Transcultural adaptation and assessment of psychometric properties of the Spanish version of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes.

PURPOSE: To adapt the Scale for the Evaluation of Staff Patient Interactions in Progress Notes to Spanish and to test the psychometric properties. DESIGN AND METHODS: The study was conducted in two phases: (1) Adaptation of the instrument to Spanish following the Standards for Educational and Psychological Testing. (2) Psychometric study in a sample of mental health nurses. FINDINGS: The Cronbach's alpha values were 0.97 for the total scale and 0.83 to 0.81 for each dimension. The inter-rater reliability values were between 0.94 and 0.97. PRACTICE IMPLICATIONS: The scale is a reliable tool for assessing nurses' clinical notes in relation to the quality of nurse-patient interactions.

Development and reliability testing of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI): An assessment instrument of mental health nursing documentation.

AIM: To develop and test the reliability of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI). Therapeutic nurse-patient interactions are fundamental in mental health nursing. However, little is known about how these interactions are recorded in nursing documentation and there is no instrument available for collecting this type of information for quantitative analysis. DESIGN: Instrument development and reliability testing. METHODS: The development of the SESPI was based on qualitative analyses of progress notes retrieved from patient records in two mental health services. A self psychological attunement perspective guided the analyses. SESPI was tested for internal consistency and inter-rater reliability after 22 nurses independently scored 10 progress notes. RESULTS: Cronbach's alpha for the entire instrument was 0.977, indicating that the raters' scores had very high internal consistency. ICC was 0.770. The alpha and ICC values for each step were high, varying between 0.970 and 0.992.

The quality and quantity of staff-patient interactions as recorded by staff. A registry study of nursing documentation in two inpatient mental health wards.

BACKGROUND: Therapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation. METHODS: The study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward. RESULTS: Only 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models. CONCLUSION: These findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts.

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

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 component of psychiatric care today. At the same time, the biomedical model remains strong. Research literature exploring nursing staff's experiences with writing progress 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 professional as an expert and distant observer in the progress notes, and the weak position 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 documentation. 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.