The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units
Aims. (i) To evaluate the scope and quality of nurse-patient interactions recorded in the clinical notes of inpatient mental health units and (ii) to identify nursing interventions recorded in the context of the nurse-patient relationship in the clinical notes of inpatient mental health units. Desig...
| Autores: | , , , , , , , , , , , |
|---|---|
| Tipo de recurso: | artículo |
| Estado: | Versión publicada |
| Fecha de publicación: | 2024 |
| País: | España |
| Institución: | Varias* (Consorci de Biblioteques Universitáries de Catalunya, Centre de Serveis Científics i Acadèmics de Catalunya) |
| Repositorio: | Recercat. Dipósit de la Recerca de Catalunya |
| OAI Identifier: | oai:recercat.cat:2445/219790 |
| Acceso en línea: | https://hdl.handle.net/2445/219790 |
| Access Level: | acceso abierto |
| Palabra clave: | Relacions infermera-pacient Equipaments de salut mental Presa d'apunts Nurse-patient relationships Mental health facilities Note-taking |
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The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health unitsPérez Toribio, AlonsoMoreno Poyato, Antonio RafaelLluch Canut, Ma. TeresaEl Abidi El Ghazouani, KhadijaRubia-Ruiz, GemmaRodríguez-López, Ana MaríaPérez-Moreno, Juan J.Pastor-Bernabeu, Marcelino VicenteSanchez-Balcells, SaraVentosa-Ruiz, AnaPuig Llobet, MontserratRoldán Merino, Juan FranciscoRelacions infermera-pacientEquipaments de salut mentalPresa d'apuntsNurse-patient relationshipsMental health facilitiesNote-takingAims. (i) To evaluate the scope and quality of nurse-patient interactions recorded in the clinical notes of inpatient mental health units and (ii) to identify nursing interventions recorded in the context of the nurse-patient relationship in the clinical notes of inpatient mental health units. Design. A multimethod approach was use. Methods. Employing a quantitative cross-sectional design for the first aim, and a qualitative content analysis design of secondary data for the second aim. In total, 1,714 clinical notes were examined from 44 randomly selected patients who were hospitalized in five mental health units over the years 2022-2023. Results. The patient’s experience of the interaction was present in 69.9% (n = 1,198) of the notes. However, only 12.0% (n = 205) of the notes reached a sufficient standard of quality in terms of describing the nurse-patient interactions. Specifically, more than half of the notes did not reflect any type of nursing intervention (n = 723; 60.4%). Thirty interventions compatible with the nursing intervention classification were identified, of which more than 70% corresponded to domains in the physiological area. Conclusion. This study shows that the quantity and scope of patients’ clinical notes in mental health units do not sufficiently reflect the interventions performed by nurses, nor the quality or impact of these interventions in the context of the nurse-patient therapeutic relationship. Implications for the Profession and/or Patient Care. Improving the quality of clinical notes by integrating interventions and their impact can increase the quality of nursing care. Impact. The use of standardized nursing terminologies would contribute to the understanding of the extent and quality of nurse-patient interactions recorded in clinical notes. Thus, standardized documentation would also help to improve these interactions and their recording, which will facilitate decision-making. Reporting Method. Findings were reported using COREQ and STROBE guidelines. Patient or Public Contributions. There were no patient or public contributions.John Wiley & Sons2025202520242025info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersion8 p.application/pdfhttps://hdl.handle.net/2445/219790Articles publicats en revistes (Infermeria de Salut Pública, Salut mental i Maternoinfantil)reponame:Recercat. Dipósit de la Recerca de Catalunyainstname:Varias* (Consorci de Biblioteques Universitáries de Catalunya, Centre de Serveis Científics i Acadèmics de Catalunya)InglésReproducció del document publicat a: https://doi.org/10.1155/2024/7392388Journal of Nursing Management, 2024https://doi.org/10.1155/2024/7392388cc by (c) Pérez Toribio, Alonso et al., 2024https://creativecommons.org/licenses/by/4.0/info:eu-repo/semantics/openAccessoai:recercat.cat:2445/2197902026-05-29T05:05:01Z |
| dc.title.none.fl_str_mv |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| title |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| spellingShingle |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units Pérez Toribio, Alonso Relacions infermera-pacient Equipaments de salut mental Presa d'apunts Nurse-patient relationships Mental health facilities Note-taking |
| title_short |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| title_full |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| title_fullStr |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| title_full_unstemmed |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| title_sort |
The nurse-patient relationship in nursing documentation: the scope and quality of interactions and prevalent interventions in inpatient mental health units |
| dc.creator.none.fl_str_mv |
Pérez Toribio, Alonso Moreno Poyato, Antonio Rafael Lluch Canut, Ma. Teresa El Abidi El Ghazouani, Khadija Rubia-Ruiz, Gemma Rodríguez-López, Ana María Pérez-Moreno, Juan J. Pastor-Bernabeu, Marcelino Vicente Sanchez-Balcells, Sara Ventosa-Ruiz, Ana Puig Llobet, Montserrat Roldán Merino, Juan Francisco |
| author |
Pérez Toribio, Alonso |
| author_facet |
Pérez Toribio, Alonso Moreno Poyato, Antonio Rafael Lluch Canut, Ma. Teresa El Abidi El Ghazouani, Khadija Rubia-Ruiz, Gemma Rodríguez-López, Ana María Pérez-Moreno, Juan J. Pastor-Bernabeu, Marcelino Vicente Sanchez-Balcells, Sara Ventosa-Ruiz, Ana Puig Llobet, Montserrat Roldán Merino, Juan Francisco |
| author_role |
author |
| author2 |
Moreno Poyato, Antonio Rafael Lluch Canut, Ma. Teresa El Abidi El Ghazouani, Khadija Rubia-Ruiz, Gemma Rodríguez-López, Ana María Pérez-Moreno, Juan J. Pastor-Bernabeu, Marcelino Vicente Sanchez-Balcells, Sara Ventosa-Ruiz, Ana Puig Llobet, Montserrat Roldán Merino, Juan Francisco |
| author2_role |
author author author author author author author author author author author |
| dc.subject.none.fl_str_mv |
Relacions infermera-pacient Equipaments de salut mental Presa d'apunts Nurse-patient relationships Mental health facilities Note-taking |
| topic |
Relacions infermera-pacient Equipaments de salut mental Presa d'apunts Nurse-patient relationships Mental health facilities Note-taking |
| description |
Aims. (i) To evaluate the scope and quality of nurse-patient interactions recorded in the clinical notes of inpatient mental health units and (ii) to identify nursing interventions recorded in the context of the nurse-patient relationship in the clinical notes of inpatient mental health units. Design. A multimethod approach was use. Methods. Employing a quantitative cross-sectional design for the first aim, and a qualitative content analysis design of secondary data for the second aim. In total, 1,714 clinical notes were examined from 44 randomly selected patients who were hospitalized in five mental health units over the years 2022-2023. Results. The patient’s experience of the interaction was present in 69.9% (n = 1,198) of the notes. However, only 12.0% (n = 205) of the notes reached a sufficient standard of quality in terms of describing the nurse-patient interactions. Specifically, more than half of the notes did not reflect any type of nursing intervention (n = 723; 60.4%). Thirty interventions compatible with the nursing intervention classification were identified, of which more than 70% corresponded to domains in the physiological area. Conclusion. This study shows that the quantity and scope of patients’ clinical notes in mental health units do not sufficiently reflect the interventions performed by nurses, nor the quality or impact of these interventions in the context of the nurse-patient therapeutic relationship. Implications for the Profession and/or Patient Care. Improving the quality of clinical notes by integrating interventions and their impact can increase the quality of nursing care. Impact. The use of standardized nursing terminologies would contribute to the understanding of the extent and quality of nurse-patient interactions recorded in clinical notes. Thus, standardized documentation would also help to improve these interactions and their recording, which will facilitate decision-making. Reporting Method. Findings were reported using COREQ and STROBE guidelines. Patient or Public Contributions. There were no patient or public contributions. |
| publishDate |
2024 |
| dc.date.none.fl_str_mv |
2024 2025 2025 2025 |
| dc.type.none.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
| format |
article |
| status_str |
publishedVersion |
| dc.identifier.none.fl_str_mv |
https://hdl.handle.net/2445/219790 |
| url |
https://hdl.handle.net/2445/219790 |
| dc.language.none.fl_str_mv |
Inglés |
| language_invalid_str_mv |
Inglés |
| dc.relation.none.fl_str_mv |
Reproducció del document publicat a: https://doi.org/10.1155/2024/7392388 Journal of Nursing Management, 2024 https://doi.org/10.1155/2024/7392388 |
| dc.rights.none.fl_str_mv |
cc by (c) Pérez Toribio, Alonso et al., 2024 https://creativecommons.org/licenses/by/4.0/ info:eu-repo/semantics/openAccess |
| rights_invalid_str_mv |
cc by (c) Pérez Toribio, Alonso et al., 2024 https://creativecommons.org/licenses/by/4.0/ |
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openAccess |
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8 p. application/pdf |
| dc.publisher.none.fl_str_mv |
John Wiley & Sons |
| publisher.none.fl_str_mv |
John Wiley & Sons |
| dc.source.none.fl_str_mv |
Articles publicats en revistes (Infermeria de Salut Pública, Salut mental i Maternoinfantil) reponame:Recercat. Dipósit de la Recerca de Catalunya instname:Varias* (Consorci de Biblioteques Universitáries de Catalunya, Centre de Serveis Científics i Acadèmics de Catalunya) |
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Varias* (Consorci de Biblioteques Universitáries de Catalunya, Centre de Serveis Científics i Acadèmics de Catalunya) |
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Recercat. Dipósit de la Recerca de Catalunya |
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Recercat. Dipósit de la Recerca de Catalunya |
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