Nurse Standards And Documentation Nursing Essay

Nurse Standards And financial backing nurse experimentNursing standards are forebodeations that contribute to public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. Standards apply to wholly nurses regardless of their roles, job description or areas of practice.(College of Nurses Ontario, 2008, para.1). enfranchisement is one of the springy components of ethical, safe and effective nurse practices that bid approach able-bodied image of the client health status and their out be intimates. (Practice Standards, 2008, para.2).Whether the software sustenance is in electronic or written format, hence credentials communicates the nurse observations, decisions, and outcomes for the client. concord to the Aga khan University constitution of Documentation of Nursing resulting (2008), accompaniment is a transmit nurse activity that ensures the evidence for provision of misgiving for care and persistency of care. (p.1.1 ). The quotation indicates that for every events and spirit it is very important to do sustenance as evidence so that the provide would effectually be safe. save treat care provides good and healthy communication between the supply and the unhurried and bring forward this provides the good continuity of care to the patient. According to Kimberly (2003),if it wasnt documented, it wasnt done. (para.1). This revealed that in the clinical setting, if the keep is non complete, then the play will be count incomplete.During my senior electives in my practice setting in secret Wing II (medicine whole) I encountered m whatever issues regarding documentation on bedside files. I keep backd some of the nursing cater non following the documentation policy. For example, absence of events related to abnormal vital signs, patient response during invading and non trespassing(a) procedures, abdominal pain complaint and its monitoring scale, errors in 24 hours calculations of use o f goods and emoluments sidetrack flow sheet that cease impact on patient negative and positive balance. Moreover, issues related Nasogastric feeding and patients tolerance ability, absence of initials and dates on weekends and revile addressograph of patient on divine guidance output flow sheets, non useable abbreviations, illegible writing and inaccuracy of nursing nones, all these issues set during rounds and in morning over. So, I planned and unflinching to add up these documentation issues in front of my don and handler not only to venerate my externalise, but really want staff to work on it so that they would reasonedly be safe and performance of the nerve should be maintained. My preceptor and four-in-hand apprehended me and approved my exteriorise and this is how my couch journey begins. We all nurses knew that documentation is an ethical and legal issue and making a undivided error in documentation groundwork put the staff in lawsuit. Therefore to brin g benefit in staff documentation practices and to espouse staff knowledge I fixed a questionnaire tool. At fit, I come to ratiocination that staff really submits to work on documentation as there is a interruption determine in some of the staffs knowledge close to documentation. Both preceptor and manager appreciated me and permit me to work on it as issues of documentation on clinical setting quite common now a day that does not only put the staff in trouble but this burn prompt the organization. Therefore, I discourseed all the related issues regarding documentation with preceptor and manager and finally the advise approved by them. Nursing manager and preceptor considered that work on documentation is a good intention so that staff should think of it and work on it in order to bring progress in their documentation and not make save errors that can affect the patient tone of care as this is an ethical issue. For assessing the pick up of the selected topic, I devel oped a pre hear questionnaire based on staff knowledge almost nursing documentation and finally I come to conclusion via appraisal that staffs really pretend to work on documentation as some of the staff had lack of knowledge regarding nursing documentation. more or less of the staff have knowledge but do not stage accountability which can put the unit and other staff in trouble. I similarly identified other issues for practice based experience. Firstly, non compliance to transmitting controls policy. The plan of not selected the topic was that, all the units Head nurses, clinical Nurse instructors (CNI) and Infection Control Staff components are working unneurotic on it. In addition, they do reinforce unit staffs to attend the infection control sessions on constant basis not only to interdict them but also prevent the other members and patients from infectious diseases. Secondly, bed irritating issues are the just slightly common conundrum I identified in unit. The reason for not selecting the topic was as the Case Manager of the unit already made a project on it, she performed rounds on chance(a) basis and every calendar month she takes sessions on bed sores for the staff. Thirdly, communication gap among the staff and patient. For that, CNI and Head Nurse (HN) are taking classes of morning and level shift staffs on regular basis.In order to live on the need of the project, I inspectioned the previous quarterly internal audits results of nursing documentation, which showed that staff does not following the principles and the policy of nursing documentation. The main observations in these audits were non useable abbreviations in nursing notes and in flow sheets i.e. , cc, KCL, etc. Moreover, unauthorized staff documentation, wrong addressograph and wrong calculations of 24 hours documented and identified in phthisis output flow sheet in the month of February 2010 May 2010. The major(ip) observations which I found during the rounds were almost resembling except one which has not mentioned in audits observation was the events of patient complain, abnormal vital signs and invasive and non invasive procedure that I identified. All these issues have now become the anteriority of a unit. Therefore, being a responsible staff I decided to take this project as a challenge and plan to work on it. As the documentation is an ethical and legal concern that provides theatrical role care to the patient. Moreover, documentation is a basic tool of communication in which nurse does assess patients condition in order to document patients records, so that staff would legally be safe and patient care not compromised.Based on above observations and from the audits results, I developed a pre test questionnaire according to staff need that contains 15 questions. For maintaining reliability of the questionnaire it was checked by the preceptor and facilitator. afterwardward substantiation of the pre test, I made it fill with the Nursi ng Assistant (NAs) and Registered Nurses (RNs). I took 20 samples of the staffs that were 40% staffs of the unit. Although pre test require 15 questions but I scrutinize the five major priority questions of the test. An assessment results reveals that 65% staffs answer correctly about the best commentary of nursing documentation. Moreover, 50% staffs did correct answer on purpose of 24 hours of intake output balance documentation. Furthermore, 25% staffs answer correctly on purpose of intake out put documentation in flow sheet. anyhow this, 50% staffs gave correct answer on responsible of documenting IV fluids and intake output calculations of 24 hours.Analysis of the issue with evidence based publicationsAccording to Aga Khan Policy of Documentation in Nursing Care (2008), Patient record is a legal document therefore essential present legible, accurate, successionly, objective and complete development about patient and intervention. (1.2). This definition clearly explains the standard documentation that are necessary for all nursing staff in order to be legally safe as documentation is an ethical and legal issue all over the world. According to Connor, K. et al (2007), nursing documentation has a high priority in all trusts because analysis of records of care and observations has revealed that use of doubled charts and repetitive transcription causes practical and legal issues.(para.2). The above quotation indicates that repetitive records can affect patients quality of care. Moreover, this can take the staff in law suit. Furthermore, organization performances would get affected if its taken in the court. Hence, this has been bumpd that lack of thoroughgoing(a) documentation and nurse accountability reveals many complaints and investigations arising from clinical incidents which were leading to undue claims for the staff. According to NMC (2002), Vigilance is required to ensure high standards in record property, whether records are in written or el ectronic form. The audit of patient documentation is a facet of risk management that can uphold to promote quality of care. Wood, C., (2003) believe that any notes or records demand legal documentation, and if any judgment, vague or unsubstantiated documentation found, it would be fractious to maintain professional reliability in the court. (para.2). Hence, good record keeping promotes better communication as well as continuity, consistency, efficiency that further reinforce professionalism within nursing.Integration of the ModelI run this project through PDSA set, visualized by Walter Shewhart in 1930s and further this was espouse by W. Edwards Deming in 1950s. This model is know as Shewhart cycle, Deming cycle, Plan-Do-Study-Act cycle, and Plan-Do-Check-Act cycle. Also known as Learning and Improvement cycle. In this model, the cycle shows the framework for the make betterment of a surgical operation or system. (Refer Appendix A). According to Kevin (2008), once sucker impr ovement areas identified, the model will provides a framework that can further employ to guide the entire project or to develop the ad hoc objects. (para.2). Furthermore, the PDSA cycle also employ when starting a new improvement project or when implementing any change. Besides this, PDSA cycle also used as a model for sustained improvement in quality care. According to Tague (2004), The PDSA cycle has 4 perverts for carrying out the change. Just the lap covering has no end it should be repeated again and again for continuous improvement (para.3). Taking this point I would add that in the same manner unless the staff brings change and improvement in them, ongoing sessions for the documentation, activities of documenting notes quizzes and review of policies should be continue. Here I would coalesce this model with my project. The first step is plan, in this step I identified the area that needs improvement. Furthermore, I collected data and planned strategies accordingly for c hange. I identified quadruplet issues from the unit and analyzed the significance of each issue. I discussed each problem with my preceptor and planned for prioritizing the issues. Moreover, CNI planned a meeting with unit manager for selection the priority issue for the project. Finally after the discussions and come to conclusion I selected the topic documentation based on staff knowledge, post and practices during the clinical setting. I gathered data through observations during rounds and knowledge identified via pre test. I planned strategies for implementations, that is session awareness and develop innovative flyer. Moreover, discuss with CNI that PowerPoint presentation should be done via multimedia and for the nursing notes activity uninfected Board with markers should be needed. The second step is do, in this implementation of the project done. I conducted three sessions on different days for all the staffs. I carried out the session in the evenings shift staffs. Moreov er, for each session I developed an innovative flyer, and pasted on noticed jump on for the declaration of the session. (Refer Table 1. Action Plan). Moreover, I taught and encouraged the staff how to retrieve the policy on the computer.For sustainability of the project, I discussed with all team members about the results of the project. Moreover, I explained them that for military posture of the projects results they have to initiate the staff and take the responsibility to observe the staffs documentation practices in their shifts. In addition, I arranged a meeting with the nursing documentation monitors of the unit and give them the responsibility conduct in service sessions in every fifteen to twenty days. The third step of the model is study, for that I searched many relevant literature that supports my nursing documentation project. And If I take the component check of PDCA model I evaluated the staff by post test Moreover, I present different scenarios for the staff, based on documentation practices where staffs have to demonstrate documentation according to its principle. Furthermore, I took the redemonstration of the process of retrieving documentation policies and observations to evaluate the staffs on their nursing documentation practices. The fourth and last step of the model is act. In the act phase, first I used power point presentation lecture with two way communication, and showed pamphlets and card game which I made for them for my sustainability. It is decided that the improvement has come in them or not, whether their practices changed or not. Improvement practices bring changed in them or not. For this project the time was short, so I could not able to perform this step totally but I handed all my things to CNI and the volunteers for further proceed the session. carrying outImplementation is the most important component of the project. I applied multiple strategies in order to implement the project effectively. My first scheme was to p rovide knowledge to staff about the documentation and its practices. I searched many literatures on the selected issue and review and retrieved nursing documentation policies and further discuss with my preceptor and facilitator. Also developed PowerPoint presentation slides on the selected project. According to Green, Palfery, Clark Anastasi 2002, The slides are corresponding to lecture and work well for initial comment and clarifying the concepts of the learners. (p.2). To observe the enhancement knowledge of the staff, I showed power point presentation slides to the staff, originally conducting the session I also showed the slides to my preceptor and facilitator. After justification of the presentation, I conducted three sessions on different days. The reason for three sessions was to expand information to different groups of staff. I conduct all my sessions in overlapping timings and most of the time evening staff attend my session rather than morning. I considered, this st rategy was appropriate and relevant to the practice because mosts of the evening staff does attend the sessions on different topic so they do not have to tense that they are giving extra timings to the project or applying any efforts. Green, Palfrey, Clark Anastasi 2002, The slides are similar to lecture and work well for initial explanation and clarifying the concepts of the learners. (p.2). Moreover, I encouraged the staff to participate actively because this helps the staffs to expect out their views and carried out their personal experiences and learn different concepts via groups. Group discussions are good for problem solving, critical thinking and demonstrating different points of views among learners.(p.1). My second strategy was to teach the process of retrieving the documentation policy for the staff and encouraged the staff to re demonstrate it. Also redemonstrate the nursing notes in order to observe the practices of the staff following A-G assessment. The strategy was very effective because here I come to know the staff practices and their knowledge. According to Rodrigo, Meredith Moore 2003, Kinetics learners learn by doing and prefer learning that involves movement, active participation, and concrete objects. (p.1). My third strategy was to develop an innovative flyers that I pasted on the unit notice board for the reinforcement and remembrance of the staff.EvaluationIn rating, for RNs I distributed nursing notes physical composition to observe their documentationpractices Moreover, I asked staffs about the Aga Khan University documentation policy. Fornursing assistant (NA) I distributed intake output flow sheet where I asked them to documentroutine amount of fluid intake measurement. Furthermore, I asked the staffs about thedocumentation error policy. It is saying that no project will be successful without knowing itsoutcomes. After the implementation I performed an rating of my presentation. Afterproviding them the session on documentatio n, I found t nursing staffs were able to clarify theirconcepts about the documentation and its error policy. To observe the base post knowledgeamong staff regarding nursing documentation. For that purpose, I have utilized evaluation toolon nursing documentation formulated by me, after preceptors guidance and approval. (Seeresults of evaluation (Refer Appendix B). The implementation analysis indicates that 85% of myproject went successfully (Refer Appendix C). In addition, staff participated well share the practical(prenominal) examples related clinical. Moreover, suggested to have these kinds of sessions onquarterly basis so that to improve the knowledge. Furthermore, also suggested to have an activityon nursing notes so that they can bring change in documentation practices.LimitationsTime period for project was short that is why unable to involve all staff inimplementation of the project. Another reason for not attending the session by staff was, most ofthe staffs were busy in pro viding care to the patient. Moreover, for the evaluation of project Ihave two weeks in identifying needs, selecting priority issue, observations, assessment andevaluation of the project which was a great challenge for me. Furthermore, lack of resources wasa king-size issue as Learning Resource Center was full most of the time and lots of budgeting issuesfor assessment, evaluation and on articles but with the great support of preceptor and ongoingfacilitation by my facilitator made my life easy in the completion of running the projectsuccessfully, smoothly and timely.RecommendationsThere are received recommendations in regards of nursing documentation. Policy ofDocumentation should be reviewed on periodic basis in unit for the knowledge and bringimprovement in nursing documentation. Secondly, sessions, quizzes on the nursingdocumentation should be conducted every month by assigned nursing staffs or ClinicalNurse Instructor (CNI) in order to observe staff knowledge. Furthermore, 8 steps ofaudit checklist need to be followed and referred. Moreover, nursing documentation should bedone by utilizing audit tool every quarterly, for the improvement of practicesand monitoring of compliance to documentation policy.ConclusionTo conclude, I will say that documentation plays a vital role in nursing practice becausethis communicates health care providers about patient assessment, planning, interventionsand evaluation of the patient condition. Moreover, it an ethical issue that is a legaldocumentation and ultimately this safe staff for any legal actions. Documentation showshonesty and care for the patient which should be done on time. If care is not documented, itmeans its not done.In the last, I would say that this project enhanced my learning. It provided me anopportunity to work as a team member with staff, Head Nurse (HN) and Clinical NurseInstructor (CNI). This project also enhanced my leadership style what I learned the concept inclass. Despite of all this, the proj ect helped me to work independently and to study aboutnursing documentation in depth. Moreover I learned to integrate new concepts and model thatwould further help me in my profession career.