Date of Award

Summer 2024

Project Type

Thesis

College or School

CHHS

Department

Nursing

Departments (Collect)

Department of Nursing

Program or Major

Direct Entry Master's of Nursing

Degree Name

Master of Science

First Advisor

Pamela Kallmerten

Abstract

Abstract

Background: Quality documentation in healthcare settings is essential to ensure nurse satisfaction and patient safety. Documentation templates for patient charting should be in a format that follows best practice nursing care and captures all necessary assessments and interventions ordered by providers for patient care. A quality improvement was conducted in a PACU to evaluate the nurse satisfaction with the use of a new and revised documentation template for pain block procedures.

Local Problem: Within the perianesthesia care unit (PACU) of a Same Day Surgery center, a problem was identified regarding the nurse dissatisfaction with the template in place for post pain block documentation. The original template in place did not follow best practice and did consist of all provider orders necessary to complete when recovering a patient from a pain block procedure.

Methods: Surveys were distributed to nurse on the PACU unit, evaluating their satisfaction with original template in place or pain block procedures. With the use of a Plan-Do-Study-Act (PDSA) model, interventions were implemented with the use educational poster to present and enhance the nurses’ knowledge on best practice care for pain block procedures. A print out of the revised template was also presented to the nurses, which captured all provider orders and standard care. Post surveys were then distributed to the PACU nurses to evaluate their satisfaction of the revised template for future use, based off the template presentation.

Results: Based off of the pre-survey results, 100% of the six PACU nurses were dissatisfied/very dissatisfied with the original template in place. After the presentation of the educational poster and revised template for future use, the post survey results showed that out of the new template increased nurse satisfaction to 100%. A team of operating room (OR) nurses were added into the post survey results separately due to their contribution to patient care with pain block procedures. After verbalizing their dissatisfaction with the original template, the post survey results also showed that 100% of the OR team was satisfied with the new templated presented to them.

Conclusion: The revision and implementation of a new documentation template for future use in nerve block care, showed an increase in nurse satisfaction. The intervention shows that use of a documentation template that follows best practice is crucial to ensure quality documentation, nurse satisfaction, and patient safety. Future research and studies should consider this intervention other healthcare settings as it is important to ensure all documentation and charting follows current nursing standards and best practice care.

Keywords: nerve block assessment, pain block, best practice documentation, nursing care for nerve block, and postoperative

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