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Dissertation/Thesis Abstract

Creating a protective picture: A grounded theory of how medical-surgical nurses decide to follow a “charting-by-exception” policy on a day-to-day, patient-by-patient basis
by Kerr, Noel M., Ph.D., Rutgers The State University of New Jersey - Newark, 2011, 197; 3457501
Abstract (Summary)

Rationale 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.

Indexing (document details)
Advisor: Lev, Elise L.
School: Rutgers The State University of New Jersey - Newark
Department: Graduate School - Newark
School Location: United States -- New Jersey
Source: DAI-B 72/08, Dissertation Abstracts International
Subjects: Nursing
Keywords: Charting-by-exception, Nursing documentation, Variance charting
Publication Number: 3457501
ISBN: 978-1-124-68129-0
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