Factors Associated with the Completeness of Nursing Process Documentation in the Center Surgical Units

2.50
Hdl Handle:
http://hdl.handle.net/10755/601869
Category:
Full-text
Format:
Text-based Document
Type:
Presentation
Title:
Factors Associated with the Completeness of Nursing Process Documentation in the Center Surgical Units
Other Titles:
Factors Associated with the Completeness of Nursing Process Documentation [Session]
Author(s):
Turrini, Ruth Natalia Teresa; Silva, Thatiara Cardoso; Guedes, Erika de Souza; Sousa, Regina M'rcia Cardoso de; Nogueira, Lilia de Souza; Monteiro da Cruz, Din' de Almeida Lopes
Lead Author STTI Affiliation:
Non-member
Author Details:
Ruth Natalia Teresa Turrini, RN, rturrini@usp.br; Thatiara Cardoso Silva; Erika de Souza Guedes, RN; Regina M'rcia Cardoso de Sousa, RN; Lilia de Souza Nogueira, RN; Din' de Almeida Lopes Monteiro da Cruz, RN
Abstract:
Session presented on Saturday, July 25, 2015: Purpose: In the surgical center unit documentation of nursing process are used to identify potential risks to anesthetic-surgical process and record care actions by the nursing team. Since the introduction of nursing process in the nurse care practice until present day, this care model has some challenges for its complete implementation. Objective: To identify the variables associated with complete documentation of the nursing process.' 'Methods: Cross-sectional study developed in public hospitals under the management of the Sao Paulo state board of health, Brazil, from Jan/2010 to Jan/2011. The research was developed in 40 hospitals, where was identified 25 surgical center units that perform the nursing process. The information was obtained by observing the medical records and interviews with nurses in the operating room units considering completeness of the nursing process documentation (assessment, diagnoses, nursing orders, progress notes, and nursing notes), quantitative dates about surgeries performed, unit and institution characteristics, including the Nursing Work Index ' Revised (NWI-R) e Malasch Burnout Inventory. A descriptive analysis of the variables, Kruskal-Wallis test to compare means and chi-square test for the analysis of qualitative variables were performed. The significance level was 5% and all analyzes were performed by SPSS v17. The project was approved by the Research Ethics Committee. 'Results: Analyzing the medical record, 22,2% (6) of units does not document the nursing process, 48,1% (13) documents partially and 2.2% (6) documents completely. About the hospitals' size, the 63% (17) were large. The median surgeries per day was 10.2 (range 2.2 to 31.0), with a high frequency of small and medium procedures, 'only one unit was located in an ambulatory. The findings of the analysis of quantitative variables, by Kryskall-Wallis test, showed that only emotional exhaustion and personal dimensions of Malasch Burnout Inventory showed statistically significant differences in relation to completeness of the nursing process documentation (p<0,05). Although, the lowest average in the emotional exhaustion and highest average in personal accomplishment dimensions were associated with incomplete documentation of the nursing process, the average observed to complete and no documentation of nursing process was equal. 'Conclusion: The documentation of the nursing process is very important to patient safety undergoing surgery, because it identifies potential risks. Strategies that promote personal accomplishment and avoid emotionalexhaustion may impact on the completeness of clinical documentation of nursing in the operating room, but iot is necessary to investigate further because nurses that do not document the nursing process completely has average similar to those who do it.
Keywords:
nursing process; operating room; documentation
Repository Posting Date:
17-Mar-2016
Date of Publication:
17-Mar-2016 ; 17-Mar-2016
Other Identifiers:
INRC15F13
Conference Date:
2015
Conference Name:
26th International Nursing Research Congress
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
San Juan, Puerto Rico
Description:
Research Congress 2015 Theme: Question Locally, Engage Regionally, Apply Globally. Held at the Puerto Rico Convention Center.

Full metadata record

DC FieldValue Language
dc.language.isoenen
dc.type.categoryFull-texten
dc.formatText-based Documenten
dc.typePresentationen
dc.titleFactors Associated with the Completeness of Nursing Process Documentation in the Center Surgical Unitsen
dc.title.alternativeFactors Associated with the Completeness of Nursing Process Documentation [Session]en
dc.contributor.authorTurrini, Ruth Natalia Teresaen
dc.contributor.authorSilva, Thatiara Cardosoen
dc.contributor.authorGuedes, Erika de Souzaen
dc.contributor.authorSousa, Regina M'rcia Cardoso deen
dc.contributor.authorNogueira, Lilia de Souzaen
dc.contributor.authorMonteiro da Cruz, Din' de Almeida Lopesen
dc.contributor.departmentNon-memberen
dc.author.detailsRuth Natalia Teresa Turrini, RN, rturrini@usp.br; Thatiara Cardoso Silva; Erika de Souza Guedes, RN; Regina M'rcia Cardoso de Sousa, RN; Lilia de Souza Nogueira, RN; Din' de Almeida Lopes Monteiro da Cruz, RNen
dc.identifier.urihttp://hdl.handle.net/10755/601869-
dc.description.abstractSession presented on Saturday, July 25, 2015: Purpose: In the surgical center unit documentation of nursing process are used to identify potential risks to anesthetic-surgical process and record care actions by the nursing team. Since the introduction of nursing process in the nurse care practice until present day, this care model has some challenges for its complete implementation. Objective: To identify the variables associated with complete documentation of the nursing process.' 'Methods: Cross-sectional study developed in public hospitals under the management of the Sao Paulo state board of health, Brazil, from Jan/2010 to Jan/2011. The research was developed in 40 hospitals, where was identified 25 surgical center units that perform the nursing process. The information was obtained by observing the medical records and interviews with nurses in the operating room units considering completeness of the nursing process documentation (assessment, diagnoses, nursing orders, progress notes, and nursing notes), quantitative dates about surgeries performed, unit and institution characteristics, including the Nursing Work Index ' Revised (NWI-R) e Malasch Burnout Inventory. A descriptive analysis of the variables, Kruskal-Wallis test to compare means and chi-square test for the analysis of qualitative variables were performed. The significance level was 5% and all analyzes were performed by SPSS v17. The project was approved by the Research Ethics Committee. 'Results: Analyzing the medical record, 22,2% (6) of units does not document the nursing process, 48,1% (13) documents partially and 2.2% (6) documents completely. About the hospitals' size, the 63% (17) were large. The median surgeries per day was 10.2 (range 2.2 to 31.0), with a high frequency of small and medium procedures, 'only one unit was located in an ambulatory. The findings of the analysis of quantitative variables, by Kryskall-Wallis test, showed that only emotional exhaustion and personal dimensions of Malasch Burnout Inventory showed statistically significant differences in relation to completeness of the nursing process documentation (p<0,05). Although, the lowest average in the emotional exhaustion and highest average in personal accomplishment dimensions were associated with incomplete documentation of the nursing process, the average observed to complete and no documentation of nursing process was equal. 'Conclusion: The documentation of the nursing process is very important to patient safety undergoing surgery, because it identifies potential risks. Strategies that promote personal accomplishment and avoid emotionalexhaustion may impact on the completeness of clinical documentation of nursing in the operating room, but iot is necessary to investigate further because nurses that do not document the nursing process completely has average similar to those who do it.en
dc.subjectnursing processen
dc.subjectoperating roomen
dc.subjectdocumentationen
dc.date.available2016-03-17T12:57:44Zen
dc.date.issued2016-03-17-
dc.date.issued2016-03-17en
dc.date.accessioned2016-03-17T12:57:44Zen
dc.conference.date2015en
dc.conference.name26th International Nursing Research Congressen
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen
dc.conference.locationSan Juan, Puerto Ricoen
dc.descriptionResearch Congress 2015 Theme: Question Locally, Engage Regionally, Apply Globally. Held at the Puerto Rico Convention Center.en
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