Situation awareness and documentation of changes that affect patient outcomes in progress notes

Area of Science:

• Nursing
• Cognitive Psychology
• Healthcare Informatics

Background:

• Patient progress notes are crucial for communication but often incomplete.
• Nurses' decision-making processes during documentation are under-explored.
• Situation awareness is a key precursor to effective decision-making in nursing.

Purpose of the Study:

• To describe registered nurses' (RNs) situation awareness during patient condition documentation.
• To investigate the relationship between situation awareness and decision-making in nursing documentation.
• To identify factors influencing nurses' documentation practices.

Main Methods:

• Utilized Endsley's situation awareness framework for conceptualization.
• Employed a naturalistic paradigm for interpreting decision-making.
• Used think-aloud methods and semi-structured interviews to gather data.
• Analyzed audio recordings and interview texts for situation awareness cues.

Main Results:

• Nurses employed complex mental models and pattern-matching across all three levels of situation awareness.
• Level 1 SA provided context, Level 2 SA indicated condition significance, and Level 3 SA reflected reflective thought.
• Key themes included patient deterioration, treatment non-response, and professional practice impacts.

Conclusions:

• RNs integrate three levels of situation awareness into their decision-making models for documentation.
• Hamm's cognitive continuum theory offers a useful framework for integrating situation awareness and decision-making.
• Improved understanding of situation awareness can enhance clinical documentation practices.