TitleCreating a protective picture
NameKerr, Noël M. (Noël Marie) (author), Lev, Elise (chair), D'Alonzo, Karen (internal member), Ruggiero, Jeanne (internal member), Kossman, Susan (outside member), Rutgers University, Graduate School - Newark,
DescriptionRationale for the study: The philosophy behind the Charting-by-Exception (CBE) method of documentation remains a source of professional concern almost 30 years after its introduction. The literature lacks both qualitative and quantitative studies that address either staff nurse views of CBE, or the use of CBE data for clinical decision-making. Method: Classic Grounded Theory was used to explore the process Medical-Surgical nurses use in deciding whether to follow a CBE policy on a day-to-day, patient-by-patient basis. Approval of the Academy of Medical-Surgical Nurses (AMSN) Research Committee and the IRB at Rutgers University was obtained before the research began. Sixteen participants, recruited from the membership of AMSN were interviewed over the phone about their perspectives and experiences in using CBE to document clinical data. All participants were Registered nurses, worked as a staff nurse on an acute care, medical-surgical unit and used CBE. All interviews were recorded and transcribed verbatim. These data were managed using Atlas.ti and analyzed using the constant comparative method as described by Glaser. Results: The theory which emerged from the data is a three-step process which includes Coming to Terms with the Method, Being Responsible in Documentation and
Creating a Protective Picture. Creating a Protective Picture is the Core category which explains how the participants resolved their main concern; Create
documentation they believed would be protective of their patients, themselves and/or their employers. Conclusion: The findings provide insight into what
nurses consider responsible documentation practices and the decision-making process they use when documenting under a CBE policy with an exception-based electronic documentation system. Although documentation has historically been viewed by nurses as a task that takes time away from more
important duties, the documentation choices made by each of the participants in this study demonstrated a) many of the reasons why nurses value taking time to
record data with more detail than possible when following CBE policy and b) the value participants placed on the contribution nursing documentation makes to the provision of quality patient care.
NoteIncludes bibliographical references
Noteby Noël M. Kerr
CollectionGraduate School - Newark Electronic Theses and Dissertations
Organization NameRutgers, The State University of New Jersey
RightsThe author owns the copyright to this work.