Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting

Abstract

Purpose: This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology.

Methods: An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review.

Findings: Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans.

Conclusions and implications: The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care.

Clinical relevance: The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care.

Keywords: ATIC terminology; Basic nursing care; Communication; Fundamentals of care; Nursing interventions; Nursing language systems; Psychosocial care.