School of Nursing & Midwifery, Griffith University, Nathan, Qld, Australia.
J Clin Nurs. 2012 Oct;21(19-20):2917-29. doi: 10.1111/j.1365-2702.2012.04135.x. Epub 2012 Jul 12.
To examine registered nurses' decision-making when documenting care in patients' progress notes.
What constitutes effective nursing documentation is supported by available guidelines. However, ineffective documentation continues to be cited as a major cause of adverse events for patients. Decision-making in clinical practice is a complex process. To make an effective decision, the decision-maker must be situationally aware. The concept of situation awareness and its implications for making safe decisions has been examined extensively in air safety and more recently is being applied to health.
The study was situated in a naturalistic paradigm. Purposive sampling was used to recruit 17 registered nurses who used think-aloud research methods when making decisions about documenting information in patients' progress notes. Follow-up interviews were conducted to validate interpretations. Data were analysed systematically for evidence of cues that demonstrated situation awareness as nurses made decisions about documentation.
Three distinct decision-making scenarios were illuminated from the analysis: the newly admitted patient, the patient whose condition was as expected and the discharging patient. Nurses used mental models for decision-making in documenting in progress notes, and the cues nurses used to direct their assessment of patients' needs demonstrated situation awareness at different levels.
Nurses demonstrate situation awareness at different levels in their decision-making processes. While situation awareness is important, it is also important to use an appropriate decision-making framework. Cognitive continuum theory is suggested as a decision-making model that could support situation awareness when nurses made decisions about documenting patient care.
Because nurses are key decision-makers, it is imperative that effective decisions are made that translate into safe clinical care. Including situation awareness training, combined with employing cognitive continuum theory as a decision-making framework, provides a powerful means of guiding nurses' decision-making.
研究注册护士在患者病程记录中记录护理时的决策制定过程。
现有的指南支持有效的护理记录，但仍有无效的护理记录被认为是导致患者不良事件的主要原因。临床实践中的决策制定是一个复杂的过程。为了做出有效的决策，决策者必须对情况有清醒的认识。情景意识的概念及其对做出安全决策的影响在航空安全领域得到了广泛的研究，最近也被应用于卫生领域。
该研究处于自然主义范式中。采用目的抽样法招募了 17 名注册护士，他们在对患者病程记录中的信息进行记录做出决策时使用了出声思维研究方法。进行了随访访谈以验证解释。对数据进行了系统分析，以寻找表明护士在记录文档时的决策中具有情景意识的线索。
从分析中揭示了三个不同的决策情景：新入院患者、病情如预期的患者和出院患者。护士在病程记录中使用心智模型进行决策，护士用于指导评估患者需求的线索在不同层面上展示了情景意识。
护士在决策过程中表现出不同层次的情景意识。虽然情景意识很重要，但使用适当的决策框架也很重要。认知连续体理论被建议作为一种决策模型，当护士做出记录患者护理的决策时，可以支持情景意识。
由于护士是关键决策者，因此必须做出有效的决策，将其转化为安全的临床护理。包括情景意识培训，并采用认知连续体理论作为决策框架，为指导护士的决策提供了一种有力的手段。
