Table 4.

Major themes with examples by site

	Hospital A	Hospital B	Hospital C	Hospital D
Theme 1: variation in documentation and communication practices
Use of paper	Fewest forms (7) Heavy use of personalized ‘scraps’ to organize nursing activities	Most forms (24) Used graphics for patient progress Transcription of EHR data to paper (eg, labs, meds, orders) Moderate use of personalized ‘scraps’ to organize nursing activities	Kardex with overview of each patient Heavy use of personalized ‘scraps’ to organize nursing activities	Multiple forms used to organize care Least use of personalized ‘scraps’ to organize nursing activities
Balance of paper versus electronic charting	Primarily used paper documentation	Maintained both paper and electronic records (site with greatest amount of electronic documentation)	Relied more fully on computers (C2 in particular) Easy access to computers	Maintained both paper and electronic records
RN hand-off practices	Face-to-face report on RNs assigned patients typically received from multiple RNs Used standard worksheets and scraps—both discarded	B1 used audio-taped report on all unit patients Focused on tasks to be completed Most consistent hand-off (format and content) among all eight study units	Individual face-to-face hand-offs at computer stations outside patients' rooms Shortest hand-offs Utilized paper Kardex, computer MAR, paper flow sheet, and scraps	Individual face-to-face hand-off at nursing station Oncoming RNs viewed paper forms before hand-off Focus was on completed and future tasks
Theme 2: absence of a centralized care overview in the patient's EHR
Patient overview forms homegrown and not part of the patient's record	Standard hospital paper worksheets used to gather broad patient overview	Patient overview on a report sheet Master copy of overviews on all unit patients at front desk, updated throughout patient stay	RN individualized ‘organization sheets’ with patient overview developed for each assigned patient	RNs collaboratively designed an Excel spreadsheet to provide overview of all patients on the unit
Theme 3: rarity of interdisciplinary communication
Across sites
Paper forms designed to facilitate interdisciplinary communication were infrequently used. Non-nurse disciplines were rarely present on the patient care unit. Majority of ‘other’ discipline communication took place by phone. Efficiency of care was dramatically affected when needed care team member was unavailable. RNs frequently consolidated and interpreted information from a variety of sources and disciplines to coordinate care without seeking team validation. Information related during interdisciplinary communication was rarely documented.

A, university hospital; B and C, large community hospitals; D, small community hospital.

EHR, electronic health record; MAR, medication administration record; RN, registered nurse.