‘Scraps’: hidden nursing information and its influence on the delivery of care

Hardey, Michael; Payne, Sheila; Coleman, Peter G.

doi:10.1046/j.1365-2648.2000.01443.x

Cited by 105 publications

(126 citation statements)

References 18 publications

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“…O'Connell et al (2000) found that care plans and documentation not specific to individual specialties or patients are usually out of date and therefore of little value. Many studies indicate that, despite the problems discussed, nurses viewed it as an important aspect of their work (Allen, 1998;Martin et al, 1999;Hardy et al, 2000;Friberg et al, 2005;Cheevakasemsook et al, 2006;Irving et al, 2006). Three studies cite lack of time as a factor affecting the documentation process (McKenna et al, 2000;Cheevakasemsook et al, 2006;Kalisch, 2006).…”

Section: Literature Reviewmentioning

confidence: 99%

“…Clemow (2006) and Hardy et al (2000) suggest that, unlike other health professionals, who record their observations in the knowledge that their assessments will be read and acknowledged by others, nurses do not. O'Connell et al (2000) found that care plans and documentation not specific to individual specialties or patients are usually out of date and therefore of little value.…”

Section: Literature Reviewmentioning

confidence: 99%

“…Hardy et al (2000) argue that most forms of nursing documentation, including care plans and progress reports, were not used to inform nursing care. Rather than refer to documentation, nurses preferred to communicate verbally, using their own 'scraps' of paper which held important information that would not be open to scrutiny by others.…”

Section: Literature Reviewmentioning

confidence: 99%

See 2 more Smart Citations

Improving nurse documentation and record keeping in stoma care

2010

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Evidence suggests that nurse documentation is often inconsistent and lacks a coherent and standardized approach. This article reports on research into the use of nurse documentation on a stoma care ward in a large London hospital, and explores the factors that may affect the process of record keeping by nursing staff. This study uses stoma care as a case study to explore the role of documentation on the ward, focusing on how this can be improved. It is based on quantitative and qualitative methods. The medical notes of 56 patients were analysed and in addition, focus groups with a number of nurses were undertaken. Quantitative findings indicate that although 80% of patients had a chart filed in their medical notes, only a small portion of the form was completed by nursing staff. Focus group findings indicate that this is because forms lacked standardization and because the language used was often ambiguous. Staff also felt that such documentation was not viewed by other nurses and so, was not effective in improving patient care. As a result of this study, significant improvements have been made to documentation used on the stoma care ward. This is an important exploration of record keeping within nursing in the context of the Nursing and Midwifery Council’s emphasis on the importance of documentation in achieving effective patient outcomes.

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Section: Literature Reviewmentioning

confidence: 99%

Section: Literature Reviewmentioning

confidence: 99%

Section: Literature Reviewmentioning

confidence: 99%

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Improving nurse documentation and record keeping in stoma care

2010

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“…That is, prior research illustrates that many workarounds prevent seeking longer-term and more satisfactory solutions. Worse, they also frequently require special data entry systems or processes and increased opportunities for error [20,21].…”

Section: Discussion and Outlookmentioning

confidence: 99%

Unintended Consequences: New Problems, New Solutions

Koppel

Chen²

2016

Yearb Med Inform

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SummaryObjective: To select the best of the 2015 published papers on unintended consequences of healthcare information technology (HIT). Method: Literature searches in several areas of scholarship, including IT, human factors, evaluation studies, medical errors, medical informatics, and implementation science. Also, because the specific terms "unintended consequences" were not often included in abstracts and titles, a more nuanced search algorithm was developed. Results: We identified 754 papers that had some empirical research on unintended consequences of HIT. An initial screen of titles and abstracts reduced this to 171 papers of potential interest. We then further filtered out papers that did not meet the following criteria: 1) the paper had to report an original empirical investigation, and 2) the impact reported had to be not negligible, i.e., in quantitative studies, the results related to unintended consequences were statistically significant; and in qualitative studies the relevant themes emerged were prominent. This resulted in 33 papers of which 15 were selected as best paper candidates. Each of these 15 papers was then separately evaluated by four reviewers. The final selection of four papers was made jointly by the external reviewers and the two section editors. Conclusions: There is a growing awareness of the importance of HIT's unintended consequences-be they generated by the HIT vendors, the implementation process, the consultants,

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“…Paper towels may act as temporary cognitive artifacts in certain instances and are quick and easy to access to write notes down [34]. They can be used as a quick way to store information when official records or EHRs are not available or do not fit the time sensitive nature of a situation.…”

Section: A Documentation Practicesmentioning

confidence: 99%

Designing Collaborative Healthcare Technology for the Acute Care Workflow

Gonzales¹,

Cheung²,

Riek³

2015

EAI Endorsed Trans Perv Health Tech

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Abstract-Preventable medical errors in hospitals are the third leading cause of death in the United States. Many of these are caused by poor situational awareness, especially in acute care resuscitation scenarios. While a number of checklists and technological interventions have been developed to reduce cognitive load and improve situational awareness, these tools often do not fit the clinical workflow. To better understand the challenges faced by clinicians in acute care codes, we conducted a qualitative study with interprofessional clinicians at three regional hospitals. Our key findings are: Current documentation processes are inadequate (with information recorded on paper towels); reference guides can serve as fixation points, reducing rather than enhancing situational awareness; the physical environment imposes significant constraints on workflow; homegrown solutions may be used often to solve unstandardized processes; simulation scenarios do not match real-world practice. We present a number of considerations for collaborative healthcare technology design and discuss the implications of our findings on current work for the development of more effective interventions for acute care resuscitation scenarios.

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‘Scraps’: hidden nursing information and its influence on the delivery of care

Cited by 105 publications

References 18 publications

Improving nurse documentation and record keeping in stoma care

Improving nurse documentation and record keeping in stoma care

Unintended Consequences: New Problems, New Solutions

Designing Collaborative Healthcare Technology for the Acute Care Workflow

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