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Sung S, Jung H, Kim Y. Exploring Nursing Care for Patients With COVID-19 Using International Classification for Nursing Practice-Based Nursing Records. Comput Inform Nurs 2024; 42:127-135. [PMID: 37579774 DOI: 10.1097/cin.0000000000001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
This study explored nursing care topics for patients with the coronavirus disease 2019 admitted to the wards and intensive care units using International Classification for Nursing Practice-based nursing narratives. A total of 256630 nursing statements from 555 adult patients admitted from December 2019 to June 2022 were extracted from the clinical data warehouse. The International Classification for Nursing Practice concepts mapped to 301 unique nursing statements that accounted for the top 90% of all cumulative nursing narratives were used for analysis. The standardized number of nursing statements for each concept was calculated according to the types of nursing care and compared between the two groups. The most documented topics were related to infection; physical symptoms such as sputum, cough, dyspnea, and shivering; and vital signs including blood oxygen saturation and body temperature. Nurses in the intensive care units frequently documented concepts related to the directly monitored and assessed physical signs such as consciousness, pupil reflex, and skin integrity, whereas nurses in wards documented more concepts related to symptoms patients complained. This study showed that the International Classification for Nursing Practice-based nursing records can be used as source of information to identify nursing care for patients with coronavirus disease 19.
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Affiliation(s)
- Sumi Sung
- Author Affiliations: Office of Hospital Information (Dr Sung, and Ms Kim) and Biomedical Research Institute (Dr Sung), Seoul National University Hospital, Seoul; and, Department of Nursing, Inha University, Incheon (Dr Jung), Republic of Korea
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Nool I, Tupits M, Parm L, Hõrrak E, Ojasoo M. The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records. Int J Nurs Knowl 2023; 34:4-12. [PMID: 35343084 DOI: 10.1111/2047-3095.12363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/24/2022] [Indexed: 01/11/2023]
Abstract
AIM The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA-I nursing diagnoses training. METHODS Research employed the interventional study design, and pre-post study design. Before and after the NANDA-I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre-post study, using D-Catch instrument. RESULTS The most often documented problem-centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results' quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment. CONCLUSIONS The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased. IMPLICATIONS FOR NURSING PRACTICE Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.
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Affiliation(s)
- Irma Nool
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Mare Tupits
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Lily Parm
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Eha Hõrrak
- Junior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Merle Ojasoo
- Associate Professor at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
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Matlhaba KL, Nkoane NL. Understanding the learning needs to enhance clinical competence of new professional nurses in public hospitals of South Africa: A qualitative study. BELITUNG NURSING JOURNAL 2022; 8:414-421. [PMID: 37554484 PMCID: PMC10405665 DOI: 10.33546/bnj.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/16/2022] [Accepted: 08/01/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND A competent nursing workforce plays an important role, as it will ensure effective management of the healthcare system by providing quality nursing care. However, from the literature, it is evident that the learning needs of new professional nurses are not well explored and documented. OBJECTIVE The objective of this paper was to report identified learning needs of new professional nurses to enhance their clinical competence to ensure that they are able to provide excellent quality nursing care to patients with confidence. METHODS A qualitative study design was used to understand the perceptions of operational managers regarding the learning needs of new professional nurses to enhance their clinical competence. The study was conducted at seven public hospitals in the three districts of the North West Province, South Africa, between September and November 2021. Data were analyzed thematic. RESULTS Four themes emerged from data analysis: 1) Ethos and professional practice, 2) Management and leadership skills, 3) Assessment and observation skills, and 4) Documentation and record keeping. CONCLUSION This study provides valuable information regarding the learning needs of new professional nurses. Understanding these learning needs can provide insight into how to better transition student nurses to registered nurses so that they are able to adequately and safely take care of a diverse patient population and work successfully as new nurses.
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Affiliation(s)
| | - Naomi L. Nkoane
- Department of Health Studies, University of South Africa, South Africa
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Ojo IO, Olaogun AA. Challenges to sustainability of standardized nursing care plan in selected tertiary health institutions in Nigeria. Int J Nurs Knowl 2022. [PMID: 36205459 DOI: 10.1111/2047-3095.12394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to assess the challenges to sustainability of standardized nursing care plan in selected tertiary health institutions in Nigeria. METHODS Using convergent mixed method design, the qualitative and quantitative data were collected from 427 nurses and nine stakeholders. This was done in one phase with the use of validated questionnaires and in-depth interview guide/key informant interview guide. Data were collected for 5 months and analyzed with SPSS version 25. Qualitative data were analyzed using themes. RESULTS The explored significant challenges by stakeholders and nurses to sustainability of standardized nursing care plan (SNCP) in all the selected hospitals were inadequate knowledge of standardized nursing languages (SNLs), inadequate staffing, lack of motivation, lack of mandate to use SNLs by the educational system, lack of computers on the wards, weakness of previous training on SNL/SNCP, lack of interest, and high patient load. CONCLUSION The study concludes that inadequate knowledge of SNLs and inadequate staff could contribute to non sustainability of SNCP. IMPLICATIONS FOR NURSING PRACTICE Nurses should be continuously trained on standardized nursing languages. Staff motivation and increasing the number of staff on the wards would increase the interest of the nursing staff. This will in turn improve the quality of documentation and patient care.
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Affiliation(s)
| | - Adenike A Olaogun
- Department of Nursing Science, Obafemi Awolowo University, Ile Ife, Osun, Nigeria
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Ameyaw EK, Amoah RM, Njue C, Tran NT, Dawson A. Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study. BMC Health Serv Res 2022; 22:347. [PMID: 35296312 PMCID: PMC8925182 DOI: 10.1186/s12913-022-07760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Effective referral of maternity cases, which cannot be managed at the primary healthcare level, with detailed referral forms is important for reducing possible delays in the provision of higher-level healthcare. This is the first study to audit documentation or referral forms that accompany referred maternity cases to a referral hospital in the northern region of Ghana. Materials and methods This study employed an explanatory sequential mixed-method design, starting with a quantitative review of referral forms that accompanied all patients referred to four units (antenatal, antenatal emergency, labour and neonatal intensive care) of a referral hospital in northern Ghana. In-depth interviews were held with the heads of the four units afterwards. Descriptive statistics were computed for the quantitative data. The qualitative data was subjected to content analysis. Integration of the data occurred at the data interpretation/discussion level. Results A total of 217 referral forms were analysed. Nearly half of the cases were referred from the Tamale Metropolis (46.5%) and 83.9% were referred for advanced care, whilst 8.3% were referred due to a lack of medical logistics and equipment such as oxygen and skilled personnel (6%). Completion rates of the referral forms were as follows: < 50% completion (n = 81; 37.3%), 50–75% completion (n = 112; 51.6%) above 75% completion (n = 24; 11.1%). Some of the handwriting were not legible and were quite difficult to read. The key informants stated that incomplete forms sometimes delay treatment. The head of the antenatal care unit at the referral hospital suggested professional development sessions as a strategy for supporting clinicians to fill the forms as expected. Conclusion The Ghana Health Service should conduct regular audits, develop job aides and provide incentives for health professionals who accurately complete referral forms. Completing forms and digitizing health records can help ensure further efficiencies in the health information system and sustain good maternity referral documentation practices.
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Affiliation(s)
- Edward Kwabena Ameyaw
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - Roberta Mensima Amoah
- Department of Public Health, School of Allied Sciences, University for Development Studies, Tamale, Northern Region, Ghana
| | - Carolyne Njue
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Nguyen Toan Tran
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Angela Dawson
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Abstract
BACKGROUND Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored. AIM To explore ethical dilemmas in nurses' conversations about nursing documentation. RESEARCH DESIGN, PARTICIPANTS AND CONTEXT The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman. ETHICAL CONSIDERATION This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent. FINDINGS Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice. DISCUSSION Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records. CONCLUSION Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.
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Affiliation(s)
- Lone Jørgensen
- Aalborg University Hospital and Aalborg University, Denmark
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Munroe B, Curtis K, Fry M, Shaban RZ, Moules P, Elphick TL, Ruperto K, Couttie T, Considine J. Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study. J Clin Nurs 2021; 31:2874-2885. [PMID: 34791742 DOI: 10.1111/jocn.16115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/30/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. BACKGROUND Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. DESIGN A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. METHODS HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data. RESULTS The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. CONCLUSION Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. RELEVANCE TO CLINICAL PRACTICE The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.
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Affiliation(s)
- Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia
| | - Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia.,Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,George Institute for Global Health, University of NSW, Newtown, NSW, Australia.,Faculty of Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,University of Technology Sydney School of Nursing and Midwifery, Sydney, NSW, Australia.,Northern Sydney Local Health District, St Leonards, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia
| | - Ramon Z Shaban
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Camperdown, NSW, Australia.,Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
| | - Peter Moules
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tiana-Lee Elphick
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Research Central, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Kate Ruperto
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tracey Couttie
- Division of Kids and Families, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute of Health Transformation, Deakin University, Geelong, Vic., Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Vic., Australia
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Martin K, Ricciardelli R. A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation. Can J Nurs Res 2021; 54:134-143. [PMID: 34024163 DOI: 10.1177/08445621211018061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information. PURPOSE Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients. METHODS Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content. RESULTS Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context. CONCLUSIONS The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.
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Affiliation(s)
- Krystle Martin
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Faculties of Health Science and Social Science and Humanities, Ontario Tech University, Oshawa, ON, Canada
| | - Rosemary Ricciardelli
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Department of Sociology, Memorial University of Newfoundland, St. John's, NL, Canada
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Gusar I, Lazinica A, Klarin M. Work motivation, job satisfaction, and nursing record-keeping: do they differ in surgery and internal disease departments? CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2020. [DOI: 10.15452/cejnm.2020.11.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Kamil H, Rachmah R, Irvanizam I, Wardani E. <p>Exploring Health Professionals’ Perceptions on Health-ID, an Electronic Integrated Patient Progress Documentation System: A Qualitative Study in Indonesia</p>. J Multidiscip Healthc 2020; 13:1649-1656. [PMID: 33239885 PMCID: PMC7682598 DOI: 10.2147/jmdh.s270740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hajjul Kamil
- Nursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh23111, Indonesia
- Correspondence: Hajjul Kamil Email
| | - Rachmah Rachmah
- Nursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh23111, Indonesia
| | - Irvanizam Irvanizam
- Department of Informatics, Faculty of Mathematic and Nature Sciences, Universitas Syiah Kuala, Banda Aceh23111, Indonesia
| | - Elly Wardani
- Nursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh23111, Indonesia
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Martin K, Ricciardelli R, Dror I. How forensic mental health nurses' perspectives of their patients can bias healthcare: A qualitative review of nursing documentation. J Clin Nurs 2020; 29:2482-2494. [PMID: 32242997 DOI: 10.1111/jocn.15264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/12/2020] [Accepted: 03/12/2020] [Indexed: 01/05/2023]
Abstract
AIMS AND OBJECTIVES Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases. BACKGROUND Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals. DESIGN This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis. METHODS We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014. RESULTS The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients. CONCLUSIONS When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals. RELEVANCE TO CLINICAL PRACTICE Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.
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Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Ontario Tech University, Oshawa, Ontario, Canada
| | - Rosemary Ricciardelli
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Itiel Dror
- University College London (UCL), London, UK
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