The quality and quantity of staff-patient interactions as recorded by staff. A registry study of nursing documentation in two inpatient mental health wards

Facilitating a safe and caring atmosphere in everyday life in forensic mental health wards - a qualitative study

PURPOSE

To explore healthcare professionals' experiences with facilitating a safe and caring atmosphere in patients' everyday lives in forensic mental health wards.

METHODS

This qualitative study employed interviews with 16 healthcare professionals working shifts in two forensic mental healthcare wards in Norway. Data were analysed using phenomenological hermeneutic analysis.

RESULTS

The findings are presented in terms of two themes. The first theme is "Creating a calming atmosphere" and includes the subthemes "Creating caring surroundings with safety, comfort and trust" and "Balancing everyday life activities". The second theme is "Facilitating risk assessments and care" and includes the subthemes "Acting as a team", "Becoming aware of the meaning in signs" and "Becoming aware of vulnerability and the window of tolerance".

CONCLUSIONS

Involvement in patients' history and lived lives is important both for understanding general social behaviour as well as for assessing signs, symptoms, and changes in patients' conditions; furthermore, it provides valuable information that allows healthcare professionals to become aware of the underlying meanings in signs, which can facilitate examinations and treatment. Acting as a team is essential to solve issues in a calm and safe way when signs of violence occur. In addition, our participants highlighted the need to be aware of individual patients' vulnerability and windows of tolerance to obtain a deeper understanding of patients' lived lives as a whole in the context of providing therapy and care to patients.

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study

AIM

Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions.

BACKGROUND

Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed.

METHODOLOGY/APPROACH

A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity.

RESULTS

The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery.

CONCLUSION

The guidance developed has face and content validity.

Patient-reported outcomes of the nurse-patient relationship in psychiatric inpatient hospitals: A multicentred descriptive cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric and/or mental health nurses are struggling to measure the outcomes of the nurse-patient relationship. Collecting nurse-sensitive patient outcomes is a strategy to provide outcomes of a nurse-patient relationship from patients' perspectives. Because there was no validated scale, the Mental Health Nurse-Sensitive Patient Outcome-Scale (six-point Likert-scale) was recently developed and psychometrically evaluated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study using the Mental Health Nurse-Sensitive Patient Outcome-scale to measure nurse-sensitive patient outcomes of the nurse-patient relationship in psychiatric hospitals. Moderate to good average scores for the MH-NURSE-POS total (4.42) and domains scores (≥4.09). are observed. Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60). Our results are consistent with the patient-reported effect(s) of relation-based nursing in qualitative research. The scores generate evidence to support the outcomes of the nurse-patient relationship and implicates that further investment in (re)defining and elaborating nurse-patient relationships in mental healthcare is meaningful and justified. More comparative patient-reported data can determine how nurse-sensitive patient outcomes are affected by the patient, nurse, and context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Demonstrating patient-reported outcomes of the nurse-patient relationship can be important to enhance the therapeutic alliance between nurses and patients, organize responsive nursing care, and create nursing visibility in mental healthcare. Further nursing staff training on interpersonal competencies, such as self-awareness and cultural sensitivity, can be pivotal to achieving the patient-reported outcomes for inpatients with mental health problems.

ABSTRACT

INTRODUCTION: Identifying patient-reported outcomes of the nurse-patient relationship is a priority in inpatient mental healthcare to guide clinical decision-making and quality improvement initiatives. Moreover, demonstrating nurse-sensitive patient outcomes can be a strategy to avoid further erosion of the specialism of psychiatric and/or mental health nursing.

AIM/QUESTION

To measure nurse-sensitive patient outcomes of the nurse-patient relationship.

METHOD

In a multicentred cross-sectional study, 296 inpatients admitted to five psychiatric hospitals completed the recently developed and validated Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS). The MH-NURSE-POS consists of 21 items (six-point Likert-scale) in four domains: 'growth', 'expression', 'control', and 'motivation'.

RESULTS

Participants displayed moderate to good average scores for the MH-NURSE-POS total (4.42) and domain scores (≥4.09). Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60).

DISCUSSION

The results demonstrate that patients perceive the nurse-patient relationship and the care given by psychiatric and/or mental health nurses as contributing to their treatment.

IMPLICATIONS FOR PRACTICES

Patient-reported outcomes can guide nurses and managers to provide and organize nursing care and to build a nurse-patient relationship that has a positive impact on these outcomes. Additionally, outcomes can create nursing visibility as a profession in- and outside mental healthcare.

Transcultural adaptation and assessment of psychometric properties of the Spanish version of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes

PURPOSE

To adapt the Scale for the Evaluation of Staff Patient Interactions in Progress Notes to Spanish and to test the psychometric properties.

DESIGN AND METHODS

The study was conducted in two phases: (1) Adaptation of the instrument to Spanish following the Standards for Educational and Psychological Testing. (2) Psychometric study in a sample of mental health nurses.

FINDINGS

The Cronbach's alpha values were 0.97 for the total scale and 0.83 to 0.81 for each dimension. The inter-rater reliability values were between 0.94 and 0.97.

PRACTICE IMPLICATIONS

The scale is a reliable tool for assessing nurses' clinical notes in relation to the quality of nurse-patient interactions.

Delineating Quality Indicators of Inpatient Psychiatric Hospitalization

BACKGROUND

Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist.

AIMS

To isolate and describe quality elements of inpatient psychiatric treatment.

METHODS

A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units.

RESULTS

Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience.

CONCLUSIONS

The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

Prevalence, associated factors and adverse outcomes of workplace violence towards nurses in psychiatric settings: A systematic review

Workplace violence towards psychiatric nurses by psychiatric patients is common, which can potentially affect care quality as well as nurses' health. This study aimed to synthesize the literature on workplace violence towards psychiatric nurses and identify the prevalence and factors influencing workplace violence and related outcomes. PubMed, Cochrane Library, CINAHL, EMBASE and PsychINFO were searched for English articles on workplace violence against psychiatric nurses published from January 2011 to December 2020. Sixteen articles were selected for the systematic review. This was followed by quality assessment and data extraction. The workplace violence prevalence ranged 11.4-97.6%. Diagnosis of the patient; nurse-related factors such as age, sex, marital status, education, emotional intelligence level and personality; and work shift were associated with the occurrence of workplace violence. Psychiatric nurses who experienced workplace violence had primarily poor mental health such as depressive symptoms and negative work-related outcomes such as turnover intention. The results revealed that there were relatively few patient-related factors associated with workplace violence and few reports on workplace violence-related to nurses' physical health, suggesting the need for a multi-dimensional approach. Future studies are needed to develop standardized instruments for workplace violence investigation considering inpatients psychiatric settings. Effective workplace violence prevention strategies should consider comprehensive patient-, nurse- and occupation-related factors.

Measuring text similarity and its associated factors in electronic nursing progress notes: A retrospective review

AIMS AND OBJECTIVES

To measure text similarity in electronic nursing progress notes and determine factors associated with text similarity.

BACKGROUND

Electronic clinical notes with redundant information masks clinically relevant information, increases clinicians' cognitive burden and undermines patient safety.

DESIGN

Retrospective review of electronic medical record nursing progress notes.

METHODS

The study was conducted between November 2018 and February 2019 in two Australian Paediatric Intensive Care Units. De-identified, randomly selected inpatient data were extracted from the network's database. Manually classified shift summary progress notes for each admission were sequenced from admission to discharge. Text similarity was calculated for consecutive pairs of nursing progress notes. Linear regression was undertaken to determine the association between the similarity scores and variables of interest: note word count, total number of notes and unit. The STROBE checklist was used for reporting.

RESULTS

921 shift summary nursing progress notes were analysed. Similarity scores were widely distributed with a median of 10.37%. Only 17.2% (n = 144) of the notes have similarity scores above 20%. Of these, 5% (n = 47) were above 50% similar in comparison with a previously written note. Similarity above 50% was observed as early as the first note pair in the course of a patient's admission. A significant difference was found between the similarity scores of Unit 1 and Unit 2. Hospital unit was the only variable of interest significantly associated with similarity scores.

CONCLUSION

Text similarity among electronic nursing progress notes in Australian Paediatric ICUs is minimal; however, notes with >50% similarity have been identified. Text analytics provides measurable data and insights about electronic clinical documentation to inform future nursing practice, research and eMR design.

RELEVANCE TO CLINICAL PRACTICE

Findings have implications for nursing practice in the way that nursing staff are educated to maintain data quality, professional accountability and effective communication in electronic documentation and to avoid unnecessary repetition of text.

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.

An analysis of documentation language and word choice among forensic mental health nurses

Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n = 55), we explored the adjectives and verbs used across a subsection of their documentation over a three-month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight - or valence - of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias.

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

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.

Controlling emotions-nurses' lived experiences caring for patients in forensic psychiatry

Purpose: Nurses working in forensic psychiatry often encounter offenders who have a severe mental illness, which may cause ethical challenges and influence nurses' daily work. This study was conducted to illuminate the meaning of nurses' lived experiences of encounters with patients with mental illnesses in forensic inpatient care. Methods: This qualitative study employed narrative interviews with 13 nurses. Interviews were audiotaped and transcribed verbatim and analysed following a phenomenological-hermeneutic approach. Results: Four key themes were revealed: "Being frustrated" (subthemes included "Fighting resignation" and "Being disappointed"), "Protecting oneself" (subthemes included "To shy away," "Being on your guard," and "Being disclosed"), "Being open-minded" (subthemes included "Being confirmed," "Developing trust," and "Developing compassion"), and "Striving for control" (subthemes included "Sensing mutual vulnerability" and "Regulating oneself"). Further, working in forensic psychiatry challenged nurses' identity as healthcare professionals because of being in a stressful context. Conclusions: Dealing with aggressive patients with severe mental illnesses threatens nurses' professional identity. Nurses must attempt to empathize with patients' experiences and respond accordingly. Utilizing strategies rooted in compassion such as self-reflection, emotional regulation, and distancing themselves when necessary may enable nurses to more effectively respond to patients' needs.