Nursing documentation in inpatient psychiatry: The relevance of nurse–patient interactions in progress notes—A focus group study with mental health staff

Myklebust, Kjellaug K.; Bjørkly, Stål; Råheim, Målfrid

doi:10.1111/jocn.14108

Cited by 27 publications

(39 citation statements)

References 45 publications

(65 reference statements)

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“…If the nurse is not aware of this, the barrier to building trust and relationship remains in place and continues to exert negative effects. Myklebust, et al (2018) study of psychiatric nursing documentation provides insight into ways in which nurses can lose sight of their consumer's individual human needs and strengths through their everyday practices. Through content analysis of nursing notes in acute care settings, they identified lack of focus on the personhood of the consumer, as well as the absence of documentation of relational intervention.…”

Section: Policies and Practicesmentioning

confidence: 99%

Barriers to recovery‐focused care within therapeutic relationships in nursing: Attitudes and perceptions

Harris

Panozzo

2019

Int J Mental Health Nurs

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There are numerous barriers to the therapeutic relationship between nurses and persons with schizophrenia, such as time constraints, communication issues and the requirements of practice policies. The main point of this paper is that the nature of these barriers is such that the nurse may not conceptualize these as barriers or be aware of how his or her responses to these can further entrench existing barriers to relationship or create new ones. If the nurse is not aware of how he or she responds to time pressure, frustration or lack of clarity of practice policy and address this, there is a risk that the patient may perceive the nurse's actions as lacking in care, presence or involvement. As consumers increasingly embrace recovery approaches to mental health that prioritize therapeutic activities within the context of collaborative relationship, psychiatric nurses, with a long tradition of therapeutic relationship, can rise to meet them. It is suggested here that this can only occur if nurses are fully aware of barriers to relationship, their responses to these and the impact of these on relationship with patients. Suggestions for educational and empirical work to further raise awareness and promote understanding of this process are provided.

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Section: Policies and Practicesmentioning

confidence: 99%

Barriers to recovery‐focused care within therapeutic relationships in nursing: Attitudes and perceptions

Harris

Panozzo

2019

Int J Mental Health Nurs

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“…The staff focused on documenting observations of patients for diagnostic purposes rather than on staff–patient interactions. Neither challenging interactions that succeeded in attuning to patients nor communications that failed to meet patients' emotional needs were reported (Myklebust, Bjørkly, & Råheim, ).…”

Section: Introductionmentioning

confidence: 99%

“…Neither challenging interactions that succeeded in attuning to patients nor communications that failed to meet patients' emotional needs were reported (Myklebust, Bjørkly, & Råheim, 2018).…”

Section: Introductionmentioning

confidence: 99%

Development and reliability testing of the Scale for the Evaluation of Staff‐Patient Interactions in Progress Notes (SESPI): An assessment instrument of mental health nursing documentation

Myklebust

Bjørkly

2019

Nursing Open

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Aim To develop and test the reliability of the Scale for the Evaluation of Staff‐Patient Interactions in Progress Notes ( SESPI ). Therapeutic nurse–patient interactions are fundamental in mental health nursing. However, little is known about how these interactions are recorded in nursing documentation and there is no instrument available for collecting this type of information for quantitative analysis. Design Instrument development and reliability testing. Methods The development of the SESPI was based on qualitative analyses of progress notes retrieved from patient records in two mental health services. A self psychological attunement perspective guided the analyses. SESPI was tested for internal consistency and inter‐rater reliability after 22 nurses independently scored 10 progress notes. Results Cronbach's alpha for the entire instrument was 0.977, indicating that the raters' scores had very high internal consistency. ICC was 0.770. The alpha and ICC values for each step were high, varying between 0.970 and 0.992.

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“…It is possible that RNs participating in this project performed patient education on the target topics more often than was documented; the results in Table speak to the likelihood that there was a discrepancy between what nurses did and what they documented doing. Myklebust, Bjørkly, and Råheim () described the gap that exists between the care psychiatric nurses provide to patients and how (and whether) they document that care. According to Lewin's classic force field model, one of the requirements for change is that participants link motivation to action (Lewin, ).…”

Section: Discussionmentioning

confidence: 99%

“…speak to the likelihood that there was a discrepancy between what nurses did and what they documented doing Myklebust, Bjørkly, and Råheim (2017). described the gap that exists between the care psychiatric nurses provide to patients and how (and whether) they document that care.…”

mentioning

confidence: 99%

Improving patient education about tobacco withdrawal and nicotine gum use by registered nurses in inpatient psychiatry: A feasibility study

Muladore

Brown

Haefner

et al. 2018

Psychiatric Ment Health Nurs

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Introduction Tobacco use is prohibited in most psychiatric facilities in the United States, yet many psychiatric inpatients are tobacco users. Psychiatric nurses have reported inadequate education about best practices for managing tobacco dependence. Aim To explore the feasibility of an educational intervention for psychiatric nurses designed to improve their ability to educate patients about best practices for managing tobacco dependence, as well as effective use of nicotine gum. Method Fourteen nurses on a psychiatric inpatient unit at a community hospital were educated about the targeted topics. Chart reviews of nonequivalent pre-intervention and post-intervention patient groups were conducted to explore the outcomes of the intervention. Results Patients received more teaching, and used nicotine gum more often, following the intervention. However, no statistically significant differences between the pre-intervention and post-intervention patient groups were found. Discussion Educating nurses about best practices for managing tobacco withdrawal symptoms may have positive outcomes. Existing research suggests that such interventions may be most effective when support and structure are provided to ensure long-term practice changes. Implications for practice This feasibility study demonstrates that a brief nurse education intervention has the potential to improve the experience of tobacco withdrawal for psychiatric inpatients. Future research that expands upon the current project is warranted.

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Nursing documentation in inpatient psychiatry: The relevance of nurse–patient interactions in progress notes—A focus group study with mental health staff

Abstract: This study contributes to the critical examination of the documentation praxis, as well as to the critical examination of the documentation tool as to what is considered important to document.

Cited by 27 publications

References 45 publications

Barriers to recovery‐focused care within therapeutic relationships in nursing: Attitudes and perceptions

Barriers to recovery‐focused care within therapeutic relationships in nursing: Attitudes and perceptions

Development and reliability testing of the Scale for the Evaluation of Staff‐Patient Interactions in Progress Notes (SESPI): An assessment instrument of mental health nursing documentation

Improving patient education about tobacco withdrawal and nicotine gum use by registered nurses in inpatient psychiatry: A feasibility study

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