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.
Akhu-ZaheyaL.Al-MaaitahR.HaniS. B. (2018).
Quality of nursing documentation: Paper-based health records versus electronic-based health records. Journal of Clinical Nursing,
27(3–4), e578–e89. https://doi.org/10.1111/jocn.14097
2.
BerghA. L.BerghC. H.FribergF. (2007).
How do nurses record pedagogical activities? Nurses' documentation in patient records in a cardiac rehabilitation unit for patients who have undergone coronary artery bypass surgery. Journal of Clinical Nursing,
16(10), 1898–1907. https://doi.org/10.1111/j.1365-2702.2007.01810.x
CheevakasemsookA.ChapmanY.FrancisK.DaviesC. (2006).
The study of nursing documentation complexities. International Journal of Nursing Practice,
12(6), 366–374. https://doi.org/10.1111/j.1440-172X.2006.00596.x
9.
College of Nurses of Ontario. (2014). Entry-to-practice competencies for registered nurses. Pub. No. 41037.
10.
College of Nurses of Ontario. (2019). Code of Conduct. Pub. No. 49040.
11.
DickensG.PiccirilloM.AldermanN. (2013).
Causes and management of aggression and violence in a forensic mental health service: Perspectives of nurses and patients. International Journal of Mental Health Nursing,
22(6), 532–544. https://doi.org/10.1111/j.1447-0349.2012.00888.x
12.
DrorI. E. (2018).
Biases in forensic experts. Science,
360(6386), 243.
13.
GlaserB. G.StraussA. L. (1967). The discovery of grounded theory: Strategies for qualitative research.
Aldine Publishing Company.
14.
GunhardssonI.SvenssonA.BerteröC. (2008).
Documentation in palliative care: Nursing documentation in a palliative care unit—A pilot study. American Journal of Hospice and Palliative Medicine,
25(1), 45–51. https://doi.org/10.1177/1049909107307381
15.
HegartyM.HammondL.ParishK.GlaetzerK.McHughA.GrbichC. (2005).
Nursing documentation: Non-physical dimensions of end-of-life care in acute wards. International Journal of Palliative Nursing,
11(12), 632–636. https://doi.org/10.12968/ijpn.2005.11.12.20230
16.
HörbergU. (2018).
The art of understanding in forensic psychiatric care—From a caring science perspective based on a lifeworld approach. Issues in Mental Health Nursing,
39(9), 802–809. https://doi.org/10.1080/01612840.2018.1496499
17.
InstefjordM. H.AasekjærK.EspehaugB.GraverholtB. (2014).
Assessment of quality in psychiatric nursing documentation—A clinical audit. BMC Nursing,
13(1), 32. http://www.biomedcentral.com/1472-6955/13/32
18.
JefferiesD.JohnsonM.GriffithsR. (2010).
A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice,
16(2), 112–124. https://doi.org/10.1111/j.1440-172X.2009.01815.x
19.
JohnsonM.JefferiesD.LangdonR. (2010).
The nursing and midwifery content audit tool (NMCAT): A short nursing documentation audit tool. Journal of Nursing Management,
18(7), 832–845. https://doi.org/10.1111/j.1365-2834.2010.01156.x
20.
KamilH.RachmahR.WardaniE. (2018).
What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences,
9, 111–114.
21.
KärkkäinenO.BondasT.ErikssonK. (2005).
Documentation of individualized patient care: A qualitative meta-synthesis. Nursing Ethics,
12(2), 123–132. https://doi.org/10.1191/0969733005ne769oa
22.
KelleyT.DochertyS.BrandonD. (2013).
Information needed to support knowing the patient. Advances in Nursing Science,
36(4), 351–363. https://doi.org/10.1097/ANS.0000000000000006
23.
MacArthurJ. (2016).
Review: ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care?Journal of Research in Nursing,
21(8), 649–650.
24.
MarinisM. G. D.PireddaM.PascarellaM. C.VincenziB.SpigaF.TartagliniD., Alvaro R., & MatareseM. (2010).
If it is not recorded, it has not been done!’? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing,
19(11–12), 1544–1552. https://doi.org/10.1111/j.1365-2702.2009.03012.x
25.
MartinK.HamE.HiltonN. Z. (2018a).
Staff and patient accounts of PRN administration for anxiety. International Journal of Mental Health Nursing,
27(6), 1834–1841. https://doi.org/10.1111/inm.12492
26.
MartinK.HamE.HiltonN. Z. (2018b).
Documentation of psychotropic PRN medication administration: An evaluation of electronic health records compared with paper charts and verbal reports. Journal of Clinical Nursing,
27(15–16), 3171–3178. https://doi.org/10.1111/jocn.14511
27.
MartinK.RicciardelliR.DrorI. (2020).
How forensic mental health nurses’ perspectives of their patients can bias healthcare. Journal of Clinical Nursing,
29(13–14), 2482–2494. https://doi.org/10.1111/jocn.15264
28.
MillerP.PastorinoC. (1990).
Daily nursing documentation can be quick and thorough. Nursing Management,
21(11), 47–49.
29.
Müller-StaubM.NeedhamI.OdenbreitM.Ann LavinM.Van AchterbergT. (2007).
Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications,
18, 5–17https://doi.org/10.1111/j.1744-618X.2007.00043.x
30.
MyklebustK.BjørklyS. (2019).
The quality and quantity of staff-patient interactions as recorded by staff. A registry study of nursing documentation in two inpatient mental health wards. BMC Psychiatry,
19(1), 251–212. https://doi.org/10.1186/s12888-019-2236-y
PaansW.SermeusW.NiewegR.van der SchansC. P. (2010).
D-Catch instrument: Development and psychometric testing of a measurement instrument for nursing documentation in hospitals. Journal of Advanced Nursing,
66(6), 1388–1400. https://doi.org/10.1111/j.1365-2648.2010.05302.x
ShoqiratN.MahasnehD.DardasL.SinghC.KhreshehR. (2019).
Nursing documentation of postoperative pain management: A documentary analysis. Journal of Nursing Care Quality,
34(3), 279–284. doi:10.1097/NCQ.0000000000000372
36.
StevensS.PickeringD. (2010).
Keeping good nursing records: A guide. Community Eye Health,
23(74), 44–45.
37.
StraussA. L.CorbinJ. (1990). Basics of qualitative research: Techniques and procedures for developing grounded theory.
SAGE Publishing Ltd.
38.
WangN.YuP.HaileyD. (2015).
The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study. International Journal of Medical Informatics,
84(8), 561–569.
39.
WilkinsonJ. M. (2007). Nursing process and critical thinking (4th ed.).
Pearson Prentice Hall.
