Departement of Nursing Care and Elderly Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands.
Thebe Wijkverpleging (Home-Care Organisation), Tilburg, The Netherlands.
Health Expect. 2022 Aug;25(4):1508-1516. doi: 10.1111/hex.13492. Epub 2022 Apr 5.
Patients are increasingly expected to take an active role in their own care. Participation in nursing documentation can support patients to take this active role since it provides opportunities to express care needs and preferences. Yet, patient participation in electronic nursing documentation is not self-evident.
To explore how home-care patients perceive their participation in electronic nursing documentation.
Semi-structured interviews were conducted with 21 home-care patients. Interview transcripts were analysed in an iterative process based on the principles of reflexive inductive thematic analysis.
We identified a typology with four patient types: 'high need, high ability', 'high need, low ability', 'low need, high ability' and 'low need, low ability'. Several patients felt a need for participation because of their personal interest in health information. Others did not feel such a need since they trusted nurses to document the information that is important. Patients' ability to participate increased when they could read the documentation and when nurses helped them by talking about the documentation. Barriers to patients' ability to participate were having no electronic devices or lacking digital skills, a lack of support from nurses and the poor usability of electronic patient portals.
Patient participation in electronic nursing documentation varies between patients since home-care patients differ in their need and ability to participate. Nurses should tailor their encouragement of patient participation to individual patients' needs and abilities. Furthermore, they should be aware of their own role and help patients to participate in the documentation.
Home-care patients were involved in the interviews.
患者越来越被期望在自己的护理中发挥积极作用。参与护理文件记录可以支持患者发挥这种积极作用，因为它提供了表达护理需求和偏好的机会。然而，患者参与电子护理文件记录并非不言而喻。
探讨居家护理患者如何看待他们在电子护理文件记录中的参与。
对 21 名居家护理患者进行了半结构化访谈。根据反思性归纳主题分析的原则，对访谈记录进行了迭代分析。
我们确定了一个有四种患者类型的分类：“高需求、高能力”、“高需求、低能力”、“低需求、高能力”和“低需求、低能力”。一些患者因为对健康信息感兴趣而感到有参与的需求。其他人则没有这种需求，因为他们信任护士记录重要信息。当患者能够阅读文件记录，并且护士通过讨论文件记录来帮助他们时，他们参与的能力会增加。患者参与的障碍是没有电子设备或缺乏数字技能、护士的支持不足以及电子患者门户的可用性差。
患者在电子护理文件记录中的参与程度因人而异，因为居家护理患者在参与需求和能力方面存在差异。护士应该根据患者的个人需求和能力来调整他们对患者参与的鼓励。此外，他们应该意识到自己的角色，并帮助患者参与文件记录。
居家护理患者参与了访谈。
