Nursing care documentation is an important aspect of clinical decision-making processes and affects patient safety. Documentation in the perioperative setting has been described as poor and incomplete and varies among nurses. The purpose of this qualitative study was to examine perioperative nurses' documentation practices using a realistic evaluation framework that focuses on relationships between context, mechanisms, and outcomes. Through participant observations using multiple qualitative data-generation methods, the study found that perioperative nurses' documentation practices are driven by a mix of educational, cultural, and organizational factors, including competing demands, local values and traditions, and everyday circumstances. Understanding the cultures of different subgroups in the perioperative setting may help improve nurses' documentation practices.
Keywords: context-mechanism-outcome (CMO) configuration; nursing documentation; realistic evaluation; unit culture.
© AORN, Inc, 2019.