Exploring the Creation of Nurses' Informal Documentation and Use in Clinical Work - Final Report

Sep 4, 2026

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Research develops a deep understanding of nurses' informal “paper brains” used in a medical oncology unit within a cancer hospital. The study examines how these self-created documentation artifacts support safe communication, synthesize patient information, and influence workflow across an entire shift. Focus includes meaning attributed to brains, processes of their production, and how reliance on paper persists despite robust EHRs. Grounded theory analysis identifies major concepts.

LanguageEnglish

CategoryGeneral

FormatPDF

Pages20

Reading Time7 min

AccessFree to download

Structured Abstract

Purpose

Scope

Methods

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Key Words

Purpose

Background on “brains”

Rationale for understanding meanings and production

Exploring the Creation of Nurses' Informal Documentation and Use in Clinical Work Principal Investigator: Jacquelyn W. Blaz, MS University of Utah, Salt Lake City, UT Dates: February 1, 2013 – April 30, 2014 Federal Project Officer: Tamara Willis This project was supported by grant number R36HS022183 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the author and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. 2 2. Structured Abstract Purpose: The purpose of this research was to develop a deep understanding of nurses' brains in the context of a medical oncology unit at a cancer hospital that is part of an academic health sciences center, and to derive successful strategies for the development of electronic tools based on this deep understanding. Scope: Nurses are well known to produce their own personalized objects , known as paper “brains,” to organize information during a shift. Inter-shift handoffs have significant potential to create patient harm due to breakdowns in communication from information loss or misinterpretation. Nurses continued reliance on paper forms, despite availability of robust EHRs and electronic handoff tools , could be traced to insufficient understanding of the role the handoff tool or ‘brains’ play in nurses’ clinical work. Methods: Thirteen nurses from a medical oncology unit in an intermountain west cancer specialty hospital were shadowed during an entire shift and interviewed following the shift. In addition, digital scans of the nurses’ paper brains were obtained immediately prior to and after handoff at the beginning and end of the shift. A grounded theory approach was used to analyze these data. Results: Though a final substantive theory is not yet complete, initial findings suggest four major concepts: brains provide cognitive support, brains are a representation of nurse identity, brains represent the patient, and brains are living objects. Key Words: medical oncology nursing, cognitive artifacts, documentation, handoff, safety, communication, informatics 3. Purpose Nurses are well known to produce their own personalized objects to organize information during a shift. (1- 6) Previous research has characterized these objects as "handoff tools." (7-14) However, this characterization may be a limited view of the purposes these objects serve and the processes that lead to their construction. The term also assumes that these are purely functional objects, produced for the specific task of the inter-shift handoff, yet the collection or organization of patient information for handoffs accounts for only a portion of their use. Interestingly, nurses themselves do not refer to these objects as "handoff tools." Nurses have been known to call them "scraps,"(1) "my paper," (1,5,6) and "brains." (5,6) The latter term indicates a deeper purpose for these objects than just handoffs, thus the term "brains" will be used to represent these objects in this report. Previous research has described brains as private spaces that combine personal and professional knowledge. Brains are an informal documentation outside of the official healthcare record and have only recently been recognized as an integral part of nursing workflow . (1,4-6,15) Nurses have reported using their brains to synthesize information about patients and plan care for the upcoming shift. (1,5,6) Yet brains are more than just a place to store information and prioritize tasks. Hardey, et al. (1) claim that nurses' brains exist as a space to define and organize nursing knowledge. Because brains are designed as a personal and private space, they are a safe place to record information and reminders that might be inappropriate to include in the official medical record. (4-6) Though these studies were limited to the context of handoff, results hint at uses beyond this context that influence how nursing is practiced. Even so, res

FAQs

What are nurses' “paper brains” in this research, and what purpose do they serve?

“Paper brains” are personalized, informal documentation artifacts nurses create to organize and synthesize information during a shift. The report emphasizes that their purpose goes beyond inter-shift handoffs to include cognitive support, identity, patient representation, and living-object aspects.

Why does the study focus on the role of handoff tools and EHR-linked electronic tools?

Although robust EHRs and electronic handoff tools exist, nurses continue relying on personally created paper brains. The study links this persistence to insufficient understanding of how handoff tools—or brains—function in nurses' clinical work.

How were the data collected and analyzed to develop the theory?

Thirteen nurses from a medical oncology unit were shadowed throughout an entire shift and interviewed afterward. Digital scans of paper brains were collected before and after handoff at the start and end of the shift, and a grounded theory approach was used for analysis.

Sep 4, 2026

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