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

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.