Engen Eli Johanne Haugan, Devik Siri Andreassen, Olsen Rose Mari
Nord Trøndelag Health Trust, Namsos Hospital, Namsos, Norway.
Nord University, Namsos, Norway.
Glob Qual Nurs Res. 2020 Oct 15;7:2333393620960076. doi: 10.1177/2333393620960076. eCollection 2020 Jan-Dec.
Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.
护理记录一再被报告为不充分且不尽人意。尽管护士应采用整体护理方法,但他们往往更多地记录身体需求,而不是其他护理方面。本研究旨在描述护士在为接受长期护理的老年患者记录心理健康状况时的经历。对九名护士进行了个人访谈,并通过内容分析法进行分析。出现了一个主要主题、两个类别和七个子类别。研究结果表明,护士认为心理健康是一种模糊的现象,可能难以观察、解释和达成共识。因此,护士不确定哪些概念和词汇与他们的观察结果相对应。他们还难以找到合适的词汇来创建准确完整的记录,同时又不违反保密原则或损害患者的尊严。这些研究结果对不同类型医疗服务中的护士以及教育环境具有重要意义,以确保全面的护理记录。