Nursing documentation in inpatient psychiatry : the relevance of nurse-patient interactions in progress notes : a focus group study with mental health staff

Kjellaug Klock Myklebust, Stål Bjørkly, Målfrid Råheim

Vitenskapelig artikkel
Journal of Clinical Nursing, 2017
Online / DOI:

Aims and objectives: To gain insight into mental health staff’s perception of writing
progress notes in an acute and subacute psychiatric ward context.
Background: The nursing process structures nursing documentation. Progress notes
are intended to be an evaluation of a patient’s nursing diagnoses, interventions and
outcomes. Within this template, a patient’s status and the care provided are to be
recorded. The therapeutic nurse–patient relationship is recognised as a key compo-
nent of psychiatric care today. At the same time, the biomedical model remains
strong. Research literature exploring nursing staff’s experiences with writing pro-
gress notes in psychiatric contexts, and especially the space given to staff–patient
relations, is sparse.
Design: Qualitative design.
Methods: Focus group interviews with mental health staff working in one acute
and one subacute psychiatric ward were conducted. Systematic text condensation, a
method for transverse thematic analysis, was used.
Results: Two main categories emerged from the analysis: the position of the profes-
sional as an expert and distant observer in the progress notes, and the weak posi-
tion of professional–patient interactions in progress notes.
Conclusions: The participants did not perceive that the current recording
model, which is based on the nursing process, supported a focus on patients’
resources or reporting professional–patient interactions. This model appeared to
put ward staff in an expert position in relation to patients, which made it
challenging to involve patients in the recording process. Essential aspects of
nursing care related to recovery and person-centred care were not prioritised for
Relevance to clinical practice: This study contributes to the critical examination of
the documentation praxis, as well as to the critical examination of the documentation
tool as to what is considered important to document.
Keywords: documentation, mental health nursing, nurse–patient interactions, nurse–patient relations,
nursing process, psychiatric nursing