Lerbæk Birgitte, Kusk Kathrine Hoffmann, Jørgensen Lone, Laugesen Britt
Unit for Psychiatric Research, Psychiatry-Aalborg University Hospital, Aalborg, Denmark.
Research Unit Thisted, Aalborg University Hospital, Thisted, Denmark.
J Adv Nurs. 2025 May;81(5):2604-2616. doi: 10.1111/jan.16502. Epub 2024 Oct 1.
To explore how Danish registered nurses (RNs) in hospitals experience documenting nursing care in electronic patient records when the content is accessible to patients.
In a qualitative research design, data were generated in six focus groups conducted in late 2022 and early 2023, comprising 31 RNs employed in inpatient wards at a university hospital in Denmark. Subsequently, qualitative content analysis was applied to the gathered data.
The findings include three themes: (1) weighing one's words, (2) building trust or triggering conflicts and (3) risking loss of knowledge. Together, these three themes illustrate the complexities that RNs navigate when patients have access to the content of nursing documentation.
Patients' access to nursing documentation requires RNs to navigate a complex interplay of factors, including awareness of language-use, influence on the nurse-patient-relative relationships, and the risk of losing essential knowledge. Therefore, although patients' access to nursing documentation can induce a positive change in terms of strengthening the professional focus on documentation, it can also result in changes in documentation practices in ways that may compromise nursing documentation as a working tool.
The findings emphasize an urgent need to explore and discuss how sensitive nursing observations can be shared in a safe and appropriate way when patients have access to the documentation. Furthermore, to prevent misunderstandings and conflicts with patients, it is essential to focus on and prioritize patient involvement in nursing documentation.
RNs navigate complex practices when patients have direct online access to nursing documentation content. It is crucial to clarify which content nursing documentation should entail and how sensitive nursing observations can be shared in a safe and appropriate way.
The COREQ checklist was used for reporting.
探讨丹麦医院注册护士在患者可查阅电子病历中护理记录内容时，对记录护理过程的体验。
采用定性研究设计，于2022年末和2023年初进行了6个焦点小组访谈，参与者为丹麦一家大学医院住院病房的31名注册护士。随后，对收集到的数据进行定性内容分析。
研究结果包括三个主题：（1）措辞谨慎；（2）建立信任或引发冲突；（3）面临知识流失风险。这三个主题共同说明了护士在患者可查阅护理记录内容时所面临的复杂情况。
患者可查阅护理记录要求护士应对诸多复杂因素的相互作用，包括对语言使用的意识、对护患关系及亲属关系的影响，以及知识流失的风险。因此，尽管患者可查阅护理记录能促使专业人员更注重记录，但也可能导致记录方式发生变化，从而影响护理记录作为工作工具的效用。
研究结果强调迫切需要探讨和讨论在患者可查阅记录的情况下，如何以安全、恰当的方式分享敏感的护理观察结果。此外，为防止与患者产生误解和冲突，必须重视并优先考虑患者参与护理记录。
当患者可直接在线查阅护理记录内容时，护士面临复杂的情况。明确护理记录应包含的内容以及如何以安全、恰当的方式分享敏感的护理观察结果至关重要。
采用COREQ清单进行报告。
