Using the Nursing Interventions Classification to identify nursing interventions in free‐text nursing documentation in adult psychiatric outpatient care setting

AbstractAims and objectivesTo identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting.BackgroundDocumentation is an important part of nurses’ work, and in the psychiatric outpatient care setting, it can be time‐consuming. Only very few research reports are available on nursing documentation in this care setting.MethodsA qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016–2017). The data consisted of 1,150 free‐text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting.ResultsWe identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of over