Date of Award
Summer 2025
Project Type
Thesis
College or School
CHHS
Department
Nursing
Departments (Collect)
Nursing
Program or Major
Direct Entry Masters of Nursing
Degree Name
Master of Science
First Advisor
Deborah Simonton
Abstract
Background: Documentation is an essential component of healthcare delivery, especially in perianesthesia nursing. Electronic health records (EHR) have helped create high-quality documentation according to the standards of the American Nurses Association. However, EHRs have been found to be burdensome on nurses when they interfere with their workflow.
Local Problem: The documentation process for pre-operative anesthesia assessments within a nine bed PACU in Southern New Hampshire was found to be inefficient, increased chances of error or mistakes, and delayed patient data being accessible to the team.
Methods: Using the Plan-Do-Study-Act (PDSA) model, a quality improvement project was performed to update and implement an updated pre-procedure nursing assessment template for anesthesia patients according to nursing feedback and best-practice. Pre- and post-implementation surveys were distributed amongst the nursing staff in the microsystem to gain feedback, measure nurse satisfaction, and evaluate template usability.
Results: The results showed that nurse satisfaction and template usability both increased after updating the EHR according to feedback and best-practices. Prior to the implementation of the updated template, the average usability score on a Likert scale from one to ten was 7.25 1.30 After implementation of the updated template, the average usability score increased to 9.40 0.49. This data showed a 29.7% increase in template usability. Similarly, the average nurse satisfaction score prior to implementation was 6.50 2.06. After implementation, the average nurse satisfaction score increased to 9.40 0.49. This data showed a 44.6% increase in nurse satisfaction scores.
Conclusion: The QI project revealed that a template redesign can enhance nursing satisfaction and usability. When the nursing staff are included in template redesign, valuable feedback is obtained to help with satisfaction and minimize documentation burden. In addition to this, documentation templates can be more closely aligned to the nursing process when the staff are involved. Aligning documentation to the nursing process or workflow allows for a more streamlined and efficient process. Increasing efficiency and satisfaction allows nurses to provide higher quality care. This QI project laid a foundation for updating documentation in a PACU in Southern New Hampshire and could encourage other units to reassess their documentation templates.
Keywords: perianesthesia nursing documentation, nurse satisfaction, template usability, best practice documentation
Recommended Citation
Colon, Stephanie, "A Quality Improvement Initiative to Enhance the Effectiveness of Pre-Anesthesia Documentation and Nurse Satisfaction in the PACU" (2025). Master's Theses and Capstones. 1934.
https://scholars.unh.edu/thesis/1934