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Record-keeping and routine nursing practice: the view from the wards

¹Nursing Research Centre, School of Nursing Studies, University of Wales College of Medicine, Heath Park, Cardiff.

Journal of Advanced Nursing

|July 15, 1998

Summary

Nurses hold mixed feelings about nursing records, valuing them as professional tools yet struggling to align their use with ideal nursing practices. This ambivalence stems from managerialism and workplace realities in UK hospitals.

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Area of Science:

Nursing Studies
Healthcare Management
Sociology of Health

Background:

The nursing record is a cornerstone of professional nursing practice.
Contemporary healthcare settings, particularly in the UK, face pressures from managerialism.
Understanding nurses' perceptions of the nursing record is crucial for effective practice.

Purpose of the Study:

To explore general nurses' views on the nursing record.
To investigate the routine usage of nursing records in hospital practice.
To identify factors influencing nurses' attitudes towards nursing records.

Main Methods:

Ethnographic data collection on surgical and medical wards in a UK District General Hospital.
Qualitative analysis of nurses' perspectives and experiences with nursing records.

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Main Results:

Nurses exhibited ambivalent attitudes towards the nursing record.
The nursing record was valued as a symbol of professionalism due to its link with the nursing process.
Nurses found it challenging to reconcile professional ideals with the routine application of nursing records.

Conclusions:

Nurses' ambivalence reflects the impact of managerialism on the nursing record's philosophy.
Tensions exist between the nursing record's underlying assumptions and ward realities.
Reconciling professional nursing ideals with practical ward-based record-keeping requires further attention.