Negotiating Narratives: Including Patient Perspectives in Mental Health Nursing Documentation.

Area of Science:

• Health Services Research
• Mental Health Research
• Qualitative Research

Background:

• Electronic health records (EHRs) are integral to modern mental health and substance use care.
• The integration of patient perspectives within standardized EHR systems remains unclear.
• Understanding healthcare staff experiences with patient documentation is crucial.

Purpose of the Study:

• To explore healthcare staff experiences and perceptions of including patient perspectives in clinical documentation.
• To investigate how standardized systems impact the capture of patient voices in mental health and substance use services.
• To identify challenges and facilitators for patient involvement in documentation.

Main Methods:

• Qualitative study employing in-depth interviews with 12 experienced healthcare professionals.
• Settings included Norwegian specialist and primary care for mental health and substance use.
• Analysis guided by Gadamer's philosophical hermeneutics.

Main Results:

• Five themes emerged: negotiating narratives, documenting in shadows, care vs. control, patient journals, and subjective realities.
• Standardized templates, biomedical focus, and time constraints impede patient voice inclusion.
• Recovery-oriented values emphasize documenting lived experiences, goals, and agency.

Conclusions:

• Clinical documentation in mental health is an ethical, relational practice, not a neutral task.
• Current systems often fail to support meaningful patient involvement.
• Guidelines and systems must be developed to genuinely incorporate patient perspectives for effective care.