How forensic mental health nurses' perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

Factors influencing decent work among psychiatric nurses in China: a cross-sectional study

AIMS

This study aimed to investigate the current status of decent work among psychiatric nurses and analyze its influencing factors.

METHODS

In February 2024, a cross-sectional study was conducted with a cluster sample of 358 nurses from a tertiary Grade A psychiatric hospital in Hangzhou, Zhejiang Province, China. Data were collected using a custom-made nurse demographic scale to gather demographic information. The Effort-Reward Imbalance Questionnaire (ERIQ) was used to assess the imbalance between effort and reward through the effort-reward ratio (ERR). The Social Support Rating Scale (SSRS) measured subjective support, objective support, and support utilization. The Decent Work Perception Scale (DWPS) was used to evaluate nurses' perceptions of decent work. T-tests, one-way ANOVA, Pearson's correlation analysis, and multiple linear regression analyses were employed for data analysis.

RESULTS

The study found that the correlation between decent work and social support was positive (r = 0.360, p < 0.001), while it was negative for effort-reward imbalance (r = -0.584, p < 0.001). Factors influencing perceptions of decent work included years of work experience (β = -0.164, p = 0.046 for < 5 years; β = -0.157, p = 0.040 for > 25 years), social support (β = 0.259, p < 0.001), and the effort-reward imbalance (β=-0.458, p < 0.001). These factors collectively explained 40.2% of the variance in perceptions of decent work. Furthermore, social support plays a mediating role between effort-reward imbalance and decent work (β=-0.062, Bootstrap 95% CI: -0.107, -0.023).

CONCLUSION

The findings suggest that years of work experience, social support, and the effort-reward imbalance are factors influencing decent work among psychiatric nurses. By offering career development opportunities, fostering supportive work environments, and ensuring fair compensation, we can empower psychiatric nurses to navigate job challenges effectively and sustain a sense of decency in their work.

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

This integrative review explores the current pro re nata (PRN) medication practice in acute adult mental health settings. PRN medication is commonly used in acute mental health settings but there is lack of evidence of effectiveness of this practice. PRN medications have a number of adverse effects and increase the risk of morbidity in patients with a mental illness. Articles were identified from MEDLINE, CINAHL, Scopus, PubMed, PsycINFO, and Web of Science database. The STROBE critical appraisal tool was used to evaluate the quality of evidence, and inductive thematic analysis was used to extract main themes. Five themes regarding prescription practices, poor documentation, reasons to administer, medication misuse, and insufficient use of non-pharmacological interventions emerged among the 12 eligible articles. The study identified PRN medication practice gaps in adult mental health settings included insufficient documentation practice, underuse of therapeutic non-pharmacological interventions, and significant variability in PRN medication practice across the mental health professionals due to different levels of knowledge and experience.

Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement

The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.

Exploration of note writing by mental health nurses using a video scenario

AIMS AND OBJECTIONS

We aimed to explore the content and language of nursing documentation and gain insight into the internal processes of nurses while notetaking.

BACKGROUND

Documentation is a core competency of mental health nursing, has clinical and ethical importance and is the integral to the efficient and effective care provided to patients. However, issues related to the content and quality of nursing notes continues to be a concern and there remains gaps in our understanding about the internal processes that nurses engage in when writing notes.

DESIGN

We used a mixed method design that included a content analysis with note review and interviews.

METHODS

After watching a video, psychiatric nurses (n = 27) wrote a note and then were interviewed about their note taking process. We used the COREQ guidelines for reporting our data.

RESULTS

Participants relied on four main themes when determining what to include in their notes-what happened and what the patient said or did, plus anything different than baseline, and safety concerns. Analyses revealed the presence of bias in the notetaking and participants were not familiar with effective strategies to mitigate these during the documentation process. Lastly, we found that notes are typically consistent in using some of the SOAPE format with notes focused on direct observations and the use of 'facts', while assessment and construction of treatment plans are used to a lesser extent.

CONCLUSIONS

Our results provide insight into the decision-making process of nursing staff regarding their documentation practices: overall they appear unaware of the importance of their notes, and believe that capturing the facts about their patients is important, while devaluing their own input and interpretations.

RELEVANCE TO CLINICAL PRACTICE

Our results provide evidence that mental health nurses may need additional training regarding documentation, more specifically about what to include, word choice and bias.

"Walking Together Towards Freedom." Patients' Lived Experiences of Participation in Outpatient Forensic Care

There is a general agreement regarding the significance of patient participation in care. In forensic psychiatric care, however, this appears to be troublesome because of the paradoxical nature of having responsibility; to give person-centered, recovery-oriented psychiatric care and to protect society from potentially dangerous individuals. The aim of this study was to describe patients' lived experiences of participation in outpatient forensic psychiatric care. Data were collected by means of individual interviews with five patients. The phenomenological hermeneutical analysis shed light on patient participation as having two dimensions. The outer dimension focuses on participation as "doing" and as a means of developing the understanding and skills necessary for being discharged from forensic care, while the inner dimension is related to "being" and experiences of acceptance and inclusion in communion with other people. This emphasises the importance of supporting patients' experiences of being involved in everyday life together with others, even in periods when patients' possibilities to affect decisions regarding their care are limited.

A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation

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.

Digital Technologies and Coercion in Psychiatry

Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.