Received: 8 October 2019 | Revised: 12 February 2020 | Accepted: 12 March 2020

DOI: 10.1111/jocn.15264

ORIGINAL ARTICLE

How forensic mental health nurses’ perspectives of their

patients can bias healthcare: A qualitative review of nursing
documentation

Krystle Martin PhD, Research scientist1,2 | Rosemary Ricciardelli PhD, Professor of

Sociology, the Coordinator for Criminology, and Co-Coordinator for Police Studies1,3 |
4
Itiel Dror PhD, Senior Cognitive Neuroscience Researcher

1
Ontario Shores Centre for Mental Health
Sciences, Whitby, Ontario, Canada
2
Ontario Tech University, Oshawa, Ontario,
Canada
3
Memorial University of Newfoundland, St.
John’s, Newfoundland and Labrador, Canada
4
University College London (UCL), London,
UK
Correspondence
Krystle Martin, Ontario Shores Centre for
Mental Health Sciences, 700 Gordon Street,
Whitby, Ontario L1N 5S9, Canada.
Email: martink@ontarioshores.ca
Abstract
Aims and Objectives: Our aim was to examine the notes produced by nurses, pay-
ing specific attention to the style in which these notes are written and observing
whether there are concerns of distortions and biases.
Background: Clinicians are responsible to document and record accurately. However,
nurses’ attitudes towards their patients can influence the quality of care they provide
their patients and this inevitably impacts their perceptions and judgments, with im-
plications to patients’ care, treatment, and recovery. Negative attitudes or bias can
cascade to other care providers and professionals.
Design: This study used a retrospective chart review design and qualitative explora-
tion of documentation using an emergent theme analysis.
Methods: We examined the notes taken by 55 mental health nurses working with
inpatients in the forensic services department at a psychiatric hospital. The study
complies with the SRQR Checklist (Appendix S1) published in 2014.
Results: The results highlight some evidence of nurses’ empathic responses to patients,
but suggest that most nurses have a style of writing that much of the time includes
themes that are negative in nature to discount, pathologise, or paternalise their patients.
Conclusions: When reviewing the documentation of nurses in this study, it is easy to
see how they can influence and bias the perspective of other staff. Such bias cascade
and bias snowball have been shown in many domains, and in the context of nursing it
can bias the type of care provided, the assessments made and the decisions formed
by other professionals.
Relevance to Clinical Practice: Given the critical role documentation plays in health-
care, our results indicate that efforts to improve documentation made by mental
health nurses are needed and specifically, attention needs to be given to the writing
styles of the notation.

KEYWORDS

bias, documentation, forensic, mental health, nursing

2482 | © 2020 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2020;29:2482–2494.
MARTIN et al.
1 | I NTRO D U C TI O N
Nurses are supposed to observe, collect, capture, and document
data about the patients in their care. Such data cover information
from patients’ health to the outcomes of interventions. These play
a critical role in informing and shaping many components of health-
care, including decisions about medication, care plans, and discharge.
According to the College of Nurses of Ontario (2014), documented
information is expected to be “clearly, concisely and accurately” re-
ported (p. 9). However, researchers have questioned both the ve-
racity and the thoroughness of nursing notation (e.g., MacAuthur,
2016; Martin, Ham, & Hilton, 2018; Shoqirat, Mahasneh, Dardas,
Singh, & Khresheh, 2019). Inadequacies or distortions in notations
are problematic as these notes are intended to facilitate communica-
tion within multidisciplinary teams and often are the basis of assess-
ments and evaluations conducted by other professionals. In addition
to supporting direct healthcare, nurses’ documentation may be used
for other purposes such as research and program evaluation initia-
tives. Systematic review of documentation can help organisations
determine the quality of care provided to their patients and facilitate
quality improvement (Urquhart, Curell, Grant, & Hardiker, 2009).
Given the critical role documentation plays in healthcare, it is im-
portant to examine the notes produced by nurses, and specifically
to pay attention to the style in which these notes are written, ob-
serving whether there are concerns of distortions and biases (Dror,
2018; Kassin, Dror, & Kukucka, 2013). Such issues of documentation
may arise from nurses’ attitudes towards mental health patients, and
therefore before presenting our study we provide a brief review of
the literature about the perspectives of mental health nurses to-
wards the patients in their care. We conclude our literature review
by presenting the relevant existing research about nursing docu-
mentation, and the research about how cognitive bias may influence
experts.
2 | LITE R AT U R E R E V I E W
2.1 | Mental health nurses’ perceptions
Studies looking at nurse attitudes towards mental health patients
have produced diverse findings (de Jacq, Norful, & Larson, 2016).
Some indicate that nurses generally hold more negative and less-opti-
mistic views of mental health patients compared to other healthcare
providers (e.g., Mood Disorders Society of Canada, 2007). Some
mental illnesses, such as substance misuse and schizophrenia, have
been especially associated with such negative attitudes (Hsiao, Lu,
& Tsai, 2015). Conversely, other scholars claim that mental health
nurses generally have a positive and optimistic view towards patients
with mental illness (Chambers et al., 2010). Researchers have tried
to understand what factors might mediate these attitudes. There is
some evidence to suggest that older and more experienced nurses
have most positive attitudes towards people with mental health
struggles (e.g., Chambers et al., 2010; Hsiao et al., 2015). However,
| 2483
What does this paper contribute to the wider
global clinical community?
• Our study provides a description of the writing styles of
mental health nurses – information about which is lack-
ing in the current literature – and indicates that mental
health nurses tend to write in a more negative writing
style
• The results suggest that nurses should be provided with
education and training that presents the evidence about
documentation and bias, and that organisations should
take advantage of electronic health record systems
that may be able to provide technological solutions:
for example, the use pull-down menus and prewrit-
ten description choices that the nurses choose from or
checks and balances of nurses’ writing prior to it being
submitted to patients’ charts may help to reduce bias in
documentation.
other studies have found no such differences in attitudes among
people of different ages or positions (e.g., Mårtensson, Jacobsson,
& Engström, 2014).
Mental health nurses who work in forensic programs may also
be influenced by additional factors, such as the incidence of aggres-
sive or violent acts that occur when providing care to their patients
(e.g., Jansen, Dassen, & Groot Jebbink, 2005). For instance, Fluttert,
Meijel, Nijman, Bjørkly, and Grypdonck (2010) explored the expe-
riences of potentially traumatic exposures (PTEs) and found that
this led to some nurses perceiving these actions as occupational
challenges when providing care to forensic patients. Similarly, in a
discourse analysis of notes written by forensic nurses following in-
cidents of aggression, researchers found that nurses tended to re-
cord the incident with an over-focus on the behaviour of the patient,
rather than the entirety of the situation, in ways that were stereo-
typing in nature (Berring, Pedersen, & Buus, 2015).
Forensic mental health nurses have reported using detached con-
cern as a coping strategy when working with their patients (Fluttert
et al., 2010). Detached concern may help with nursing staff burnout
given that this strategy could potentially allow nurses to keep their
emotional distance from their patients in an effort to reduce the psy-
chological impact of instances of aggression (Fluttert et al., 2010).
Similar issues apply to other professionals that work within forensic
settings, which impact their performance (Jeanguenat & Dror, 2018).
Nurses’ attitudes towards their patients can influence the quality
of care provided to their patients. If a nurse, or any other profes-
sional, possesses a negative attitude toward their patient, this inev-
itably impacts their perceptions and judgments, which can degrade
the quality of decisions (Dror & Murrie, 2018; Zapf & Dror, 2017;
Zapf, Kukucka, Kassin, & Dror, 2018), with implications to patients’
care, treatment, and recovery. Negative attitudes do not only af-
fect the person who has them, but they often cascade to other care
2484 | MARTIN et al.
providers and professionals, which perpetuated the bias towards the
patient (Dror, 2018) These attitudes can even be relayed to the pa-
tients themselves (Happell, 2007).
2.2 | Documentation in mental health care
Documentation is considered a core competency of nursing prac-
tice, including mental healthcare, as it plays a critical role in patient
care and safety (College of Nurses of Ontario, 2014; Wilkinson,
2007). Additionally, nurses have reported that their primary
source of information for learning about the patients in their care
is through the documented health record (Kelley, Docherty, &
Brandon, 2013). Despite their importance, previous research re-
veals that nursing notes do not always provide an accurate account
(e.g., Marinis et al., 2010; Inan & Dinc, 2013; Instefjord, Aasekjær,
Espehaug, & Graverholt, 2014), and may not even include vital
information (e.g., Marinis et al., 2010; Martin et al., 2018; Wang,
Yu, & Hailey, 2015). Researchers have found that notation about
interventions provided - compared to other domains of care (e.g.,
observations, evaluations) - are lacking (Paans, Sermeus, Nieweg,
& van der Schans, 2010) and rarely are staff-patient interactions
sufficiently described (Myklebust & Bjorkly, 2019). Similarly,
Myklebust, Bjorkly, and Raheim (2018) highlighted in their qualita-
tive analysis using focus groups that mental health staff report
a model of documentation that places them as the expert over
patients thereby reducing patient-centred considerations and fully
incorporating recovery-oriented approaches – two valuable com-
ponents of current mental health care.
Over the last few decades, efforts have been made to im-
prove the quality and usability of nursing notes. For example, the
International Council of Nurses developed a framework (Registered
Nurses’ Association of Ontario, 2011) intended to unify and stan-
dardise nursing classification systems to capture data about nurs-
ing practice, interventions and outcomes. Another system that
has been adopted to improve documentation is the Systematized
Nomenclature of Medicine (SNOMED). Together with the Health
F I G U R E 1 Taxonomy of seven factors
that may unconsciously affect the
decision-making of experts (Jeanguenat &
Dror, 2018) [Colour figure can be viewed
at wileyonlinelibrary.com]
Information, Nursing Components (HI:NC) nursing data standards
developed by the Canadian Nursing Association in 1991, nurses are
encouraged to use commonly accepted health terminology and in-
clude essential data elements in their documentation.
These formal guidelines were thought to be especially necessary
for the use of electronic health records (EHR) and were valuable
tools as healthcare organisations adopted new technologies. In fact,
people were hopeful that EHR technology would solve many of the
shortcomings of written notations: “[w]ith an EHR, every health care
event will be documented using standard terms in computerised sys-
tems” (Lunney, Delaney, & Duffey, 2005, p.1).
However, even though technology can play a critical role in cre-
ating improvements, it does not, by itself, overcome biases inherent
in humans. In fact, technology can enhance and perpetuate such bi-
ases by incorporating bias, sometimes indirectly and unintentionally,
into technological documentation systems, regardless of common
language or structure. Such technologically induced biases have
been theoretically and empirically documented in forensic science
decision-making (Dror & Mnookin, 2010; Dror, Wertheim, Fraser-
Mackenzie, & Walajtys, 2012).
2.3 | Bias
The bias discussed in this article, cognitive bias, is not intentional
discriminatory bias, such as racism, and sexism. Cognitive bias
arises when our preconceived notions and emotions impact our
judgments. For example, consider auditions to play for symphony
orchestras. When the auditions occurred ‘in the open’ women
were rarely accepted, even though, the candidate's success was,
supposedly, solely based on their ability to play the musical in-
strument. However, preconceived notions and other biasing fac-
tors caused the judges to ‘hear’ women playing instruments as
less able than men. A change occurred when auditions started to
take place ‘blind’, whereby the person auditioning was behind a
screen, and the panel of judges could not see them. Once blind
auditions began, the number of women in symphony orchestras
MARTIN et al.
substantially increased (Goldin & Rouse, 2000). The example,
among many examples of cognitive bias, illustrates the kind of bias
discussed in this paper.
Such biases can arise from a whole array of factors and sources
(see Figure 1). Some biases may arise from the case in hand (some-
thing about this patient, this disorder) that impacts an individual,
other biases may have nothing to do with the case at hand but
arise from an individual (personal experiences, training, working
environment, beliefs, etc.), whereas other sources of bias arise
from human nature and impact all people (the basic cognitive ar-
chitecture of the brain and how it process information) –see the
taxonomy in Figure 1.
Such biases have shown to impact forensic scientists, experts
doing DNA or fingerprinting (Kassin et al., 2013). These biases not
only impact specific experts, but their affects cascade and snow-
ball from one expert to the next, from one stage to another (Dror,
2018). In response, researchers have begun to document such bi-
asing effects within healthcare professionals (e.g., Goddu et al.,
2018).
Goddu et al. (2018) identified stigmatising language in clin-
ical documentation and explored its impact on physicians’ deci-
sion-making. Their results revealed an alarming connection: notes
containing stigmatising language led to the patient's pain being
managed less aggressively (Goddu et al., 2018). The study demon-
strates the biasing effect of documentation and, how bias and
stigma can cascade from one individual to the next through notes,
thereby perpetuating the stigma and with implication for patient
care.
3 | CU R R E NT S T U DY
Nurse documentation requires examination, yet only a few studies
have explored how mental health nurses document those in their
care. In the current study, we respond to this lacuna in knowledge.
To this end, we investigated the writing style of forensic mental
health nurses in a clinical setting. We examined the notes taken by
55 different nurses working with men and women who are being
treated under the Ontario Review Board due to being found not
criminally responsible on accord of mental disorder (NCRMD). We
use these real case data to understand emergent themes tie to
how nurses describe their patients, the care they provide, and
evaluations made.
4 | M E TH O DS
We used a retrospective chart review design in the current study; a
part of a larger study examining two specific cognitive biases in rela-
tion to nursing documentation. We used the Standards for Reporting
Qualitative Research (SRQR) (O'Brien, Harris, Beckman, Reed, &
Cook, 2014) to guide our approach (See Appendix S1). The study
| 2485
did not commence until approval was granted by the Ontario Shores
Research Ethics Board (Approval #16-022-D).
4.1 | Recruitment and data collection
An email was circulated to all nurses within the forensic department
that provided potential participants with an introduction to the re-
search project, including its aims and opportunities for involvement
by staff. Individuals interested in participating were directed to an
online survey hosted by Survey Monkey and guided through in-
formed consent. Once consent was received, participants completed
two research questionnaires – the Mindset and the Attribution
Questionnaires – in addition to providing basic personal informa-
tion – name, age range, gender, years of experience, and profession
(i.e., Registered Nurses [RNs] in Canada are university trained, hold a
degree, and as such have much autonomy while Registered Practical
Nurses [RPNs] are community college trained, hold a diploma, and
need to consult RNs as the complexity of care they are to provide
increases). After a period of three months, we extracted all the notes
from the electronic health record database authored by the partici-
pants that were completed during this time period; however, only
the first 30 notes were included in our analysis as theme saturation
occurred which made the review of additional notes unnecessary.
These notes were progress notes that all nurses write throughout
their shifts at the hospital (on average one to three times per shift)
and include documentation from all patients, across all time periods
(i.e., morning, afternoon, overnight). All names of patients and staff
were removed from the notes prior to any review of the notes to
protect the identity of the individuals mentioned. Most patients in
the forensic department are male and have been diagnosed with a
psychotic illness.
4.2 | Participants
Fifty-five participants took part in our study. They were all employed
at a provincial psychiatric hospital in Ontario, Canada, that provides
comprehensive mental health and addictions services for individuals
with serious mental illness. All participants were members of the fo-
rensic services department which includes six units designed for indi-
viduals found NCRMD. The participant data are presented in Table 1.
Fourteen participants were self-identified as male and 40 were
self-identified as females (one participant chose not to self-identify
their gender). Over 65% of the participants were over the age of 35,
with about a third of nurses between 18 and 34. There were almost
equal numbers of participants who reported being a RN compared to
a RPN. Nearly two-thirds of the sample had over 10 years of experi-
ence working as a nurse.
Each participant was assigned a number (e.g., Participant 01) and
each note he/she wrote was assigned a number (e.g., Note 01). Of
the 55 participants, four did not have 30 notes (one had 18 notes,
2486 | MARTIN et al.

TA B L E 1 Participant data (N = 55) in how they conveyed, through their writing style, the behaviours
of those under their care, clear trends emerged: the negative group
Percent
(N = 33) was more likely to discount, pathologise, or be paternalistic
Gender±
in their interpretations; whereas, the positive group (N = 2) was more
Female 72.7
likely to be empathic and to make note of client-centred practices.
Male 25.5 Twenty participants fell in the balanced group: the notes from these
Age range participants included both positive and negative themes within their
18–34 34.5 notes. We structure the results to first unpack the notes with nega-
35–44 25.5 tive writing interpretations with a focus on discounting, patholo-
45–54 25.5 gising, and paternalistic interpretations conveyed in their writing
55–64 14.5 styles. We then turn to notes with positive writing orientations that
Professional designation± expressed empathy and client-centred approaches in the ways in

Registered nurse 45.5 which they write about their patients. Note that when we explored
connections between personal traits (i.e., gender, age range, or type
Registered practical nurse 52.7
of nursing license), none of these variables were correlated to writ-
Year experience
ing style.
0–5 14.6
6–10 23.6
10+ 61.8
5.1 | Negative interpretations: discounting
Note: ± 1 person preferred not to say.
Discounting, although the least common of the negative interpreta-
another 19 notes and the other two had 23 notes).The fewer num- tions, was evidenced in a total of 68 incidents across 32 participants.
bers of notes could have been due to vacation, illness or part-time Discounting, defined as the staff writer neither believing the patient
status. nor (and) appreciating the patient's experience, suggests that the pa-
tient's claims are considered unauthentic, which leaves the patient
largely discredited (see Goffman, 1963).
4.3 | Data analysis

In order to analyse these notes, we identified emergent themes
within the styles of writing of nursing staff. A codebook was con-
structed a priori to the data analysis but involved a structured
process of drawing themes from the notes, with subthemes to con-
stitute a comprehensive coding schedule to follow. Each theme was
operationalised and was mutually exclusive from the next; themes
continued to be documented in the codebook until reviewing the
notes revealed no new themes from the data; this process was con-
sistent with a semi-grounded (Glaser & Strauss, 1967; Ricciardelli,
Clow, & White, 2010; Ricciardelli & White, 2011) approach but with
elements of constructed grounded theory (Charmaz, 2006). After
the codebook was finalised, and theme saturation ensured, all notes
were coded anew by two independent researchers. All scores were
coded 0 (does not demonstrate this) or 1 (does demonstrate this).
5 | R E S U LT S
5.1.1 | Interpretations of desires versus needs
Discounting was most commonly evidenced among nurses who in-
terpreted their patients as ‘wanting’ medicine but not necessarily
being in need. Such interpretations included participants requesting
medicine for psychological needs (e.g., complaints of anxiety) as well
as for physical needs (e.g., complaints of pain):
P01: Pt [patient] requesting PRN ++ [a lot] however not
displaying anxiety when observed by writer. Pt compliant
with scheduled medications. Currently she is visible in the
day area socialising with peers.
P33: Mr. P requested prn tylenol for back pain rating it 10
out of 10. His presentation did not warrant a 10 out of 10
and writer explained the rating to him and he said it was
a 9 out of 10. Tylenol given for back pain.

Emergent theme analysis revealed both negative and positive writ-
ing styles. In terms of representation of these styles, participants fell
into one of three diverse groups: those who tended to write posi-
tively about their patients, those whose documentation portrayed
patient behaviour rather negatively, and nurses whose documenta-
tion included both positive and negative themes in a balanced man-
ner. Although neither of the first two groups was entirely exclusive
In the former excerpt from P01, the writer has discounted that
their patient requires the requested PRN (i.e., pro re nata or as needed
medication) despite their complaint; further, the writer justifies her/
his discrediting of the patient's claim by suggesting that because the
patient is visibly socialising with peers, their need for a PRN was inau-
thentic; implying the PRN was desired rather than a necessity. In the
latter example, P33 notes that the patient is asking for medication to
MARTIN et al.
help manage his physical back pain. The writer discounts Mr. P’s claim
by explaining that his pain did not present as “10 of 10,” and implies
that despite Mr. P’s rating, it is not possibly a “9 of 10.” Mr. P is discred-
ited as his claims are discounted and deemed unauthentic (i.e., he is
thought to be exaggerating his pain). In both cases, requests for medi-
cation for physical and psychological aliments, patients’ claims are dis-
counted. Despite this, in both cases the nurses provided the requested
medication.
5.1.2 | Interpretations of denial and fabrication
Patients who failed to recall prior events or corroborate staff reports
were discredited such that their lack of memory or difference in their
recall was discounted. For example, P03 writes “Patient claims he
does not remember Nurse W. and Nurse A. approached him in the
pica lounge” [this is a specific area of the unit]. The writer's words
suggest that it is unlikely that the patient does not recall being ap-
proached by the nurses and instead is not being truthful. Likewise,
P11 notes that her/his patient “denies having thoughts of self-harm,
even though it was reported that he endorsed suicidal ideation.”
Here again the inconsistency in the reporting of other nurses is
privileged as authentic and correct over the patient's own descrip-
tion. The patient is discounted; the implication being that they are
dishonest. In discussions of self-harming behaviour or other such ac-
tions that could increase patient supervision or reduce privileges, we
noticed that the denial of prior events was particularly scrutinised
by the writers.
Beyond discounting patients in their recollection of staff interac-
tions, writers also expressed a sense that the patient in question was
fabricating their responses. Thus, the credibility of the patient was
questioned. For instance, P05 described the lack of authenticity of a
patient who “suddenly began to cry (without tears) talking about her
diet,” (emphasis added). The writer's inclusion within the parenthe-
ses reveals their association of a lack of tears with the idea that her
crying was more of an act and less of an expression of hurt.
5.1.3 | Interpretations of patients’ life
as not normal or valid
In some instances, we observed nurses writing in a way that dis-
counted the normalcy of their life experience or suggested that what
they described in their life was not valid. For example, P16 writes:
“Patient was also shadowed for his last privilege, writer observed
patient meeting up with his 'girlfriend.'” The writer's use of the word
girlfriend in single quotes shows that he/she discounted Mr. H; spe-
cifically he/she denotes that the label girlfriend is questionable. In
later notes the discounting remains pervasive in her/his writing as
this participant requests to speak with Ms. J to confirm that she is
agreeable to interacting with Mr. H.
Overall, across all such cases, what is thematically clear is that
patients are easily discounted with their credibility limited, their
| 2487
words holding lesser status compared to staff, and their life expe-
riences questioned.
5.2 | Negative interpretations:
pathologising behaviour
The most common negative writing style evidenced in the nurses’
notes was the tendency to pathologise the behaviours of pa-
tients. Pathologising was evidenced 290 times by 53 participants.
Pathologising behaviour was operationalised as any, otherwise ‘nor-
mal,’ behaviour being redefined and interpreted as abnormal, devi-
ant, or unusual. Said another way, a normal behaviour, such as an
individual not being hungry, is reinterpreted as representative of a
symptom of mental illness. Additionally, pathologising was identified
when seemingly normal behaviour was documented without a clear
link to the patient's mental health suggesting that it is possible that
the link does not exist which then merely pathologises the behav-
iour. The very mention in documentation by the nurses of patient
behaviour and responses gives weight to these actions as important
events and things that related directly to their health.
5.2.1 | Redefining tasks of daily living
Most commonly among writers, routine tasks of daily living (e.g., eat-
ing, sleeping, dressing) were pathologised such that if a patient was
distracted, doing otherwise, or non-compliant with the requests of
staff to complete such tasks their behaviour was deemed aberrant
and identified as part of their mental illness. In essence, an over-
whelming theme that emerged was related to failed compliance with
normative behaviour, the routine of the unit, or the demands of staff
underpinned the pathologising of the patients behaviours:
P11: Ate dinner; however, refused HS [bedtime] snack
P04: He was offered his breakfast but refused
P04: Pt eventually went to her room to lay down just be-
fore lunch. She woke for lunch and returned to bed again
after. Pt was encouraged to come up and engage but she
refused in order to sleep.
P29: (pt was asleep) After her name was called loudly, a
few times, she eventually stirred and with an annoyed/
irritated tone, stated "would you…" but trailed off
P35: Eating sunflower seeds ++ in day area
All of the excerpts from nurses’ documentation show that pa-
tients failing to comply with staff requests resulted in their behaviour
being viewed as flawed. P11 and P04, for instance, echoed others in
demonstrating that refusal of any meal was deemed deviant as the
2488 | MARTIN et al.
mere mentioning of it deems it worthy of attention and therefore
encourages consideration that is it symptomatic of their mental ill-
ness. P04 and P29 demonstrate that sleep, or oversleeping, was also
deemed unusual and redefined as an expression of mental illness
rather than an expression of tiredness. Moreover, that a patient may
be annoyed by being woken up when sleeping was also pathologised
to instead represent non-compliance and an unusual response. Such
a redefinition of a normal act as deviant can include simple acts, like
P35 reveals, such as “eating sunflower seeds ++ in the day area.”
In this case, by including the statement about the sunflower seeds,
the nurse is identifying that this behaviour is unusual and the ac-
tion meaningful, suggesting it is an important part of their care. By
writing about the patient eating sunflower seeds (which could be a
normal behaviour), she is suggesting to the next reader that eating
sunflower seeds is an important fact that should be officially docu-
mented. If the nurse had a reason to believe that eating sunflower
seeds was indeed linked to the patient's mental health, she should
have provided an explanation and this would have, in fact, made it
less biasing because other clinicians would not have to speculate but
would know about how the patient activities are connected to their
health and therefore the reasoning for documenting the behaviour
would be clearer.
Moreover, the fact that not all patients openly and consistently
wanted to interact with staff was also redefined as abnormal, at-
tributed to the internal nature of the patients rather than anything
to do with the nurses themselves. For instance, P12 noted that a
“patient [was] guarded, and not wanting to talk;” the idea being that
all patients should want to interact with staff and not wanting to
is problematic. Similarly, P05 wrote that his/her patient was “ap-
proaching +++ to have needs met (shaved, did laundry, showered,
given mail)” while P09 notes that his/her patient “approaches staff
only to have needs met.” Echoing others, these participants’ words
reveal how avoiding staff or approaching selectively is interpreted
negatively.
Rather than relaying the facts of behaviour, some nurses’ writing
style was overtly untoward towards their patients:
P07: Yet another opportunity to go on Level 8 [relates to
privileges off the unit] was declined. Steadfast in his re-
fusal. He wants to go home, but he cannot grasp that the
way home is via his proven ability to engage and func-
tion risk-free to the satisfaction of the treatment team
members.
In this example, the writer’s frustration and chastisement of the
patient’s lack of understanding in this situation is clear in the style in
which the information is relayed.
P08: Writer met with Mr. X for a 1:1 to discuss last night
when he was asked to provide a urine sample. Patient be-
came defensive and stated "I wasn't pissed or upset, why
are you talking about not giving it I gave it I just couldn't
go right away". After writer explained the urine samples
were random patient replied "I don't like it that often. I've
never had a positive test for 5 years, since I've been here
because I don't do that stuff". Mr. X's concerns were ac-
knowledged but he was reminded that this was part of
his disposition but patient continued to voice "I just don't
understand why it's so often, it seems like every 3 days
for the past couple months".
In the above excerpt, P08 fails to include in his/her writing any em-
pathic statements of Mr. X’s frustration with being frequently elected
to provide urine samples; rather than showing compassion for Mr. X
who feels as though he has given a sample “like every three days for
the past couple of months” the writer reminds Mr. X that “this was part
of his disposition” (i.e., determined by the legal system). The style of
writing hints that Mr. X’s annoyance at constantly being required to
pee in a cup is abnormal or deviant. Again, noncompliance with staff
demands are being written about in such a way that is pathologising
rather than empathising.
Overall, within this theme the patients’ thoughts, feelings, and
behaviours are noted and meaning is made of them suggesting that
they are related to their health and wellness. Furthermore, their
noncompliance is not tied to their capacities, rationales and feelings
but instead attributed to their mental illness and status.
5.3 | Negative interpretations:
paternalistic behaviour
The final negative writing style that thematically emerged within
40 participants’ notes was a paternalistic interpretation of pa-
tients. One-hundred twenty-nine incidents were documented that
showed writers’ paternalistically describing patient behaviour. We
operationalised this as writers using condescension or words that
are patronising in nature or intent. Again, there was no link between
personal factors and the likelihood of writing in this style.
5.3.1 | “Encouraged”: seeming
judgments of behaviours
Paternalistic interpretations of patients were most evident through
the use of words, such as “encouraged”, to suggest that a patient is
less than capable of performing the task at hand without prompting
from staff. Often, encouragement was oriented at patients’ comple-
tion, or lack thereof, of routine tasks of daily living; but always docu-
mented with undertones of paternalism across notes:
P15: Encouraged to have a shower but declined stating
"A 40 yr old man does not need to be told to shower.”
P03: Patient was encouraged to shower, agreeable to
shower, however when reminded of same replied that
she will do it later
MARTIN et al.
P04: He was adherent to his meds [medications] and
meals. Pt attended court yard with no concerns. Writer
encouraged pt to have a shower today, as he expressed
he has not one for "3 days". He stated he will have one
on "Monday". Writer educated the importance of proper
hygiene.
P33: Writer encouraged her to tidy up the Quiet Room [a
shared area in the unit]
The collective of excerpts presented here, representative of
many others, use the word “encouraged” to suggest that, without
said reminding, patients will not perform the requested tasks. The la-
tent effect of such patronising instruction is most evidenced in P15’s
note that, after encouraging his/her patient to shower, the patient
replied that “a 40 yr old man does not need to be told to shower”.
Clearly, being “encouraged to have a shower” had an effect rather
opposite than that intended—it confirmed a desire not to shower
and comply with the staff. Similarly, P03 and P04 both “encourage”
their patients to shower, but neither complies. Rather than consid-
ering that an individual may not feel like showering at that point in
time, their patients’ behaviours are reinterpreted as representative
of their unwillingness to engage in self-care and practice hygiene,
acts that may or may not be indicative of mental illness. P04 actually
concludes her/his notes by stating that “writer educated the impor-
tance of proper hygiene.” P33, in a similar manner, also suggests that
without “encouragement” the patient will not engage in tidying the
room, although it is unclear if this would be a choice or required ac-
tion to complete. The tone of the writing is key here, where the pa-
tient is presented as otherwise less than competent, demonstrating
symptoms of mental illness, or even somewhat lazy because they do
not feel like completing a task at that time.
Such condescending undertones here are also evidenced in
how the writers describe the tasks completed by their patients, for
instance P01 writes “Used the phone appropriately.” Here the idea
of a patient being able to do something “correctly” is put forth,
rather paternalistically and perhaps unintentionally suggesting
that the patient is generally unable to use a telephone. Similarly,
P05 writes “reminded of breakfast”; suggesting that without such
a reminder breakfast would be unnoticed. What is clear, is a ten-
dency among writers to believe that without their intervention pa-
tients on their unit cannot function in ways appropriate for daily
living. For instance, a number of notes referred to patients’ inabil-
ity to dress according to what the weather demands or the climate
of the unit:
P23: Ms. M was informed that she could not leave the
unit, patient was encouraged to stay in as the weather
is very cold and she did not have proper foot wear on
P34: Pt is currently wearing a toque to bed and he was
reminded that maybe he should remove same so he does
not become over heated
| 2489
P22: Encouraged to put some footwear on as she was
ambulating around the unit in bare feet
Across all examples, the similarity is that the patients cannot
choose appropriate attire, suggesting a lack of capacity rather than
perhaps a lack of attire or simply reflective of mood or personal state.
P23, for instance, writes that she/he does not consider the patient to
be wearing “proper” footwear while P22 “encouraged” his/her patient
to not walk barefoot on the unit. Moreover in P22 is the judgment ex-
pressed about lack of footwear despite the fact that the patient lives
on the unit and may simply prefer to not wear shoes in their home.
Similarly P34 reminds his/her patient to remove his toque to help mod-
erate his temperature when sleeping; suggesting he would not realise
he could do so if he became hot when sleeping. The patronising under-
pinning to the notes removes the agency of the patients and instead
suggests some degree of incapacity rather than recognising personal
choice, mood and desires.
5.4 | Positive interpretation: empathy
Empathy, although the less common of the positive interpretations,
was evidenced in 34 incidents across 16 participants. Empathy is op-
erationalised as notes where the writing style is indicative of actions
taken up by nurses to display their understanding of the patient's cir-
cumstances and processes. Being empathic would suggest that the
nurse considers their patient's claims as authentic and thus credits
the patient's authenticity in their actions (rather than discrediting
their person; Goffman, 1963). There were no trends of association
between this writing style and personal factors.
5.4.1 | Kindness and understanding
Although the least common theme, kindness was demonstrated in
the writing when nurses were empathetic to their patient's needs or
situations; particularly when the patient was hurting. In such cases,
writers demonstrate kindness in their word choice, actions, and tone
rather than discount the patient or pathologise their behaviours:
P05: Accepting of empathy and support as he sat with
writer for a 1:1…Writer provided him with the contact
number for Ms. X (patient advocate) and her role was
explained. He was thankful. [this was for a client who
was on an assessment order and confused as to why he
was there – didn’t believe he did anything wrong – very
anxious].
P08: After speaking with his brother Mr. X informed
writer that he would no longer be going to get his hair
done and to visit his family. Mr. X informed writer that his
brother requested "$20 each way" for gas and he did not
have the funds for this. When I asked Mr. X if he was okay
2490 | MARTIN et al.
he replied "yeah I'm alright". Patient explained "when I
first talked to him he didn't mention anything about gas
money but after he cancelled and rescheduled he started
mentioning money for gas. I won't have any money until
I get my next cheque". Support was provided as writer
was aware that Mr. X had been looking forward to visit-
ing with his family.
P11: Co-staff reported to writer that she had a lengthy
1:1 with patient, who spoke about somatic pain in her
legs which was inflicted, due to police brutality. Co-staff
reported that empathy was provided and pain meds were
offered; however, patient refused the same. Writer spoke
to patient a short while after, inquiring if she needed any-
thing to help with the pain. Patient became very labile,
raising her voice saying "you don't understand what it's
like, not to be able to sing in the morning -it helps to calm
me", patient's feelings of frustration was validated, writer
was thanked for same.
Across examples, nurses highlight and bring attention to the pa-
tients’ needs and suffering. P05 recognises that her patient is con-
fused and anxious, and tries to offer practical support and comfort
to the patient. P08 makes specific mention of the disappointment
of Mr. X, recognising that he “had been looking forward to visiting
with his family” and understanding his sadness and pain that he ex-
periences when his trip is cancelled for the second time. P08 kindly
notes that Mr. X says he's “alright” but in essence is clearly hurting
and is sympathetic to his plight. P11 recognises the physical discom-
fort in her patient's legs and, rather than discounting the pain or its
intensity, offers pain medicine. Even when the patient appears to
respond to the nurses mildly incoherently, the nurses empathise and
validate the patient's feelings rather than responding in a conde-
scending or pathologising manner. Each patient is viewed as an au-
thentic self, capable of representing themselves accurately beyond
their mental illness.
5.4.2 | Empathy and Natural Human Connection
There is evidence in some notes of nurses being empathic for no
particular reason—patients were not demonstrating need as noted
in the prior examples—instead the general practice of nurses was
to display kindness and compassion. For instance, P32 simply “ap-
proached patient to inquire of his well-being” simply to inquire,
rather than in response to an outburst or challenge. Such practices
were echoed by others:
P15: Very excited about her Mothers visit today
(Saturday) at 1100hrs. Stated she hasn’t seen her in
some time…Expressed how much she loves and misses
her mother. Reminisced with writer of how things used
to be when she lived with her mother and what a happy
time it was in her life…Was excited to have her hair done
(blow-dried and flat ironed) for her visit…Appreciative of
time spent with her and on her hair by writer.
P34: Pt asked to go off unit to cafeteria for Black History
month lunch. …He was pleased with food choices and en-
joyed some for his lunch. He offered both writer and co-
staff to try the dessert that is native to Jamaica. Writer
accepted offer pt provided pt with a small sample. He
was thanked for his generosity in sharing same.
Across these excerpts from nurses’ documentation, the nurses
credited the authentic selves of their patients – listening to them as
regular people with histories, likes and dislikes, and experiences rather
than focusing on their mental illness and interpreting their actions
as symptomatic of their diagnosis. P15, for instance, spends time
with her/his patient and also expresses fulfillment in that the patient
appreciates the time they spent together. The nature of the writing
demonstrates the nurse's thoughtful consideration of the patient's
situation; the writer is quite taken with the reminiscing and relates to
the patient. Plus, he/she helps the patient to prepare for her highly
anticipated event by doing her hair for her. Similarly, P34 expresses a
positive impact on self that results from the patient's kindness towards
staff, which is shown in response to the staff's kindness and support. In
both examples here, like others, the nurses are relating to the interests
of the patients in a manner consistent with natural human connection.
In this way, the writing style reveals a perspective that the nurses see
the person before the disease. Perhaps the most pressing example is
that of the empathy noted when a nurse considers another staff's as-
sessment of a patient to be inaccurate; as such assessments undoubt-
edly impact the patient's conditions of confinement. P07 notes of the
patient:
P07: He is not aggressive: on the contrary, he is gentle
and mild-mannered, with a willingness to help out his
peers who might be in need of some clothing articles or
monies etc. … Given the above, I would request the treat-
ment team to re-evaluate the beneficence versus the
risk of our pursuing this treatment option for Mr. X. [this
nurse is commenting about the fact that the pt doesn’t
want to have ECT and the healthcare team is telling him
he has to go].
P07 clearly recognises the frustration and pain that their client will
likely experience because of the assessment made by another clinician.
Rather than discounting his “gentle and mild-mannered” presentation,
he/she instead considers the presentation of self as relevant and cred-
its his demeanor and actions such that he/she requests a re-evaluation
of Mr. X.
Evinced across the documentation coded as demonstrating em-
pathy is the practice of kindness, understanding and compassion in
occupational practices towards patients. Not only did nurses here
strive to support their patients and pay attention to their person,
MARTIN et al.
they chose to write about it and therefore formalise the value of this
perspective to be included in the patients’ care.
5.5 | Positive interpretations: patient-
centred approach
The more common positive writing style by nurses, although more
difficult interpretation to identify in nursing notations, is that of
nurses who take a patient-centred approach in their occupational
practices. A patient-centred approach is operationalised as writing
indicative of actions taken by the nurse that displayed their willing-
ness to incorporate the client's needs/desires in decision-making
about their care. Patient-centred approaches were noted in 51 notes
across 22 participants. Analysis did not reveal any associations be-
tween this writing style and personal factors.
5.5.1 | Person first. Patient second
Nurses, in these notations, recognise their patient first, and fore-
most, as a person; persons with reactions to the circumstances and
environment around them which is not always consistent with ideal
behaviours (e.g., nurses may choose not to wake up a sleeping pa-
tient or pathologise their behaviours if they are upset or annoyed
about being woken up). In seeing patients as people first, nurses
sought, as we observe in their notation, to make reasonable deci-
sions that would be provided to most humans (i.e., not psychiatric
patients) and to work with patients to help moderate the more nega-
tive experiences they may undergo while in custodial care.
P32: MSA not completed. Patient in bed all shift. [MSA=
mental status assessment, essentially this is noting that
the nurse did not wake the patient in order to do a routine
assessment].
P31: Currently doing crafts with a select peer in day area.
This second attempt has gone well thus far. Will keep him
out for as long as he can tolerate. [In this case the patient
is on special monitoring and the nurse is saying he/she is
trying to keep him out of seclusion as long as possible].
P20: Enjoyed a long walk around the perimeter of the
hospital grounds with another staff and patient. Writer
encouraged him to consider asking his assigned nurse for
an escorted grounds walk every morning and to apply for
level 2 indirectly supervised privileges. [This is a level of
security with greater independence].
In the first excerpt, P32 elected not to wake up a patient, thereby
allowing the patient to remain sleeping rather than forcing the per-
son to wake up to complete a routine assessment; thus, the notation
highlights their decision to put the patient first rather than following a
| 2491
scripted care process for all patients. In a similar manner, P31 too put
her/his patient first by helping to ensure the patient stayed out of se-
clusion as long as possible, writing in such a manner that reinforces the
nurse's focus on what is ‘best’ for the person. In the latter quote, P20
also shows consideration of what would be best for the patient and
helps to find a way for the patient to engage in activities he enjoys (in
this case escorted walks outside on hospital property). The nurse's no-
tation evidences that the nurse recognised that the patient enjoys the
walks, and suggests ways for the patient to continue to pursue such
activities more routinely.
5.5.2 | Consideration of patient needs
Another example of the patient-centred writing style is when nurses
specifically mentioned how they acted in accordance with patient
needs or preferences: P29: Informed (via message written on paper
by writer) that snack would be served within 10 min. She nodded.
[In this case the client had been using paper to communicate so the
nurse also used written words to ‘talk’ to the patient and therefore
was participating in this method of communication]. As is evident,
the preference of the patient is put first and her needs are incorpo-
rated into her care.
6 | D I S CU S S I O N
Documentation is a critical component of good quality health care.
It plays a critical role in how decisions are shaped and can bias the
treatment (and future treatment) of patients. Therefore, it is critical
that notes are as objective as possible and that they do not include,
explicitly or implicitly, irrelevant attitudes and biases. Despite this,
our results suggest that most nurses have a style of writing that
much of the time (if not exclusively) includes themes that are nega-
tive in nature to discount, pathologise or paternalise their patients.
These instances of patients being discredited, is likely – at least
in part – to arise from their mental health status and criminal justice
involvement (e.g., Goffman, 1963). Goffman (1963) points out that
the patients reside in a mental health facility which, in itself, may
leave a patient discredited simply by the nature of their placement.
Behaviours that may be normal, may be deemed aberrant and in need
of reminding due to the context of the patient. The idea is not new
and was described in the research by Rosenhan (1973), who con-
ducted several studies exploring the accuracy of psychiatric diagno-
ses by getting healthy participants (including himself) admitted into
psychiatric facilities. For example, he noted that one pseudopatient
wrote extensive notes about his observations while an inpatient. The
nurse documenting this indicated that he had “writing behaviour”
and Rosenhan, in his discussion of this experience, argues that pa-
tients are pathologised:
given that the patient is in the hospital, he must be psy-
chologically disturbed. And given that he is disturbed,
2492 | MARTIN et al.
continuous writing must be a behavioural manifestation
of that disturbance…Consequently, behaviours that are
stimulated by the environment are commonly misat-
tributed to the patient's disorder.
(Rosenhan, 1973, p. 33)
Furthermore, as identified in the documentation reviewed in our
study, there is a tendency for nurses to take a paternalistic role with
forensic patients which is expressed as “control, rule enforcement,
and parenting behaviours” (Marshall & Adams, 2018). The NCRMD
finding suggests that as a society, we have taken an individual's
responsibility for their actions and committed to supporting their
return to full citizenship. In essence, this act itself is paternalistic
in nature because we take away the autonomous decision-making
abilities of individuals found NCRMD and because of their criminal
justice involvement, do not believe that they have the capacity to
engage in self-determination as their views may be considered to
be antisocial or risky (Dorkins & Adshead, 2011). In turn, this can
lead to forensic patients developing dependence on mental health
clinicians and may help to explain why research has found that clini-
cians working in forensics departments are often concerned about
how to facilitate processes that enhance healthy independence (see
Jamieson, Taylor, & Gibson, 2006).
Even if participants receive the benefit of the doubt and try to
view their notes as without malign, without specific details and/or
the context provided in the notes, the reader may be left assuming
that any statements are meaningful and indicative of something
important in regard to a patient's health and well-being. Therefore,
in many cases the descriptions of patients captured in documen-
tation are interpreted by readers as pathological and linked to
patients’ mental illness. These notes elicit within the reader spe-
cific emotions and thoughts about the patients. Alternatively, the
writing styles that are positive in nature and capture more com-
passionate and considerate practices/approaches leave the reader
feeling warmer emotions. Our study highlights the less frequent
occurrence of these more positive records of such practices, and
supports previous research in this area that demonstrated that
nursing documentation often lacks evidence of patient-centred
care (Myklebust et al., 2018).
6.1 | Limitations
We acknowledge that the participants in this study are a unique set
of mental health nurses who work with a specific inpatient popu-
lation. As a result, the generalisability of our results requires more
research, such as review of nursing documentation from additional
nursing staff in other settings. Also, given that we highlight the po-
tential for bias to be “cascaded” from one nurse to the next when the
notes are read, we understand that the writing styles we observe
and describe in this research study have been heavily impacted by
the participants’ years of exposure to nursing documentation in gen-
eral (see Dror, 2018). Therefore, future researchers, we suggest, may
wish to examine how the consumption of bias changes the writing
styles of nursing staff over time.
7 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
When reading the excerpts (e.g., the examples of the writing
styles) it becomes clear that writing style can influence and bias
the perspective of other staff towards the patients who are de-
scribed and as such may contribute to the type of care provided,
the assessments made, and decisions formed of the patients
in the care of other professionals. Thus, that efforts to improve
documentation made by mental health nurses are made is critical.
Specifically, attention needs to be directed to the writing styles of
the notation. For example, nurses should be provided with edu-
cation and training that presents the evidence about documenta-
tion and bias using specific examples of their own writing both
when they are initially onboarded into a nursing position but also
at regular intervals throughout their career as scholars suggest
that nurses require ongoing support to maintain standards (Blair
& Smith, 2012). Furthermore, researchers highlight that education
has the most pressing affect on quality of documentation as de-
fined by nursing staff (Kamil, Rachmah, & Wardani, 2018); specifi-
cally education improves motivation to document well (Mediarti,
Rehana, & Abunyamin, 2018).
Another option to consider is how electronic health record (EHR)
systems may be able to provide technological solutions to bias in doc-
umentation. Following the adoption of EHRs, researchers have found
improvements in the quantity of information documented (e.g., Martin
et al., 2018), the ability to support quality improvement and data ana-
lytics (e.g., Howley, Chou, Hansen, & Dalrymple, 2015; Kern, Edwards,
Pichardo, & Kaushal, 2015), and ease of data sharing (e.g., Vest, Kern,
Silver, & Kaushal, 2015). One option is to use pull-down menus and
prewritten description choices from which nurses choose. This may
help by providing a more structured note writing, which will reduce
making certain biased notes. Another option is in the form of checks
and balances of nurses’ writing prior to it being submitted to patients’
charts. This could be in the form of prompts or checkboxes that ask
staff to reflect on their writing in relation to specific components such
as patient-centredness, recovery and bias. Okaisu and colleagues
(2014), in their effort to improve documentation practices, found that
in addition to education, redesign of documentation forms was nec-
essary. In their comprehensive review of studies exploring nursing
documentation and audit tools, Wang and colleagues found that when
standardised documentation systems (i.e., programs that used specific
nursing theories to guide notation and language used) were used, the
content of nursing documentation improved (2011).
8 | CO N C LU S I O N
Documentation by nursing staff is a core component of patient care.
Our study demonstrates that documentation is not a technical and
MARTIN et al.
simple operation, and far from objective. Nursing notes are influ-
enced by a whole array of factors and attitudes, which can result in
distorted and biased note that influence (e.g., through bias cascade
and bias snowball) the care provided to patients and the assess-
ments made about them.
Forensic mental health nurses tend to write in a more negative
writing style, which is concerning because it reflects the biases of
the nurses and due to the possibility for bias and other negative per-
spectives to cascade from one clinician to the next. Indeed, there
is the potential for a snowballing effect in which the extent of the
bias grows larger and larger (Dror, 2018). Nursing professionals need
to address the challenges associated with preconceived notions and
biases, and how it may impact accurate and effective documentation
practices.
ORCID
Krystle Martin https://orcid.org/0000-0003-0419-8328
Rosemary Ricciardelli http://orcid.org/0000-0002-0905-8968
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Martin K, Ricciardelli R, Dror I. How
forensic mental health nurses’ perspectives of their patients
can bias healthcare: A qualitative review of nursing
documentation. J Clin Nurs. 2020;29:2482–2494. https://doi.
org/10.1111/jocn.15264