Perceptions and attitudes toward COVID-19 vaccination among health professional students in Australia: a qualitative study.

Using two qualitative data sources: free-text responses to an open-ended question of an online survey and subsequent interviews and focus groups, we explored perceptions and attitudes toward COVID-19 vaccination among health professional students enrolled in Australian universities during the pandemic with data collected from October 2021 to April 2022. Students provided free-text responses to the open-ended question (n = 313) in the online survey and participated in interviews or focus groups (n = 17). Data analysis revealed three themes, including perceptions of COVID-19 seriousness and the risk of contracting the virus, information dissemination, and attitudes toward the vaccine mandate. The study identified evolving perceptions of COVID-19 seriousness among Australian health professional students and their sentiments toward the vaccine mandate. There is a need to ensure the quality of information dissemination related to the vaccine mandate. This may not only support students' uptake of mandatory vaccination but also provide a means for them to address vaccination with healthcare consumers and patients.

Implementation of a nurse practitioner service in a rural setting: a qualitative analysis of healthcare practitioners' experiences.

BACKGROUND: Nurse Practitioners work independently and collaboratively within multidisciplinary teams to fill unmet service delivery needs. Despite strong evidence of the benefits of the nurse practitioner service model, organisational support for nurse practitioners varies in terms of resources and support from leadership and other healthcare professionals. AIMS: The study aimed to explore healthcare practitioners' experiences of implementation of a NP service in a rural setting. METHODS: Semi-structured interviews were conducted with ten healthcare practitioners to investigate their perspectives of a recently implemented NP service. Data were analysed inductively using thematic analysis. FINDINGS: Themes emerged related to facilitating collaborative practice, person-centred continuity of care and positive health outcomes for the community. Challenges and limitations related to operational role clarity, scopes of practice and leadership. CONCLUSION: Healthcare practitioners were mostly satisfied with the service however challenges caused tension. Change management principles provide a framework to strengthen the effective clinical alignment of the service.

Barriers and facilitators to COVID-19 vaccine uptake among Australian health professional students during the pandemic: a nationwide study.

Using a cross-sectional online survey we investigated knowledge, attitudes, and risk perception about COVID-19 vaccination and identified factors influencing vaccine uptake among Australian health professional students from October 2021 to January 2022. We analysed data from 1114 health professional students from 17 Australian universities. Most participants were enrolled in nursing programs (n = 958, 86.8%), and 91.6% (n = 858) of the participants received COVID-19 vaccination. Approximately 27% believed COVID-19 was no more serious than seasonal influenza and that they had a low risk of acquiring COVID-19. Nearly 20% disagreed that COVID-19 vaccines in Australia were safe and perceived they were at higher-risk of acquiring COVID infection than the general population. Higher-risk perception viewing vaccination as their professional responsibility, and vaccine mandate strongly predicted vaccination behaviour. Participants consider COVID-19 information from health professionals, government websites, and World Health Organization as the most trusted information sources. The findings highlight that healthcare decision-makers and university administrators need to monitor students' hesitancy with vaccination to improve students' promotion of the vaccination to the general population.

Factors that impact Australian early career nurses' intentions to remain in their position and the profession: A prospective cohort study.

AIM: The aim of this work is to identify factors that impact on early career nurses' intentions to remain in their current position and compare with what impacts on intention to remain in the profession. BACKGROUND: Early exits of nurses from a position and the profession are a result of evolving factors. A lack of longitudinal follow-up impedes knowledge about these factors or what proportion of temporary exits become permanent. METHOD: The study used prospective cohort survey design. The sample was obtained from non-probability convenience sampling of graduating nursing students from two universities. Data was collected across three time points over 12 months, commencing in November 2016. RESULTS: The professional turnover rate was 6.7% in total. Higher Work Environment, Support and Encouragement scores and Stress in personal life were the only predictors of intending to remain in the profession. Statistical modelling could not predict intention to remain in current position. CONCLUSION: There were differences identified when comparing intention to remain in a position and the profession. Nurses are satisfied with their career choice and intend to remain in the profession, although many are intending to move positions. IMPLICATIONS FOR NURSING MANAGEMENT: To effectively retain the nursing workforce, stakeholders must focus on the work environment, appropriate support and remuneration, and facilitate career progression.

The Current Contexts of Newly Graduated Nurses' Competence: A Content Analysis.

Producing and sustaining a competent nursing workforce is imperative to protect the public. Identifying current issues and trends in nursing competence can strengthen insights and provide direction for the future nursing workforce. A summative content analysis was performed; PubMed, CINAHL, and Scopus were searched for content from the last ten years. A total of 3225 titles and abstracts regarding nursing competence were identified and analysed using the big-data analysis software Leximancer. Five themes were discovered from the analysis: (1) standardisation of nursing competencies with emerging competencies, (2) assessment competency levels, (3) graduates' expectations and achievement, (4) safe and quality practice with teamwork, and (5) competency curriculum development. This found standardised nursing competencies, which suggests prioritising which core competencies should be focused on during education to produce competent generalist professional nurses, and employers could help nursing graduates improve their competence in specialised areas. This review also suggests that further education strategies should be developed to better prepare graduates for culturally safe practice to meet the needs of diverse minority populations and for informatics competency during the COVID-19 pandemic. Competence assessment methods must be extensively investigated to measure nursing competencies both longitudinally and cross-sectionally.

Exploration of health and health behaviours of undergraduate nursing students: a multi-methods study in two countries.

BACKGROUND: Nurses play a vital role in health promotion, and there may be a link between a nurse's own lifestyle practices and how they educate others. Supporting health and well-being in student nurses is critical given they will be educating others once registered and practicing. OBJECTIVES: To explore the health and health behaviours of undergraduate nursing and midwifery students considering the demands of their profession, their public health role and their ability to be role models. DESIGN: Multi-methods study. METHODS: Undergraduate nursing students in the second and third years of their programme were invited to self-complete a health and health behaviour questionnaire in a Scottish and Australian Higher Education Institution. Qualitative data were collected from a convenience sample of 20 third-year nursing and midwifery students. RESULTS: Two hundred and thirty-five Scottish students and 113 Australian students, 175 (85%) and 84 (74%), respectively, completed the questionnaire. Some differences and similarities were noted across groups, in particular, perceived physical health, the prevalence of binge drinking, smoking and being overweight/obese and some dietary measures were found to be less favourable among Scottish students. There were worryingly high levels of poor mental well-being at both higher education institutions, with scores on a mental well-being scale suggesting that (82) 34.7% of Scottish students and 33 (29.6%) of Australian students were at risk of depression. Nine Scottish students and 11 Australian students were interviewed. Key contributors and barriers to healthy behaviours were noted across both groups of students in relation to lifestyle. Students perceived that certain elements of their curriculum had implications on their ability or motivation to make healthy lifestyle choices. CONCLUSION: The poor health and health behaviours of future nurses need to be addressed in their higher education to shape resilient role models for future nursing practice. IMPACT STATEMENT: Priority should be given to supportive learning environments for student nurses that foster emotional support and encourage healthy lifestyles.

Core procedural skills competencies and the maintenance of procedural skills for medical students: a Delphi study.

BACKGROUND: It is well recognised that medical students need to acquire certain procedural skills during their medical training, however, agreement on the level and acquisition of competency to be achieved in these skills is under debate. Further, the maintenance of competency of procedural skills across medical curricula is often not considered. The purpose of this study was to identify core procedural skills competencies for Australian medical students and to establish the importance of the maintenance of such skills. METHODS: A three-round, online Delphi method was used to identify consensus on competencies of procedural skills for graduating medical students in Australia. In Round 1, an initial structured questionnaire was developed using content identified from the literature. Respondents were thirty-six experts representing medical education and multidisciplinary clinicians involved with medical students undertaking procedural skills, invited to rate their agreement on the inclusion of teaching 74 procedural skills and 11 suggested additional procedures. In Round 2, experts re-appraised the importance of 85 skills and rated the importance of maintenance of competency (i.e., Not at all important to Extremely important). In Round 3, experts rated the level of maintenance of competence (i.e., Observer, Novice, Competent, Proficient) in 46 procedures achieving consensus. RESULTS: Consensus, defined as > 80% agreement, was established with 46 procedural skills across ten categories: cardiovascular, diagnostic/measurement, gastrointestinal, injections/intravenous, ophthalmic/ENT, respiratory, surgical, trauma, women's health and urogenital procedures. The procedural skills that established consensus with the highest level of agreement included cardiopulmonary resuscitation, airway management, asepsis and surgical scrub, gown and gloving. The importance for medical students to demonstrate maintenance of competency in all procedural skills was assessed on the 6-point Likert scale with a mean of 5.03. CONCLUSIONS: The findings from the Delphi study provide critical information about procedural skills for the Clinical Practice domain of Australian medical curricula. The inclusion of experts from medical faculty and clinicians enabled opportunities to capture a range of experience independent of medical speciality. These findings demonstrate the importance of maintenance of competency of procedural skills and provides the groundwork for further investigations into monitoring medical students' skills prior to graduation.

Nursing degree students' clinical placement experiences in Australia: A survey design.

AIM: This study aimed to evaluate Australian nursing students' views of placements at seven tertiary education institutions with the use of the Placement Evaluation Tool (PET). BACKGROUND: Clinical placements are a core element of healthcare education programs around the world (Chuan and Barnett, 2012) with undergraduate nursing students required to complete a prescribed number of hours as part of their degree. The quality of nursing clinical placements varies with a range of positive and negative learning experiences. DESIGN: A survey design was used with a contemporary survey tool- the Placement Evaluation Tool (PET). Using Qualtrics software (Qualtrics, 2005) the on-line survey was distributed to approximately 6265 undergraduate nursing students at six Australian universities and one Technical and Further Education (TAFE) college where Bachelor of Nursing degree students were enrolled. Three Australian States were covered. Sites were selected where a project team member was employed. METHODS: A total of 1263 nursing students completed the Placement Evaluation Tool (PET) - 19 items (rated 1-5), one global rating (rated 1-10) - following placement in three Australian States (July 2019-February 2020). Most - 618 (48.9%) completed a placement in acute care with placements positively rated overall. RESULTS: The total PET mean score was 78.3% with 29.8% being 'extremely satisfied' (10 out of 10 - Item 20). However, 11.0% were dissatisfied with global ratings of four or less, whilst ratings between States differed significantly (p = <0.001). One third of respondents answered a free text statement relating to placement experiences, with significantly more comments from older students (p = <0.001) and from those with ratings in the lower range (p = <0.001). Three core themes emerged: 1. Staff Attitudes to Students, 2. Environment and 3. Lifestyle. CONCLUSIONS: Whilst students' clinical experiences in Australia tend to be positive a minority reported exposure to negative staff attitudes, in unsafe environments, with lifestyle detriments. Further work is required to understand and enhance student experiences.

Factors that influence Australian early career nurse employment outcomes and settings: A prospective cohort study.

AIM: To identify the factors influencing employment outcomes and settings for early career nurses. BACKGROUND: A shortage of nurses attracted to work in out-of-hospital settings exists. Despite this, not all nursing graduates can secure work as a nurse. Information on the factors that impact wider graduate employment is available. However, a nursing perspective is missing, especially for hard to recruit to areas. METHODS: A prospective cohort study was conducted. Participants were 293 final-year undergraduate nursing students, recruited from two universities. Data were collected over 12 months, commencing November 2016. RESULTS: English as a first language was the greatest predictor of employment for graduates. Previous health care experience and workplace preferences predicted employment in the out-of-hospital setting. CONCLUSIONS: Misalignment between English language requirements and industry expectations about language may lead to bias in recruitment of graduate nurses with English as their second language. Recruitment to out-of-hospital settings may be promoted by having health care experience and targeting those with a preference. IMPLICATIONS FOR NURSING MANAGEMENT: Reviewing current employment policies to ensure they reflect the need for cultural diversity in the nursing workforce is critical. Additionally, research that aims to understand how preferences for out-of-hospital settings are developed will help target graduate employment strategies.

Interprofessional, student-led community health clinic: expanding service provision and clinical education capacity.

Student-led interprofessional health clinics offer valuable opportunities for student learning and meeting the health care needs of the community. This case study describes the operation of a new interprofessional student-led community health service over its initial 13-month period of operation. This case study also presents an overview of the service provision, student placement opportunities and focuses on the challenges associated with the service and the impact on future planning.

Measuring the quality of nursing clinical placements and the development of the Placement Evaluation Tool (PET) in a mixed methods co-design project.

BACKGROUND: The quality of nursing clinical placements has been found to vary. Placement evaluation tools for nursing students are available but lack contemporary reviews of clinical settings. Therefore, the aim of this study was to develop a feasible, valid and reliable clinical placement evaluation tool applicable to nursing student placements in Australia. METHODS: An exploratory mixed methods co-design project. Phase 1 included a literature review; expert rating of potential question items and Nominal Group Technique meetings with a range of stakeholders for item development. Phase 2 included on-line pilot testing of the Placement Evaluation Tool (PET) with 1263 nursing students, across all year levels at six Australian Universities and one further education college in 2019-20, to confirm validity, reliability and feasibility. RESULTS: The PET included 19-items (rated on a 5-point agreement scale) and one global satisfaction rating (a 10-point scale). Placements were generally positively rated. The total scale score (19 items) revealed a median student rating of 81 points from a maximum of 95 and a median global satisfaction rating of 9/10. Criterion validity was confirmed by item correlation: Intra-class Correlation Co-efficient ICC = .709; scale total to global score r = .722; and items to total score ranging from .609 to .832. Strong concurrent validity was demonstrated with the Clinical Learning Environment and Supervision Scale (r = .834). Internal reliability was identified and confirmed in two subscale factors: Clinical Environment (Cronbach's alpha = .94) and Learning Support (alpha = .96). Based on the short time taken to complete the survey (median 3.5 min) and students' comments, the tool was deemed applicable and feasible. CONCLUSIONS: The PET was found to be valid, reliable and feasible. Use of the tool as a quality assurance measure is likely to improve education and practice in clinical environments. Further international evaluation of the instrument is required to fully determine its psychometric properties.

Exploration of the expected and achieved competency levels of new graduate nurses.

AIM: To explore the expected and achieved competency levels of new graduate nurses. BACKGROUND: There are global concerns about a perceived disconnect between the educational preparation of new graduates and the expectations of employers about their work readiness. It is important to understand competency levels expected and achieved of new graduate nurses. METHOD(S): The study was conducted in three phases: the identification of competencies, development of a survey instrument and exploration of levels of competency from the perspectives of key stakeholders. RESULTS: New graduates were well prepared for demonstrating respect to patients, but needed to be closely supported when providing emergency care. Results highlighted that new graduates felt less competent than graduating students in those competencies related to legal and ethical practice. Importantly, expectations about new graduates' competency varied between educators and managers. CONCLUSION(S): The findings provide important information about new graduates' competency levels, revealing a mismatch in the perception of key stakeholders about competency levels. This has important implications for building new graduates readiness for practice and highlights the importance of collaboration between key stakeholders to address competency gaps. IMPLICATIONS FOR NURSING MANAGEMENT: Supportive opportunities should be provided to new graduate nurses to fill gaps in beginner competency.

The Nominal Group Technique: Generating Consensus in Nursing Research.

The purpose of this article is to describe the Nominal Group Technique and its application as a consensus-generating approach in nursing research. The approach incorporates face-to-face meetings to explore opinions, generate ideas, and determine priorities. The nominal group technique process, which is based on a study designed to develop a nursing student clinical placement (clinical practicum) evaluation tool, is described. Advantages of the approach include creative face-to-face discussions with minimal resource demands. The nominal group technique is beneficial and can be used to achieve consensus in nursing research, but a lack of anonymity may preclude the process in some investigations. [J Nurs Educ. 2020;59(2):65-67.].

Situation awareness and the decision-making processes of final-year nursing students.

AIMS AND OBJECTIVES: To investigate final-year nursing students' use of situation awareness when making clinical decisions about patients' progress postsurgery. BACKGROUND: Making clinical decisions about patient care is a generic nursing competence, developed in preregistration nursing programmes and critical to providing safe patient care. Situation awareness is an important precursor to making decisions and is linked to improved clinical outcomes. However, there is evidence to suggest that nursing students feel inadequately prepared to make clinical decisions. DESIGN: Endsley's (Situation awareness analysis and measurement. Hillsdale, NJ: Lawrence Erlbaum Associates, 2000) 3-level situation awareness framework was used to guide the study. Level 1 situation awareness is perception of information required to make a decision. Level 2 relates to comprehending the information. Level 3 situation awareness is projecting how this information will inform the future. Twelve final-year nursing students were recruited to participate. Think-aloud research method was used to capture students' decision-making, followed by semi-structured interviews. Data were analysed using an adapted protocol analysis and were encoded inductively. The COREQ checklist has been used in reporting the study. RESULTS: Students demonstrated level 1, 2 and 3 situation awareness when making clinical decisions. However, it was not demonstrated consistently and at times subsequent decision-making was inappropriate. Three themes emerged: "systems approach to assessment of postoperative patients"; "policy drives practice"; and "deferring decisions to registered nurses". Within the themes, students demonstrated differing levels of situation awareness. CONCLUSION: Making safe clinical decisions is a paramount skill for nurses; however, student nurses are ill-equipped to undertake this skill. Situation awareness is important in informing safe decision-making, but students' use of situation awareness is variable. Cognitive apprenticeship, applied to supporting development of situation awareness, affords the opportunity to develop students' decision-making. RELEVANCE TO CLINICAL PRACTICE: Clinical decision-making is a generic competence for all registered nurses and imperative for safe practice. However, student nurses are unprepared to undertake this skill once registered.

Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review.

AIMS AND OBJECTIVES: The aim of this integrative literature review is to identify themes associated with improved patient outcomes related to orthogeriatric co-managed inpatient unit models of care for patients who had sustained a hip fracture. APPROACH: An integrative literature review was undertaken from 2002-July 2013 using electronic databases with specific search terms. METHODS: The theoretical framework of Whittemore and Knafl was used to guide the review. This framework was chosen as it allows for the inclusion of varied methodologies and has the capability to increase informed evidence-based nursing practice. RESULTS: Five distinct themes relating to outcomes emerged from the analysis, which were: time from admission to surgery; complications; length of stay; mortality and initiation of osteoporosis treatment. CONCLUSION: The analysis of this integrative literature review clearly indicates the need for national and international sets of agreed outcome measures to be adopted to facilitate the comparison of models of care. This would significantly improve the way in which outcomes and costs are reported, further enhancing international partnerships as the health care team strive to achieve overall improvements in the management of older people presenting to hospital with hip fracture.

Using social media as a strategy to address 'sophomore slump' in second year nursing students: A qualitative study.

INTRODUCTION: An important contributing factor to the shortfall in the nursing workforce is the high attrition rate of students from nursing programmes. Recently, researchers have begun to examine the 'sophomore slump' phenomenon, related to students' sense of low self-efficacy associated with learning in their second year of study, that may be related to attrition. BACKGROUND: Academic success is heavily influenced by self-efficacy, or a student's belief in their ability to be successful. Strategies that enhance self-efficacy include peer learning, which increases students' engagement and reinforces self-regulated learning. Social networking sites such as Facebook provide students the opportunity to take part in peer learning and may promote students' self-efficacy. AIM: The aim of the study was to develop a Facebook forum that utilised peer learning, to build self-efficacy related to learning, of students commencing into the second year of a three year nursing programme. METHODS: Students commencing into year two of a Bachelor of Nursing programme were invited to join a Facebook forum to support their study. One hundred and ninety-eight students accepted the invitation. Data was collected over a twelve-week period. Text from the Facebook forum was downloaded and analysed thematically. FINDINGS: Analysis suggests that Facebook forums may be a useful peer learning strategy to build students' self-efficacy related to study in the second year of nursing study. Students shared mastery experiences, provided modelling experiences, and used verbal persuasion to reframe problems which suggested that it helped build students' self-efficacy, and alleviated some of the physiological response associated with stress. CONCLUSION: The findings suggest that social media platforms are important tools by which students can engage in peer learning to build self-efficacy around their nursing studies. This may in part help address the 'sophomore slump' phenomenon, enhance students' learning experiences more widely, and impact on students' decisions to remain in nursing programmes.

Novel technologies can provide effective dressing and securement for peripheral arterial catheters: A pilot randomised controlled trial in the operating theatre and the intensive care unit.

BACKGROUND: Peripheral arterial catheters are widely used in the care of intensive care patients for continuous blood pressure monitoring and blood sampling, yet failure - from dislodgement, accidental removal, and complications of phlebitis, pain, occlusion and infection - is common. While appropriate methods of dressing and securement are required to reduce these complications that cause failure, few studies have been conducted in this area. OBJECTIVES: To determine initial effectiveness of one dressing and two securement methods versus usual care, in minimising failure in peripheral arterial catheters. Feasibility objectives were considered successful if 90/120 patients (75%) received the study intervention and protocol correctly, and had ease and satisfaction scores for the study dressing and securement devices of ≥ 7 on Numerical Rating Scale scores 1-10. METHODS: In this single-site, four-arm, parallel, pilot randomised controlled trial, patients with arterial catheters, inserted in the operating theatre and admitted to the intensive care unit postoperatively, were randomly assigned to either one of the three treatment groups (bordered polyurethane dressing (n=30); a sutureless securement device (n=31); tissue adhesive (n=32)), or a control group (usual practice polyurethane dressing (not bordered) (n=30)). RESULTS: One hundred and twenty-three patients completed the trial. The primary outcome of catheter failure was 2/32 (6.3%) for tissue adhesive, 4/30 (13.3%) for bordered polyurethane, 5/31 (16.1%) for the sutureless securement device, and 6/30 (20%) for the control usual care polyurethane. Feasibility criteria were fulfilled. Cost analysis suggested that tissue adhesive was the most cost effective. CONCLUSIONS: The pilot trial showed that the novel technologies were at least as effective as the present method of a polyurethane dressing for dressing and securement of arterial catheters, and may be cost effective. The trial also provided evidence that a larger, multicentre trial would be feasible.

Exploring the transition experiences of students entering into preregistration nursing degree programs with previous professional nursing qualifications: an integrative review.

AIMS AND OBJECTIVES: This paper aims to investigate the transition experiences of students with previous nursing qualifications (nondegree qualifications) entering a nursing degree program. BACKGROUND: Nurses with professional nursing qualifications (nondegree) are an important pool of professionals to draw on to help address nursing shortages through providing alternative pathways to becoming registered nurses. However, research suggests this cohort need higher levels of support and intervention to be successful. DESIGN: An integrative review was conducted, guided by Whittemore and Knafl's framework. A comprehensive search was conducted and 14 studies were included in the review. METHODS: A five-stage approach was used to conduct the review: problem identification, literature search, data evaluation, data analysis and presentation of results. Constant comparative analysis was used to identify commonalities, differences and themes in the relevant literature. RESULTS: Themes emerged that suggested students struggled with academic and institutional challenges, becoming learners, managing conflicting demands of outside life, developing a student identity and experienced threat to their sense of professional identity. Additionally, the cohort did not view themselves as 'the same' as traditional students. Holland's framework provides a useful framework from which to conceptualise these students' experiences. CONCLUSION: There are challenges for this cohort of students as they transition into degree level study. Supportive activities that extend and further develop students' personality orientations may be a useful starting point in addressing some of the challenges and providing a more positive transition to university. RELEVANCE TO CLINICAL PRACTICE: The demand for health care is growing and there remains a shortfall of registered nurses. Nurses with professional qualifications (nondegree) are an important pool of professionals from which to increase registered nurse numbers and address workforce sustainability issues.

An education intervention to improve nursing students' understanding of medication safety.

Medication safety is a significant issue. Whilst medication administration is a routine task, it is a complex nursing activity. It is recognised in the literature that medication related adverse events are most often related to systems failures associated with the complex process of medication administration. This paper examines student's perceived effectiveness of an educational intervention, designed to demonstrate the complex and multidisciplinary factors of systems related failures in medication administration. The intervention was underpinned by adult and experiential learning concepts and used a problem-based learning approach. A series of short digital recordings were developed along with discussion points to illustrate multidisciplinary interactions involved in medication administration. A small sample of second and third year undergraduate nursing students (n = 28) evaluated the effectiveness of the educational resource. Our findings suggest that such resources are effective in demonstrating the complexity of medication related error and were authentic to practice. An educational intervention using problem based learning afforded nursing students the opportunity to engage with the systems factors that contribute to medication errors. Interventions that highlight these factors may play an important role in raising awareness of these issues and encourage students to carry this knowledge into clinical practice.

Situation awareness and documentation of changes that affect patient outcomes in progress notes.

AIMS AND OBJECTIVES: To report on registered nurses' situation awareness as a precursor to decision-making when recording changes in patients' conditions. BACKGROUND: Progress notes are important to communicate patients' progress and detail changes in patients' conditions. However, documentation is often poorly completed. There is little work that examines nurses' decision-making during documentation. This study focused on describing situation awareness as a precursor to decision-making during documentation. DESIGN: This study used Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) work on situation awareness to guide and conceptualise information. The study was situated in a naturalistic paradigm to provide an interpretation of nurses' decision-making. METHODS: Think-aloud research methods and semi-structured interviews were employed to illuminate decision-making processes. Audio recordings and interview texts were individually examined for evidence of cues, informed by Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) descriptions of situation awareness. RESULTS: As patients' conditions changed, nurses used complex mental models and pattern-matching of information, drawing on all 3 levels of situation awareness during documentation. Level 1 situation awareness provided context, level 2 situation awareness signified a change in condition and its significance for the patient, and level 3 situation awareness was evident when nurses thought aloud about what this information indicated. Three themes associated with changes in patients' conditions emerged: deterioration in condition, not responding to prescribed treatments as expected and issues related to professional practice that impacted on patients' conditions. CONCLUSION: Nurses used a complex mental model for decision-making, drawing on 3 levels of situation awareness. Hamm's cognitive continuum theory, when related to situation awareness, is a useful decision-making theory to provide a platform on which to draw together components of situation awareness and provide a framework on which to base decision-making regarding documentation. RELEVANCE TO CLINICAL PRACTICE: Understanding how RNs employ situation awareness and providing a framework for decision-making during documentation may assist effective documentation about changes in patients' conditions.