Registered nurses' decision-making regarding documentation in patients' progress notes

Tower, Maron, Chaboyer, Wendy, Green, Quentine, Dyer, Kirsten and Wallis, Marianne (2012) Registered nurses' decision-making regarding documentation in patients' progress notes. Journal of Clinical Nursing, 21 19-20: 2917-2929. doi:10.1111/j.1365-2702.2012.04135.x

Author Tower, Maron
Chaboyer, Wendy
Green, Quentine
Dyer, Kirsten
Wallis, Marianne
Title Registered nurses' decision-making regarding documentation in patients' progress notes
Journal name Journal of Clinical Nursing   Check publisher's open access policy
ISSN 0962-1067
Publication date 2012
Year available 2012
Sub-type Article (original research)
DOI 10.1111/j.1365-2702.2012.04135.x
Open Access Status
Volume 21
Issue 19-20
Start page 2917
End page 2929
Total pages 13
Place of publication Chichester, West Sussex, United Kingdom
Publisher Wiley-Blackwell Publishing Ltd.
Collection year 2012
Language eng
Subject 2900 Nursing
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.
Keyword Clinical decision making
Qualitative study
Registered nurses
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status Non-UQ

Document type: Journal Article
Sub-type: Article (original research)
Collection: School of Nursing, Midwifery and Social Work Publications
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