DanielEndress,BS,RN,CMSRN

SUNYDelhi

Biography

DanielEndressisaRegisteredProfessionalNurseandisaCertificatedMedical

SurgicalNurse.DanielisanAssistantProfessorofNursingatStateUniversityofNew

York,CollegeofTechnologyatDelhiandisworkingoncompletinghisMastersin

NursingEducation.Danielhasworkedinamultitudeofareasasanurse,including

emergencyroom,med/surge,andnursingadministration.

ConferenceInformation

AcademyofMedicalSurgicalNurses26thAnnualConference

- TitleofContribution

- Abstract

o Maxlength500words

o Topics

CareCoordination
 Clinical

Leadership

EvidenceBasedPractice

Research

Theconferenceiscallingforabstractsinanyoftheaboveareas.Theconferenceis

advertisedasaconventiontohelpyouimprovepatientcareandconnectwithotherswho

havethesamecompassionandcommitmenttonursingasyouhave.

AbstractTitle:

ImprovingDocumentingCompliancebyEmpoweringNurses.

Background&Purpose:

Thepurposeofthisstudyistoimprovethecompliancewiththedocumentationpolicyby

inpatientnurses.Duringroutinechartauditsinadequateandinconsistentdocumentation

wasidentified.Theinitialresponsetothefindswastodistributethecurrent

documentationpolicytonurses.Thisinitialinterventionresultedinnoimprovementin
documentation.Aninitiativetoempowerthenursesandchangetheculturewas

undertaken.Nursingasawholewaschargedtheresponsibilityofpeerchartauditing.

Setting:

InpatientNursingUnit,withapproximately25nurses,inat16bedcriticalaccess

hospital.

Procedures:

Asystematicchartreview,ofover250charts,wasconductedusingaChartAuditTool.

Thefindingsrevealedseveredocumentationdeficienciesinthecharting.Kanter'sTheory

ofEmpowermentwasusedtoimplementachangeintheinpatientdepartments

documentationpractices.Nursingempowermentwasachievedbyengagingnursesinthe

auditprocess,allowingnursesaccesstoinformation,educationontheauditprocess,and

encouragingnursestoholdpeersaccountablefordocumentation.Nursesperformedchart

reviewsandprovidedrealtimefeedbacktotheircolleagues.

Findings/Results:
Oncenursesweregiventheautonomytoperformpeertopeerauditsbyadministration,

andstartedtogiveimmediatefeedback,andeducationtotheirpeers,thedocumentation

complianceimprovedsignificantly.Allareasinitiallyshoweda1030%improvement,

whileanumberofnotedareasimprovedbyasmuchas50%inthefirst90days.The

resultscontinuetobemonitoredanddatashows90%complianceatthe180daymark.

Empowermentasagroupprovedtobeafarmoreeffectivetoolthanindividualized

education.Thestrategyhasledtoownershipoftheissuebynursingstaff,improving

documentationcompliance.Usingtheempoweringenvironmentfosteredmutual

professionalrelationships,improvedcommunicationandcollaborationtoachieveaunit

goal.

Discussion/Conclusions/Implications:

Empoweringthegroup,provedtobeafarmoreeffectivetoolthaneducatingindividuals.

Theempowermentstrategyledtoownershipofthedocumentationissuebystaffand

resultedinastartlingimprovementincompliance.Theempoweringenvironmentfosters

mutualprofessionalrelationships,increasedcommunication,andcollaborationtoachieve

aunitgoal.