Patient participation in electronic nursing documentation: an interview study among community nurses

BMC Nursing

Kim De Groot¹  Anneke L. Francke²  Elisah B. Sneep³  Wolter Paans⁴ 

[1] Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR, Utrecht, The Netherlands;Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR, Utrecht, The Netherlands;Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands;Nursing Science, Programme in Clinical Health Sciences, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands;Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA, Groningen, The Netherlands;Department of Critical Care, University Medical Centre Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands;

关键词: Patient participation[MeSH];    Nursing documentation;    Electronic health record[MeSH];    Home care;   

DOI  :  10.1186/s12912-021-00590-7

来源: Springer

【 摘 要 】

BackgroundPatient 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.MethodsA 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.ResultsCommunity 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.ConclusionsAlthough 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.

【 授权许可】

CC BY