

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