Improving the nursing documentation: professional consciousness‐raising in a Northern‐Norwegian psychiatric hospital

Abstract

The new Norwegian health legislation has increased the quality demands on nursing documentation. The staff at a psychiatric hospital has, together with us, explored their own way of producing written nursing documentation. In collaboration with them, we have analysed 32 patient journals which were made anonymous. We read through the documents with a critical view. We compared the findings with current professional quality standards. The actual language in the reports was analysed critically. The purpose was that the staff would become aware of unintentional consequences of their own parlance. We contributed by giving them a suitable analysis tool, which can be used for exploring own practice. The analysis tool became an aid in making the necessary qualitative improvements. This has made them change their practice. Today, the wards can exhibit documentation systems that to a large extent satisfy current professional and legal demands. An important change is the staff's specific contributions are made explicit. The staff has become more resource-oriented and the patient has, to a much larger extent than before, become an active participant in the development of the nursing plan.