Danish Perioperative Nurses' Documentation: A Complex, Multifaceted Practice Conneced With Unit Culture and Nursing Leadership

Susanne Friis Søndergård, Vibeke Lorentzen, Erik Elgaard Sørensen, Kirsten Frederiksen

Research output: Contribution to journalJournal articleResearchpeer-review

Abstract

Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices.
Original languageEnglish
JournalAORN Journal
Volume106
Issue number1
Pages (from-to)31-41
ISSN0001-2092
DOIs
Publication statusPublished - 2017

Keywords

  • disease, health science and nursing
  • documentation
  • electronic health record
  • nursing leadership
  • perioperative nursing data set
  • realistic evaluation

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