Documenting Stigma: A Descriptive Qualitative Study of Psychiatric Emergency Notes of Aggressive Incidents.

Abstract

Clinical notes, as subjective reconstructions of events, can unintentionally reinforce stigma, perpetuating stereotypes and power imbalances that hinder care and recovery for people receiving care. In psychiatric emergency settings, documentation of aggression incidents may reflect workplace culture, reinforcing perceptions of violence and unpredictability. The aim of this study was to explore the representations of people receiving care conveyed in clinical notes written after incidents of aggression in psychiatric emergencies. A retrospective descriptive qualitative design was used to examine clinical notes reporting aggression incidents from 108 files from a Canadian psychiatric emergency service (2012-2019) collected through the Signature Biobank. Data were analyzed using thematic analysis by Braun and Clark, guided by Link and Phelan's stigma conceptualization theory. Four themes emerged: shaping individual stigmatization through documentation, hierarchical identities revealing a social separation, structural stigmatization, and emergence of a compassionate approach. Findings highlight how institutional changes are needed to ensure more nuanced, reflective, and trauma-informed documentation practices that respect people dignity and experiences. Training in trauma-informed, recovery-oriented, and human rights-based documentation is recommended to reduce stigma and fostering person-centered care. Future research should examine broader institutional practices and explore how training impacts documentation and outcomes for people with mental illness.