Dataset Information

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.

ABSTRACT:

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.

SUBMITTER: Myklebust KK

PROVIDER: S-EPMC6650683 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Publications

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.

Myklebust Kjellaug K KK Bjørkly Stål S

Nursing open 20190321 3

<h4>Aim</h4>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.<h4>Design</h4>Instrument development and reliability testing.<h4>Methods</h4>The devel ...[more]

PMID: 31367401

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Project description:BackgroundTherapeutic 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.MethodsThe 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.ResultsOnly 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.ConclusionThese 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.

Project description:ObjectiveThe effects of shared clinical notes on patients, care partners, and clinicians ("open notes") were first studied as a demonstration project in 2010. Since then, multiple studies have shown clinicians agree shared progress notes are beneficial to patients, and patients and care partners report benefits from reading notes. To determine if implementing open notes at a hematology/oncology practice changed providers' documentation style, we assessed the length and readability of clinicians' notes before and after open notes implementation at an academic medical center in Boston, MA, USA.Materials and methodsWe analyzed 143 888 notes from 60 hematology/oncology clinicians before and after the open notes debut at Beth Israel Deaconess Medical Center, from January 1, 2012 to September 1, 2016. We measured the providers' (medical doctor/nurse practitioner) documentation styles by analyzing character length, the number of addenda, note entry mode (dictated vs typed), and note readability. Measurements used 5 different readability formulas and were assessed on notes written before and after the introduction of open notes on November 25, 2013.ResultsAfter the introduction of open notes, the mean length of progress notes increased from 6174 characters to 6648 characters (P < .001), and the mean character length of the "assessment and plan" (A&P) increased from 1435 characters to 1597 characters (P < .001). The Average Grade Level Readability of progress notes decreased from 11.50 to 11.33, and overall readability improved by 0.17 (P = .01). There were no statistically significant changes in the length or readability of "Initial Notes" or Letters, inter-doctor communication, nor in the modality of the recording of any kind of note.ConclusionsAfter the implementation of open notes, progress notes and A&P sections became both longer and easier to read. This suggests clinician documenters may be responding to the perceived pressures of a transparent medical records environment.

Project description:ObjectiveMedication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England.MethodsRegistered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants' experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason's model of accident causation.ResultsA total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication.ConclusionsTo our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent 'system' failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational 'systems' failures to reduce error.

Project description:BackgroundQuality Nursing Care (QNC) is fundamental to the profession of nursing practice. Perception of QNC differ across the globe because of differences in social norms, cultural values and political ambiance and economy. This study aimed to develop a QNC instrument congruent with the Mongolian (QNCS-M) healthcare system and cultural values and societal norms.MethodsExploratory sequential mixed-method design was implemented to develop and assess performance of QNCS-M. First, we focused on developing the components of QNCS-M and their operational definitions. Second, we dedicated to ascertaining psychometric performance of QNCS-M. The field testing consisted of assessing the construct validity and internal consistency reliability. Correlation between QNCS-M and the criterion tool, Quality of Nursing Care Questionnaire-Registered Nurse was evaluated.ResultsThe initial version of QNCS-M contained 66 items of which 7 (I-CVI < .78) were deleted after item-content validity assessment. The total-item correlation analysis yielded to exclusion of another 3 items (<.3). Additional 12 items were excluded after inter-item correlation (<.3, >.7). Results from Spearman rank-order correlation analysis of the remaining 44 items indicated relationship between social desirability and 6 items (r = -.09 to r = .11). These items were excluded to reduce the likelihood of potential information bias. A total of 38 items remained for exploratory factor analysis. Results from exploratory factor analysis yielded eigenvalues > 1.0 for the 9 domains. Three domains contained items fewer than 3. These domains and 2 items (factor loading <.4) were eliminated, yielding to 6 domains with 36-item. Results from internal consistency reliability yielded an overall Cronbach's α = .92; the coefficient values for the 6 domains ranging between .72 and .85 and Pearson correlation for stability reliability yielded an acceptable (r = .82, P < .001).ConclusionImproving the quality of healthcare services delivered by nurses is a priority for the Mongolian government. The development of QNCS-M is a major stride in addressing this concern. The final version of QNCS-M which contains 36 items, loaded into 6 domains, was morphed to the specifics of the Mongolian healthcare systems and cultural values and societal norms. QNCS-M demonstrates a high level of content and construct validity with acceptable reliability.

Dataset Information

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

Design

Methods

Results

Publications

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.

Similar Datasets

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