Nursing standards are expectations that contribute to public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. Standards apply to all nurses regardless of their roles, job description or areas of practice.(College of Nurses Ontario, 2008, para.1).
Documentation is one of the vital components of ethical, safe and effective nursing practices that provide comprehensible image of the client health status and their outcomes. (Practice Standards, 2008, para.2).Whether the documentation is in electronic or written format, hence documentation communicates the nurse observations, decisions, and outcomes for the client. According to the Aga Khan University policy of Documentation of Nursing Care (2008), “documentation is a direct nursing activity that ensures the evidence for provision of nursing care and continuity of care.” (p.1.1). The quotation indicates that for every events and record it is very important to do documentation as evidence so that the staff would legally be safe. Moreover nursing care provides good and healthy communication between the staff and the patient and further this provides the good continuity of care to the patient. According to Kimberly (2003),”if it wasn’t documented, it wasn’t done.” (para.1). This revealed that in the clinical setting, if the documentation is not complete, then the work will be count incomplete.
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During my senior electives in my practice setting in Private Wing II (medicine unit) I encountered many issues regarding documentation on bedside files. I observed most of the nursing staff not following the documentation policy. For example, absence of events related to abnormal vital signs, patient response during invasive and non invasive procedures, abdominal pain complaint and its monitoring scale, errors in 24 hours calculations of intake output flow sheet that can impact on patient negative and positive balance. Moreover, issues related Nasogastric feeding and patient’s tolerance ability, absence of initials and dates on weekends and wrong addressograph of patient on intake output flow sheets, non useable abbreviations, illegible writing and inaccuracy of nursing notes, all these issues identified during rounds and in morning over. So, I planned and decided to bring these documentation issues in front of my preceptor and manager not only to approve my project, but really want staff to work on it so that they would legally be safe and performance of the organization should be maintained. My preceptor and manager appreciated me and approved my project and this is how my project journey begins. We all nurses knew that documentation is an ethical and legal issue and making a single error in documentation can put the staff in lawsuit. Therefore to bring improvement in staff documentation practices and to observe staff knowledge I developed a questionnaire tool. At last, I come to conclusion that staff really needs to work on documentation as there is a gap identified in some of the staffs knowledge about 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 can affect the organization. Therefore, I discussed all the related issues regarding documentation with preceptor and manager and finally the project approved by them. Nursing manager and preceptor considered that work on documentation is a good project so that staff should think of it and work on it in order to bring improvement in their documentation and not make further errors that can affect the patient quality of care as this is an ethical issue. For assessing the need of the selected topic, I developed a pre test questionnaire based on staff knowledge about nursing documentation and finally I come to conclusion via assessment that staffs really have to work on documentation as some of the staff had lack of knowledge regarding nursing documentation. Some of the staff have knowledge but do not show accountability which can put the unit and other staff in trouble. I also identified other issues for practice based project. Firstly, non compliance to infection controls policy. The purpose of not selected the topic was that, all the units Head nurses, Clinical Nurse Instructors (CNI) and Infection Control Staff members are working together on it. In addition, they do reinforce unit staffs to attend the infection control sessions on constant basis not only to prevent them but also prevent the other members and patients from infectious diseases. Secondly, bed sore issues are the most common problem 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 daily basis and every 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 evening shift staffs on regular basis.
In order to support the need of the project, I reviewed 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 intake output flow sheet in the month of February 2010 – May 2010. The major observations which I found during the rounds were almost same 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 priority 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 quality care to the patient. Moreover, documentation is a basic tool of communication in which nurse does assess patient’s condition in order to document patient’s 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. After substantiation of the pre test, I made it fill with the Nursing Assistant (NA’s) and Registered Nurses (RN’s). 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 definition 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. Besides 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 literature:
According to Aga Khan Policy of Documentation in Nursing Care (2008), “Patient record is a legal document; therefore must present legible, accurate, timely, objective and complete information 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 multiple charts and repetitive recording causes practical and legal issues.”(para.2). The above quotation indicates that repetitive records can affect patient’s quality of care. Moreover, this can take the staff in law suit. Furthermore, organization performances would get affected if it’s taken in the court. Hence, this has been observed that lack of thorough documentation and nurse accountability reveals many complaints and investigations arising from clinical incidents which were leading to indefensible claims for the staff. According to NMC (2002), “Vigilance is required to ensure high standards in record keeping, whether records are in written or electronic form. The audit of patient documentation is a facet of risk management that can help 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 difficult 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 Model:
I run this project through PDSA model, visualized by Walter Shewhart in 1930’s and further this was adopted by W. Edwards Deming in 1950’s. This model is known 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 improvement of a process or system. (Refer Appendix A). According to Kevin (2008), once target improvement areas identified, the model will provides a framework that can further used to guide the entire project or to develop the specific objects. (para.2). Furthermore, the PDSA cycle also used when starting a new improvement project or when implementing any change. Besides this, PDSA cycle also used as a model for continuous improvement in quality care. According to Tague (2004), The PDSA cycle has 4 steps for carrying out the change. Just the circle 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 integrate 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 change. I identified four 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, attitude 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 White 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. Moreover, for each session I developed an innovative flyer, and pasted on noticed board for the announcement 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 effectiveness of the project’s results they have to initiate the staff and take the responsibility to observe the staff’s 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 cards 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 completely but I handed all my things to CNI and the volunteers for further proceed the session.
Implementation is the most important component of the project. I applied multiple strategies in order to implement the project effectively. My first strategy was to provide 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 similar to lecture and work well for initial explanation 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, before 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 strategy 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 express 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.
In evaluation, for RNs I distributed nursing notes paper to observe their documentation
practices Moreover, I asked staffs about the Aga Khan University documentation policy. For
nursing assistant (NA) I distributed intake output flow sheet where I asked them to document
routine amount of fluid intake measurement. Furthermore, I asked the staffs about the
documentation error policy. It is saying that no project will be successful without knowing its
outcomes. After the implementation I performed an evaluation of my presentation. After
providing them the session on documentation, I found t nursing staffs were able to clarify their
concepts about the documentation and its error policy. To observe the base line knowledge
among staff regarding nursing documentation. For that purpose, I have utilized evaluation tool
on nursing documentation formulated by me, after preceptor’s guidance and approval. (See
results of evaluation (Refer Appendix B). The implementation analysis indicates that 85% of my
project went successfully (Refer Appendix C). In addition, staff participated well; share the
realistic examples related clinical. Moreover, suggested to have these kinds of sessions on
quarterly basis so that to improve the knowledge. Furthermore, also suggested to have an activity
on nursing notes so that they can bring change in documentation practices.
Time period for project was short that is why unable to involve all staff in
implementation of the project. Another reason for not attending the session by staff was, most of
the staffs were busy in providing care to the patient. Moreover, for the evaluation of project I
have two weeks in identifying needs, selecting priority issue, observations, assessment and
evaluation of the project which was a great challenge for me. Furthermore, lack of resources was
a big issue as Learning Resource Center was full most of the time and lots of budgeting issues
for assessment, evaluation and on articles but with the great support of preceptor and ongoing
facilitation by my facilitator made my life easy in the completion of running the project
successfully, smoothly and timely.
There are certain recommendations in regards of nursing documentation. Policy of
Documentation should be reviewed on daily basis in unit for the knowledge and bring
improvement in nursing documentation. Secondly, sessions, quizzes on the nursing
documentation should be conducted every month by assigned nursing staffs or Clinical
Nurse Instructor (CNI) in order to observe staff knowledge. Furthermore, 8 steps of
audit checklist need to be followed and referred. Moreover, nursing documentation should be
done by utilizing audit tool every quarterly, for the improvement of practices
and monitoring of compliance to documentation policy.
To conclude, I will say that documentation plays a vital role in nursing practice because
this communicates health care providers about patient assessment, planning, interventions
and evaluation of the patient condition. Moreover, it an ethical issue that is a legal
documentation and ultimately this safe staff for any legal actions. Documentation shows
honesty and care for the patient which should be done on time. If care is not documented, it
means it’s not done.
In the last, I would say that this project enhanced my learning. It provided me an
opportunity to work as a team member with staff, Head Nurse (HN) and Clinical Nurse
Instructor (CNI). This project also enhanced my leadership style what I learned the concept in
class. Despite of all this, the project helped me to work independently and to study about
nursing documentation in depth. Moreover I learned to integrate new concepts and model that
would further help me in my profession career.
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