A Realistic Evaluation of Danish Perioperative Nurses' Documentation Practices. (29th October 2019)

• Record Type: Journal Article
• Authors: Søndergaard, Susanne Friis; Frederiksen, Kirsten; Sørensen, Erik Elgaard; Lorentzen, Vibeke
• Is Part Of: AORN journal. Volume 110:Number 5(2019)
• Page Start: 500
• Page End: 509
• Publication Date: 2019-10-29
• Subjects: nursing documentation -- realistic evaluation -- unit culture -- context‐mechanism‐outcome (CMO) configuration; Operating room nursing -- Periodicals; Soins infirmiers en salle d'opération -- Périodiques; Nursing -- Periodicals; Operating Room Nursing -- Periodicals; Perioperative Nursing -- Periodicals; Societies, Nursing -- Periodicals; 617.917
• DOI: 10.1002/aorn.12840
• Languages: English
• ISSNs: 0001-2092

Abstract

ABSTRACT: Nursing care documentation is an important aspect of clinical decision‐making processes and affects patient safety. Documentation in the perioperative setting has been described as poor and incomplete and varies among nurses. The purpose of this qualitative study was to examine perioperative nurses' documentation practices using a realistic evaluation framework that focuses on relationships between context, mechanisms, and outcomes. Through participant observations using multiple qualitative data‐generation methods, the study found that perioperative nurses' documentation practices are driven by a mix of educational, cultural, and organizational factors, including competing demands, local values and traditions, and everyday circumstances. Understanding the cultures of different subgroups in the perioperative setting may help improve nurses' documentation practices.