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Abstract：
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.
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.
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.
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.
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.
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.
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.
摘要：
治疗人员与患者的互动是精神病护理的基础。它本身被认为是治愈的关键，或提高精神病治疗依从性的前提。尽管如此，关于这些相互作用如何记录在护理文档中知之甚少。该研究的目的是评估护理文档中进度记录中记录的医患互动的质量和数量。
本研究采用观察性注册研究设计。从挪威急性精神病院和开放式住院地区精神病中心（DPC）的90个患者期刊中的进度记录中，随机抽取了3858个摘录。员工-患者互动评估量表（SESPI）用于评估进度记录摘录。开发它是为了根据移情协调来评估员工与患者互动的摘录描述的质量和数量。分别计算总样本和每个病房的描述性统计数据。序数和多项逻辑回归用于估计移位类型的控制，员工教育水平，医院病房的类型。
摘录总数中只有7.6％（N=3858）描述了充分的员工与患者之间的相互作用，以根据调音进行分析。与DPC相比，急性病房报告了更多的医患互动。晚上的摘录报告了比夜班更成功的调音类型。教育水平对我们的模型没有显著贡献。
这些发现对有关员工与患者互动的心理健康护理文档的质量和数量提供了独特的见解。很少描述工作人员试图与患者协调的治疗相互作用。然而,这是SESPI第一个测量护理文件的研究，需要更多的研究来验证量表和我们的发现。这项研究的一个潜在临床意义是，精神病房的人员可以使用一种量表来评估其报告实践的质量，并强调员工与患者的互动。通过定期使用，这可能有助于在环境治疗环境中继续强调强调。
本研究采用观察性注册研究设计。从挪威急性精神病院和开放式住院地区精神病中心（DPC）的90个患者期刊中的进度记录中，随机抽取了3858个摘录。员工-患者互动评估量表（SESPI）用于评估进度记录摘录。开发它是为了根据移情协调来评估员工与患者互动的摘录描述的质量和数量。分别计算总样本和每个病房的描述性统计数据。序数和多项逻辑回归用于估计移位类型的控制，员工教育水平，医院病房的类型。
摘录总数中只有7.6％（N=3858）描述了充分的员工与患者之间的相互作用，以根据调音进行分析。与DPC相比，急性病房报告了更多的医患互动。晚上的摘录报告了比夜班更成功的调音类型。教育水平对我们的模型没有显著贡献。
这些发现对有关员工与患者互动的心理健康护理文档的质量和数量提供了独特的见解。很少描述工作人员试图与患者协调的治疗相互作用。然而,这是SESPI第一个测量护理文件的研究，需要更多的研究来验证量表和我们的发现。这项研究的一个潜在临床意义是，精神病房的人员可以使用一种量表来评估其报告实践的质量，并强调员工与患者的互动。通过定期使用，这可能有助于在环境治疗环境中继续强调强调。
