Self-care nursing interventions: a qualitative study into electronic health records’ contents

Aims: This study aims to (1) analyse all self-care–related interventions Portuguese nurses documented, (2) determine potential issues that may impair semantic interoperability and (3) propose a new set of interventions representing nursing actions regarding self-care that may integrate any HER application. Background: As populations age and chronic diseases increase, self-care concerns rise. Individuals who seek healthcare, regardless of context, need prompt access to accurate health information. Healthcare professionals need to understand the information in all places where care is provided, creating the need for semantic interoperability within electronic health records. Methods: A qualitative descriptive and exploratory study was conducted in two phases: (1) a content analysis of nursing interventions e-documentation and (2) a focus group with fifteen registered nurses exploring latent criteria or insights gleaned from the findings of content analysis. The COREQ statement was used to guide research reporting. Results: We extracted 1529 nursing intervention sentences from the electronic health records and created 209 intervention categories. We identified the main issues with semantic interoperability in nursing intervention identification. Conclusion: According to the findings, nurses cooperate with clients, offering physical aid and encouraging them to overcome functional limitations to self-care tasks hampered by their conditions. Implications for nursing policy and health policy: This article provides evidence to warn policy makers against decisions to use locally customised electronic health records, as well as evidence on the importance of policy promoting the adoption of a nursing ontology for electronic health records. And, as a result, the harmonisation and effective provision of high-quality nursing care and the reduction of healthcare costs across nations.