Patient participation in electronic nursing documentation: An interview study among home‐care patients

Abstract

Abstract Background Patients are increasingly expected to take an active role in their own care. Participation in nursing documentation can support patients to take this active role since it provides opportunities to express care needs and preferences. Yet, patient participation in electronic nursing documentation is not self‐evident. Objective To explore how home‐care patients perceive their participation in electronic nursing documentation. Methods Semi‐structured interviews were conducted with 21 home‐care patients. Interview transcripts were analysed in an iterative process based on the principles of reflexive inductive thematic analysis. Results We identified a typology with four patient types: ‘high need, high ability’, ‘high need, low ability’, ‘low need, high ability’ and ‘low need, low ability’. Several patients felt a need for participation because of their personal interest in health information. Others did not feel such a need since they trusted nurses to document the information that is important. Patients' ability to participate increased when they could read the documentation and when nurses helped them by talking about the documentation. Barriers to patients' ability to participate were having no electronic devices or lacking digital skills, a lack of support from nurses and the poor usability of electronic patient portals. Conclusion Patient participation in electronic nursing documentation varies between patients since home‐care patients differ in their need and ability to participate. Nurses should tailor their encouragement of patient participation to individual patients' needs and abilities. Furthermore, they should be aware of their own role and help patients to participate in the documentation. Patient or Public Contribution Home‐care patients were involved in the interviews.

Keywords

• electronic health record
• home care
• nursing documentation
• patient involvement
• patient participation