Content analysis of nursing diagnoses in mental health records in Portugal

• Published in: International nursing review 2019-06, Vol.66 (2), p.199-208
• Main Authors: Gonçalves, P.D.B., Sequeira, C.A.C., Silva, M.A.T.C.P.
• Format: Article
• Language: English
• Subjects: Care plans; Clinical Competence - standards; Clinical decision making; Clinical nursing; Content Analysis; Data; Emotions; Health indicators; Health records; Health services; Health status; Humans; Medical diagnosis; Mental health; Mental Health Nursing; Nurse's Role; Nurses; Nursing care; Nursing Diagnosis; Nursing Evaluation Research; Nursing Informatics; Nursing Process; Nursing Records - statistics & numerical data; Nursing Staff, Hospital - organization & administration; Patient Care Planning - organization & administration; Patients; Policy making; Portugal; Professional identity; Psychiatric nurses; Psychiatric Nursing; Psychiatric Nursing - organization & administration; Psychiatric-mental health nursing; Psychiatry; Qualitative research; Workload - statistics & numerical data
• ISSN: 0020-8132; 1466-7657
• DOI: 10.1111/inr.12493

Aims To identify the diagnoses documented by nurses in Portugal to describe the nursing needs within the scope of mental health nursing and the main problems in documenting these needs. Background/Introduction The diagnosis process is an essential step in nursing care planning. This process should be carried out by nurses in a rigorous and standardized manner, in order to ensure quality practices and to obtain indicators that can increase the visibility of nursing care. A descriptive study combining 1. quantitative content analysis of nursing diagnosis records written by nurses working in 39 psychiatry departments of the Portuguese National Health Service, and 2. An focus group meeting with 14 nurses exploring the results of first study phase. Qualitative and quantitative data were analysed by content analysis. Findings The 2014 initial diagnosis records were systematized into 78 final diagnostic categories, which may represent the most relevant diagnoses in the field of mental health nursing in Portugal. The main problems found in the diagnostic identification by nurses included lack of a standardized language; confusion between nursing diagnoses and focus areas and identification of incongruent clinical judgements. Discussion/Conclusion The changes observed in the fields of behaviour, emotions and psychological process correspond to the largest concentration of nursing diagnoses and challenges in Portugal. This study revealed the lack of standardized language used by nurses in defining diagnoses. The problems identified in the diagnoses documentation suggest that more training in this area is needed. Nursing Implications This study provides information on the most relevant diagnoses in the area of mental health nursing in Portugal and may offer an important contribution towards improving nursing informatics systems and care to patients by means of standardization of language used in diagnosis definitions. Implication for Nursing Policies The standardization of language used by mental health nurses may contribute towards producing health indicators that provides evidence to policymakers about the contribution made by nursing care towards improved population health.