Nursing Documentation in Rehabilitation: What Work is Visible?

Abstract

Purpose: Nurses document their practice every day, however it is unclear whether this output fully reflects their contribution to client rehabilitation. This paper reports on one component of a larger study which aimed to understand the nature of nurses' documentation practice within the context of a brain injury facility in Aotearoa New Zealand.

Design: Critical realist methodology underpinned case study methods within this doctoral research project.

Methods: Descriptive analysis was used to explore the nurses' documentation patterns.

Results: Our study demonstrated that the typical documentation practices of rehabilitation-nurses encompassed an impersonal, task completion style. This focused on recording that the physiological aspects of clients' routines were addressed, with little attention paid to coaching, education, and support roles. However, some documentation aspects revealed a shared language structure where nurses similarly articulated their inputs, such as a phased approach to teaching client's medication self-administration.

Conclusions: The largely impersonal-regulatory style of documentation that was the normative cultural pattern within the facility, alongside the absence of nurses' rationales and team recommendations, rendered the breadth of the nursing contribution invisible. In contrast, when shared language was used, it gave nurses a structure, assisting in making those activities visible. This structure has potential to recognise and formalise these activities as legitimate 'rehabilitation nursing work' of relevance to nurses and other members of the team.

Clinical Relevance: Rehabilitation nurse leaders should consider provision of documentation exemplars within text and standards documents. Additionally, documentation that guides shared language within nursing intervention areas has the potential to collectively empower nurses.