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

Area of Science:

• Nursing Informatics
• Patient Engagement
• Health Information Technology

Background:

• Patient participation in nursing documentation enhances personalized care and shared decision-making.
• Electronic health records (EHRs) do not automatically guarantee increased patient involvement in documentation.
• Understanding community nurses' experiences with patient participation in EHR documentation is essential.

Purpose of the Study:

• To explore community nurses' experiences with patient participation in electronic nursing documentation.
• To identify challenges faced by nurses in facilitating patient participation.
• To discover strategies used by nurses to overcome these challenges.

Main Methods:

• Qualitative descriptive design utilizing reflexive thematic analysis.
• Purposive sampling of 19 community nurses using EHRs in home care.
• Face-to-face or phone interviews analyzed iteratively until data saturation.

Main Results:

• Nurses believe patient participation should be individualized and is influenced by trust in documentation accuracy.
• Challenges include EHR technical issues, work-related pressures (e.g., time), and patient medical conditions.
• Nurses often document outside the patient's home, using verbal discussions to capture patient views retrospectively.

Conclusions:

• Community nurses recognize the importance of patient participation in electronic nursing documentation.
• Significant challenges related to EHRs, work, and patients hinder effective participation.
• Verbal communication remains a primary strategy for documenting patient perspectives, highlighting areas for EHR improvement and strategy development.