Factors influencing staff nurses' decisions for non-documentation of patient response to analgesia administration

Abstract

• The purpose of this descriptive field study is to determine what factors influence staff nurses' decisions for non-documentation of patients' response to analgesic administration. • The study, based on Herbert Simon's descriptive model of decision making, has two components: (a) to determine staff nurses' perceptions of the factors that influence their documentation as well as how frequently they document analgesic administration and (b) to determine the actual frequency of nurses' documentation. • Data collected from 67 staff nurses using a questionnaire designed for this study and through an audit of 65 patients' charts allowed comparison of nurses' perceptions with their actual practice. • Analysis involved both quantitative and qualitative approaches. • The results of the study have implications for nurse educators and nurse administrators.