Danish Perioperative Nurses

Documentation: A Complex,
Multifaceted Practice Connected
With Unit Culture and Nursing
Leadership
SUSANNE F. SNDERGAARD, MLP, RN, SD; VIBEKE LORENTZEN, PhD, RN;
ERIK E. SRENSEN, PhD, MScN, RN; KIRSTEN FREDERIKSEN, PhD, RN

ABSTRACT
Researchers have described the documentation practices of perioperative nurses as awed and char-
acterized by subjectivity and poor quality, which is often related to both the documentation tool and the
nurses level of commitment. Studies suggest that documentation of nursing care in the OR places
special demands on electronic health records (EHRs). The purpose of this study was to explore how the
use of an EHR tailored to perioperative practice affects Danish perioperative nurses documentation
practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of
2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the
Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to
generate data. We found that nursing leadership was essential for improving perioperative nurses
documentation practices and that a tailored EHR may improve documentation practices. AORN J 106
(July 2017) 31-41. AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.05.003
Key words: documentation, electronic health record, Perioperative Nursing Data Set, realistic
evaluation, nursing leadership.

F or the past 20 years, there has been high demand for

increased effectiveness in the Danish health care
system.1 Health care technology is constantly
changing, and nurses have faced both explicit and tacit de-
mands regarding how to handle and incorporate technology
and improve nursing practice.1-4 The literature suggests that
electronic health records (EHRs), which have been imple-
mented to document patient-related interventions, are not
designed to capture nursing care adequately.1,2,5 Perioperative
nursing documentation is also affected by the poor design of
EHRs. Perioperative nurses documentation of nursing care
has been described as awed and characterized by subjectivity
and poor quality.6-10 Good-quality documentation of nursing
care facilitates continuity and individuality of patient care and
helps clarify the nursing process.11 Furthermore, documenta-
tion can enhance the quality of nursing care by providing a
record of the patients need for care and the patients response
to nursing interventions.11-13

http://dx.doi.org/10.1016/j.aorn.2017.05.003
AORN, Inc, 2017
www.aornjournal.org AORN Journal j 31
Sndergaard et al
This study is a follow-up to a baseline study we conducted in
2014 (S.F. Sndergaard, unpublished dissertation, 2016). In
the 2014 baseline study, we concluded that Danish periop-
erative nurses documentation practices were complex and
inuenced by a mixture of cultural, organizational, and
educational conditions. We showed that the documentation
systems deciencies in relation to specialized content, its
adaptation to nurses workow, the nurses use of the EHR,
and established patterns of documentation adversely affected
perioperative nurses documentation practices. We suggested
that an improved documentation system with content and a
design that meets the needs of perioperative nurses could lead
to improved and more patient-specic documentation (S.F.
Sndergaard, unpublished dissertation, 2016). In this follow-
up study, we investigated how the use of an EHR tailored
to perioperative practice affects Danish perioperative nurses
documentation practices.
STATEMENT OF PURPOSE
The purpose of this study was to explore how the use of an
EHR with specialized perioperative content, design, and mode
of use (ie, use of the computer in tablet or laptop mode) affects
Danish perioperative nurses documentation practice in the
OR. For the purposes of this study, we dened intraoperative
nursing care as activities occurring during the surgical procedure.
RESEARCH QUESTIONS
We were guided by the following research questions:

How does the use of an EHR with specialized perioperative
content affect perioperative nurses documentation practices?

How does an EHR that uses software with content and a
design tailored to the perioperative workow affect periop-
erative nurses documentation practices in terms of who is
documenting what, when, and under which circumstances?
Statement of Signicance to Nursing
Perioperative nurses documentation practices ensure patient
safety and the continuity of nursing care for the surgical
patient. This research aimed to explore what inuences Danish
perioperative nurses documentation practices in the OR.
LITERATURE REVIEW
Nursing care documentation is an important part of profes-
sional nursing practice and has been discussed in the nursing
profession since the time of Florence Nightingale.14,15 Patient
health records support clinical decision making and facilitate
continuity of the patient pathway. Documentation is strongly
related to quality improvement, patient safety, and
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July 2017, Vol. 106, No. 1
transparency in the patient pathway,6,8,16 and it is a prereq-
uisite for patient safety assurance and quality assurance.17,18 In
Denmark, however, quality assurance organizations have
specied only a few requirements for documenting specialized
perioperative nursing practices in the OR.2,4,18,19
Despite the important care performed by perioperative nurses,
studies have reported incomplete and poor documentation of
nursing care for surgical patients. Researchers have subjectively
related this nding to perioperative nurses themselves, sug-
gesting that documentation is characterized by randomness,
which jeopardizes patient safety.9,10,20-22 A qualitative analysis
by Chappy23 and literature reviews by Braaf et al6 and
Wilbanks8 indicate that the amount of data and the docu-
mentation practices vary among individual nurses, de-
partments, and hospitals. These studies found that there are
organizational and individual differences in the documentation
content, documentation tools, and level of commitment to the
practice of documentation. In addition, these studies empha-
sized that differences in technical systems and templates for
documenting perioperative nursing care are an implicit cause
of awed documentation practices.
The specialized care practice in the OR places special demands
on the EHR for physical accessibility and content.2,8,10 The
collective literature suggests that a standardized vocabulary
supports uniform documentation and can increase patient
safety.2,20,24,25 AORN developed the Perioperative Nursing
Data Set (PNDS), a standardized nursing language that
supports perioperative nurses evidence-based practice.14 The
PNDS has been implemented and tested in countries outside
the United States, including Finland, Brazil, and Korea;
however, to the best of our knowledge, it has never been used
in Denmark.20,26-28 Studies on the use of the PNDS reported
the potential for increased quality of documentation and
patient safety when using its featured standardized nursing
language.20,26-28
FRAMEWORK FOR THE STUDY
The research framework for this study was inspired by the
Pawson and Tilley29 realistic evaluation (RE) process. Realistic
evaluation is based on realist principles, and its key feature is
its emphasis on the mechanics of explanation.29-32 Researchers
engaging in RE explore the conguration of context, mecha-
nism, and outcome (CMO). Context is the area of exploration
that is delineated by the research or the researcher in the
study. A mechanism is a description of how things work
beneath the surface, delving into the inner workings. The
outcome is the result of the relationship between context and
mechanism.29
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July 2017, Vol. 106, No. 1
Sidebar 1. Selected Nursing Outcomes for
the Electronic Health Record from the
Perioperative Nursing Data Set1

O.20 Patient is free from unintended retained foreign
objects.

O.30 Patients procedure is performed on the correct
site, side, and level.

O.40 Patients specimen(s) is managed in the appro-
priate manner.

O.50 Patients current status is communicated
throughout the continuum of care.

O.70 Patient is free from signs and symptoms of
electrical injury.

O.80 Patient is free from signs and symptoms of injury
related to positioning.

O.100 Patient is free from signs and symptoms of
chemical injury.

O.130 Patient receives appropriately administered
medication(s).

O.230 Patients genitourinary status is maintained at or
improved from baseline levels.

O.290 Patient is at or returning to normothermia at the
conclusion of the immediate postoperative period.
Reference
1. Petersen C, ed. Perioperative Nursing Data Set. 3rd ed.
Denver, CO: AORN, Inc; 2011.
The goal of RE is to examine how causation in social practice
can be construed and derived from the basic realist formula
context mechanism outcome. Because it examines the
mechanisms and the context, the RE model is an interpretative
process that focuses not only on outcomes, but also on an
explanation of why those outcomes were achieved. The RE
model develops a picture of the structures and measures of the
research topic.29 This method relies on data generated using
various methods (eg, observation, interviews).29,31
We were inspired by the ethnographic data generation
method suggested by Atkinson and Hammersley.33 Data
generation can consist of observing what happens, listening
to what is said, and asking questions through informal and
formal interviews.33 We collected data via participant ob-
servations, which involved using various senses. We also
collected data from different oral accounts (ie, those that
occurred naturally and those elicited in interviews) and by
observing visual phenomena (ie, taking photographs during
data generation).
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Perioperative Nurses Documentation
DESIGN, SETTING, SAMPLE, AND
SAMPLING TECHNIQUE
The content of the EHR used in this study was a Danish trans-
lation of a subsection of the PNDS that referred to intraoperative
nursing care in the gynecologic-obstetric surgical specialty in a
Danish context. We selected the content for the EHR related to
intraoperative nursing care (Sidebar 1) with permission from
AORN and in cooperation with the Syntegrity Solution team at
AORN Headquarters in Denver, Colorado. The translation and
validation process followed the medical translation method
described by Montalt Resurrecci
o and Gonz
alez Davies.34
As part of this study, we developed EHR software that
incorporated the selected portion of the Danish PNDS.
A professional programmer and software designer developed
the software in cooperation with the rst author. We tailored
the EHR to the workow of perioperative nurses and designed
it to function exibly in both laptop and tablet modes. We
named the tailored EHR SC-Solution.
The setting for the study was one university hospital and one
regional hospital in Denmark. We gathered data in two
gynecologic-obstetric departments with 24-hour emergency
services and elective and acute surgeries. In the daytime,
elective surgeries were performed in two to six ORs. The
departments were both of moderate size, with approximately
30 perioperative nurses and one charge nurse each. The hos-
pitals, departments, and participants involved in this follow-up
study were the same as those in the 2014 baseline study.
Six perioperative nurses, ranging in age from 34 to 64 years
and with different levels of education and experience, were the
participants in the study. All of the participants were women.
We originally selected the nurses for the 2014 baseline study
using a cooperative process between the researchers and the
charge nurses that was in accordance with Benners theory of
skill acquisition.35,36 Benner noted that, over time, nurses
develop ethical and clinical judgment informed by scientic
evidence and technological development according to the
model of skill acquisition.35 With the expectation that the
nurses followed this skill acquisition pattern, we established
the following inclusion criteria for the participants:

more than two years of experience as a perioperative nurse;

competence as an advanced beginner, midlevel, or experi-
enced nurse (assessed by the researchers and charge nurses in
accordance with Benners theory); and

no special role related to documentation.
To complete the participant observations, the rst author
shadowed the participants as they performed work-related
AORN Journal j 33
Sndergaard et al
Figure 1. Depiction of the data-gathering process that occurred during a three-month period.
tasks. The data-gathering process (Figure 1) took place during
a three-month period in the winter of 2015 to 2016.
ETHICAL CONSIDERATIONS
The Danish Data Protection Committee approved this study
(ID number 2007-58-0010). The study followed the
Declaration of Helsinki and complied with all requirements to
ensure the safety of the human volunteers.37 All participants
provided written informed consent. We individually informed
each nurse of the project, the expectations and duties as a
participant, and the right to leave the study if needed. Each
nurse gave individual consent to participate. Neither the
photographs nor observations contained information that
could be used to identify the surgical patients. Data gathering
focused solely on the perioperative nurses documentation of
nursing activities.
METHODS
We gathered the data using a structured research guide con-
taining research questions regarding perioperative nursing
documentation. Data included different oral accounts;
descriptions of auditory, visual, and olfactory observations;
Figure 2. Depiction of the analysis process. CMO context, mechanism, and outcome.
34 j AORN Journal
July 2017, Vol. 106, No. 1
and photographs of visual phenomena collected during peri-
operative documentation practices. The rst author wrote eld
notes and spoke to participants while observing in the OR. We
linked the photographs to the eld notes using identifying
information (eg, the time and location).38 Immediately after
making our observations, we recorded the generated data as
audio les, which we transcribed and imported into the
qualitative data analysis software tool NVivo 10. We observed
participants for 147 hours during the three-month period. We
observed each participant on average for seven days, captured
86 photographs in total, and developed three photo essays.
Data Analysis
The analysis followed the RE process of knowledge accumu-
lation in evaluation research. Evaluation research is applied
research that addresses how and why and attempts to penetrate
the surface of observable practices.29,31,32 We used analytic
induction, as suggested by Pawson and Tilley,29 to begin the
analysis with specics and move to abstract elements (ie, from
the participant observations in the OR to identifying
CMOs) (Figure 2).
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July 2017, Vol. 106, No. 1
Figure 3. A descriptive comparison of the baseline and follow-up results encoded for high, medium, or low
occurrence. The distance between the baseline and test dots represents the comparison between the assessed
results from the baseline and test (ie, current) studies. The center of the chart represents a low assessed occurrence
and the outer edge represents a high assessed occurrence.
We sorted the photographs and created photo essays, each
with a short descriptive text or heading.38 In this context, a
photo essay is a series of photographs that creates emotions
regarding the research view and portrays a particular argu-
ment.38 Photo essays can range from purely photographic
works to photographs with captions and can be included as
independent data to provide information about how cultural
and social relationships play a part in a study.38
The research questions guided our analysis, and we explored
recurring or noteworthy occurrences in the material. We
interpreted the meaning of the transcribed text and photo-
graphs and assigned meaningful headings (ie, each CMO was
assigned a thematic heading that described the content and the
relation to the context, mechanism, and outcome) in NVivo
10. We then compared and organized the meaningful head-
ings into thematic units. In the interpretative analysis, we
identied and encoded each CMO via a process of continually
identifying how the use of an EHR with specialized content,
design, and mode of use affects perioperative nurses docu-
mentation practice.
The RE process also relies on an established baseline against
which before-and-after measures can be plotted and
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Perioperative Nurses Documentation
compared.39 Therefore, we performed a descriptive comparison
of the results from the 2014 baseline study and the current
study. Results were encoded for high, medium, or low occur-
rence, and a radar chart (ie, a graphic method of displaying three
or more variables)40 was used when results converged (Figure 3).
RESULTS
During analysis and interpretation, we identied two CMOs
formulated in two meaningful headingsdnursing leadership
and tailored EHRdthat suggested how using an EHR with
specialized content, design, and mode of use affects periop-
erative nurses documentation practices (Table 1). In addition,
we completed a descriptive comparison of the results of our
two studies.
Nursing Leadership
We found that nursing leadership was a critical component
that inuenced perioperative nurses documentation prac-
tice, regardless of whether SC-Solution was used (ie, we also
found this in the baseline study conducted before the
introduction of SC-Solution). In the baseline study, peri-
operative nurses documentation practice relied on a unit
culture of old habits, with time as an important framework
AORN Journal j 35
Sndergaard et al
Table 1. Contexts, Mechanisms, and Outcomes Identied in the Study
Heading Context
Nursing leadership
Old habits control practice

Time as a framework for
nursing
Tailored electronic
Heterogeneous
health record management of technology

Working conditions reduce
patient safety
(eg, keeping track of time seemed to be of higher impor-
tance than documenting the nursing care performed). We
observed improvements in the provided nursing care and a
decreased focus on time as a framework for nursing in this
study compared with the ndings of the baseline study. We
found that an outcome of using SC-Solution was increased
reection on the perioperative nurses professional practice.
We observed that in situations in which either the charge
nurse or a nurse with an informal leadership role joined the
discussions concerning nursing values and perioperative
nursing practice, the issues that the leader discussed were later
used by nurses as explicit justication for changes in the OR.
After a discussion with a charge nurse, one participant said
the following:
[The charge nurse] said that we are not done with a patient
until we nalize the documentation. Of course, we are the ones
who set the time to call the next patient. If only we have
support from [the charge nurse], then I think we just have to
take our time (Field note 12.3).
We found that nursing leadership increased during this
study compared with that in the baseline study. For
example, we observed how the charge nurses increased their
attention toward the legal aspects of documentation and the
use of the data in the documentation system to improve
both nursing care and patient safety. We also observed how
the perioperative nurses became more explicit in their de-
mands for the documentation of the nursing care in their
department.
In our study, we identied that the manner in which nursing
leaders discussed and approved distinct attitudes toward
nursing practice, including documentation practices, directly
affected how the nurses acted. We observed how acknowl-
edgment and clear guidance from the nurse leaders (formal or
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Mechanism Outcome
Leadership that claries the The use of a perioperative-
culture of perioperative specic documentation
nursing and determines system increased the
the documentation reectivity of the
practices and outcome professional practice
When the documentation The use of a perioperative-
system is perceived as specic documentation
meaningful, the concern system had an effect on
about time spent on the documentation
documentation is reduced content and practice
informal) were of great importance to the perioperative nurses.
The explications and guidance from nurse leaders were
continuously referred to and repeated by the nurses during
these three months.
We found that time was a contextual condition for practice.
At the beginning of the study, perioperative nurses re-
ections emerged as frustration when they found it impos-
sible to complete their usual documentation practices within
the same timeframe as they could previously (ie, documen-
tation via SC-Solution was slower than documentation
without it). The nurses found that they spent too much time
completing the documentation and following the process
structure using SC-Solution. Moreover, the perioperative
nurses were challenged by the contextual conditions gov-
erned by a unit culture of old habits and basic assumptions
related to the documentation concerning what, how, when,
and by whom documentation was completed. The unit
culture of old habits and basic assumptions was sanctioned
by the nurse leader. One perioperative nurse expressed her
frustrations and assumptions regarding perioperative docu-
mentation as follows:
It is because there is too much information. No one has time to
consider this much information (Field note 21.3).
A nurse who was identied as an informal leader observed:
When the patients temperature had to be documented, we
normally do not take any interest in this. We usually do
nothing more for the cesarean section procedure than provide
warm blankets. Its over quickly and the women are so young
(Field note 12.1).
This observation indicated a lack of interaction among nursing
care, documentation, and patient safety modeled by an
informal leader. We observed how this nurses approach
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July 2017, Vol. 106, No. 1
inuenced the documentation practices of other nurses,
because the informal leader was explaining her documenta-
tion practices.
We individually educated the perioperative nurses on the
use of the tailored EHR. The nurses did not perceive the
tailored EHR to be a customary working method, however.
Old habits showed a high occurrence in the baseline study,
so old habits may have controlled practice when we intro-
duced SC-Solution. As the nurses became more familiar
with SC-Solution, they recognized that the tool was
meaningful:
It has not been customary to consider the patients comorbidity.
[SC-Solution] makes me think in a completely new way.
Although its hard here in the beginning, I think that this is
what we should do. Previously, I just did as we usually do, but
it was not concerned with individuals. It was just standard
procedure (Field note 13.1).
The amount of reection on professional practice was partic-
ularly visible in the descriptive analysis. In the baseline study,
we interpreted the amount of reection by the nurses as low,
whereas during the SC-Solution test, we regarded the amount
of reection on professional practice as high. We observed
how the participants professional reection was discussed with
the nurse leaders and among colleagues, thus challenging
traditions and old habits and producing changes in the
documentation practice.
Tailored EHR
Our analysis revealed that the use of SC-Solution encouraged
perioperative nurses to change their documentation practices.
We found that patient documentation increased in the base-
line study after SC-Solution was implemented.
We found that difcult working conditions (eg, increased
amount of equipment, dysfunctional information technology
systems, continuous changes in procedures and collaborative
relationships) presented challenges for perioperative nurses.
The ability to ensure adequate documentation of perioperative
nursing care was lacking. One outcome that we discovered was
the development of perioperative nurses documentation
practice as they became increasing familiar with SC-Solution.
The nurses recognized that the use and content made sense for
their practice; thus, they changed their nursing care and
documentation to fulll the required aspects of documentation
using SC-Solution. An example of this change is illustrated in
the following observation, which was made as a participant
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Perioperative Nurses Documentation
began to document and reached the Preoperative assessment
of skin status step:
Well, it ts quite well with my workow because in a moment,
I have to place a catheter in the bladder. While doing that,
I can observe the patients abdomen. (Field note 14.3).
SC-Solution guided the perioperative nurses through the
important areas of perioperative nursing care, and the nursing
care was supported by the nursing process and documentation
workow. SC-Solution was specic to the nursing care of the
surgical patient during a specic surgical procedure, so the
perioperative nurses recognized its content as meaningful. One
participant described the meaningfulness of the content for the
continuity of nursing care before transferring a patient to the
postanesthesia care unit in a situation in which a patient was at
risk for a perforated uterus:
It makes sense that I describe what Im doing here in the OR. I
have never thought about it before, but it just makes perfect
sense (Field note 14.3).
The new sense of meaningfulness implied that the amount of
time spent on documentation became less and less important
to the perioperative nurses. The fact that SC-Solution entailed
the use of a 14-inch laptop that could be used as a stationary
personal computer or a tablet (instead of a wall-mounted
computer) seemed to improve the continuity of documenta-
tion. In particular, the nurses practice changed not only in
relation to nursing care and documentation but also in relation
to the collaboration of these two components in the OR.
[Participant] folds the project computer to tablet mode, looks
toward the nurse anesthetist and asks, We must do check-in?
The nurse anesthetist replies, Well, we have just done that,
but [participant] says, At the time, the patient was not here.
Shortly after, while the patient identies herself, [participant]
lls in the documentation in SC-Solution (Field note 1.2).
The EHR demonstrated the potential to improve perioperative
nurses documentation practices because the mobile computer
allowed the nurses to document during the ow of nursing
care. We observed how different levels of technology man-
agement by each participant inuenced their documentation
practices. We recognized that improving perioperative nursing
documentation practice also depends on the nurses compe-
tence in using the EHR. We found heterogeneous manage-
ment of technology, which ranged from excellent use of the
technology to poor use of the technology. Thus, the nurses
level of competence using the technology affected documen-
tation practice.
AORN Journal j 37
Sndergaard et al
DISCUSSION
Our study shows that the documentation practice of periop-
erative nurses is highly complex and relies on more than an
EHR with specialized content, design, and mode of use. Our
exploration of perioperative nurses documentation practices
and use of SC-Solution yielded a detailed impression of peri-
operative nurses documentation practices for the contextual
circumstances, the mechanisms of documentation practices,
and two CMOs.
We found that nursing leadership is essential for improving
perioperative nurses documentation practice. The reection
encouraged by leaders and their acknowledgment of the value
of documentation seemed to be critical for establishing a
culture of effective documentation. When comparing the re-
sults of the baseline study with the results of this study, we
conrmed that old habits and basic assumptions of the nursing
culture primarily controlled the documentation practices.
However, we observed that the practice moved away from old
habits as the participants gained more familiarity with
SC-Solution and when a formal or informal leader took an
active role in encouraging reection.
Few studies on perioperative nurses documentation have
addressed issues concerning the effect of nursing leadership on
documentation.8,10,16,41 Often, there is an implicit reference to
implementation, education, nursing acceptance, or culture.10
A review by Wilbanks8 argues that organizational culture is
directly reected by the management of the department or
hospital. Wilbanks8 denes culture as the pattern of knowledge,
beliefs, social norms, and behaviors. He argues that culture
arises from the inuence of individuals. Furthermore, system
implementation failures can be traced back to the organiza-
tional culture. Tiusanen et al20 and Sndergaard et al2 also
reported the effect of culture on documentation and empha-
sized that the importance of cultural adaptation cannot be
diminished and that cultural habits affect perioperative nurses
documentation.
A study by Waneka and Spetz16 is aligned with our nding
that nurse leaders inuence documentation and the culture of
documentation. Their study emphasized how nursing leaders
play an integral role in the success of documentation and the
use of hospital information technology systems. These ndings
are supported by Bossen et al,1 who found that support from
managers led to the successful implementation and use of an
EHR. These authors emphasized that such support likely
inuenced staff members intentions for use.1,16
Previous studies support the value of nursing leadership to
perioperative nurses documentation, but to the best of our
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July 2017, Vol. 106, No. 1
knowledge, no previous study has addressed contextual
conditionsdfor example, the time frame for implementation.
In this study, over time we observed development in the
nurses understanding and use of the documentation system.
As formal or informal leaders discussed and sanctioned as-
sumptions related to documentation of perioperative nursing
care, the use of and familiarity with SC-Solution became
meaningful for the perioperative nurses. We found that the
nurses moved from feeling irritated and displaying resistant
behavior to accepting and implementing changes in their
documentation practices, which demonstrates the important
role that nurse leaders play in encouraging reection.
Another nding of our study was that an EHR tailored to
specialized perioperative nursing care can improve periopera-
tive nurses documentation practice. Park et al26 found that
the use of the PNDS led to increased documentation of
essential data and saved time when recording information.
These ndings are supported by Lee and Lee,24 who tested the
use of standardized language and observed decreased time
consumption and increased patient safety when the PNDS was
used in the perioperative setting. Brazilian researchers
concluded that the use of standardized language was important
because it allowed for reection concerning the nursing
practice and the quality of care provided.27 Furthermore, a
large amount of perioperative documentation research has
explored the use of nursing diagnosis and the PNDS in
the Finnish setting. For example, Junttila et al42 and
Tiusanen et al20 reported enhanced quality and patient safety,
but they also determined that the current EHR systems must
better t the actual practice and that the general education of
perioperative nurses should be considered.
Our study shows that tailored documentation systems have the
potential to improve perioperative nurses documentation
practice, but it also demonstrates that in addition to nursing
leadership, the heterogeneous management of technology
determines whether a tailored documentation system will
improve documentation practice. The ndings from our study
are not uniformly supported by the literature; we found
documentation practices to be more complex and multifaceted
than some studies concluded. Wilbanks8 found that infor-
mation systems need to be designed according to individual
and organizational structures and processes. Cartwright and
Edney43 concluded that a lack of understanding of system
functionality and a fear of technology are major hurdles for
perioperative nurses to overcome.
In this study, all participants received equal training in using
SC-Solution. In accordance with our ndings, Kim et al44
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July 2017, Vol. 106, No. 1
described increased documentation quality after documenta-
tion training was established. Furthermore, the absence of
training led to a lack of proper documentation and major
patient safety hazards.
Sweeney41 emphasized the importance of basic computer skills
to enable perioperative nurses to safely and successfully manage
information technology in the OR and cited a current lack of
competencies. In addition, the author determined that periop-
erative nurse education is of great importance if information
technology in the OR is to lead to improved patient safety,
reduced costs, and fewer errors. Waneka and Spetz16 found no
correlation between lack of computer literacy and attitudes to-
ward technology. They found that nurses developed an unsat-
isfactory attitude if the technology interfered with their
workow. Their study provided no references to the unit cul-
ture, however; therefore, we cannot determine whether it would
have inuenced the ndings.
Limitations
The data in this study were collected at two different hospitals,
so we must consider whether any differences between these
hospitals could have inuenced the data. We found no dif-
ferences; the study had a single data collector and we analyzed
the photographs during group reection among the authors.
We conducted the study in a Danish context. Different
cultures and conditions are important contextual circum-
stances that can yield different results. Our RE analysis
revealed important knowledge regarding how an EHR with a
specialized content, design, and mode of use affects Danish
perioperative nurses documentation practice.
Our methodological strategy using RE contributes to trans-
parent research by presenting ndings that focus not just on
results and outcomes, but also on contextual circumstances
and the mechanisms that inuence perioperative nurses
documentation practice. Realistic evaluation is imbedded in
qualitative research, which is why it is situated in the inter-
pretive paradigm.28 Realistic evaluation does not produce
infallible results, but it explains and sheds light on the topic
being evaluated. Malterud45,46 notes that the ndings from a
qualitative study are notions or theories applicable in a
specialized setting. Furthermore, reectivity is critical to
ensure credibility, dependability, and transferability.45,46
In our study, we engaged in an ongoing reective process to
discuss and verify the accuracy of our analysis and interpre-
tation for mechanisms and context, with the constant use of
comparisons. Through this process, we found that photograph
elicitation contributed to the quality of our ndings.
www.aornjournal.org
Perioperative Nurses Documentation
Recommendations for Clinical Practice
Our ndings suggest that a documentation system with
specialized perioperative content, design, and mode of use
can improve perioperative nurses documentation practice.
To fulll this potential, the nursing leader must be
aware of the unit culture and perioperative nurses atti-
tudes toward documentation. Along with education, dis-
cussions of habits and culture are essential to increase
perioperative nurses documentation practice and improve
patient safety.
Recommendations for Future Research
We suggest additional supplemental research that explores
the importance of perioperative nurses opinions of their own
professional identity with respect to documentation; this
could further enhance understanding of perioperative nurses
documentation practices. We also suggest full-scale testing of
the SC-Solution tool, which would enable a comprehensive
investigation of its effects on the continuity of nursing care
and on patient safety during surgery and other invasive
procedures.
CONCLUSION
The use of a documentation system with specialized peri-
operative content, design, and mode of use can improve
perioperative nurses documentation practices. Our study
highlights factors that should be considered to achieve this
improvement. First, nurse leaders must be aware of the staff
members documentation culture, competence, and attitude
toward documentation. Second, nurse leaders must ensure
that the contextual environment supports perioperative
nurses documentation practice. Our study shows that peri-
operative nurses documentation practice is complex, multi-


faceted, and specically connected to unit culture and
nursing leadership.
Acknowledgments: The authors acknowledge AORN and the
Syntegrity Solution team at AORN Headquarters, Denver, CO.
Without their support and kindness, this study would never have
been completed. The authors also acknowledge the two tran-
scription assistants, Vibeke Jacobsen and Ditte Ellebk Zander,
former student nurses at VIA University College, Viborg,
Denmark. Finally, the authors thank Solutionmaker, Herning,
Denmark, for their cooperation in the development and design of
SC-Solution.
Editors notes: AORN Syntegrity is a registered trademark of
AORN, Inc, Denver, CO. NVivo is a registered trademark
of QSR International PTY Ltd, Doncaster, Australia.
AORN Journal j 39
Sndergaard et al
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Susanne F. Sndergaard, Master of Learning
Processes (MLP), RN, Diploma in Health Science (SD), is a
doctoral student in the section for Nursing at the
Department of Public Health at Aarhus University, Aarhus,
Denmark, and at the Centre for Nursing Research, Viborg,
www.aornjournal.org
Perioperative Nurses Documentation
Denmark. Ms Sndergaard has no declared afliation that
could be perceived as posing a potential conict of in-
terest in the publication of this article.
Vibeke Lorentzen, PhD, RN, is an associate
professor at the Centre for Nursing Research, Viborg,
Denmark, in the section for Nursing at Aarhus
University, Aarhus, Denmark, and at the School of
Nursing and Midwifery, Faculty of Health, at Deakin
University, Burwood, Victoria, Australia. Dr Lorentzen
has no declared afliation that could be perceived as
posing a potential conict of interest in the publication
of this article.
Erik E. Srensen, PhD, MScN, RN, is head of research
and a professor at the Clinical Nursing Research Unit,
Aalborg University Hospital, and in the Department of
Clinical Medicine at Aalborg University, Aalborg,
Denmark. Dr Srensen has no declared afliation that
could be perceived as posing a potential conict of
interest in the publication of this article.
Kirsten Frederiksen, PhD, RN, is an associate
professor in the section for Nursing at the Department
of Public Health, Aarhus University, Aarhus, Denmark.
Dr Frederiksen has no declared afliation that could be
perceived as posing a potential conict of interest in the
publication of this article.
AORN Journal j 41