Exploring the Creation of Nurses Information Documentation and Use in Clinic Work

Nurses commonly track and organize patient information on paper during their shifts, and then rely on this paper, commonly referred to as “brains,” during patient handoff at change of shift. These handoffs have significant potential to create patient harm due to breakdowns in communication from information loss or misinterpretation of what has been written on the paper. The continued reliance on paper, despite the availability of electronic handoff tools, is poorly understood and may reflect a lack of knowledge of the role that paper plays in clinical work. The purpose of this research was to develop a better understanding of nurses' use of paper during their shift and handoff in the context of a medical oncology unit at an academic health sciences center.

The specific aims of this project are as follows:

• Use a grounded theory approach to develop a deep understanding of nurses’ brains, including the meanings ascribed to brains, how nurses produce their brains, the functions brains serve for nurses practicing in a medical oncology setting, and the content and structure found in brains.
• Derive successful strategies for the development of an electronic brain that can be used as a tool during the entire nursing shift, including handoff.

Thirteen medical oncology nurses were shadowed during an entire shift and subsequently interviewed. In addition, digital scans of the nurses’ paper tools were obtained immediately prior to and after handoff at the beginning and end of the shift. A grounded theory approach was used to analyze these data. Although a final substantive theory is not yet complete, initial findings suggest nurses’ paper tools: (1) provide cognitive support, (2) are a representation of nurse identity, (3) represent the patient, and (4) are living objects.

The project team concluded that development of a successful electronic shift handoff tool will require digital formats to go beyond merely mimicking nurses' paper support, as electronic formats can impose difficulties that do not exist in paper formats. Given the current state of technology, the development of a successful tool is unlikely to in the near future due to rigid electronic data entry structures and the size and weight of devices.