Situation awareness and documentation of changes that affect patient outcomes in progress notes

Tower, Marion and Chaboyer, Wendy (2014) Situation awareness and documentation of changes that affect patient outcomes in progress notes. Journal of Clinical Nursing, 23 9-10: 1403-1410. doi:10.1111/jocn.12404

Attached Files (Some files may be inaccessible until you login with your UQ eSpace credentials)
Name Description MIMEType Size Downloads

Author Tower, Marion
Chaboyer, Wendy
Title Situation awareness and documentation of changes that affect patient outcomes in progress notes
Journal name Journal of Clinical Nursing   Check publisher's open access policy
ISSN 0962-1067
1365-2702
Publication date 2014-05
Sub-type Article (original research)
DOI 10.1111/jocn.12404
Open Access Status
Volume 23
Issue 9-10
Start page 1403
End page 1410
Total pages 8
Place of publication Chichester, West Sussex, United Kingdom
Publisher Wiley-Blackwell
Collection year 2015
Formatted abstract
Aims and objectives: To report on registered nurses' situation awareness as a precursor to decision-making when recording changes in patients' conditions.

Background: Progress notes are important to communicate patients' progress and detail changes in patients' conditions. However, documentation is often poorly completed. There is little work that examines nurses' decision-making during documentation. This study focused on describing situation awareness as a precursor to decision-making during documentation.

Design: This study used Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) work on situation awareness to guide and conceptualise information. The study was situated in a naturalistic paradigm to provide an interpretation of nurses' decision-making.

Methods: Think-aloud research methods and semi-structured interviews were employed to illuminate decision-making processes. Audio recordings and interview texts were individually examined for evidence of cues, informed by Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) descriptions of situation awareness.

Results: As patients' conditions changed, nurses used complex mental models and pattern-matching of information, drawing on all 3 levels of situation awareness during documentation. Level 1 situation awareness provided context, level 2 situation awareness signified a change in condition and its significance for the patient, and level 3 situation awareness was evident when nurses thought aloud about what this information indicated. Three themes associated with changes in patients' conditions emerged: deterioration in condition, not responding to prescribed treatments as expected and issues related to professional practice that impacted on patients' conditions.

Conclusion: Nurses used a complex mental model for decision-making, drawing on 3 levels of situation awareness. Hamm's cognitive continuum theory, when related to situation awareness, is a useful decision-making theory to provide a platform on which to draw together components of situation awareness and provide a framework on which to base decision-making regarding documentation. Relevance to clinical practice: Understanding how RNs employ situation awareness and providing a framework for decision-making during documentation may assist effective documentation about changes in patients' conditions.
Keyword Clinical decision-making
Decision-making
Documentation
Qualitative study
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2015 Collection
School of Nursing, Midwifery and Social Work Publications
 
Versions
Version Filter Type
Citation counts: TR Web of Science Citation Count  Cited 1 times in Thomson Reuters Web of Science Article | Citations
Scopus Citation Count Cited 2 times in Scopus Article | Citations
Google Scholar Search Google Scholar
Created: Thu, 05 Mar 2015, 11:03:35 EST by Vicki Percival on behalf of School of Nursing, Midwifery and Social Work