Nursing interventions in mental health and psychiatry: Content analysis of records from the nursing information systems in use in Portugal

Gonçalves, Patrícia; Sequeira, Carlos; Silva, Maria Antónia Taveira da Cruz Paiva E

doi:10.1111/jpm.12536

Cited by 11 publications

(17 citation statements)

References 24 publications

(29 reference statements)

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“…Another limitation of this study was the absence of an external observer in the focus group meeting or videotaping, making it difficult to focus on participants' non‐verbal communication and interactions. We only conducted one focus group meeting that allowed data saturation (Goncalves et al 2019) but did not allow potential differences in the opinion of the participants to be identified over time. Another concern is related to the size of the focus group; if we conducted more meetings with smaller groups, the participants could have interacted more, perhaps leading to more in‐depth insights.…”

Section: Discussionmentioning

confidence: 99%

Nursing diagnoses focused on universal self‐care requisites

Queirós

Silva

Cruz

et al. 2021

International Nursing Review

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Aims (1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self‐care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self‐care requisites. Background/Introduction Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self‐care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions. Methods A qualitative study using inductive content analysis and focus group: 1. nursing e‐documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results. Results From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self‐care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting. Conclusion Results reveal that nursing diagnoses related to universal self‐care requisites can emphasize the impairment or potentialities of the individuals performing self‐care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self‐care requisites, resulting in different diagnoses to express the same needs. Implications for nursing practice Representation of most relevant nursing diagnoses within the scope of universal self‐care requisites. Implications for health policy Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.

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Section: Discussionmentioning

confidence: 99%

Nursing diagnoses focused on universal self‐care requisites

Queirós

Silva

Cruz

et al. 2021

International Nursing Review

View full text Add to dashboard Cite

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“…Nurses consider it a complex system due to the difficulty in the recording process and data consultation. Other authors also reinforce the nurses' perception of the complexity in optimizing the SClínico program (Gonçalves et al, 2019;Oliveira et al, 2020;Vieira, 2018). The lack of standardization of records reported by the participants is a relevant limitation, because the use of a common language by nurses is crucial for the construction of formal knowledge (Gonçalves et al, 2019).…”

Section: Discussionmentioning

confidence: 69%

“…Other authors also reinforce the nurses' perception of the complexity in optimizing the SClínico program (Gonçalves et al, 2019;Oliveira et al, 2020;Vieira, 2018). The lack of standardization of records reported by the participants is a relevant limitation, because the use of a common language by nurses is crucial for the construction of formal knowledge (Gonçalves et al, 2019). Also, Oliveira et al (2020) highlighted the non-standardization of the care documentation process.…”

Section: Discussionmentioning

confidence: 69%

A co-construção de um modelo de acompanhamento aos familiares cuidadores

França¹,

Festa²,

Santos³

et al. 2022

Rev. Enf. Ref.

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“…There has been some research on the use and relevance of SNTs in documentation in the psychiatric care but most of this has taken place in inpatient settings (e.g. Frauenfelder, van Achterberg, & Muller-Staub, 2018;Gonçalves, Sequeira, & Silva, 2019). Frauenfelder et al (2018) concluded that the NIC could be a suitable means to describe nursing care in the psychiatric inpatient setting but some interventions were found to be missing.…”

Section: What Does This Paper Contribute To the Wider Global Clinicalmentioning

confidence: 99%

Using the Nursing Interventions Classification to identify nursing interventions in free‐text nursing documentation in adult psychiatric outpatient care setting

Ameel

Leino

Kontio

et al. 2020

Journal of Clinical Nursing

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Aims and objectives To identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting. Background Documentation is an important part of nurses’ work, and in the psychiatric outpatient care setting, it can be time‐consuming. Only very few research reports are available on nursing documentation in this care setting. Methods A qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016–2017). The data consisted of 1,150 free‐text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting. Results We identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of overlapping interventions and the difficulty of naming group‐based interventions. Conclusion There is an urgent need to improve patient documentation in the adult psychiatric outpatient care setting, and standardised nursing terminologies such as the Nursing Interventions Classification could be a solution to this. However, the problems of overlapping interventions and naming group‐based interventions suggest that the classification needs to be further developed before it can fully support the systematic documentation of nursing interventions in the psychiatric outpatient care setting. Relevance to clinical practice This study describes possibilities of using a systematic nursing language to describe the interventions nurses use in the adult psychiatric outpatient setting. It also describes problems in the current free text‐based documentation.

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Nursing interventions in mental health and psychiatry: Content analysis of records from the nursing information systems in use in Portugal

Cited by 11 publications

References 24 publications

Nursing diagnoses focused on universal self‐care requisites

Nursing diagnoses focused on universal self‐care requisites

A co-construção de um modelo de acompanhamento aos familiares cuidadores

Using the Nursing Interventions Classification to identify nursing interventions in free‐text nursing documentation in adult psychiatric outpatient care setting

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