Areas of Work
Background
- Registered nurse, NTNU, Trondheim
- Interdisciplinary continuing education in mental health care, Molde University College
- Master’s in Clinical Helping Relations, Molde University College
- PhD in Health and Social Sciences, Molde University College
- Several years practice as a nurse in mental health services and in municipal mental health care
Publications
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Myklebust, Kjellaug Klock & Hoemsnes, Helene
(2026).
Practitioners' Perspectives on Engaging Adolescents in Collaborative Documentation in Municipal Child and Family Support Services.
Child & Family Social Work.
ISSN 1356-7500.
doi:
10.1111/cfs.70149.
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Adolescents' right to access their client records is closely tied to their right to participate. Few studies have examined collaborative documentation between practitioners and adolescents, but research suggests they are interested in reading what is recorded about them. This study explores how practitioners in a Norwegian municipal child and family support service experience collaboration with adolescents in writing case notes. Six qualitative in‐depth interviews were conducted and analysed through systematic text condensation using the theoretical frame of Laura Lundy's (2007) model for conceptualizing participation under Article 12 of the UN Convention on the Rights of the Child. The findings revealed two main themes: case notes as a tool for increasing adolescent involvement and the challenge of involving adolescents in the process of documentation. Case notes were found to support adolescents' participation, both through collaborative documentation and as a tool for practitioner reflection in preparing for future encounters. However, most notes were written solely by practitioners, reflecting challenges with collaborative approaches during sessions, uncertainty about parental access, decisions on what content to include and time constraints. The findings highlight the need for practitioner training in collaborative documentation and further research on adolescents' perspectives on involvement in creating case notes.
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Myklebust, Kjellaug Klock; Ramstad, Julia Bogen & Vatnar, Solveig Karin Bø
(2024).
Healthcare Professionals’ Documentation in Supported Accommodation for People with Profound Intellectual Disabilities: An Educational Intervention Study.
Healthcare.
12(16).
doi:
10.3390/healthcare12161606.
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Good-quality relationships in which individuals with profound intellectual disabilities (intelligence quotient, IQ < 20–25) are recognized by healthcare professionals (HPs) are essential for the quality of healthcare and promoting autonomy. This study examines the impact of an educational intervention on documentation of the interplay between HP and individuals receiving services in supported accommodation in Norway. An educational intervention study was designed to encourage HPs to document their approaches and interplay. The Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI) was applied to measure documentation before and after the intervention. Journal notes written over a three-month period before the intervention and a three-month period after the intervention were measured. Prior to the intervention, only 23.1% of the journal notes described the resident’s experiences, increasing by 5.4% (p = 0.041) post-intervention. Practical solutions to individual experiences increased from 0.9% to 8.5% (p < 0.001). The educational intervention demonstrated a significant increase in the documentation of residents’ experiences and the interplay between HPs and residents. Future research should explore the generalizability of these findings. Incomplete documentation of HPs’ relational work conceals important aspects of the healthcare provided, potentially resulting in confining autonomy and participation for individuals with intellectual disabilities.
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Myklebust, Kjellaug Klock; Hoemsnes, Helene; Kvello, Øyvind & Vatnar, Solveig Karin Bø
(2024).
Collaboration with clients to create journal notes : a mixed methods evaluation of a pilot intervention study in a municipality mental health services team.
Counselling and Psychotherapy Research.
ISSN 1473-3145.
25(1).
doi:
10.1002/capr.12829.
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Introduction:
The purpose of this study was to evaluate an intervention designed to encourage therapists in a municipality mental health services team to collaborate with their clients when writing journal notes. The team was part of a low-threshold mental health service for children, adolescents and their parents. The therapists offered individual therapeutic sessions with children, adolescents and parents, as well as family sessions. The therapists documented their encounters in the clients' electronic health records.
Methods:
The study used a convergent mixed methods design. First, the quality and quantity of documented therapist–client interactions were measured before and after the intervention using the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI). Cross-tabulation and logistic regression analyses were used to examine potential differences in the recording of therapists' approaches before and after intervention. Second, we explored the therapists' experiences of participating in this project by conducting individual in-depth interviews. Qualitative interviews were analysed by systematic text condensation. Finally, the quantitative results from assessing the journal notes were contextualised with the qualitative results from the interviews.
Results:
The number of journal notes describing therapist approach and client response increased by 25% points after the intervention. In the interviews, the therapists acknowledged the intervention's relevance to their practice. However, they invited only a limited number of clients to co-create journal notes. The clients welcomed the invitation.
Conclusion:
Collaborative documentation challenges established journal documentation practices and may strengthen the client's voice. This study provides suggestions for strengthening the intervention in the future full-scale studies.
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Myklebust, Kjellaug Klock; Rønning, Solrun Brenk; Vatnar, Solveig Karin Bø & Bjørkly, Stål
(2022).
Terapeutisk relasjon – en hjørnestein i miljøterapi – hva viser sykepleierapportene?
Nordisk sygeplejeforskning.
ISSN 1892-2678.
12(3),
p. 1–15.
doi:
10.18261/nsf.12.3.2.
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Bakgrunn og hensikt: Det er faglig enighet om at terapeutiske relasjoner skal være et hovedfundament i miljøterapi i psykisk helsevern. Likevel mangler det forskning på hvordan relasjonelt arbeid dokumenteres. Metode: Denne studien er en kvalitativ og deskriptiv analyse av daglige rapporter i sykepleiedokumentasjon. Vi har undersøkt hvordan miljøpersonalet ved en akuttavdeling i psykisk helsevern dokumenterte inntoning og samspill med pasienter. Et utvalg på 363 rapportutdrag som beskrev pasienters opplevelser ble hentet fra 14 pasientjournaler. Resultat: 94% av rapportene dokumenterte ubehagelige pasientopplevelser og 6% positive pasientopplevelser. Det ble identifisert to hovedkategorier av rapporterte tilnærminger til pasientopplevelsene:Ingen beskrivelse av inntoning og Beskrivelser av forsøk på inntoning. Kun 25% av rapportutdragene beskrev forsøk på inntoning. Majoriteten av tilnærmingene var observasjons- og handlingsorienterte uten at det var lagt vekt på pasientopplevelse og gjensidige samspill. Konklusjon: Videre forskning på sykepleiedokumentasjon bør inkludere miljøpersonalets inntoning og pasientenes medvirkning i rapportskriving.
Nøkkelord: inntoning, miljøterapi, psykisk lidelse, sykepleiedokumentasjon, sykepleie-pasient-forhold, terapeutisk relasjon
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Myklebust, Kjellaug Klock & Bjørkly, Stål
(2019).
Development and reliability testing of the Scale for the
Evaluation of Staff‐Patient Interactions in Progress Notes
(SESPI) : an assessment instrument of mental health nursing
documentation.
Nursing Open.
6(3),
p. 790–798.
doi:
10.1002/nop2.254.
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Aim: To develop and test the reliability of the Scale for the Evaluation of Staff‐Patient
Interactions in Progress Notes (SESPI). Therapeutic nurse–patient interactions are
fundamental in mental health nursing. However, little is known about how these interactions
are recorded in nursing documentation and there is no instrument available
for collecting this type of information for quantitative analysis.
Design: Instrument development and reliability testing.
Methods: The development of the SESPI was based on qualitative analyses of progress
notes retrieved from patient records in two mental health services. A self psychological
attunement perspective guided the analyses. SESPI was tested for internal
consistency and inter‐rater reliability after 22 nurses independently scored 10 progress
notes.
Results: Cronbach's alpha for the entire instrument was 0.977, indicating that the
raters’ scores had very high internal consistency. ICC was 0.770. The alpha and ICC
values for each step were high, varying between 0.970 and 0.992.
Keywords: empathy, inpatients, instrument development, medical record, nurse–patient relations,
nursing assessment, psychiatric nursing
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Myklebust, Kjellaug Klock & Bjørkly, Stål
(2019).
The quality and quantity of staff-patient interactions as recorded by staff : a registry study of nursing documentation in two inpatient mental health wards.
BMC Psychiatry.
19,
p. 1–12.
doi:
10.1186/s12888-019-2236-y.
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Background: Therapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation.
Methods: The study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward.
Results: Only 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models.
Conclusion: These findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts.
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Myklebust, Kjellaug Klock; Bjørkly, Stål & Råheim, Målfrid
(2017).
Nursing documentation in inpatient psychiatry : the relevance of nurse-patient interactions in progress notes : a focus group study with mental health staff.
Journal of Clinical Nursing (JCN).
ISSN 0962-1067.
27(3-4),
p. e611–e622.
doi:
10.1111/jocn.14108.
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Aims and objectives: To gain insight into mental health staff’s perception of writing
progress notes in an acute and subacute psychiatric ward context.
Background: The nursing process structures nursing documentation. Progress notes
are intended to be an evaluation of a patient’s nursing diagnoses, interventions and
outcomes. Within this template, a patient’s status and the care provided are to be
recorded. The therapeutic nurse–patient relationship is recognised as a key compo-
nent of psychiatric care today. At the same time, the biomedical model remains
strong. Research literature exploring nursing staff’s experiences with writing pro-
gress notes in psychiatric contexts, and especially the space given to staff–patient
relations, is sparse.
Design: Qualitative design.
Methods: Focus group interviews with mental health staff working in one acute
and one subacute psychiatric ward were conducted. Systematic text condensation, a
method for transverse thematic analysis, was used.
Results: Two main categories emerged from the analysis: the position of the profes-
sional as an expert and distant observer in the progress notes, and the weak posi-
tion of professional–patient interactions in progress notes.
Conclusions: The participants did not perceive that the current recording
model, which is based on the nursing process, supported a focus on patients’
resources or reporting professional–patient interactions. This model appeared to
put ward staff in an expert position in relation to patients, which made it
challenging to involve patients in the recording process. Essential aspects of
nursing care related to recovery and person-centred care were not prioritised for
documentation.
Relevance to clinical practice: This study contributes to the critical examination of
the documentation praxis, as well as to the critical examination of the documentation
tool as to what is considered important to document.
Keywords: documentation, mental health nursing, nurse–patient interactions, nurse–patient relations,
nursing process, psychiatric nursing
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Myklebust, Kjellaug Klock & Bjørkly, Stål
(2011).
Selvpsykologiske tilnærminger til utfordringer i brukermedvirkningsrelasjoner – en kvalitativ studie blant psykisk helsearbeidere.
Vård i Norden.
ISSN 0107-4083.
31(3),
p. 35–39.
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Published Sep. 3, 2018 3:04 PM
- Last modified Oct. 13, 2026 11:24 AM
