An analysis of documentation language and word choice among forensic mental health nurses.

Abstract

Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n=55), we explored the adjectives and verbs used across a subsection of their documentation over a three-month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight - or valence - of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias.