Helsinki University Hospital, Helsinki, Finland.
Department of Nursing Science, University of Turku, Turku, Finland.
J Clin Nurs. 2020 Sep;29(17-18):3435-3444. doi: 10.1111/jocn.15382. Epub 2020 Jun 28.
To identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting.
Documentation is an important part of nurses' work, and in the psychiatric outpatient care setting, it can be time-consuming. Only very few research reports are available on nursing documentation in this care setting.
A qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016-2017). The data consisted of 1,150 free-text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting.
We identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of overlapping interventions and the difficulty of naming group-based interventions.
There is an urgent need to improve patient documentation in the adult psychiatric outpatient care setting, and standardised nursing terminologies such as the Nursing Interventions Classification could be a solution to this. However, the problems of overlapping interventions and naming group-based interventions suggest that the classification needs to be further developed before it can fully support the systematic documentation of nursing interventions in the psychiatric outpatient care setting.
This study describes possibilities of using a systematic nursing language to describe the interventions nurses use in the adult psychiatric outpatient setting. It also describes problems in the current free text-based documentation.
识别和描述成人精神科门诊环境中的患者文档中的护理干预措施，并探讨在该环境中使用护理干预分类进行文档记录的潜力。
文档记录是护士工作的重要组成部分，在精神科门诊护理环境中，这可能会很耗时。关于该护理环境中的护理文档记录，仅有极少数的研究报告。
对包含 79 名患者（2016-2017 年四个门诊科室）的护理文档进行二次数据分析，采用定性分析方法。这些数据包括 1150 个描述与 79 名患者、其家属或支持网络及其 17 份护理护理总结的接触或尝试接触的自由文本条目。使用演绎和归纳内容分析法。采用 SRQR 指南进行报告。
我们确定了 71 种不同的护理干预措施，其中 64 种在护理干预分类中有所描述。监测和护理协调是最常见的干预措施。分析揭示了两个挑战分类使用的观点：干预措施重叠的问题和基于群体的干预措施命名的困难。
成人精神科门诊护理环境中急需改进患者文档记录，标准化的护理术语，如护理干预分类，可以解决这个问题。然而，干预措施重叠和基于群体的干预措施命名的问题表明，在分类能够充分支持精神科门诊护理环境中护理干预的系统文档记录之前，需要对其进行进一步开发。
本研究描述了使用系统护理语言描述护士在成人精神科门诊环境中使用的干预措施的可能性。它还描述了当前基于自由文本的文档记录中的问题。
