De Groot Kim, Sneep Elisah B, Paans Wolter, Francke Anneke L
Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR, Utrecht, The Netherlands.
Nursing Science, Programme in Clinical Health Sciences, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
BMC Nurs. 2021 May 1;20(1):72. doi: 10.1186/s12912-021-00590-7.
Patient participation in nursing documentation has several benefits like including patients' personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses' experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation.
A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection-data analysis-more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting.
Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients' trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient's home. Nurses still tried to achieve patient participation by verbally discussing patients' views on the nursing care provided and then documenting those views at a later moment.
Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.
患者参与护理记录有诸多益处，比如将患者个人意愿纳入个性化护理计划以及促进共同决策。然而，电子健康记录的兴起未必会自动促使患者更多地参与护理记录。本研究旨在深入了解社区护士在患者参与电子护理记录方面的经验，探讨护士面临的挑战以及他们应对患者参与电子护理记录相关挑战所采用的策略。
采用基于反思性主题分析原则的定性描述性设计。通过目的抽样法招募了19名在家访护理中使用电子健康记录的社区护士。2019年，依据访谈指南，通过面对面或电话方式进行访谈。在数据收集 - 数据分析 - 更多数据收集的迭代过程中进行归纳分析，直至达到数据饱和。遵循主题分析的步骤，即熟悉数据、生成初始编码、寻找主题、审查主题、定义和命名主题以及报告。
社区护士认为患者参与护理记录必须因人而异。实际参与情况取决于所记录的护理过程阶段，并且患者对记录准确性的信任有助于参与。护士在三个领域遇到挑战：与电子健康记录相关的（即技术问题）、工作方面的（如时间压力）以及患者方面的（如病情）。由于这些挑战，护士经常在患者家外进行记录。护士仍试图通过口头讨论患者对所提供护理的看法，然后在稍后记录这些看法来实现患者参与。
尽管社区护士认为患者参与电子护理记录很重要，但他们意识到在实现患者参与方面存在与电子健康记录、工作和患者相关的各种挑战。在应对这些挑战时，护士常常依赖于关于记录的口头沟通。这些见解有助于护士和政策制定者改进电子健康记录，并制定提高患者参与电子护理记录的有效策略。
