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Nursing Documentation in the Emergency Department: Nurses’ Perspectives

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Nursing Documentation in the Emergency Department: Nurses’ Perspectives Title Page NURSING DOCUMENTATION IN THE EMERGENCY DEPARTMENT: NURSES’ PERSPECTIVES by Paula Caroline Grainger A thesis submitted to Victoria University of Wellington, New Zealand in partial fulfilment of the requirements for the degree of Master of Nursing (Clinical) Victoria University of Wellington 2007 Grainger (2007) Nursing Documentation In The Emergency Department: Nurses’ Perspectives Abstract Nursing documentation is a required aspect of care, but for various reasons it can be curtailed. Nursing records are a critical aspect of communication and without them coordinated and safe care can be difficult to achieve. Study aim: To explore emergency nurses’ perspectives and practices about the quality, importance and value of emergency nursing documentation in relation to their personal beliefs, past experiences and preferred systems of documentation; the practical and contextual factors that influence documentation practices within an emergency department (ED); their interests in documentation tools or systems; and their interests in relation to further development of documentation practices and systems. Methodology and design: A qualitative descriptive study (informed by Sandelowski). Ten emergency nurses from one ED in New Zealand were recruited. Participants were interviewed using interactive interview methods, and completed a Likert scale to identify the relevance of internationally recognised general influences on documentation to their own practices in the context of an ED. Findings: The participants’ practices were influenced by factors in the workplace including competing priorities for time e.g. care provision vs. documentation, competition for access to patient records, and extant culture in relation the purpose, content and frameworks for documentation. Documentation practices were influenced by the participant’s own clinical histories, philosophies, familiarity with particular frameworks and education. The participants recommended routes to development through partnership, participation and process engagement. Recommended strategies included document development, knowledge advancement and support. These findings were reported qualitatively and reveal areas of agreement and divergence. Contribution and consequences: These results compare well to the general literature regarding known influences on documentation. Importantly they provide insight and generate new knowledge into context specific influences and to the relevance of personal histories to documentation practices. A consequence of this research will be to better understand the context and practice of nursing documentation in ED, the factors that influence it and the potential means for development which support the legal and professional goals of optimal documentation. Keywords Nursing Records; Emergency Nursing; Qualitative Description; Nursing Documentation; Emergency Nurses’ Perspectives; Interviews, Context Specific Influences; Facilitating and Inhibiting factors ii Grainger (2007) Nursing Documentation In The Emergency Department: Nurses’ Perspectives Acknowledgements Participants: For everyone who gave up their time to share their thoughts and ideas so freely, for their confidence, sharing their wisdom, and for contributing to the development of new knowledge about ED nursing practice in relation to documentation Victoria University of Wellington: Denise Blanchard – supervisor for the first part of this thesis programme – for getting me started and by giving me the courage to work as I like to work Jan Duke – for supervision back-up when it was required Cheryle Moss – supervisor for the second part of this thesis programme – for facilitating the discovery of so many answers to many questions and for helping me complete Kathy Nelson and Sara Quirke – my second readers Beverley Taylor - for enabling my work to go on and providing comprehensive and constructive feedback Others of note: John Dean – for recommending Annette Finlay to me and providing moral support Brian Dolan – for providing proof reading skills, constructive criticism and alternative options Marilyn Farrell – for providing support for my project in my absence during the Te Komiti Whakarite Committee meeting to assess the cultural safety aspects of the study Annette Finlay – Chair of the Te Komiti Whakarite Committee, Christchurch Hospital, for her practical and constructive advice to achieve ethical approval and her supportive presence in the Health Research Council Ethics Committee meeting Sue Hayward, Mark Newsome, Anne Esson and Charlotte Douglas – for providing me with the opportunity and encouragement to develop this study iii Grainger (2007) Nursing Documentation In The Emergency Department: Nurses’ Perspectives Table of Contents Title Page ......................................................................................................................................................................... i Abstract ........................................................................................................................................................................... ii Acknowledgements ...................................................................................................................................................... iii Table of Contents ......................................................................................................................................................... iv List of Tables .............................................................................................................................................................. viii List of Terms ................................................................................................................................................................. ix List of Abbreviations .................................................................................................................................................. xii Chapter 1: Introduction ................................................................................................................................................ 1 Introduction ............................................................................................................................................................... 1 Research aim, objectives and focus ........................................................................................................................ 1 Contribution to nursing knowledge .................................................................................................................. 2 Justification ............................................................................................................................................................ 2 Personal background and beliefs ....................................................................................................................... 3 Approach ............................................................................................................................................................... 4 Limitations in research foci ................................................................................................................................ 4 Presentation of this thesis ................................................................................................................................... 5 Chapter 2: Literature Review ....................................................................................................................................... 6 Introduction ............................................................................................................................................................... 6 Search strategy ........................................................................................................................................................... 6 Part One: Documentation systems ........................................................................................................................ 7 Historical perspectives ......................................................................................................................................... 8 Discussion of documentation frameworks ................................................................................................... 18 Summary ............................................................................................................................................................. 21 Part Two: Rationale for documentation ............................................................................................................. 23 Introduction ....................................................................................................................................................... 23 National and international situations ............................................................................................................. 24 Litigation ............................................................................................................................................................. 26 Communication and collaboration ................................................................................................................. 27 Professionalism and visibility of practice ...................................................................................................... 28 Research, best practice, professional
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