AI Article Synopsis

  • The study aimed to analyze the documentation style of mental health nurses and investigate any distortions or biases present in their notes.
  • Results indicated that while some nurses showed empathy toward patients, many tended to use negative language that could undermine patient care, reinforcing stereotypes and biases.
  • The findings highlight the importance of improving documentation practices among mental health nurses to ensure more accurate and supportive patient assessments and treatment decisions.

Article Abstract

Aims And Objectives: Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases.

Background: Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals.

Design: This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis.

Methods: We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014.

Results: The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients.

Conclusions: When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals.

Relevance To Clinical Practice: Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.

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Source
http://dx.doi.org/10.1111/jocn.15264DOI Listing

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