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Nursing Documentation in Aged Care

A Guide to Practice

Other titles by Ausmed Publications


Nurse Managers: A Guide to Practice Edited by Andrew Crowther Aged Care Nursing: A Guide to Practice Edited by Susan Carmody and Sue Forster Dementia Nursing: A Guide to Practice Edited by Rosalie Hudson Palliative Care Nursing: A Guide to Practice (2nd edn) Edited by Margaret OConnor and Sanchia Aranda Lymphoedema Edited by Robert Twycross, Karen Jenns, and Jacquelyne Todd Communicating with Dying People and their Relatives Jean Lugton How Drugs Work Hugh McGavock Evidence-based Management Rosemary Stewart Communication and the Managers Job Annie Phillips Assertiveness and the Managers Job Annie Phillips Renal Nursing--A Practical Approach Bobbee Terrill Ageing at Home--Practical Approaches to Community Care Edited by Theresa Cluning Complementary Therapies in Nursing and Midwifery Edited by Pauline McCabe Keeping in Touch--with someone who has Alzheimers Jane Crisp Geriatric Medicine--a pocket guide for doctors, nurses, other health professionals and students (2nd edn) Len Gray, Michael Woodward, Ron Scholes, David Fonda & Wendy Busby Living Dying Caring--life and death in a nursing home Rosalie Hudson & Jennifer Richmond Caring for People with Problem Behaviours (2nd edn) Bernadette Keane & Carolyn Dixon Practical Approaches to Infection Control in Residential Aged Care (2nd edn) Kevin Kendall Nursing the Person with Cancer--a book for all nurses Edited by Gordon Poulton Caring for the Person with Faecal Incontinence--a compassionate approach to management First edn authors: Karen Cavarra, Andrea Prentice & Cynthea Wellings Second edn author: Janette Williams Spirituality--the heart of nursing Edited by Susan Ronaldson Nursing Documentation--writing what we do Edited by Jennifer Richmond Thinking Management--focusing on people Edited by Jean Anderson

All of these titles are available from the publisher: Ausmed Publications 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: <www.ausmed.com.au> email: <ausmed@ausmed.com.au>

Nursing Documentation in Aged Care


A Guide to Practice
Edited by Christine Crofton and Gaye Witney
Foreword by Rosalie Hudson

AUSMED PUBLICATIONS

MELBOURNE SAN FRANCISCO

Copyright Ausmed Publications Pty Ltd 2004 Ausmed Publications Pty Ltd Melbourne San Francisco Melbourne ofce: 277 Mt Alexander Road Ascot Vale, Melbourne, Victoria 3032, Australia ABN 49 824 739 129 Telephone: + 61 3 9375 7311 Fax: + 61 3 9375 7299 email: <ausmed@ausmed.com.au> website: <www.ausmed.com.au> San Francisco ofce: Martin P. Hill Consulting 870 Market Street, Suite 720 San Francisco, CA 94102 USA Tel: 415-362-2331 Fax: 415-362-2333 Mobile: 415-309-2338 email: <mphill@pacbell.net> Although the Publisher has taken every care to ensure the accuracy of the professional, clinical, and technical components of this publication, it accepts no responsibility for any loss or damage suffered by any person as a result of following the procedures described or acting on information set out in this publication. The Publisher reminds readers that the information in this publication is no substitute for individual medical and/or nursing assessment and treatment by professional staff. Nursing Documentation in Aged Care: A Guide to Practice ISBN 0-9750445-4-0. First published by Ausmed Publications Pty Ltd, 2004. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in, or introduced into a retrieval system or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the written permission of Ausmed Publications. Requests and enquiries concerning reproduction and rights should be addressed to the Publisher at the above address. National Library of Australia Cataloguing-in-Publication data Nursing documentation in aged care : a guide to practice. Bibliography. Includes index. ISBN 0 9750445 4 0. 1. Nursing records - Handbooks, manuals, etc. 2. Geriatric nursing - Handbooks, manuals, etc. I. Witney, Gaye. II. Crofton, Christine, 1947- . 610.7365 Produced by Ginross Publishing Printed in Australia

Contents
Dedication and Acknowledgments Foreword Preface About the Authors Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Understanding Nursing Documentation
Christine Crofton and Gaye Witney

1 19 31 45 63 79 97

Clinical Reasoning
Bart OBrien

Professional Communication
Christine Crofton and Gaye Witney

Nursing Care Plans


Shirley Schulz-Robinson

Progress Notes
Joanne Hope and Pamela Bell

Clinical Pathways
Jenni Ham, Ann-Maree Conners, and Angela Crombie

Documenting Behaviour and Emotion


Felicity Humble

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Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 References Index

Documenting Complementary Therapies


Sue Forster

109 123 137 151 169 181 193 209 249 255 261 267 273 279 285 289 293 299

Documenting Pain Management


Michael Cully

Documenting Restraint
Sue Forster

Incident Reports
Adrian Cross

Documenting Evaluative Criteria


Sue Forster

Documenting Staff Issues


Sue Forster

Effective Design for Documentation


John Collins

A Systems Model for Documentation


Christine Crofton and Gaye Witney

Faecal Incontinence
Janette Williams

Behavioural Management
Robyn Daskein

Diabetes
Victoria Stevenson

Nausea
Robyn Millership

Stomal Care
Heather Hill

Leg Ulcer Management


Sue Templeton

PEG Nutrition
Patsy Montgomery

Wandering
Beverly Smith

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Dedication
This book is dedicated to aged-care nurses for their courage, resilience, and professionalism and to the elderly people who share so much of their lives with the nurses who care for them.

Acknowledgments
To Jim, Jacinta, Robert, Eleanor, and Zoe, who have supported our passion for aged care, and who have encouraged us in all that we attempt. To our family and friends, who have been there when needed. To our industry colleagues for support and inspiration over the years and to the many skilled nurses who have influenced us during our careers. To Cynthea and Ausmed Publications for having faith in us, and for making this book possible.

Foreword
Rosalie Hudson
Documentation has come alive! In Nursing Documentation in Aged Care: A Guide to Practice, the drudgery and monotony are taken out of an important aspect of nursing that has become, for many, a dreaded necessity. Nurses will be inspired to take a fresh look at the many positive aspects of documentation and to enjoy the professional rewards of improved practice. The issues are presented in ways that reinforce current good practice, encourage reflection on practice, and offer new ideas to guide improved practice. The rewards of good documentation are to be found not only in professional pride, but also in creating more time for resident care. The book is therefore timely in addressing the frustration expressed by many aged-care nurses: How can we achieve a good balance between documentation and resident care?. The various models of documentation described throughout this book will help to identify the unique details of each residents care. What does this record convey about the care of this particular resident? Who is

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this person in the context of his or her significant relationships? It is this personal and relational emphasis that makes this book on documentation come alive. The practical examples provided will inspire nurses with confidence to try new approaches. To allow for creativity and flexibility to suit local circumstances, a variety of options is presented. Each component of documentation is described and distinguished from othersshowing clearly how to avoid the duplication evident in contemporary practice. Helpful case studies based on everyday experience make this an enjoyable book of practical learning. Throughout this book, communication is the cornerstone of effective documentation. In communicating with their colleagues, nurses do more than merely record facts and details; they also evaluate responses to specific episodes of care and thus learn from one another. Good communication promotes continuity of care as each person takes up the storythus capturing the essence of holistic care. By making explicit the link between the care and the writing, the documented record is a profoundly insightful expression of professional holistic care. Nursing Documentation in Aged Care: A Guide to Practice challenges nurses to regard quality documentation as a reflection of quality care. Good documentation is presented as the key to evidencenot only for legal and regulatory purposes but also for improved professional practice. Evidence of quality leads to expanded knowledge, and provides a rich, fertile ground for future research. This book therefore has enduring qualities. It has the potential to influence the whole of aged-care practice. Written by people committed to the cause, there is something in every chapter that will inspire nurses to replace outmoded habits and attitudes with innovation and clarity of purpose. The purpose of documentation is clearly articulated throughout the bookto communicate the essence of resident care in a way that encourages professional pride and paves the way for best practice to be achieved. Nurses are prompted to write their documentation in a way that makes nursing visiblethus placing on record the difference that good nursing makes to the care of residents.

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Nurses will be encouraged by the enduring qualities in this important and timely book. It not only answers immediate needs but also promotes documentation in aged care as a model worthy of wider attention by all nurses.

Rosalie Hudson
Dr Rosalie Hudson is a registered nurse who holds bachelors degrees in applied science and theology, a masters degree in theology, a graduate diploma in gerontic nursing, and a PhD. After a long and distinguished career in clinical and academic nursing, including 12 years experience as the director of nursing of a 50-bed nursing home, Rosalie is now a private consultant in aged care and palliative care, and an honorary senior fellow in the School of Nursing, University of Melbourne. Rosalie has presented and published numerous papers and articles internationally on the subjects of spirituality, palliative care, dementia, pastoral care, and ethics at the end of life. Rosalie edited Dementia Nursing: A Guide to Practice (Ausmed Publications 2003). She has also co-authored two other Ausmed books, and has contributed chapters to several others. Rosalie enjoys family life with her husband, adult children, and grandchildren.

Preface
Christine Crofton and Gaye Witney

A guide to practice
Nurses constantly complain that they have insufficient time for proper documentation. In many ways this is understandable. Nursing is essentially about caring, and many aged-care facilities today are understaffed and under-resourced. In these circumstances it is hardly The title of the book is carefully surprising that many nurses chosen nursing documentation feel that caring comes first and in aged careif performed with pride and professionalismis documentation comes secondthat truly a guide to practice. they have time to care or time to write, but do not have time for both. Documentation can be perceived as being primarily an administrative and legal requirement that takes up valuable timetime that might have been otherwise spent on resident care. Although this perception of documentation is understandable, Nursing Documentation in Aged Care: A Guide to Practice is written from

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a different perspective. The title of the book is carefully chosen. All of the contributors to this book firmly believe that nursing documentation in aged careif performed with pride and professionalismis truly a guide to practice. In most jurisdictions, registered nurses are required to adhere to codes of ethics and codes of professional conduct. They have a responsibility to the individual, society and the profession to provide safe, competent nursing care which is responsive to individual, group and community needs (ANCI 2000). A nurses professional practice with respect to documentation should reflect such safe, competent nursing care. Each nurse is responsible for his or her own nursing practiceand documentation is a part of that responsibility. In addition to their ethical and professional responsibilities, caring nurses are aware of the personal satisfaction to be gained from holistic and reflective nursing practice. In this respect, nurses are increasingly recognising that documentation is a wonderful opportunity to Documentation is of the utmost record, share, and reflect upon importance as a guide to nursing practicepractice that is ethical, all that is good in nursing. professional, holistic, and reective. Documentation is more than a tiresome chore. Comprehensive and accurate documentation shares astute nursing insights, reflects the excellence of holistic aged-care nursing, and provides a record of the professional and personal support that nurses provide every day to residents and their families. Nursing Documentation in Aged Care: A Guide to Practice is therefore written by and for nurses who believe that documentation is of the utmost importance as a guide to nursing practicepractice that is ethical, professional, holistic, and reflective.

The purpose of documentation


In documenting aged care, nurses are recording and communicating information about many important matters. These include (among others): care needsthe identification and assessment of the needs of those in their care;

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care plans and progress notesthe documentation of nursingcare plans to address these needs, and the subsequent progress of residents; communication and teamworkthe communication of this information among members of the healthcare team, thus ensuring teamwork, shared responsibility, and continuity of care; education and researchthe professional sharing of insights, knowledge, and trends in aged-care nursing; legal requirementsa legal record to protect residents, nurses, and the organisation in which they live and work; and auditing and fundinga validation of the standards of nursing care and the establishment of documented links between the level of nursing care and the resources required to support it. This book therefore shows how professional documentation allows nurses to share their knowledge, observations, and skillsand thus make a crucial contribution to their own professional lives and to the quality of life of those in their care.

The structure of this book


The book begins with three chapters that provide comprehensive overviews of the broad subject of nursing documentation in aged care. The first chapter, Understanding Nursing Documentation, sets the scene with a general discussion of the major issues. The second chapter, Clinical Reasoning, explores how nurses make clinical decisions and canvasses the interaction (and possible conflict) between real nursing experience and administrative documentary requirements. This is followed by a chapter on Professional Communicationstressing the significance of documentation as an exercise in effective communication between professional colleagues in a multidisciplinary team. Having canvassed these broad introductory issues, the book then moves on to discuss three important forms of nursing documentation Nursing Care Plans, Progress Notes, and Clinical Pathways. This is followed by chapters on some selected clinical issues that can provide documentation problemsDocumenting Behaviour and

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Emotion, Documenting Complementary Therapies, Documenting Pain Management and Documenting Restraint. The book then moves onto a consideration of the documentation of wider managerial and administrative issuesIncident Reports, Evaluative Criteria, and Documenting Staff Issues. The second-last chapter of the book provides some helpful advice on Effective Design for Documentationwith hints on how to design documentation forms that are functional and effective. The final chapter in the main body of the book draws everything together in a comprehensive Systems Model for Documentation. The model presented here puts many of the topics of earlier chapters into an overall context. In doing so, it provides guidance to clinical nurses and nurse managers in how to go about establishing a comprehensive documentation system that promotes positive attitudes and outcomes with respect to this vital aspect of aged-care nursing. Following the main body of the book, several case studies are discussed in the appendices. These short case studies present common clinical problems and provide examples of the types of documentation that are appropriate in each case. In keeping with the evidence-based nature of the text, the book concludes with a list of references and a comprehensive, cross-referenced index.

A wide-ranging, evidence-based textbook


This is therefore more than a how-to-do-it workbook on nursing documentation. With contributions from a range of experts, this wideranging, evidence-based textbook More than a how-to-doexplores the issues surrounding it workbook on nursing documentation, reveals the importance documentation this wideof effective communication within ranging, evidence-based multidisciplinary teams, and guides textbook explores the issues nurses in enhancing their professional surrounding documentation. practice.

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The authors of this book trust that it can help aged-care nurses to see documentation as more than a necessary burden. Rather, documentation can be an exciting and valuable aspect of their shared professional lives. The authors believe that this book will assist aged-care nurses to recognise that they have control over the philosophy and application of documentation in an increasingly difficult work environment. If performed with pride and professionalism, nursing documentation in aged care can truly be a guide to practice.

About the Authors


Adrian Cross
Chapter 11

Adrian Cross holds a diploma in production engineering, a degree in arts, and a graduate diploma in ergonomics. Adrian worked in industry for 25 years, dealing with quality assurance and occupational health and safety. He then worked in the public service for 15 years specialising in facilities managementincluding the management of hospitals and aged-care facilities. Adrian is now a lecturer in aged-services management and occupational health and safety at Victoria University and Kangan Batman TAFE (Melbourne, Australia).

Pamela Bell
Chapter 5

Pamela Bell is a registered nurse who holds a bachelor of arts degree and a PhD. She was formerly the professor of nursing at Charles Sturt University (South Australia) and is now an honorary senior research fellow in the Faculty of Nursing at the University of Technology (Sydney, Australia). Pam is also a registered psychologist who supervises interns undertaking pre-registration requirements at the College of Psychological Practice, Sydney. Before becoming an academic nurse, Pam had many years of clinical practice in Victoria and New South Wales. Having grown up in northern Victoria, Pam has an excellent understanding of the problems facing rural health practitioners, and she successfully led the Charles Sturt University component of a joint venture with Monash University in forming the Australian governments National Rural Health Unit.

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John Collins
Chapter 14

John Collins holds a diploma in continuing education, a bachelors degree in arts, and a masters degree in education. He has worked as a senior bureaucrat in a number of educational systems. This employment has involved him in the design and implementation of a range of records and documents. John is well aware of the importance of well-designed and user-friendly forms for documentation.

Ann-Maree Conners
Chapter 6

Ann-Maree Conners is a registered nurse and midwife who holds bachelors and masters degrees in health science. For the past ve years, she has been the director of the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia), and has recently been appointed to the role of acting group director of nursing at the Bendigo Health Care Group. Ann-Maree has extensive experience in the development and coordination of education programs for registered nurses and has been involved in health research for a number of years. Her research interests have included (among others): video-conferencing of educational models; a regional telerehabilitation project; post-acute-care programs in regional hospitals; careplanning in rural areas utilising critical-pathway methodology; and community nursing clinical pathways for providers of care to veterans.

Christine Crofton
Subject specialist editor, Chapters 1, 3, 15

Christine Crofton is a registered nurse who holds a bachelors degree in education and training, diplomas in frontline management and business (community services and health), and certicates in gerontology, training and development, assessment, and workplace training. Christine has been involved in aged care for many years as a registered nurse in various rolesincluding senior management of aged-care facilities. She is currently a nurse educator and is completing her masters degree in education and training. Christine believes that older people must be valued, respected, and cared for in accordance with the highest professional standards. If this is to be achieved, Christine believes that documentation must be undertaken effectively and efciently. If aged-care nurses are empowered and condent in their own abilities, positive resident outcomes and excellence in documentation will be assured.

Angela Crombie
Chapter 6

Angela Crombie is a registered nurse who holds a bachelors degree in nursing and masters degree in health science. Angela also holds additional qualications in psychiatric nursing and workplace assessment and training. She is employed as a

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research ofcer and nurse educator with the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia), specialising in research and education on aged-care issues. Angela has been involved in a number of research projects, many of which have included the design and development of care pathways in a variety of settings. Some of these projects have included: a regional dementia management strategy; health assessments under Medicare schedule items; asthma management in rural Victoria; health surveillance in the elderly using a healthsurveillance screening instrument; and home and community care best-practice projects.

Michael Cully
Chapter 9

Michael Cully is a registered nurse with a degree in education, a graduate diploma in education and training, and a masters degree in nursing studies. He is a nurse educator at Ipswich Hospital (Queensland, Australia) with interests in mental-health nursing, care of older persons, and aggression minimisation. Michael has a particular interest in the mechanics of clinical decision-making under conditions of uncertainty. In his spare time, he listens to classical music, enjoys the company of his family, walks in the national parks of south-eastern Queensland and north-eastern New South Walesand wonders whether the Carlton Football Club will ever win another premiership!

Robyn Daskein
Appendix 2

Robyn Daskein is a registered nurse who holds a diploma in nurse education, a bachelors degree in applied science (nursing) and a masters degree in health administration. She is currently undertaking doctoral studies. Robyn is the national quality assurance manager for the Regis Group. In this role, she maintains the companys continuous-improvement systems across 16 aged-care facilities in Queensland and Victoria (Australia). Robyn has been working in aged care and has been an aged-care registered nurse adviser since 1987. As director of her own company, Health Care Essentials, Robyn has specialised in providing education, continuous quality improvement, and management services to the aged and community care industry. Robyns PhD studies are directed towards quality outcomes in documenting challenging behaviour in residential aged care.

Sue Forster
Chapters 8, 10, 12, 13

Sue Forster completed her general nurse training in the Queen Alexandra Royal Naval Nursing Service in the UK and abroad. She has extensive clinical, educational, and managerial experience at senior levels gained from a long nursing career in Europe, Australia, and Africa. For the past ten years Sue has managed her own educational consultancy business. Her special interests include gerontic care, continuous quality

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improvement, and human-resource management. Sue is dedicated to the education and empowerment of her nursing colleagues through the provision of sound evidence-based practice within an holistic framework of quality care.

Jenni Ham
Chapter 6

Jenni Ham is a registered nurse and midwife who holds a graduate diploma and a masters degree in health science. Since 1994, she has worked as a project manager and acting operations manager at the Collaborative Health Education & Research Centre (CHERC) of the Bendigo Health Care Group (Victoria, Australia). Jenni has extensive experience in the design and implementation of clinical pathways. Her research projects have included the design, implementation, and evaluation of clinical pathways in acute and rehabilitation settings, and the design and implementation of clinical pathways in smaller rural hospitals. Jenni and her colleagues at CHERC have demonstrated that clinical pathways can be implemented successfully for patients with complex needs. Jennis work has achieved national recognition, as demonstrated by frequent invitations for her to present at workshops and conferences.

Heather Hill
Appendix 5

Heather Hill is a fellow of both the New South Wales College of Nursing and the Royal College of Nursing, Australia. She is also a life member of the Australian Association of Stomal Therapy nurses and the World Council of Enterostomal Therapy. Heather has been involved in clinical practice and education in stomal nursing since 1981. She has lectured extensively and has written papers for nurses, allied health personnel, doctors, and laypeople. Heather has presented at numerous international conferences and seminars and was the onsite clinical co-educator for the inaugural stomal-therapy course conducted by the Singapore Ministry of Health and Singapore Cancer Society.

Joanne Hope
Chapter 5

Joanne Hope graduated as a general nurse from the Royal North Shore Hospital (Sydney, Australia) in 1973. She also holds a diploma in nurse education and a masters degree in education. Joanne is currently working as a nurse administrator in the agedcare sector. Her past positions in aged care have included executive nurse advisor, director of care, deputy director of nursing and education, and quality and accreditation coordinator. Before specialising in aged care, Joanne held the position of principal lecturer of nursing at La Trobe University (Victoria, Australia). She has also been a consultant with the World Health Organization. Joanne is passionate about continuous quality-improvement processes and excellent care outcomes for aged-care residents.

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She believes that timely, accurate, and comprehensive nursing documentation is vital to achieving such outcomes.

Felicity Humble
Chapter 7

Felicity Humble is a registered nurse and registered psychiatric nurse who holds bachelors and masters degrees in nursing, and a diploma in applied science (advanced psychiatric nursing). Despite being in a nervous and unprepared state when she was sent to the psychiatric ward for her last rotation as a student general nurse in 1975, Felicity fell in love with this area of nursing and has remained passionately interested in psychiatric nursing ever since. Throughout this time she has been enriched by an array of experiences with the elderly, and has worked with aged patients in acute admission, rehabilitation, and secure settings. She has also been part of a community mental-health team for the aged in which she was involved in the assessment and management of aged people in their own homes or in other accommodation settings in the community. Over the past 12 years Felicity has worked as a clinical educator with undergraduate student nurseshelping them make sense of their psychiatric nursing experience and endeavouring to raise their interest in a career in mental health. She has also had several years experience working with postgraduate psychiatric nurses. Felicity is currently a psychiatric nurse educator working with nursing staff at Barwon Health Community and Mental Health (Geelong, Australia).

Robyn Millership
Appendix 4

Robyn Millership is a registered nurse and registered midwife who holds diplomas in nursing education, intensive care, and ward management. She also holds a certicate in palliative care. Robyn has worked in palliative care as a nurse consultant for more than 15 years. Her background is diverse including clinical practice, intensive care, administration, and education. Robyn is passionately committed to providing excellence in symptom control for patients with terminal illnesses. She believes that most people can achieve what seem to be impossible goals if they are provided with optimal symptom control, knowledge, encouragement, and support. Robyn was a recipient of a Victorian Nurses Care Award in 1994. She is currently a nurse consultant in palliative care at the Peter MacCallum Cancer Institute, St Vincents Hospital and Caritas Christi (both Melbourne, Australia).

Patsy Montgomery
Appendix 7

Patsy Montgomery is a registered nurse, registered midwife, and stomal therapist who holds a bachelors degree in educational studies. She is co-founder and consultant

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for the Gastrostomy Information Support Service, president of the Peninsula Ostomy Association (Melbourne, Australia), and the coordinator and clinical nurse consultant for the Abbott Nutrition Service, Victoria (Australia). Patsys role is to provide a support service for tube-fed people, their families, and their carers when patients are discharged from hospital into the community. This includes information and help for managing enteral tubes and equipment, advice about methods of feeding and nursing care, and information regarding supplies of formula, equipment, and pumps. Patsy also provides education and practical hands-on training for gastrostomy-fed people and carers. She also provides in-service training, workshops, videos, and literature for healthcare professionals.

Bart OBrien
Chapter 2

Bart OBrien is registered nurse who holds a bachelors degree and postgraduate qualications in nursing. Bart has worked in a variety of position in residential aged care since 1986including educator, clinical nurse consultant, assistant director of nursing, consultant, continence advisor, and quality coordinator. His PhD thesis was on the subject of nursing praxiswhat nursing does to improve care and outcomes for residents. As a result of this and other research, Bart has contributed to the development of a practice-based model for aged-care nursing. Bart has edited, written, and co-authored a number of books and monographs, book chapters, refereed journal articles, and research reports, and is frequently invited to contribute to the professional development of aged-care nursing through participation in seminars, lectures, consultations, and research projects. He is a member of the Royal College of Nursing, Australia, and is currently the quality coordinator at the James Brown Memorial Trust, Belair (South Australia).

Shirley Schulz-Robinson
Chapter 4

Shirley Schulz-Robinson has worked for 30 years as a clinician and manager in various practice settingsincluding psychiatric nursing, developmental disability nursing, medical and surgical nursing, womens health, and community health. For 19 years she worked in nurse education, including terms as the clinical director and assistant dean in the Faculty of Nursing at Newcastle University (Australia). Shirleys research interests include community-health nursing, health policy, and collaborative health-promotion strategies with patients and communities. Her current research has demonstrated that much of the work undertaken by nurses is hidden, and that it is commonly attributed to the efforts of other professions. Shirley has been chairperson of the Hunter Chapter of the Royal College of Nursing, Australia, president of the New South Wales Community Health Association, a member of the Public Health Research and Development Committee of the National Health and Medical Research Council

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(Australia), and a member of the New South Wales Nurses Tribunal. Shirley retired from Newcastle University in 2003 to devote more time to writing and consulting.

Beverly Smith
Appendix 8

Beverly Smith holds a bachelor of nursing, a certicate of rehabilitation and extended care, and postgraduate diplomas in gerontological nursing and aged-care services management. Beverly has had varied experience as a clinical nurse specialist and manager in Melbourne (Australia)at rst in rehabilitation, and later in aged-care services. As a result of these experiences, and her work as an external aged-care standards agency assessor, she has developed a particular interest in documentation. Beverly believes that documentation should be succinct, creative, and streamlined to focus on maximising the life opportunities of residents.

Victoria Stevenson
Appendix 3

Victoria Stevenson is a registered nurse and registered midwife who holds a graduate diploma in health education. She is completing her masters degree in nursing. Victoria is a fellow of the Royal College of Nursing, Australia, and is a credentialled diabetes educator with the Australian Diabetes Educators Association (ADEA) who has established a diabetes education service at Maroondah Hospital and further diabetes services at the Alfred Hospital (both Melbourne, Australia). She began part-time private practice many years ago. Victoria speaks frequently at seminars and conferences and has co-authored and produced a video DiabetesUnderstanding It. She is a past vicepresident and national conference convenor of the ADEA and has represented members on a number of committees. Victoria is currently the diabetes clinical nurse coordinator at the Alfred Hospital. Her role includes promotion of nursing practice in this speciality area, collaboration with health providers to provide education for people with diabetes, staff education, and participation in professional community services.

Sue Templeton
Appendix 6

Sue Templeton is a registered nurse who holds a bachelors degree in nursing, a certicate in hyperbaric nursing, and a certicate in orthopaedic nursing. She has more than 15 years experience in the management of acute and chronic wounds and has contributed to the development of wound-assessment tools and clinical pathways for the management of venous leg ulcers. Sue frequently conducts wound-management education for nurses in a variety of settings and has published and presented at local and national forums. She is a clinical nurse consultant and advanced wound specialist with the Royal District Nursing Service of South Australia, a clinical tutor with the University of Adelaide, and a member of the South Australian Wound Management

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Association, the South Australian Vascular Nurses Society, and the Australian Council of Community Nursing Services.

Janette Williams
Appendix 1

Janette Williams is a registered nurse who holds a masters degree in nursing bioethics. Janette has worked as a continence consultant for more than 12 years. She planned and conducted the original continence training course in New South Wales (Australia) and has been involved in the Continence Foundation of Australia at national and international levels. Janette is immediate past chairperson of the Australian Nurses for Continence. She is the author of the Ausmed publication, Management of Faecal Incontinence.

Gaye Witney
Subject specialist editor, Chapters 1, 3, 15

Gaye Witney is registered nurse who holds a bachelors degree in education, diplomas in primary education, training and development, frontline management, and business (community services and health), and certicates in gerontic nursing, management, industrial education and training, personal skills development, training, and workplace assessment. She is currently undertaking studies towards her masters degree in education. Gaye has had a passionate interest in aged care for longer than she wishes to admit! Her interest in documentation arose from her work with the Australian government on documentation validation and standards accreditation. Gaye is now a nurse educator who encourages her students to take pride in being nursesenthusing them to achieve high standards of documentation in their preparation of nursing assessments, nursing-care plans and progress notes.

Chapter 1

Understanding Nursing Documentation


Christine Crofton and Gaye Witney

Introduction
Nursing documentation is vitally important, and it is essential that all aged-care facilities have a clear vision of their objectives and requirements with respect to this aspect of care. Many time-consuming and costly documentation issues Poor documentation can put can be avoided if a clear vision and accompanying guidelines are residents at risk and can jeopardise funding to the organisation. provided for all nursing staff. To avoid incomplete, inconsistent, ambiguous, and reactive documentation, it is essential that nurses understand the documentation requirements of the organisation in which they work. Poor documentation can put residents at risk and can jeopardise funding to the organisation. An organisation must therefore be positive, proactive, and definite about what it requires of nurses, and must ensure that processes are in place to guide and support them to fulfil these requirements. Time and

2 Nursing Documentation

commitment will be required if the organisation is to ensure that staff members are informed and educated with respect to its expectations.

Key terms
Before exploring the subject in greater detail, it is helpful to establish an understanding of the terminology used in this important subject. The Box below contains a glossary of some key terms.

Glossary of key terms


Documentation Documentation can be dened as a written record of proceedings. It is a collection of documents that provides an account of the care delivered by the multidisciplinary healthcare team. Leadership Leadership is a commitment to assisting others to feel, think, or behave in a certain way. A leader is someone who has a vision, takes action, and demonstrates a commitment to the documentation process. Ethics Ethics are principles that act as a guide to decision-making for nurses involved in the documentation process. Values Values are the personal rules by which nurses live. They are the silent factors that inuence and shape a nurses practice. Values develop from the inuence of signicant people and events through life and can affect all aspects of a nurses practice, including how he or she regards the issue of documentation. Standards of practice Standards of practice are expectations of professional nursing conduct. Registered nurses accept the professional responsibility and trust inherent in their role, and are required to adhere to professional codes of conduct.

3 Understanding Nursing Documentation

Importance of documentation
Nursing documentation is central to quality nursing care, and is essential to the appropriate and accurate management of people in care. Documentation is essentially about communication, and must therefore make sense and have meaning if it is to be a communication tool for all involved. It is essential to have a documentation system in place. All those involved in the care of residents must be aware of their responsibilities, duty of care, and the requirements of the organisation. In instituting such a system, it should be noted Documentation is essentially that documentation has moved from about communication. a medical focus (whereby nurses documented their care to ensure that doctors orders were followed) to a nursing focus (in which nurses initiate nursing care and ensure that the nursing process is followed). The two models are complementary, and accurate documentation ensures that appropriate and consistent nursing care is planned and implemented in accordance with medical diagnoses.

Purposes of documentation
The purposes of documentation are: to act as a communication tool by enabling clear, concise, and relevant information to be exchanged among those involved in the care of residents; to ensure continuity of care with respect to residents nursing care needs; to be a legal record to protect residents, nurses, and the organisation; to assist in research and the development of new ways of delivering nursing care; to act as an educational tool; and to meet funding requirements by providing all required statutory information.

4 Nursing Documentation

Leadership
Leadership is required within an organisation when setting the standards for documentation. The minimum requirements for documentation are the imposed documentation processes linked with a funding model, but many organisations are showing leadership by choosing to go beyond these minimal requirements. A documentation process that is restricted to the requirements of a funding model can be perceived by nursing staff as a burden to be borne, and negative attitudes can easily develop. If the leadership vision goes beyond mere funding requirements, a If the leadership vision goes beyond positive environment can be mere funding requirements, a created in which standards of positive environment can be created. excellence are set and in which the leader can become a true agent and facilitator of change. In these circumstances, nurses become involved, are inspired, and develop confidence in themselves and the importance of nursing documentation. Leaders need to: stimulate colleagues; be enthusiastic; have vision; remain focused; overcome obstacles; take action; demonstrate commitment; take responsibility; listen actively; be flexible; seek input from others (and value the information); create a learning culture; be positive about managing the documentation process;

5 Understanding Nursing Documentation

push the boundaries; and be aware of their own strengths while seeking support and guidance as appropriate.

Legal issues
Various statutory requirements dictate the professional practice of registered nurses in all respectsincluding nursing documentation. As professionals, nurses are required to uphold a duty of care, and all nurses must be aware of the implications of this with respect to documentation. Precise responsibilities and constraints vary from jurisdiction to jurisdiction, but the Box below lists some of the important principles to be observed.

Legal constraints on documentation


Precise legal requirements with respect to documentation vary from jurisdiction to jurisdiction, but some of the legal principles that apply include: Condentialityonce information is collected, it must be protected. Objectivityfacts should be recorded; nurses should not make assumptions or give personal opinions; documentation should be specic, factual, accurate, concise, and evidence-based; residents can be quoted when appropriate. Date, time, and designationwhenever a record is made, the date, time, and nursing staff designation must be recorded to ensure that the writer is identied and that an accurate sequence of events is recorded. Permanencynotations must be made in permanent blue or black ink; records can become legal documents in a court of law. Timingbest practice requires that the notations be made in the record as things happen (rather than being recorded some time after the event). Legibilitywhat is written must be legible to all members of the multidisciplinary healthcare team; mistakes can be made if team members are unable to read entries in the notes.
(continued)

6 Nursing Documentation

(continued)

Abbreviationsa consistent set of abbreviations should be used to avoid confusion; many facilities now have a recognised list of abbreviations to be used by all team members. Accessit is essential that all appropriate legal constraints be followed with respect to access to records, and nurses must be aware of these constraints if requests are made for access; in most cases, there is unlimited access to a residents records by members of the multidisciplinary healthcare team caring for that person. Storagerecords must be stored in a secure place, with access being limited only to authorised people. Destructiona record must be kept for a specic time (as per local regulations) after the last admission or death of a resident; the record can then be destroyed by shredding. Blank spacesno blank spaces are to be left after the documentation is completed; if the line has not been lled, it might be appropriate to draw a line through the space to the end of the line. Correctionsif an error is made, a line should be drawn through the error, the word error should be entered, and the notation should be initialled and dated; errors should not be erased, and whiteout should not be used. Personal responsibilitynurses should never document for someone else, nor sign another persons name; nursing documentation is a legal record.

Ethics
The ethics of documentation can be challenging for nurses. The fundamental ethics of nursing dictate that nurses promote and restore health, prevent illness, and alleviate sufferingand these requirements must be reflected in everything that is written. A failure to record incidents can lead to a communication breakdown for the whole team and can affect resident outcomes. For example, it is inappropriate to fail to document an incident because that is how the resident always is.

7 Understanding Nursing Documentation

Nurses and the organisation need to be open, honest, and willing to discuss ethical documentation issues as they arise. Conflict can occur, but with professional understanding and healthy debate, appropriate decisions will be reached. Consensus should always be sought on contentious ethical issues. It is inevitable that some people will be somewhat dissatisfied with the decisions reached, but this is part of professional life and personal growth. Once a decision has been made, all nursing staff must be informed of the outcome and the documentation requirements that will result from that decision. Conflict between various team members regarding documentation can have adverse effects on residents and can cause ethical issues for nurses. A mismatch between the values and beliefs of an individual nurse regarding documentation and those of the rest of the multidisciplinary healthcare team (or the organisation as a whole) is referred to as cognitive dissonance. If a nurse continues to work in this environment, his or her satisfaction with the situation will decrease and can cause increasing discontent and poor morale in the workplace. This must be acknowledged and addressed. If not, it will affect the quality of care, choices, and dignity of both residents and staff. To avoid these sorts of problems, a set of ethical guidelines with respect to documentation should be observed by the organisation. A suggested set of such guidelines is presented in the Box on page 8.

Values
Values make up the inner world of personal hopes, ideals, dreams, and images by which nurses judge the outer world of everyday life and human behaviour. Values are thus the filter through which nurses view the world and by which they judge what is important to them and society. As Hall (1995, p. 21) observed: Values are Values are the lter through the ideas that give significance to our which nurses view the world and lives, that are reflected through the priorities that we choose, and that we judge what is important to them. act on consciously and repeatedly. Values thus affect everything in professional life, including nurses responses to documentation requirements. The ethical demands on nurses

8 Nursing Documentation

with respect to documentation are demanding (see above), and if nurses fail to recognise or respond to conflicts between their own values and the ethical requirements put upon them, their documentation practice will suffer.

Ethical guidelines for documentation


To ensure the highest standards of professional practice in documenting nursing care, the following ethical guidelines are suggested. Nurses should respect the lives, dignity, and rights of all residents, irrespective of ethnic origin, age, gender, politics, or social status. Nurses should acknowledge the values, customs, and spiritual beliefs of all residents. Nurses should maintain the dignity of residents at all times in terms of what they write about residents, their familes, and signicant others. Nurses should take personal and professional responsibility for what they write and must ensure that organisational policies and procedures relating to documentation are followed. Nurses should ensure that their knowledge and skills remain up to date by undertaking ongoing training and continuing education. Nurses should have a clear understanding of their scope of practice, should undertake only nursing care that is within that scope, and should record only the nursing care that they deliver. Nurses should be respectful of the contribution of their colleagues in the multidisciplinary health team by reading what others document and noting how they document it. Nurses must maintain condentiality with respect to all that is written and discussed about residents and their nursing care. Nurses should ensure that everything that is recorded is an accurate and true record of events, and should always be be mindful of how others might interpret what is written. In particular, nurses should not record anything that will bring disrepute to residents, nursing colleagues, the management of the organisation, or aged care generally. If negative issues need to be noted, nurses should follow proper process in expressing their concernsthrough incident reports, staff meetings, or private meetings with authorities.

9 Understanding Nursing Documentation

Nursing practice
Codes of conduct
In most jurisdictions, registered nurses are required to adhere to a code of professional conducta responsibility to the individual, society and the profession to provide safe, competent nursing care which is responsive to individual, group and community needs (ANCI 2000). A nurses practice with respect to documentation should reflect such safe, competent nursing care. Professional nurses must ensure that appropriate documentation is written at all times. Nurses must be knowledgeable about, and competent in, the documentation Each nurse is responsible process that is in place within their for his or her own nursing organisations. They should become practiceand documentation is change agents in addressing any a part of that responsibility. areas that cause them concern. Each nurse is responsible for his or her own nursing practiceand documentation is a part of that responsibility.

Standards of practice
Nurses are familiar with standards in various aspects of their practice, but many have not considered the role of standards with respect to documentation. Table 1.1 (page 10) presents suggested benchmark standards for documentation.

Holistic nursing practice


Holistic nursing care incorporates a broad range of issuesincluding documentation. Each aspect of the holistic nursing process has a corresponding application in documentation, as shown in Table 1.2 (page 12). Once information has been collected about the range of healthcare issues (as noted in Table 1.2), an analysis of the information must be undertaken. This is followed by the development of a nursing-care plan that reflects a broad picture of quality holistic nursing care.

10 Nursing Documentation

Table 1.1 Benchmark standards for nursing documentation


ADAPTED FROM NORRIS (1994)

Aspect Quality control

Actions and standards Team leader should note quality improvement opportunities, identify issues, collect data, evaluate data, and take corrective action. Team members in each clinical care area should clearly dene their groups function in relation to documentation, and identify the breadth and scope of the documentation requirements in their area. Team members should dene the critical components of the documentation system, determine the type of documentation used, note what is used most frequently, who uses what, and why different components are used. Team members should note any critical incidents that have occurred in relation to documentation. Team members should identify the latest documentation indicators from research, journals, and professionals. Team members should undertake studies to identify indicators for each key aspect of the system as follows: (i) Structural indicators (describe the environment, equipment, and qualications of the nursing staff involved); (ii) Process indicators (identify policies and procedures, and thus demonstrate what nurses routinely do in relation to the documentation process; and (iii) Outcomes indicators (focus on critical incidents and construct processes to address the issues identied).

Application Documentation system, representative, and committee Documentation philosophy, policy, and procedures Job descriptions, and duty statements

Scope of documentation

Key aspects of the documentation process

Continuous qualityimprovement program, best-practice principles, and benchmarking

Indicators

Evidence-based processes Auditing and benchmarking

(continued)

11 Understanding Nursing Documentation

Table 1.1 Benchmark standards for nursing documentation (continued)


Aspect Internal benchmarks Actions and standards Team leaders establish internal benchmarks to measure documentation compliance; such validation identies processes not being followed and might indicate a need to review resources, staff education, a particular process, or an extensive review. Having established internal benchmarks, the team collects and organises data for each indicator. Team analyses data, identies patterns, and determines if a problem exists. Team recommends or initiates corrective action. If the corrective action is beyond scope of practice, the team makes recommendation to those who have the authority to act. Team monitors and evaluates critical aspects of the action taken above and ensures continuous improvement is maintained. Team publishes ndings and use these as an education tool for other clinical areas. Team compares documentation with other facilities, encourages collaboration (rather than competition), and objecties the documentation process. Application Benchmarking

Data collection

Auditing Benchmarking

Data analysis

Auditing Benchmarking Action plan

Taking action

Evaluation of outcome

Systems adjustments

Communication of ndings

Staff meetings, annual reports, conferences, journal articles, education programs, books Meetings, secondment of staff members, and joint projects

External benchmarks

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Table 1.2 Holistic nursing care and documentation


AUTHORS PRESENTATION

Nursing care General health status (breathing, circulation, past history, current health status) Health management Clinical measurements and assessment Nutritional status (food, uid) Bladder and bowel function Hygiene and grooming Skin integrity and wound care Exercise and activity

Documentation application Admission form Admission form Admission form Nutrition assessment Elimination assessment Bowel function record Activity of daily living assessment Social prole Skin assessment Mobility assessment Physiotherapy assessment Manual-handling risk assessment Sleep assessment Social prole Mini-mental status Social prole Pain assessment Risk assessment Social prole Admission form Social prole Admission form Social prole Behavioural assessment Sexual health assessment Depression assessment Social prole Behavioural assessment Visual and hearing assessment

Rest and sleep Cognitive function Pain Safety and protection Family, values, and socialisation Coping/grieving/losses

Sexuality Self-concept Spiritual health Stress management Sensory function

13 Understanding Nursing Documentation

Reflective nursing practice


Reflection on nursing practice in general, and on documentation in particular, assists nurses to become fully cognisant of their knowledge and actions. If nurses are honest in their reflections on documentation, this process can be difficult and uncomfortable. Such reflection might lead some nurses to recognise that they must alter the style of documentation that they have used for a long time. Indeed, some nurses find it easier not to reflect (to avoid facing the necessary changes to their practice), and some even choose to opt out of the profession completely because the demands of the documentation process are perceived to be so onerous and overwhelming. However uncomfortable the process might be, professional nurses have an obligation to reflect on their practice. At the very least, such reflection is an opportunity to ensure that their documentary practice is up to date with contemporary expectations. Reflection also represents a chance for nurses to look within and to get to know who they really are. They must be prepared to confront and understand the discrepancies It is important that management between their own documentation provides nurses with professional space in which to reect. practice and best practice within the profession. Reflection allows nurses to look at the documentation process from various angles, and to identify what has worked and what has not worked. Reflection thus provides nurses with an opportunity to become change agents by engaging in a problem-solving process that fosters accountability. It is important that management provides nurses with professional space in which to reflect. Staff ratios and the demands of cost-efficiency often mean that nurses have little time to reflect in the work environment.

Praxis
As noted above, reflecting on all documentation issues (even those that seem insignificant) provides nurses with an opportunity to become change agents.

14 Nursing Documentation

To enable this to occur, nurses must engage in the process of critical reflection and then act upon this reflection. This process is called praxis. This involves four phases (Schon 1987): knowing in actionthat is, the actual doing of the documentation; knowledge in actionthat is, explaining how to do the documentation and what it involves; reflecting in actionthat is, thinking about the documentation process that is taking place, including lateral thinking about changes and new processes that might be required for a better outcome; and reflection in actionthat is, thinking back on the whole process to see if required documentation processes have been followed and whether desired outcomes have been achieved.

Management issues
The organisation is obliged to implement the standards of documentation and to make a concerted commitment to support the process. Management has an obligation to ensure that nurses fulfil their responsibilities with respect to their professional duty of care and codes of conduct, and should support them in their efforts to do so. Management must develop policies to guide nurses in their practice, facilitate education to assist their understanding of documentation, and provide resources to enable Management has an obligation them to document appropriately. to ensure that nurses full their This management responsibility responsibilities and should can be delegated. However, support them in their efforts to do so. if desired documentation outcomes are to be achieved, clear guidelines must be in place to assist those who have been delegated the responsibility. Management issues that can arise with respect to documentation include problems with:

15 Understanding Nursing Documentation

language, jargon, and forms of expression; documentation not being performed; qualifications of nursing staff, levels of experience, and staff skills mix; attitudes of nursing staff to documentation and time-management skills; and government regulation. Each of these is discussed below.

Language, jargon, and forms of expression


Differences in documentation create confusion. This can be overcome by taking care to establish accepted uses of jargon terms and abbreviations within the organisation. English as a second language and literacy capability can also be an issue. It might be necessary to ensure that a documentation resource is available at all times for nursing staffincluding a dictionary and a glossary listing the meaning and interpretation of key words and phrases.

Documentation not being performed


Contemporary nursing requires all nursing staff to document any changes in the condition of residents and any alteration in their nursingcare plans. Anything out of the ordinary should be recorded, as should any gaps in the nursing-care plan Anything out of the ordinary in relation to the changing needs should be recorded, as should any of residents. Management should gaps in the nursing-care plan. ensure that all nurses are aware of their responsibilities in this regard. Confusion can arise in multidisciplinary teams if there is uncertainty regarding the documentation responsibilities of various members of the team. It is important that all members of the team understand their scope of practice within the team, and who has responsibility for which aspects of the documentation process.

16 Nursing Documentation

Qualifications of nursing staff, levels of experience, and staff skills mix


Problems can occur if nurses do not understand the requirements of documentation, if they have difficulty delegating responsibility to others, or if they are reluctant to hold others accountable for their standards of documentation. Staff education is the key to ensuring that all documentation processes are followed. If there are varying levels of documentation knowledge and skill among members of the nursing staff, conflict can arise. In some organisations, nurses with a higher level of competence are expected to undertake all the documentation, and this can lead to a perception that colleagues with lesser skills are avoiding their responsibilitiesthus creating tension within the team. Some experienced and able nurses might refuse to share their expertise with others. Some experienced and able nurses might take it upon themselves to change the system without full consultation with colleagues and without regard to organisational policies and structure. The increasing use of casual and agency staff members (who might have less commitment to organisational processes) can lead to outright disregard for the documentation process.

Attitudes of nursing staff to documentation and timemanagement skills


Nurses attitudes are crucial to the success of the documentation process. Negative attitudeswhich perceive documentation as a burden rather than as a positive process that enhances Nurses constantly complain that nursing carecan diminish the they have insufcient time for quality of documentation and have proper documentation. adverse outcomes for residents. Nurses constantly complain that they have insufficient time for proper documentation. Education about time management will assist nurses in discharging their responsibility to include documentation as

17 Understanding Nursing Documentation

an essential part of the nursing process. If nurses are supported with appropriate resources and organisational processes, their efficiency will be improved. Moreover, their complaints (that they do not have enough to document without compromising resident care) will be alleviated.

Government regulation
Both nursing staff and the organisation can feel that over-regulation is an issue. Management must promote a positive attitude to documentation to ensure that the requirements of government are met. This is best done by emphasising that the real focus of documentation is positive outcomes for residents.

Conclusion
The documentation process involves leadership, legal issues, ethics, values, standards of practice, holistic nursing, reflective practice, and good management. Management must be visionary and have clear guidelines to ensure that all nurses are aware of their responsibilities in relation to High-quality documentation documenting nursing care. Highensures that residents are not placed quality documentation ensures at risk and that funding to the facility is not placed in jeopardy. that residents are not placed at risk and that funding to the facility is not placed in jeopardy.

Chapter 2

Clinical Reasoning
Bart OBrien

Introduction
Clinical reasoning is the process of reaching clinical conclusions through professional judgment, knowledge, and experience. Clinical reasoning also involves an understanding of the politics of clinical practice. Nurses in residential aged care need to understand the regulatory, political, and social customs that dictate the care that is provided, when it is provided, and who provides it. Clinical reasoning thus helps nurses Clinical reasoning is the key working in aged care to identify and to successful documentation. access the resources necessary to provide the elderly with the best available standards of care, as well as providing a means of identifying and documenting best practice in care delivery. Clinical reasoning is the key to successful documentation because it helps nurses to decide what needs to be documented and in what detail.

The nature of clinical reasoning


Three theories
Clinical reasoning is the way that [nurses] collect, store, retrieve and use information (Greenwood 1998a, p. 110). Clinical reasoning has been

20 Nursing Documentation

the subject of extensive investigation for more than 40 years. During that time there have been several interpretations of the concept and how it works, and consensus has been difficult to achieve (Greenwood 1998b). Three ways of describing clinical reasoning are (Greenwood 1998b): decision theory; information-processing theory; and skills-acquisition theory. Each of these is discussed below. However, whatever theory (or combination of theories) best describes clinical reasoning, the practical process is eventually dependent on nurses understanding of those in their care.
Decision theory According to decision theory, clinical reasoning involves understanding the relationships among various possibilities. Decision theory is based on experienceif something happened previously it is probable that it will occur again under similar Decision theory is based on circumstances. An example is the experienceif something so-called sundowner syndrome happened previously it is probable whereby people with dementia often that it will occur again under exhibit certain predictable behaviours similar circumstances. in the early evening. By reasoning in this way, nurses can predict with some certainty what a particular resident will do, what provokes the person to do it, and what nursing intervention might alter the behaviour. However, some behaviours do not have such an obvious and predictable pattern. Information-processing theory Information processing uses a sequence of thoughts, recollections, and interpretations to create an understanding of what is occurring. Nurses observe a person behaving in a certain manner and draw on their nursing experience and knowledge to make sense of the event. Acting on their interpretation, nurses interact with the person to alter the behaviour. As they try various options, nurses thus accumulate more knowledge and experience.

21 Clinical Reasoning

Three theories of clinical reasoning


There have been several interpretations of clinical reasoning and how it works. Three ways of describing clinical reasoning are: decision theory; information-processing theory; and skills-acquisition theory. In addition to the insights to be gained from these theories, the practical process of clinical reasoning is eventually dependent on nurses understanding of those in their care.
ADAPTED FROM GREENWOOD (1998B)

Information-processing theory is different from decision theory in that it places equal value on reasoning and experience. Whereas decision theory assumes that nurses know the answers before they start, information-processing theory assumes Information-processing that feedback about the nursing strategies theory places equal value on that have been implemented is essential to reasoning and experience. validating the most appropriate approach.
Skills-acquisition theory The skills-acquisition theory of clinical reasoning was developed by the Dreyfus brothers in the late 1970s, and was applied to nursing by Benner (1984). According to this theory, the more skilful and experienced a nurse is, the more likely he or she is to use personal experience to drive clinical decision-making. For example, an inexperienced nurse has little personal knowledge of what constitutes inappropriate or According to skills-acquisition theory, challenging behaviour. Such a skilful and experienced a nurse is nurses therefore tend to follow more likely to use personal experience the directions and nursing-care to drive clinical decision-making. plans set by others, rather than acting on their own initiative. As a relationship develops between a nurse and a particular person, the nurse learns what behaviours are likely to occur, under what circumstances, and what to do about them. According to skills-acquisition

22 Nursing Documentation

theory, clinical reasoning improves as nurses acquire greater skills. These are acquired by implementing nursing strategies that have worked before, thus allowing nurses to manage people more easily.

Nurses understanding of those in their care


The three theories described above make sense of the way in which nurses process the amount of information they have to deal with on a shift-byshift basis. At various times, each theory has had its following, and each has its applications in particular The key to effective nursing care is circumstancesdepending on nurses developing a comprehensive the knowledge and experience understanding of those in their care. of the nurse who makes clinical decisions. Taken together, the three theories discussed above make sense of some aspects of clinical reasoning, but they do not provide a full explanation of the process. A fourth approach complements these theories by suggesting that the key to effective nursing care lies with nurses developing a comprehensive understanding of those in their care. The essential parts of such a comprehensive knowledge base are (Radwin 1996): nurses knowledge of the particulars that set individuals apart from others with the same diagnosis; nurses knowledge of: (i) residents responses to treatments; (ii) their routines and habits; (iii) their coping resources; (iv) their physical capacities and endurance tolerances; and (v) their body type and characteristics; nurses understanding of each persons current status together with that persons baseline responses to specific treatments and interventions; nurses awareness of how people perceive situations in which they find themselves (thus assisting nurses to understand and deal effectively with residents concerns); and nurses experience of residents needs and responses to previous nursing care.

23 Clinical Reasoning

Understanding those in care


In addition to the three theories of clinical reasoning discussed in this chapter, the key to effective nursing care lies with nurses developing a comprehensive understanding of those in their care. This depends on nurses awareness of: the particulars that set individuals apart from others with the same diagnosis; residents responses to treatments, their routines and habits, their coping resources, their physical capacities, and their body type and characteristics; each persons current status and responses to specic treatments; how people perceive situations in which they nd themselves; and residents needs and responses to previous nursing care.
ADAPTED FROM RADWIN (1996)

To communicate their understanding of those in their care, nurses require a framework that allows them to explain to each other what has occurred and what actions have been taken. The 24-hour-a-day nature of nursing means that teams of nurses are involved in the care of Documentation that reects group experience communicates a richer any given person. Documentation understanding of a persons needs that reflects group experience and than that of any individual nurse. group observations communicates a richer and more comprehensive understanding of a persons needs than that of any individual nurse. If these shared understandings are clearly documented, any nurse can access information collected from multiple experiences without having to interrupt other nurses to obtain information verbally. A reluctance to interrupt others can mean that a nurse might work without the knowledge and experience of colleagues who have gone off duty. Collecting the information needed for decision-making is continuous and cumulative in the real world of clinical practice. Rarely is all the information available at the time it is needed, so nurses start with what seems reasonable and continually validate their knowledge base. They use feedback from residents and their peers, as well as other resources in the

24 Nursing Documentation

clinical settingprovided that this information can be sourced within a meaningful timeframe (Greenwood 1998b).

Politics of clinical reasoning and documentation


Nurses must consider the environment or context in which clinical reasoning takes place. Health care is political, and it is costly to provide services. There are therefore many people and authorities who are keen to see that nursing care is providing value for the money. This social monitoring is readily evident in residential aged carewhich costs societies around the world huge sums of money every year. Documentation in residential aged care is thus a means of accounting for the cost of providing nursing care, as well as recording and communicating the nursing care that is given. Best practice requires nurses to have knowledge and Factors other than residents needs understanding of the aged care can (and do) inuence how care is industry as well as of the needs communicated and recorded. of individual residents. This does not mean that nurses must be directly involved with the politics of aged care, but it does mean that nurses who document must be aware that factors other than residents needs can (and do) influence how care is communicated and recorded.

Conflicts between clinical reasoning and documentation


Theoretical plans and clinical experience
Conflicts can arise between clinical reasoning and the demands of nursing documentation. In particular, nursing-care plans are a potential source of conflict. The following sorts of problems can arise: experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning; nurses can feel constrained to follow nursing plans against their better judgment;

25 Clinical Reasoning

it is difficult to write a care plan that is appropriate to all members of the nursing team; documentation can be perceived as an administrative requirement that takes up valuable time; and theoretical nursing models can be perceived as being irrelevant. Each of these is discussed below.
Lesser quality than clinical reasoning

In many instances, experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning. Compared with a nursing Care given in accordance with care plan (NCP), an experienced written nursing plans can be of nurse can initiate actions that are lesser quality than that provided by more immediately relevant [and] an experienced nurse who follows more strategic and farsighted than clinical reasoning. an NCP. The experienced nurse is also able to intervene in ways that reduce anxiety and agitation in ways more ingenious than those suggested by the NCP (Aidroos 1991, p. 179).
Constrained to follow nursing plans

The difficulty with NCPs is that nurses can feel constrained to follow themeven though autonomous thinking and practice would actually be in the better interests of patients. NCPs can be used to satisfy organisational and professional expectations, rather than being used to direct nursing care (Aidroos 1991). Indeed, concerns of this nature led the American Joint Commission on Accreditation of Healthcare Organisations (JCAHO) to remove NCPs from its list of required documentation (Brider 1991).
NCPs inappropriate to all nurses

It is difficult to write an NCP that is appropriate to all members of the nursing team. NCPs written for a novice or an inexperienced nurse can seem wordy to a proficient nurse and redundant to an expert nurse.

26 Nursing Documentation

This is not a problem if nurses of similar experience are involved in a team. In these circumstances, it is possible to develop a style of clinical documentation that has relevance to everyoneand which is therefore used, valued, and maintained. However, in residential aged care there is often a spread of experienced and inexperienced staff members, and it is likely that competent, proficient, and expert nurses will be responsible for writing NCPs for staff members who have significantly less knowledge and experience. In these circumstances, a proficient or expert nurse can become frustrated with a tedious exercise that is apparently aimed at compliance with regulatory requirements, rather than directing handson staff. In addition, there is a risk that the documentation can miss its intended targetby being too detailed for the staff members who are supposed to follow it.
Administration taking up care time

Documentation can be perceived primarily as an administrative requirement that takes up valuable time that might have been otherwise spent on resident care. This is probably the most common complaint about NCPs among aged-care nursing staff.
Irrelevant theoretical framework

Even if documentation does address clinical issues, the theoretical nursing model framework in use can be perceived as being irrelevant. Nurses can feel embarrassed about asking certain questions if they feel that the questions are irrelevant or inappropriatesuch as questions about sexuality (Mason 1999). In these circumstances, nurses can respond by maintaining a secondary form of real working documentationwhich directs practice while paying lip-service to the formal NCP framework required by regulatory authorities. For these reasons, it is not surprising that Mason (1999, p. 380) observed:
There is strong evidence that care plans are viewed negatively by nurses and poorly implemented, with little evidence to suggest that they have any positive effect on quality of care or patient outcomes.

27 Clinical Reasoning

Theoretical plans and clinical experience


Conicts can arise between theoretical plans and clinical experience. These include the following. Experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning. Nurses can feel constrained to follow nursing planseven though autonomous thinking and practice would actually be in the better interests of patients. It is difcult to write an NCP that is appropriate to all members of the nursing team. Documentation can be perceived primarily as an administrative requirement that takes up valuable time that might have been otherwise spent on resident care. The theoretical nursing model framework that is in use can be perceived as being irrelevant.

However, if nurses believe in the NCP framework and the purposes of documentation, they will pay it more than lip-service. In these circumstances, nurses attitudes to documentation are generally positive, patients are consulted about proposed care, and care plans are used to assist in explanation, communication and a guide to practice (Mason 1999, p. 384).

Differing expectations
Most regulatory bodies require prescribed record-keeping because they believe that documentation is an essential component of safe professional practice. However, documentation is likely to Nurses frequently complain that they have time to care or time to write be ignored or inadequately but do not have time for both. completed if it does not achieve what nurses see as valid goals. In these circumstances, nurses frequently complain that they have time to care or time to writebut do not have time for both.

28 Nursing Documentation

Nurses document to meet: the clinical requirements of those in their care; and the requirements of organisational and regulatory compliance. The two needs co-exist. However, nurses might not respect the second if organisational documentation frameworks do not adequately reflect the clinical reasoning processes of nurses. Organisational and legislative compliance is directed Like it or not, funding is an towards funding requirements and essential ingredient in the providing evidence that established provision of residential aged care. standards are being met. These requirements are pragmatic and political. In monitoring standards, documentation is used as evidence that rational thinking and planning are being used in aged-care nursing. Like it or not, funding is an essential ingredient in the provision of residential aged care. Nurses are a major expense in the aged-care budget, and they must be accountable for the effective spending of that money. Appropriate standards of aged care must be established and monitored to confirm that professional standards are being maintained, and to justify funding for nursing care.

Effective documentation
To work for all involved, effective documentation should be (Mason 1999): descriptive of practice-in-use (without neglecting legal or regulatory requirements); integrated with practice and evaluated throughout the day (rather than being an add on that is done before or after the event); owned by the staff members who write and use it; flexible and tailored to the needs of the clinical area in which it is used; innovative and imaginative (to catch the attention and maintain the interest of nursing staff who use it); and kept to a minimum (to avoid repetitious and redundant entries).

29 Clinical Reasoning

In addition, nurses should re-invent documentation that does not work for them, and management should encourage innovation in the development of practice-focused documentation (Mason 1999). However, regulatory compliance must not be ignored. The clinical needs of individuals should shape nursing documentation, but the administrative needs of the regulatory authorities must be respected.

Conclusion
Nurses rely on their own experiences and on organisational and legislative demands to guide and inform the documentation of nursing practice (Brosnahan & Tracy 2002). However, rather than rely on routine and direction, nurses must appreciate that the capacity to The capacity to think through the think through the implications implications of nursing documentation of nursing decisions and nursing is an important factor in establishing professional recognition. documentation is an important factor in establishing recognition of their professional status. In this context, documentation should meet the following criteria. It should effectively link individually assessed resident needs with contemporary best practice in aged care to achieve the best possible outcomes for residents. Those responsible for documentation must therefore know the residents about whom they are writing, and must be aware of the contemporary practices best suited to their needs. Nurses must bring documentation to life by making it relevant and useful to colleagues who are expected to understand it and follow its directions. Nurses must recognise that documentation is a critical factor in the monitoring of quality and the meeting of funding requirements. Documentation that adequately meets the requirements of the resident needs and the direction of nursing care must also be capable of meeting the requirements of policy and regulatory compliance.

30 Nursing Documentation

Criteria for effective documentation


Effective documentation should meet the following criteria: link individually assessed resident needs with contemporary best practice; be relevant and useful to colleagues who are expected to understand it and follow its directions; and be recognised as a critical factor in the monitoring of quality and the meeting of funding requirements.

To meet the criteria of effective documentation, nurses must evaluate the format and purpose of documentation to ensure that the needs of both the regulatory bodies and those of residents and staff are being met. For their part, residential aged-care facilities must consider documentation models that promote clinical reasoning by nurses. Finally, clinical and educational forums must be facilitated to enable the complementary roles of clinical reasoning and regulatory documentation to be discussed and implemented.

Chapter 3

Professional Communication
Christine Crofton and Gaye Witney

Effective written and verbal communication in aged-care nursing demands a level of articulation that goes well beyond telling stories about what has occurred in the care of a particular resident on a particular day. Documentation in aged care serves many functions beyond a simple account of the days nursing Effective communication in aged-care activitiesand the level of professional communication nursing demands a level of articulation that goes well beyond telling stories in documentation must reflect about what has occurred. this. In documenting aged care, nurses are communicating information that affects the following important matters: the identification and assessment of nursing-care needs; communication among members of the healthcare team; the requirements of the funding systemby establishing links between the level of nursing care that is provided and the financial reimbursement provided; educationincluding more effective ways of documenting nursing care;

Introduction

32 Nursing Documentation

researchby establishing trends in aged-care needs; auditingto validate standards of nursing care; and legal requirementsespecially protection of staff and the residents in their care. Contemporary aged care thus requires a more rigorous approach to professional communication in documentation than has been required in the past.

It must be recognised that documentation today is an essential aspect of a healthcare organisations comprehensive, analytical communication system. Organisations must consider how the process of documentation forms part of overall organisational processes. Properly done, documentation can serve as a powerful problem-solving tool. To achieve this, documentation must use feedback, Properly done, documentation reflection, and analysis to enable nurses can serve as a powerful to communicate more effectively about problem-solving tool. the many complex issues that arise in relation to nursing care. If a systematic approach is instituted, a different set of stories begins to appear in the documentationstories that reflect a proactive approach to health needs and nursing care, rather than a narrative of reactive responses to what has happened. A systematic model of documentation encourages a participative and collaborative approach linked to the development of a learning culture in aged-care facilities (Senge et al. 1994).

Communication within organisations

Codes of ethics and practice

Codes of ethics and professional practice support the contention that communication in nursing documentation should be of the highest standard. All nurses subscribe to a code of ethics on entering the profession, and nurses who understand and value the ethics of the nursing profession will

Codes of ethics

33 Professional Communication

recognise their responsibility to utilise the documentation system as an integral part of the role of the nurse in aged care. To ensure that the highest ethics of nursing are reflected in their professional communication, the documentation of nurses should be: factual; accurate; current; and organised.

Codes of professional practice


Codes of professional practice remind nurses that they are part of a professional team. If nurses are to maintain their professional standing within these teams, it is important that the highest nursing competencies be reflected in the quality of their documentation. To be professional communicators in the context of nursing documentation, nurses need to attend to their professional responsibilities as outlined in the Box below.

Professional responsibilities in documentation


To be professional communicators in the context of nursing documentation, nurses need to: be skilled in documenting nursing care; know who they are working with, and for whom, within the aged-care facility; be holisticby looking at the whole documentation system, not merely the entry that they are making in the notes on any given day; be dependable, reliable, and trustworthy when attending to their documentation responsibilities; be an advocateby putting the interests of the resident rst when recording their notations; be genuinely supportive of the organisations documentation processes and work with integrity within the organisations processes for improvement in the system; (continued)

34 Nursing Documentation

(continued)

anticipate documentation requirements (rather than waiting to be told what to do); become involved in documentation processes and opportunities for improvement, rather than merely completing the minimum requirements of assigned tasks; actively seek personal and professional responsibility in undertaking a role in documentation processes; accord documentation a high priority and ensure that documentation is completed properly and promptly; be a team player by leading and supporting colleagues as they attend to their documentation responsibilities; be observant and honest when recording nursing care; be loyal and respectful towards the organisations leaders and documentation processes; actively listen when being advised of the requirements of the facility in terms of documentation; show initiative when attending to documentation responsibilities; and accept constructive criticism regarding gaps in knowledge, skills, or attitudes with respect to documentation.
ADAPTED FROM MASTERS (2003)

Establishing professional communication


Holistic perspective
As noted above (page 32), documentation is an integral part of the overall functioning of aged-care facilities, and documentation thus forms part of a comprehensive communication system within such facilities. One aspect of the documentation system cannot exist without the other parts, and the value of documenting Documentation forms part of a professionally is that it brings comprehensive communication system the separate components of within aged-care facilities. care together.

35 Professional Communication

An obsession with funding requirements and how they impact on the quality and quantity of documentation can distort a holistic understanding of documentation as an integral part of the nursing care delivered to residents in aged care.

Overcoming resistance
The establishment of a systematic approach to documentation requires planning and consultationfrom when a resident enters the facility to when that person leaves. If the inter-relatedness of the various parts of the documentation process is continuously promoted, nurses will be encouraged to collaborate with each other in implementing a comprehensive system of professional communication. Once established, the effectiveness of the system must be continually monitored to ensure that it is producing the required standard of documentation. At first there might be some resistance to the new system among nurses. Some will be reluctant to use the system, At rst there might be some resistance and some might even actively to the new system among nurses. Some will be reluctant to use the system, and sabotage it. However, once a some might even actively sabotage it. more efficient and effective process is established, nurses will gradually accept this and come to see that the new system is more effective. Eventually they will even claim it as their own.

Managerial skills
In overseeing the introduction of an effective documentation process, nurse managers have to develop new managerial skills. They need to monitor the day-to-day processes of the system itself, as well as the patterns of behaviour and mindsets of the nurses as they use the system. If the organisation adopts an holistic approach to the documentation process, committed nurse managers will find that they need to add a new dimension to their management practice. Two suggested strategies are described in the Box on page 36.

36 Nursing Documentation

Two strategies for nurse managers


The introduction of a new documentation system puts increased demands on nurse managers. Two strategies that nurse managers will nd helpful are described in this Box. Identifying the issue In analysing any given issue with the documentation process, nurse managers should ask themselves whether the problem is: an issue related to a particular process within the system? an issue related to the implementation of the system as a whole? an issue related to nurses attitudes to documentation in general? an issue related to nurses attitudes to the new system in particular? Having identied the exact nature of the issue, the nurse manager can then address the following questions: Why is this an issue? Have I, as a unit manager, contributed to this issue? How would other unit managers see this issue? What is preventing me dealing with this issue? What are the consequences of not dealing with the issue? This approach allows the nurse manager to analyse the issue dispassionately and logicallythus enabling problems to be tackled more effectively. Asking Why? Another strategy that might be useful for nurse managers in assessing issues with a new documentation system is to ask a series of Why? questions. For example: 1. Why was this assessment not analysed? Answer: The nurse responsible became distracted and did not complete the requirements. 2. Why did the nurse become distracted? Answer: The nurse was working on a shift that was short of staff today and the nurse was trying to ll too many gaps.
(continued)

37 Professional Communication

(continued)

3. Why was there a shortage of staff? Answer: A colleague called in late and there was no opportunity to organise a replacement. 4. Why did that prevent the nurse completing the analysis? Answer: The nurse did not have time and space to complete the process. 5. Why was that not possible? Answer: The process was too complicated to manage when other matters become disorganised and rushed. This approach allows an analysis of a situation that avoids a judgmental assessment of what a particular person did or did not do. The approach concentrates on why a particular process has not been completedthus reducing the tendency to ascribe blame to individuals.

Encouraging and coaching nurses


Negative perceptions of documentation are common among nurses and this negative attitude can easily become accepted as the norm. However, as professionals, nurses are responsible for developing their own perceptions, rather than seeing the world from a reactive point of viewand Nurses have to deal with the daythere are many nurses who do to-day reality of apathy and low morale that is so common with have a positive perception of their respect to documentation. professional responsibilities with regard to documentation. They should be encouraged. It is important for the organisation to foster the intrinsic desire of those nurses who wish to improve their own documentation capabilities and those of their colleagues. However, the organisation must also acknowledge that nurses have to deal with the day-to-day reality of apathy and low morale that is so common with respect to documentation. Management should therefore encourage enthusiastic nurses to take on the role of coach in the workplace. Coaching can be defined as the

38 Nursing Documentation

ability to unlock potential to maximise performance. In this sense, coaching is helping [others] to learn rather than teaching them (Whitmore 2002, p. 8). The process of coaching involves the asking of open-ended questionswhat?, why?, when?, where?, who?, and how?. These questions facilitate creative thinking about the issuesin contrast to the reactive thought response that is Coaching is helping others to likely to be engendered by instruction learn rather than teaching them. that simply tells people what they should do. The aim is to generate a constant awareness among nurses of their own capabilities and those of their colleagues. This encourages nurses to take responsibility for the processes as designed, or to make suggestions for improvements to the processes.

Assessing the system


Positive feedback
As noted above, individual nurses have different attitudes to documentation. Some avoid the responsibility altogether and others use it as a chance to have a rest. However, there are those who use the opportunity to learn as much as they can about the Documentation is part of nurses documentation system and about professional responsibilities to those the residents as individuals. A in their care and an integral part of successful documentation system the care that nurses deliver. is more likely to be achieved if all staff members value the system as part of their professional responsibilities to those in their care and as an integral part of the care that nurses deliver. A positive staff attitude to documentation is more likely to be achieved if nurse managers reflect on their own attitudes to the documentation process and engage in ongoing constructive discussion of the issues. However, in doing so, they should avoid constant carping criticism of the organisation in general and documentation in particular.

39 Professional Communication

In addressing the attitudes of individual nurses, patterns of belief can be assessed and altered by constructive feedback. Feedback loops can be used to create a new story about documentation, and this new story will gradually be passed around the facility. As staff members come to see the transparent advantages of the system, and as they become accustomed to a more streamlined system, past practices will be forgotten and the new practices will become accepted as the norm.

Gap analysis
Once a new documentation system is introduced, it is important to keep the process alive and flexible. This involves ongoing analysis and assessment. This should be a problem-solving processrather than a process of attributing blame for any inadequacies in the system. The approach is that we have a problem rather than he or she is the problem. The approach is that we have This process is called gap a problemrather than he or she is the problem. analysis, and it should be part of a quality-auditing process that involves all aspects of the organisationmanagement, nursing staff, and any ancillary staff who might be involved in documentation. As the name suggests, a gap analysis involves the identification of gaps (or deficiencies) in the process. In instituting a gap analysis, the following steps are required: planning for the analysislooking at skills, knowledge, and attitudes; conducting an initial meeting about the process of gap analysis; implementing the gap analysis itselfidentifying the deficiencies in the documentation process, at all levels of the organisation; preparing a reportbased on the evidence collected in the survey; and conducting another meeting to report the findings. An action plan is then developed to implement strategies to address the gaps. A follow-up gap analysis can then be planned to measure the success of the plan. The process then starts again.

40 Nursing Documentation

The Box below lists some of the matters that should be examined in any gap analysis.

Gap analysis
A gap analysis should include consideration of such matters as: Management level the goals of the documentation process within the organisation; documentation policies and procedures; evaluation of documentation resources; roles and responsibilities of all staff in relation to documentation; expectations of staff performance in relation to documentation; understanding the role of government in documentation processes; and education and training to support documentation processes. Nursing level the goals of nursing staff in relation to documentation; the role and responsibilities of nurse managers in relation to documentation; expectations of performance of nursing and ancillary staff in relation to documentation; attendance at educational and training session related to documentation; current documentation knowledge and skills levels of nursing and ancillary staff involved in documentation; and willingness of high-achievers with exemplary knowledge, skills, or attitude towards the documentation process to be promoted as team leaders. Ancillary staff understanding of documentation policies and procedures; understanding of government requirements; utilisation of support resources; utilisation of principles of effective documentation; and literacy.

41 Professional Communication

It is essential to evaluate the impact of a new system on nurses and to understand the processes on which they rely to guide them. Performance improvement must be approached systematically if it is to improve productivity and competence. Gap analysis provides such a systematic analysis.

The role of risk management


Any new system should be subjected to a risk-management analysis. Indeed, risk management is a key process in the encouragement of experimentation and creativity. Although risk management is The identication of risk factors sometimes seen as a negative and in meeting responsibilities with documentation enables nurses to defensive process, a positive riskhave condence in approaching assessment process means that this important task. nurses will not feel threatened by a new system. The identification of risk factors in meeting responsibilities with documentation enables nurses to have confidence in approaching this important task. An organisation that adopts a negative attitude of risk control tries to prevent nurses from ever making mistakes. Such an organisation has a tyrannical attitude in enforcing the rules of documentation. In contrast, an organisation that adopts an An attitude of risk management attitude of risk management encourages nurses to use their encourages nurses to use their clinical judgment. clinical judgment. In such an organisation, there is always a risk of not getting it right all the time. However, this is balanced by the fact that nurses are given space to learn from experience, trust their intuition, and develop their judgment. The Box on page 42 contains some strategies to encourage sensible risk-taking in implementing a comprehensive professional documentation system.

42 Nursing Documentation

Strategies for positive risk-taking


To encourage sensible and positive risk-taking, nurse managers are encouraged to adopt the following strategies: design a formal framework for evaluating risk to ensure that the process is transparent and known to all nurses in the facility; analyse mistakes rather than punishing them; encourage experimentation and creativity; avoid discouragement unless repeated mistakes are made through a lack of insight and an unwillingness to learn from them; encourage nurses to rely on a balance of informed factual analysis and intuitive awareness; and encourage an environment in which nurses feel free to discuss ideas and gather resources to assist their own decision-making and that of others (rather than formalising everything and forcing staff to seek approval for any innovation).
ADAPTED FROM BENNETT & MATHESON (2002)

Conclusion
Most nurses who are involved with documentation in aged care work positively to discharge their responsibilities. They do so with an earnest desire to meet the demands of often complex requirementseven if they have little faith in the systems with which they are forced to work. The implementation of a comprehensive documentation A comprehensive documentation system that enhances professional system enhances professional communication provides such communication and provides nurses with a sense of ownership nurses with a sense of ownership of the system. of the system and a strong sense of being involved. The most effective aged-care facilities encourage nurses to learn and grow by offering challenging (and often difficult) work through the documentation system. Even if the work is risky, meaningful tasks enhance professional pride in the nursing role.

43 Professional Communication

Along with risk comes reward, and successful organisations often celebrate outstanding achievementsuch as coming unscathed through a government audit of the facilitys documentation processes. Although there is often a healthy and constructive conflict of ideas about how to meet the requirements of documentation, a well-functioning facility shares a culture of trust in which nurses feel confident to divulge their uncertainties about their ability to meet the requirements of documentation. This requires leadership in which all nurses are held accountable for their documentation practices and encouraged in their efforts to improve. In implementing a documentation system that encourages professional communication among all stakeholders, an effective organisation: researches what is required and how best to go about meeting those requirements; resolves external and internal obstacles to professional documentation; makes a careful assessment of what should be documented and how to go about documenting it; responds positively to changing requirements; and accepts new ideas and expands upon suggestions for improvements in the documentation system. A comprehensive documentation system should be seen as an exercise in professional communicationrather than as a chore to be carried out in accordance with regulatory requirements. In the In the nal analysis, documentation final analysis, documentation is a professional responsibility is a professional responsibility in accordance with the ethical responsibilities of nurses and their that is in accordance with the codes of professional practice. ethical responsibilities of nurses and their codes of professional practice.

Chapter 4

Nursing Care Plans


Shirley Schulz-Robinson

Introduction
This chapter discusses the use of nursing-care plans (NCPs) in residential aged-care facilities. The purpose of NCPs is to provide individualised nursing care, but they have not always achieved their intended purpose. This is partly because they have been standardised and simplified. In the future, national policy and funding criteria will influence how nursing care is categorised, provided, and documented. New systems of The purpose of NCPs is to provide documentation will evolve. This individualised nursing care, but they have not always achieved is likely to involve a combination their intended purpose. of NCPs and care pathways that emphasise a persons individual needs. Nurses and their professional organisations will need to think strategically about nursing care, and how it is planned and implemented. They will need to determine what should be done for residents (given current knowledge and national standards), rather than what is currently being done.

46 Nursing Documentation

Individualising nursing care

Since the 1930s, teachers of nursing have used NCPs to assist students in critical analysis and systematic assessment of the physical, behavioural, psychological, and social needs of those in their care (Daly, Buckwalter & Meriden 2002; Grant 1979; Saunders 1999). Students were required to develop NCPs to identify care requirements, urgency of care, and who should provide care. By the 1970s students were required to apply models and frameworkswhich reflected different views of health, illness, environment, and nursing. These involved five steps: (i) assessment; (ii) formulation of nursing problems; (iii) interpretation of observations; The purpose of such NCPs was the provision of individualised (iv) development of NCPs; and (v) care, rather than care based on evaluation of care. This became rules, rituals, and traditions. known as the nursing process (Meleis 1997; Yura & Walsh 1967). These models and frameworks drew upon the social sciences (psychology, sociology, philosophy) and the biological sciences (anatomy, physiology, physics, chemistry) (Orem 1971; Roy 1987; Neuman and Young 1972; Roper, Logan & Tierney 1996; Caplan 1964). During the 1980s, nursing diagnosis was developed. This was a classification system developed by the North America Nursing Diagnosis Association (NANDA) (Lewis, Heitkemper & Dirksen 2000). Selected diagnoses (such as self-care deficit, powerlessness, helplessness, injury risk, altered thought processes, and anxiety) were used to structure NCPs for people with various conditionsincluding Alzheimers disease, Parkinsons disease, various types of cancer, incontinence, immobility, depression, and anxiety (Lewis, Heitkemper & Dirksen 2000). Such textbook NCPs were useful because they identified actual and potential problems and needs for persons with specific conditions. Computerised and standardised plans also offered prompts (Daley, Buckwalter & Maas 2002). The purpose of such NCPs was to promote the provision of individualised care, rather than care that was based on rules, rituals, and traditions (Grant 1979; McCoppin & Gardner 1994).

47 Nursing Care Plans

Historically, nursing notes have acted as an aide-mmoire for doctors, rather than being a means for nurses to monitor the effectiveness of the care they provide (Schulz-Robinson 1997). Nurses have shared their observations and judgments verbally with their peers at hand-over. This practice allowed nurses Verbal communication reduced to do things their way if they the visibility of nurses work, their thought it appropriate (Wicks accountability for what they did, and 1999), and it worked well if all their provision of individualised care. nurses knew the idiosyncracies of the rules, routines, policies, and medical practices of caring for residents. However, the reliance of nurses on verbal communication had negative professional consequences because it reduced the visibility of their work, their accountability for what they did, and their provision of individualised care. Continuity of care was rarely achieved because the system allowed for variability of care if nurses felt it appropriateand residents suffered as a result.

Benefits and problems of NCPs


Benefits
By focusing attention on nursing care, NCPs have benefited nurses, their employers, and the recipients of nursing care (Grant 1979). NCPs allowed nursing care to be isolated and costed. Managers were able to calculate the hours of care required for residents needs to be met, and were able to staff units accordingly. Continuity of care became achievableeven if Because NCPs provided numerous nurses provided care. an historical record the

professional accountability and Because NCPs provided an visibility of nurses increased. historical record, they could be reviewed for clinical audits, qualityimprovement activities, and accreditation. It became possible to judge whether competent nursing assessments had been made, and whether appropriate care had been provided. The professional accountability and visibility of nurses had increased.

48 Nursing Documentation

For these reasons, documentation is now an integral part of nursing. It fulfils professional and legal responsibilities, conveys information about the care provided, and communicates information relevant to the system as a whole (Axford 1995). However, nurses can sometimes experience difficulties in writing care plans (Coker 1998; Grant 1979). It can be difficult to identify goals, interventions, and outcomes that meet residents needs. Nurses require knowledge about individualswho they are, their specific conditions and problems, and the best strategies Nurses require knowledge about for assisting them. One of individualswho they are, their the easiest care plans is the specic conditions and problems, and SOAPIE systemsubjective, the best strategies for assisting them. objective, assessment, planning, implementation, and evaluation. Following assessment, problems are listed and numbered, and described from the perspective of the patient (subjective) and the nurse (objective). Similarly, activities and interventions are planned and evaluated from subjective and objective perspectives. Because the method allows subjective evaluation, the views of patients are given prominence. The problem intervention statements provide an up-to-date overview of problems, their status, and the care provided.

Problems
NCPs take time and effort to develop. To save time and to promote consistency of information, many facilities have adopted standardised NCPs. However, because nurses are still required to record data (such as temperature, fluid balance, elimination patterns, medication, functional independence, cognitive or emotional state, and food intake) on forms that are later included in files, as well as recording the same data in file notes, little time has been savedespecially when nurses are also required to develop and maintain NCPs for their own use. Documentation still consumes a large proportion (1550%) of nurses time (Daly, Buckwalter & Maas 2002; Grant 1979). Some nurses complain that much of this work is unnecessary and that it reduces the time they have available

49 Nursing Care Plans

for providing care. However, Comprehensive documentation is comprehensive documentation is essential if individualised care essential if individualised care is is to be provided. to be provided. Long-term care poses a challenge for nurses who must identify needs in ways that are meaningful to staff members from various educational backgrounds. NCPs are often difficult to understand, and many nurses therefore choose to rely on discussions with peers to gain information. Discussion is useful, but nurses must be able to interpret NCPs consistently if they are to provide safe and appropriate care. Standardising and streamlining NCPs have reduced their relevance. Reliance on predetermined questions that are answered by ticking boxes (yes, no, or not applicable) limits the quality and quantity of information obtained. Personal information is often omitted because openended questions, and those that are considered irrelevant, remain unasked. Nurses are left with insufficient information for planning ongoing individualised care (Coker 1998). If nurses focus on the completion of a prescribed form, rather than focusing on the person, it is difficult to obtain the information that they require to develop a residentcentred NCP. Gaining a sense If nurses focus on the completion of a of who the person is can be a prescribed form, rather than focusing challenging and time-consuming on the person, it is difcult to obtain the information that they require. task. Writing informative NCPs is difficult and standardised plans do not make it easier. The Box on page 50 provides an example of an NCP based on obtaining relevant individual information, rather than relying on the completion of a predetermined proforma. In long-term care, NCPs should tell a person story (Coker 1998). These stories should relate what these people wanted to achieve, what they did achieve, what they value, where they lived, how they earned a living, who and what they cherished, their interests, and their hobbies. It is very difficult for nurses to hold meaningful conversations with residents if their knowledge of those in their care is restricted to their diseases and medications.

50 Nursing Documentation

An NCP based on relevant information


Mrs A was admitted unwillingly to residential care because her daughter was ill and unable to care for her. Mrs A had been born in eastern Europe and had emigrated to Australia as a refugee in 1947. Since the death of her husband ve years ago, her health had deteriorated. Mrs A was illiterate in her own language and her English skills were poor. As a child she had survived internment in a concentration camp during World War II, and she was therefore afraid of authority, government institutions, and hunger. On her arrival at her new home, Mrs A was withdrawn and fearful, and was reluctant to let go of her daughters hand. To respond appropriately to this womans needs, nurses developed an NCP by obtaining information that assisted nursing staff to empathise with her situation, and to respond appropriately to her needs. Mrs As care plan focused on strategies and processes that reduced her fear and helped her to feel safe and in control. As a result, Mrs A gradually began to feel respected and safe.

Individualised care can also be impeded by practical considerations including resident/staff ratios, staff mix, skill mix, knowledge levels, physical facilities, rigid rules, and fixed routines.

Different views of nursing


Different views of nursing and the purpose of residential care influence how NCPs are used. Resident-centred care must be a stated philosophy of a facility. It must be part of the culture of the facility that is enacted in all activities. Society has various, often conflicting, expectations of nurses (Chiarella 2002). Nurses can be viewed as doctors handmaidens and, simultaneously, as responsible practitioners in their own right. Indeed, the nursing profession itself has not achieved a consensus about the nature of nursingeven in specialty areas of nursing such as aged care, community nursing, and mental health. Many researchers have identified people and their health as the primary focus of nursing (Lewis, Heitkemper & Dirksen 2000; Schulz 1992), as have many professional organisations

51 Nursing Care Plans

(including the International Council of Nursing 1994, the World Health Organization 1993, the American Nurses Association 1994, the Canadian Nurses Association 1988, the Royal College of Nursing 1994, and the Some nurses continue to believe that real nursing occurs only Royal College of Nursing, Australia in acute general hospitals and 1996). This perspective suggests that high-tech facilities. nurses are resources for people to use to regain or maintain their health (Schulz 1992). Other views continue to dominate many practice settings, with service managers still seeing nursing as primarily concerned with illness, hospitals, and medical care. Some nurses continue to believe that real nursing occurs only in acute general hospitals and high-tech facilities, and that working in aged care, community nursing, and mental health is not real nursing. However, although the care that people require in aged-care facilities is often nontechnical or non-medical, the needs of ageing people are rarely simple. Overworked staffmany of whom have modest educational preparation for their rolesare unable to care for all of these complex needs. This lack of consensus about nursing makes it difficult for nurses to develop effective NCPswhich should state what needs to be done, not what is being done (Grant 1979). NCPs should state what needs to Decisions about what needs to be done, not what is being done. be done depend on ones view of what nursing is and what residents need. Many nurses consider basic personal care to be non-nursing care. However, all nurses in residential care have a professional responsibility to ensure that residents are provided with care that meets industry and professional standards.

Residents needs and the purpose of aged care


The medical, functional, and emotional needs of residents in agedcare facilities are similar to the needs of people in the wider community. For example, a resident with arthritis might require assistance

52 Nursing Documentation

when bathing. An NCP for this person should take account of a range of needs, including: stiffness and pain; personal hygiene; maintaining or improving mobility and independence; emotional and social issues (for example, cheerfulness, positivity, loneliness, depression, detachment, anxiety, grief, withdrawal, fear); and cultural factors. NCPs should focus on these and other individual needs, using the most appropriate care and contemporary interventions. People seek residential care for various reasons. In Australia, three levels of accommodation are providedprivate units, hostels, and nursing homes. Residents can move from one care level to another if necessary. People move to these NCPs should focus on individual facilities when they or their needs, using the most appropriate care families are no longer able to and contemporary interventions. copeeven with assistance from community services. Residential facilities are expected to provide aged persons with a safe, home-like environment and ready access to the care and assistance they need. Care needs tend to fluctuate over time and resident problems vary. Residents require an environment that is physically, emotionally, and socially safe. Care needs must be anticipated by nursesrather than merely attending to known Care needs must be anticipated needs or reacting to problems by nursesrather than merely as they arise. For example, attending to known needs or falls, constipation, and urinary reacting to problems as they arise. tract infections are preventable problems for many residents. The Box on page 53 gives an example of how astute nursing awareness can ensure that appropriate care is provided. To recognise changes and identify possible causes, nurses need to know, in general, how elderly persons are likely to react to illness.

53 Nursing Care Plans

Awareness of other possibilities


Mrs B was usually a cheerful and sociable woman of 85 years of age who suffered from limited mobility, congestive cardiac failure, and painful rheumatoid arthritis. In recent times Mrs B had become socially withdrawnwith episodes of confusion, agitation, and aggression. At rst these signs were interpreted as evidence of early dementia. However, nurses recognised that a woman of this age, especially with limited mobility, might develop a silent urinary tract infection with none of the usual signs and symptoms (such as dysuria, frequency, or raised temperature). They recognised that this womans social withdrawal, confusion, and agitation could be due to an infection. Mrs B was investigated for a possible urinary tract infection, which was subsequently treated with success. A failure to recognise the possibility of this urinary tract infection might have led to inappropriate treatment, or even admission to a psycho-geriatric unit for investigation.

More specifically, they must be aware of how the people in their care are likely to react to particular medical problems. The story of Mrs B (Box, above) is a good example of astute individualised nursing care that anticipates problems. The need for nursing care is increasing, but residential care facilities continue to employ staff whose educational preparation for this work is limited, if not totally inadequate. Residents needs change. Sometimes these changes are dramatic, but they can also be subtle. Nurses can fail to identify subtle Nurses can fail to identify gradual changes if they are not reported and properly documented. subtle gradual changes if they are not reported and properly documented. NCPs can remain unchanged for months if it is assumed that a residents condition is static, or that little can be done apart from providing medication and personal care. If nurses do not know residents properly, and do not understand that different people respond to specific situations in different ways, it is difficult for staff to identify and respond to situations appropriately. It is easy to make assumptions

54 Nursing Documentation

about peoplefor example, assumptions about their ability to understand or make their own decisionsand this can influence how situations are interpreted, as the example in the Box below illustrates.

Sensitive awareness of needs


Ms C was a single woman who had been admitted to a residential facility following her mothers death. Although she was relatively young (being in her mid 50s), Ms C was admitted because she had a physical impairment that required her to use a wheelchair, and because she had a mild intellectual disability. A geriatric assessment team had assessed the woman as being unable to care for herself safely. Although Ms C was reluctant to be admitted, she accepted advice that she required respite and rehabilitation. Several months later Ms C had become withdrawn. She refused to talk to anyone, get out of bed, and eat her meals. The nursing staff did not understand what was wrong with her and became annoyed. In effect, they withdrew from her. Following a psychiatric consultation, Ms C was admitted to a psychiatric unit for treatment of depression. Eventually, a social worker began to work with her and developed a plan of care that enabled Ms C to return to her home assisted by various community agencies. The unfortunate situation at the residential facility might have been avoided if all the professionals involved with Ms C, including the nurses, had assessed her with sensitivity and had responded appropriately to her sudden loss of her mother and her home in the space of a few weeks.

After moving to their new home, residents can take time to settlesometimes weeks or months. They can be depressed on admission or can become increasingly depressed over time. In contrast, others find that moving into a safe environmentwith company, nourishing meals, and social outingsprovides them with a new lease of life. Many have been previously responsible for the care of othersperhaps a spouse with dementia or another debilitating illness. Relieved of their burden of care, the wellbeing of such former carers can improve dramatically.

55 Nursing Care Plans

Every person is differentand individuals respond in their own way to what might appear to be similar situations. Fewer nurses are being employed in residential aged-care facilities partly because other workers are cheaper, and partly because nurses are reluctant to work in an environment in which their work is heavy and their wages are lower, and in which managers do little to attract or retain them (Klitch 2000; McCoppin & Gardner 1994). This situation is partly attributable to the nursing profession undervaluing the skills needed to work in residential aged care. The Box below describes a situation that is all too common in the profession today.

Lost in a backwater?
A mature-aged new graduate of nursing was delighted because she had obtained a position in a residential aged-care facility. This was what she had wanted. When she told me of her success, I congratulated her, commented on the dynamic nature of aged care today, and spoke of the skills she would gain in her new position. She said that I was the rst nurse to respond positively. Others had informed her that it was a mistake to go into aged care. They had told her that she would be stuck in aged care, and that she would be unable to obtain a position in an acute hospital. Aged care was a backwater. The nursing profession itself undervalues the skills needed to work in residential aged care.

Nurses have traditionally believed that a lower level of skill and knowledge is required to work in aged care than in acute care. However, aged-care nursing requires more skills, especially observation skills, than some areas of acute nursingin which nurses can rely on support from other professionals and in which the average length of stay is much shorter. In these circumstances, problems and needs that are missed by nurses are often noted by other services. In contrast, in long-term care, missed problems can often remain unnoticed.

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In general, residents of aged-care facilities require ongoing assessment by nurses who are: competent in using multiple assessment tools; knowledgeable about maintaining abilities and rehabilitation; aware of physical and psychological changes associated with ageing; familiar with quality-of-life issues; and aware of how relevant funding criteria apply. Regardless of their situation, residents require nursing care and assistance that is directed at promoting their health and wellbeing, and preventing (if possible) further problems or illness. Nursing care can be provided in ways that improve a persons sense of dignity, autonomy, and integrity. But it can also be provided in ways that create anxiety, shame, and powerlessnessleading to a dependence on those who provide care and assistance. In the past, residents were protected from themselves while their medical conditions were a working environment in which residents needs are met by treated. Their responsibilities were nurses and in which nurses needs few, and their rights fewer. Little are met by the employing facility. social activity was offered and, over time, their ability to make their own decisions or initiate activities declined. In short, they became institutionalised. This is now unacceptable, and nurses are now expected to have the competence, skills, knowledge, and attitudes to encourage residents to participate in making decisions about the type of care they require, and how best to provide it to meet their needs. Nurses are expected to work with people in their care. Residents require an environment that is resident-centred, in which their needs take priority over those of the facility. This does not mean that staff needs should be ignored. Rather, it means that managers are responsible for providing a working environment in which residents needs are met by nurses and in which nurses needs are met by the employing facility (Klitch 2000). In achieving this, nurse managers need to provide leadership and set an example.

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Nurses who seek to foster a sense of independence and control in residents need to think about the way in which they provide carehow they create opportunities for expression of concerns, fears, and wishes, and Residents need to be considered partners in their care, rather how they convey information about than recipients. problems. Residents need information and explanations about their care and how to improve their health. They need to be considered partners in their care, rather than recipients (Bonn 1999). Effective communication needs timeespecially when dealing with elderly people, many of whom require explanations to be given simply and slowly because their comprehension is hindered by their circumstances. Nurses working in aged-care facilities require resources if they are to provide individualised care. These resources include a sufficient number of staff members, an appropriate skill mix, ongoing education and training, and senior staff who provide leadership and create an Skills in documentation, and in NCPs in particular, are essential environment that fosters resident to collaborative nursing care. participation in assessment, careplanning, and decision-making. Skills in documentation, and in NCPs in particular, are essential to such collaborative nursing care. Documentation skills can help to facilitate: the recording of relevant information (and communication of it to colleagues); comprehensive and accurate nursing assessments; the formulation of nursing-care plans in consultation with others (taking account of the therapeutic regimens of other members of the healthcare team); the implementation of planned care; and the evaluation of outcomes, and reviews of plans in accordance with evaluation data. Nurses must be competent in all of these areas if they are to engage in safe practice in consultation with other members of the multidisciplinary care team.

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Nursing-care paths
Before NCPs became a standard part of nursing practice, nursing care was provided according to tradition, routine, and medical preference. Nursing care was often provided according to the traditional practices of particular institutions, services, or medical practitioners. Much has changed. The population of healthcare providers is now more diverse and specialised. Elderly persons often find themselves referred to practitioners other than doctors or nursessuch as social It is essential that nursing care workers, psychologists, occupational is documented so that it is therapists, and speech pathologists. readily accessible and meaningful In these circumstances, it is essential to all those involved in care. that the nursing care of residents is planned and implemented by appropriately skilled personnel, evaluated against set standards, and documented so that it is readily accessible and meaningful to all those involved in care. Plans of care are best developed in consultation with the resident concerned or in consultation with family or friends if the resident is incapable of participating. Such plans must be consistent with best practice, culturally appropriate, and individualised to reflect residents values, preferences, and personal concerns. To achieve these outcomes, plans of care are best developed by teams of people who have the appropriate skills and knowledgeguided by care paths that are accepted as effective for achieving certain outcomes. In the past decade or so, nurses, in conjunction with other professional groups, have been involved in developing such care paths or critical pathways. These paths provide staff with a guide to expected progress of specific problems over time. The benefit of these paths is that they enable nurses to identify individuals who drop off the trackby recovering more slowly, progressing differently, or developing complications. Nursing-care paths are used widely in acute medical and surgical settings, and there is no reason for such tools not being developed for residents of aged-care facilities.

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Consider the story of Ms C (Box, page 54). Nurses should be able to access a care pathway for people such as Ms C who are admitted unwillingly to residential care. Such pathways could offer guidance on: the likely response of such people; awareness that they are not adjusting as expected; how to identify signs of depression; and how to devise strategies for assisting them to adjust to their new situation. In the case of Ms C, it is likely that staff would have been able to identify her depression at an earlier stage and would have recognised it as being due to her grief over the loss of her mother and her home.

Conclusion
Comprehensive documentation cannot ensure that quality nursing care is always provided, but this is easier to achieve if those providing care reach agreement about what they are trying to do. Improved systems of documentation can facilitate continuity of care, provide accountability for clinical decisions, and ensure that the contribution of nurses to care is visible (Schulz-Robinson 1997). Increasingly, nurses are being judged on the basis of their clinical recordsjudgments are made about what occurred and what should have occurred. Records are used to assess whether nurses acted within the law, whether they complied with professional codes of Improved documentation can practice, and whether they acted facilitate continuity of care, provide accountability, and competently. Apart from these ensure that the contribution of legalistic considerations, judgments nurses to care is visible. are increasingly being made as to whether care demonstrates respect for the individual concerned, whether it takes into account personal preferences (with regard to routines, meals, interests, and so on), and whether the individuals family situation and background are reflected in the care plan.

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Poor documentation does not necessarily indicate poor practice. However, nurses, like other professional groups, have an ethical responsibility to write informative NCPs that ensure continuity of appropriate care and that indicate that their actionsbased on competent professional assessment of Nurses, like other professional groups, a residents needshave have an ethical responsibility to achieved the outcomes of write informative NCPs that ensure care desired by the resident, continuity of appropriate care. the team of professionals, and the organisation involved. Although financial affairs and budgets are primarily the responsibility of administrative and managerial staff, the documentation standards of clinical nurses has a vital role to play in budgetary allocations. To achieve high-quality nursing care, aged-care facilities require resources, sufficient qualified personnel, physical facilities, and ready access to medical staff and other health professionals. If CEOs are to obtain increases in funds to employ more qualified staff or to acquire essential equipmentthey must have evidence of need. Clinicians can provide the evidence they require. The notion of best practice or evidence-based practice offers a standard against which the quality of nursing care can be judged. Quality is a nebulous term and difficult to defineespecially in a nursing context in which its meaning is Nurses require NCPs that are explicit influenced by new knowledge about the nursing care required, how it and changing expectations of is provided, and why. society and governments. In these circumstances, nurses require NCPs that are explicit about the nursing care required, how it is provided, and why. Planning care is an essential element of nursing practice. Planning is especially important in aged-care nursing because nurses are required to care for elderly, vulnerable, and disabled individuals who have chronic health problems associated with age, disability, and difficult emotional or social circumstances. In addition, nurses are often required to delegate

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important aspects of this care to other personswhose experience, commitment, and education varies. In these circumstances, accurate and effective documentation of nursing-care plans becomes indispensible.

Chapter 5

Progress Notes
Joanne Hope and Pamela Bell

Introduction
Effective communication in aged care is vital to the quality of resident care. Documentation is used to communicate details of the nursing care provided, and to inform others of any significant events. Nursing documentation in the aged-care sector is also a record of aged-care standards and accountability. As such, documentation provides a link between funding and professional responsibility for resident-centred care. In addition to legal and funding requirements, each healthcare organisation has policies about recording and reporting resident care, and each nurse is responsible for practising in accordance with these policies. It must always be remembered that a residents notes represent a permanent written record of that persons nursing care and management.

Purposes of documentation
Documentation is a very important component of professional nursing practice. It is important for (RDNS 2000): assessment; communication;

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continuity of care; education; legal requirements; continuous quality improvement (CQI); and reimbursement. Each of these is briefly discussed in the Box below.

Purposes of documentation
The purposes of documentation can be briey summarised as follows. Assessment Nurses directly involved with the nursing care of a resident can use the documentation as a primary source of assessment data. Communication Effective record-keeping improves communication among nurses. Continuity of care Effective documentation allows ongoing nursing care to be delivered by any nurseand ensures that the effects of that care are known by all. Education Documentation allows nurses to read a history of past events, programs, and treatments relevant to the person in their care. Legal requirements Accurately reported facts are the best defence against litigation.All residents have a legal right to safe, professional nursing careincluding accurate and truthful documentation. Continuous quality improvement Standards are maintained through continuous quality improvement (CQI) practices. Many organisations have audit schedules and use audit tools to ensure that these standards are being met. Reimbursement Documentation assists aged-care facilities to receive reimbursement from government agencies. Progress notes act as a measure of the nursing needs and personal-care needs of residents, thus allowing resident dependency to be assessed.

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Principles of effective documentation


Accurate documentation is a high priority in the provision of quality aged care. Quality aged care requires quality information, and if this is to be provided, nurses need to pay attention to certain principles. The Box below summarises some important principles to follow in all forms of documentation. These principles should be applied to writing reports, writing-up plans of care, completing clinical record forms, and recording progress entries.

Principles of documentation
The following principles should be applied to all forms of documentation. Nurses should: ensure that the entry is made in the correct chart; check previous entries, and ensure follow up; never erase an error or use white out; rather, nurses should put a line through the error, initial the correction, and continue with the entry; make entries legibleif handwriting is not easy to read, entries should be printed; be concisequality not quantity; be accurate and factualwhat was done and what was seen; use simple language that staff understandnurses should not use jargon and should use only accepted abbreviations; be conscious of correct grammar and spelling; indicate the date and time in the left-hand margin at the beginning of each entry; sign all entries and write their designationprint name if signature is not legible; not leave space after or within the entry; nurses should sign it close to where the entry has nished; and never document in pencilnurses should always document in a black or blue pen.

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Progress notes (or ongoing notes) function as an ongoing communication record in a shared-care situation. These notes are commenced on the day of the residents admission and cease on the day of discharge. Progress notes act as a point of reference to inform others of any significant events or developments relating to a resident. They enable relevant personnel to become aware of each others observations and actions, and present a record of the needs, behaviours, and responses of residents to nursing care. Progress notes thus offer a record of continuity of care.

The nature of progress notes

Progress notes are located in a designated section of a residents clinical records file. This file is kept in a locked cabinet at the nurses station or in a locked room. Residents clinical files should be available only to authorised personnel. If a registered nurse is employed to care for residents in an agedcare facility, that nurse is responsible for the update and maintenance of all residents records. In facilities in which no registered nurse Residents clinical les should be available only to authorised personnel. is employed, the senior carer is responsible for overseeing residents records and ensuring that they communicate the current status of residents and promote continuity of care. There is often an expectation that all nursing staff contribute to a residents progress notes. Depending on organisational philosophy, nurses usually follow a charting-by-exception model (see below, page 70). All other health professionals attending to the resident are also required to make a professional notation in the progress notes at each visit.

Responsibility for progress notes

Frequency and quality of entries

The frequency of documentation is dependent on: the policy of the organisation collecting the data; and legal or professional best practice.

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Most facilities follow a charting-by-exception policy, with a residents level of care needs determining the frequency of entries. A facility might require a minimum of one entry per day for a resident of high care needs, and a minimum of one entry per week for a resident with low care needs. If a residents care needs increase, it is necessary to document more frequently. Nurses must ensure that all entries Although the frequency are chronological and timely. of documentation is ultimately a professional judgment, nurses must ensure that all entries are chronological and timely, that they comply with the policies of the facilitys documentation system, and that they fulfil legal requirements. It is recommended that progress notes are always maintained chronologicallyfrom the oldest to the newest. Progress notes must be written with reference to, and in conjunction with, the residents nursing-care plan at the time of each entry. All changes in nursing care needs must be reflected in the nursing-care plan. Changes to the nursing-care plan must be referred to in the progress notes. The nurse is responsible for the coordination of resident care and documentation. A critical part of this role is to ensure that there is follow up of previously identified nursing-care needs. For example, a notation in the progress notes might refer to a resident complaining of a headache and might note appropriate interventions taken by the nurse and positive outcomes following those interventions. However, subsequent entries might show the same complaint followed by similar interventions, but with no positive outcomes. In this situation, it is essential that the followup nursing actions are recorded in the progress notesfor reasons of continuity of nursing care, maintenance of professional and ethical standards, and legal accountability. All entries should be made in the progress notes as close as possible to the event or observation being noted. If progress entries are made at the time of the incident or observation, this ensures that the progress notes at any given time function as an accurate record of nursing care given to date. Sequential entries of developments must be made throughout the shift. Historically, this has not been standard practice and progress notes have

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traditionally been recorded at the end of a shift. This is unsafe practice because it relies on the nurses memory and can be affected by fatigue and time pressures. The omission of Accurate documentation is a high data has potential legal implications priority, and nurses must set time relating to duty of care. aside to attend to this important Progress notes are made by aspect of quality aged care. all health professionals involved in a residents care, and nurses are responsible for ensuring that information pertinent to the resident is professionally documented and communicated. Progress notes are therefore: a sequential record of the residents care; a reference point of updated information for other members of the healthcare team (promoting continuity of care); and part of a pattern of documentation central to all other documents in a residential aged-care facility. It should be remembered that accurate documentation is a high priority, and nurses must set time aside to attend to this important aspect of quality aged care.

Common methods of documenting progress notes


Common methods of documenting progress notes include: problem-oriented documentation; focus charting; charting by exception; narrative progress notes; and integrated progress notes. Each of these is discussed below.

Problem-oriented documentation
In a problem-oriented record, the notes are arranged according to a residents problems or concernsrather than according to the source of

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information. Plans for each active or potential problem are developed, and progress notes are recorded for each problem. Problem-oriented records alert everyone to the residents needs and make it easier to track the status of actual or potential problems arising from those needs. SOAP is a charting method devised for use with problem-oriented health records. The letters of the acronym stand for: subjective data; objective data; assessment; and planning. The SOAP charting method is described in Table 5.1 below. Over time, the SOAP format has been modified to include education and referral, as shown in Table 5.2 below.
Table 5.1 The SOAP charting method
ADAPTED FROM RICHMOND 1997, P. 107; PUBLISHED WITH PERMISSION

SOAP category Subjective data Objective data

Description What residents say and how they say it; includes residents emotional responses Observations made of residents by members of the health team; includes measurements (vital signs) as well as observable behaviour Interpretation of the subjective and objective data A plan of nursing care; action (or planned action) based on the assessment; includes evaluation of nursing care

Assessment Planning

Table 5.2 Additions to the SOAP charting method


ADAPTED FROM RICHMOND 1997, P. 107; PUBLISHED WITH PERMISSION

Category Education Referral

Description Information and education provided to the resident and to the residents family Referrals to other disciplines, services, or programs

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Common methods of documenting progress notes


This section of the text discusses the following common methods of documenting progress notes: problem-oriented documentation; focus charting; charting by exception; narrative progress notes; and integrated progress notes.

Focus charting
As the term suggests, focus charting concentrates on a specific area of a residents experience. The focus might be a change in the residents behaviour or health status, a sign or symptom, or a significant event. The progress notes are organised into three components collectively referred to as DAR. The acronym DAR stands for: data; action; and response. The data include all information relevant to the current focus including observation of resident status and behaviours, and any relevant data from flowsheets (for example, vital signs and pupil reactivity). Action includes all nursing interventions. This might also include any changes to the residents nursing care plan. Response describes an assessment of the residents response to the action.

Charting by exception
Charting by exception (CBE) is a charting system in which only significant findings or exceptions are recorded. This means that the only nursing care documented in the progress notes is care that differs from that recorded in the nursing-care plan.

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CBE has many advantages Charting by exception provides for the residential aged-care nurse more time for individual nursing because it provides more time for care by eliminating unnecessary individual nursing care by eliminating and repetitive charting. unnecessary and repetitive charting. Other benefits of CBE include: provision of an immediate, accurate picture of the resident; accessibility and easy data interpretation in emergencies; promotion of holistic nursing carethe regular and systematic review of nursing care and ongoing identification of nursing-care needs (which encourages a total view of the resident); and opportunities for the nursing-care plan to be updated simultaneously to maintain current interventions. The guidelines presented in Figure 5.1 (page 72) have been developed to assist nurses when documenting resident care.

Narrative progress notes


Narrative progress notes are used most frequently in source-oriented health records. In such source-oriented health records, different members of the healthcare team write in separate sections of the residents file for example, a physician uses a Narrative progress notes are physicians order sheet, history, descriptive accounts of a residents and progress notes, whereas status during a working shift. nurses write separate narrative nursing notes. Narrative charting consists of notes that document routine nursing care, findings, and resident problems. Such narrative progress notes are descriptive accounts of a residents status during a working shift. Some examples include: what nurses did with, and for, the residents; doctors visits; test results; and any variation in medication administration.

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Look at the standardised individualised nursing-care plan Was any nursing care delivered this shift that differs from the standardised and individualised care plan?

NO There is no need to make an entry in the progress notes this shift. Maintain the CBE process to keep healthcare team informed.

YES What nursing action was different from the care detailed in the plan? Why was the care different? Was the change: short term? long term? What was the outcome of that nursing action? Reassess the nursing care Review nursing diagnosis Adjust the individualised care plan Notify healthcare team of adjustments Recommence CBE process Notify others of the changes

Figure 5.1 Guidelines for CBE documentation


ADAPTED FROM RICHMOND 1997, P. 40; PUBLISHED WITH PERMISSION

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There is no right or wrong order to the information, although it usually follows a chronological order. Narrative notes and source-oriented records are convenient because they facilitate the tracing of information specific to the nurses own professional discipline. However, the information about a particular resident is sometimes scattered throughout a residents file, and it can therefore be difficult to find chronological information on a particular residents progress.

Integrated progress notes


The majority of residential aged-care facilities prefer to keep chronological integrated progress notes. This system is preferred to discipline-specific or segregated noteswhich are the notations made by each member of a specific health discipline. However, medical practitioners Integrated progress notes maintain often prefer to keep their medical a focus on resident needs. notes separate from an integrated system of documentation. The advantages of integrated notes include the following. They provide a common point of reference for all health professionals to access information relating to current resident-care status. They facilitate accurate communication between permanent and casual staff. They maintain a focus on resident needs, rather than the documentation being determined by the needs of external funding tools. They provide easy access for cross-referencing and sequential event mapping. They increase opportunities for continuity of care, and decrease the likelihood of fragmentation of resident information. They help to identify patterns of nursing-care needs.

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The disadvantage of integrated notes is that they can cause some inconveniencebecause access to shared documents is not always available.

Ethical and legal implications


Confidentiality
On a day-to-day basis, nurses have an ethical and legal duty of care to maintain confidentiality. Personal information should not become known by persons other than those who are directly involved in the residents care. In maintaining Nurses have an ethical and legal duty confidentiality, nurses must of care to maintain condentiality. ensure that informed consent is obtained from the resident before releasing information to any person other than those directly concerned with care. The rights and values of residents must be respected at all times.

Subpoenaed notes
It should be understood by all nurses that progress notes can be subpoenaed and used as evidence in legal proceedingseven though the author might be absent. This is more likely to occur if a significant period of time elapses between the provision of the nursing care and the hearing of a subsequent legal case. Documentation must therefore be accurate, comprehensive, and legible. It is also advisable to minimise abbreviations used in progress notes. Managers should ensure that a list of acceptable abbreviations and terminology is available for nurses to consult. Abbreviations should not be used unless they have clear and unambiguous meanings. Misinterpretation of an abbreviation can lead to harm being done to residents, and can result in malpractice actions.

Avoidance of disciplinary/legal action


To avoid events that result in disciplinary and/or legal action, documentation must represent the knowledge of the nurse who has

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written the report. The nurse who signs the report vouches for its truth and accuracy. A report should never be written or signed on behalf of another nurse, and a report should never be altered by someone other than the Documentation must represent original author. the knowledge of the nurse who

has written the report. The nurse Anything amiss with either the who signs the report vouches for resident or the environment should be its truth and accuracy. recorded and reported promptly, and verbal reporting must be followed up with documentation of any incident or concern. Documentation should therefore be attended to punctually and conscientiously, and all resident records must be kept up to date.
Because mistakes can be made, orders should never be transcribed.

As noted above (page 74), it should be remembered that progress notes are an ongoing legal record of nursing care that can be subpoenaed in a court of law. Apart from formal legal proceedings, it should also be remembered that resident records can serve as a reference for management in the event of a disciplinary complaint.

File management
A residents file is a document that is handled on a daily basis. It requires secure storage, and a variety of filing systems can be utilised for this purpose. The contents of a residents A residents le should never be file should be confidential, and left on a desk or in a public space should therefore be available only without supervision. on a restricted basis. When not in use, the residents file should be secured in a locked cabinet or room. A residents file should never be left on a desk or in a public space without supervision. Records should be held for legislated periods of time. Old records within the residents file should be regularly reviewed for currency. Those that are not immediately required should be culled and archived. A record of archived documents should be indexed in an archive register.

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The documents themselves should be stored in a fire-safe environment in a locked room. In principle, residents files must never be removed from the premises. If a request is made for a record, nurses should refer to the organisations policy on such requests. Residents les must never be Most organisations require that the removed from the premises. relevant section of the residents file be copied, and that a signed record be kept on file of what was copied, by whom it was copied, and the intended recipient and destination. In deciding how long records will be retained, considerations include clinical matters, the possibility of litigation, and research needs. Specific timeframes should be determined by legislation and organisational policy. Advice needs to be sought from a legal practitioner before destroying any resident documentation.

Electronic documentation
The same principles apply to electronic documentation as apply to hardcopy documents. The system must be efficient and effective, and the stored information must be secure. When using an electronic information system, a duplicate of all stored information must be maintained. Responsibility for this should be delegated appropriately. The same principles apply to To validate entries and to electronic documentation as apply to hardcopy documents efcient, prevent unauthorised access, there must be mechanisms to effective, and secure. control access. Organisations need to ensure that there are documented policies and procedures that address the filing, movement, retrieval, storage, and disposal of electronic documentation.

Conclusion
Progress notes are vital documents in resident care. They provide an overview of all care delivered, and an historical trail during the residents

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stay in the aged-care facility. Progress notes function as an ongoing diary of events, actions taken, and any other important information relating to a specific residentincluding physical, emotional, psychological, Accurate charting and social, and spiritual aspects of care. completion of resident records is a basic nursing responsibility. Progress notes advise nurses of changes in resident nursing-care plans and clinical assessments. This gives nursing and medical staff the current clinical data they require to make appropriate clinical decisions. In summary, progress notes reflect all aspects of nursing care in conjunction with the nursing-care plan. Accurate charting and completion of resident recordsincluding progress notesis a basic nursing responsibility.

Chapter 6

Clinical Pathways
Jenni Ham, Ann-Maree Conners, and Angela Crombie

Introduction
Healthcare costs in the Western world have increased significantly in recent years as a result of advances in technology, ageing populations, increasingly sophisticated interventions and services, and the need for highly trained health professionals. This has meant that health services are continually examining ways to reduce costswithout compromising the quality and effectiveness of the nursing care they provide. There has also been an increase in consumer interest and participation in health care, and this has prompted nurses to examine their practice with a view to ensuring that the expectations of the community are met in terms of safe and effective service provision. In response to these demands for cost reductions in an environment of increased consumer interest in health care, many acute and subacute healthcare organisations have introduced evidence-based clinical pathways (Frink & Strassner 1996; Ham 2001; Dowsey et al. 1999; Choong et al. 2000). The aim of such clinical pathways is to achieve quality outcomes within a specified timeframe, using the resources that best meet patients needs.

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In response to the challenges of the modern world, nurses in a range of healthcare settings are thus showing increasing interest in the value of clinical pathwaysand aged-care nursing is no exception.

Defining terms
The terms used in relation to clinical pathways are often misunderstood or confused. These terms include: best practice; clinical pathway; resident pathway; evidence-based practice (and evidence-based clinical pathways); interdisciplinary healthcare teams; resident-centred care; variance (and variance analysis); continuous quality improvement; guidelines; and health outcome. Each of these terms is discussed below.

Best practice
Best practice is a comprehensive, integrated, and cooperative approach to the continuous improvement of all areas of healthcare delivery (DVA 2001).

Clinical pathway
A clinical pathway is a best-practice tool used to organise and integrate all levels of health care delivered by providers from a number of disciplines. It involves the identification and documentation of a sequence of evidencebased interventions for a particular procedure, case type, or cohort of patientswith a view to achieving desired outcomes in a defined period of time.

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Clinical pathways can be more simply described as roadmaps and timelines of courses of treatment. A clinical pathway allows the interdisciplinary healthcare team involved in the treatment of a person to know exactly when treatments and therapies should occur. A pathway provides a framework to guide nurses in the provision of Clinical pathways can be simply described as roadmaps and care, thus promoting effective timelines of courses of treatment. professional practice in the clinical setting (Ham 1999).

Resident pathway
A resident pathway is a concise version of a clinical pathway that is designed for the purpose of resident education and involvement in the planning of nursing care. Information is expressed in lay terms to promote understanding of the nursing-care process and its anticipated outcomes.

Evidence-based practice and evidence-based clinical pathways


Evidence-based practice is the conduct of health care according to the principle that all interventions need to be based on the best current scientific evidence (Shorten & Wallace 1997). An evidence-based clinical pathway is one in which the events and activities contained in the pathway are based on evidence. Evidencebased practice strengthens the validity of clinical pathways Evidence-based practice strengthens the validity of clinical pathways and and increases the probability increases the probability of achieving of achieving optimal health optimal health outcomes. outcomes (Shorten & Wallace 1997).

Interdisciplinary healthcare teams


The health professionals, residents, and family who constitute an interdisciplinary healthcare team share common values and work towards common aims and objectives (Falconer et al. 1993).

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Resident-centred care
In resident-centred care, nursing care focuses on the resident and his or her desired outcomes within an estimated timeframe (which is specified in the clinical pathway). Residents (and their families and supporters) are informed of expectations and progress throughout the illness (Hampton 1993; Zander & McGill 1994).

Variance and variance analysis


A variance is a deviation from the standard events specified on a clinical pathway (Frink & Strassner 1996). The deviation might alter the residents expected outcome or expected length of stay in hospital. A positive variance results in achievements being greater than predicted, Variance analysis enables a continuous quality-improvement whereas a negative variance process to be implemented. results in achievements being less than predicted. Variance analysis determines whether predicted outcomes on a clinical pathway have been achieved, or whether unpredicted events have occurred. Variance data are collected and analysed to assess the quality and efficiency of the nursing care deliveredthus enabling a continuous quality-improvement process to be implemented (Frink and Strassner 1996).

Continuous quality improvement


Continuous quality improvement focuses on the processes used to achieve desirable outcomes. Continuous quality improvement in health care involves the ongoing analysis and improvement of all the processes of careincluding the hospital system, personnel, clinical management, and the financial structure surrounding residents (Cesta 1993).

Guidelines
Guidelines are the principles that set standards and direct the clinician in decisions regarding care. Guidelines also form a basis for the evaluation

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of various aspects of healthcare delivery. Guidelines reflect best practice and are therefore evidence-based statements.

Health outcome
A health outcome is a change in the health of an individual, a group of people, or a population, that can be wholly or partially attributed to a health intervention or a series of interventions.

Objectives and results of clinical pathways


Clinical pathways are outcome-based tools that aim to maximise the quality of resident care with the resources available. The objectives of designing and implementing clinical pathways in aged care are summarised in the Box below.

Objectives of clinical pathways


The objectives of designing and implementing clinical pathways in aged care are: to sequence and coordinate the interventions that are necessary to achieve desired resident outcomes; to base the interventions on the best evidence available; to develop a resident-care system that depends on interdisciplinary collaboration and teamwork (including the resident and family as part of the team); to develop a continuous quality-improvement process through variance analysis; to plan resident care in advance and to utilise resources effectively; to improve referral and transfer processes; to allow residents and their families access to health and lifestyle options; to implement planned activity of nursing care that enables residents to achieve mutually agreed goals, within an estimated timeframe; and to monitor residents progress.

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Clinical pathways were initially introduced with the aim of reducing the length of stay of patients in acute health settings and reducing the overall costs of hospital carewhile maintaining the quality of health care. However, with the implementation of clinical pathways, many other benefits have been recognised (see Box, below). As a result, health-service providers in other settings (such as subacute and community services) have become involved in the design and implementation of clinical pathways for their client groups (Ham 1999; DVA 2001). Organisations of varying sizes and heterogeneous client groups have increasingly become involved in clinical pathway design and implementation. The improvements that have been reported as a result of the successful implementation of clinical pathways are summarised in the Box below.

Results of clinical pathways


Some of the improvements that have been reported as a result of the successful implementation of clinical pathways include the following: the delivery of coordinated, resident-centred care with increased involvement by residents and their families in planning nursing care processes and expected outcomes; improved interdisciplinary teamwork with all members of the team being better informed by knowing in advance the plan of nursing care and desired resident outcomes; documentation being streamlined and duplication being reduced; timely response to resident problems resulting from frequent analysis of variations from the clinical pathway; implementation of a continuous quality-improvement cycle through analysis of variances; a greater awareness by the interdisciplinary team of best-practice procedures and resource management; and increased staff satisfaction.

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Clinical pathways in aged care


Clinical pathways offer many potential benefits to nurses engaged in residential aged care. In particular, clinical pathways offer benefits in terms of: changing perceptions of aged-care nursing; the functioning of interdisciplinary healthcare teams; assessment and referral; resident-centred and outcome-based care; streamlined documentation; staff satisfaction; and evidence-based practice and continuous quality improvement. Each of these is discussed below.

Changing perceptions of aged-care nursing


The traditional palliative culture that used to permeate residential aged-care facilities is undergoing significant change. An increasing need for aged-care facilities, brought about by the ageing of the population, is forcing governments and other authorities to reassess the quantity Gerontic nursing has become a specialty area requiring and quality of aged-care services. a variety of skills. Residents of aged-care facilities have more complex care needs, for which nurses must assess, plan, implement, and evaluate care. Gerontic nursing has become a specialty area requiring a variety of skills. The introduction of clinical pathways into residential aged care can assist in raising the profile of gerontic nursing by providing the same standards for nursing-care planning and documentation that are required in the acute-care health system. Many acute and subacute healthcare providers have adopted clinical pathways, and clinicians in those sectors are required to justify any variance from pathway protocols. Clinical pathways are accepted as professional tools by these clinicians, and the introduction of such pathways into residential aged care would enhance gerontic nursing as a specialty profession with its own professional tools.

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Interdisciplinary healthcare teams


If holistic health care is to be delivered, there must be collaboration, teamwork, and effective integration of the different disciplines within a healthcare team. Clinical pathways provide a framework Clinical pathways ensure that all team members are aware of what for healthcare teams to assess type of care is required, when it is and review individual care required, and who will deliver it. requirements, and to promote collaborative care planning. Interdisciplinary input into the pathway enables a comprehensive biopsychosocial approach to care and management. Clinical pathways facilitate communication among members of the healthcare teamthus ensuring that all team members are aware of what type of care is required, when it is required, and who will deliver it.

Clinical pathways in aged care


Clinical pathways offer many potential benets to nurses engaged in residential aged care. In particular, clinical pathways offer benets in terms of: changing perceptions of aged-care nursing; the functioning of interdisciplinary healthcare teams; assessment and referral; resident-centred and outcome-based care; streamlined documentation; staff satisfaction; and evidence-based practice and continuous quality improvement. Each of these is discussed in this section of the text.

Assessment and referral


One of the main advantages of implementing clinical pathways in the residential aged-care setting is to guide the nursing team through the assessment process. Evidence-based clinical pathways can help to identify

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assessment domains and can provide guidance on valid and reliable assessment tools. A generic clinical pathway in residential aged care takes the nurse through a comprehensive assessment processincluding admission assessment, risk assessment, and assessment of specific health domains. After assessment has been completed, planned interventions must reflect the individual residents abilities and limitations. Clinical pathways can assist in identifying appropriate healthcare team members to provide the required support through relevant referrals. For example, a clinical pathway incorporating a falls risk-assessment tool might reveal that a resident has balance impairment. This could trigger referral to a physiotherapist for a more comprehensive balance assessment, together with a plan of nursing-care interventions required to reduce the risk of the resident falling. The pathway should also identify desirable outcomes that reflect the residents individual goals. In the falls domain, these might include preventing further impairment in balance, or walking a certain distance each day. To take another example, Clinical pathways can guide the clinical pathway might assessment and referral, and can provide assessment of mood streamline nursing care by enhancing using a validated toolsuch collaboration among service providers. as the geriatric depression scale (GDS). The GDS score can be used to guide nurses in identifying the presence of depression and in referring the resident to specialist services. Outcomes and goals in this example might include the resolution of symptoms and the prevention of further depressive episodes. Clinical pathways can thus guide assessment and referral, and can streamline nursing care for residents by enhancing collaboration among service providers. Sharing pathways among service providers prevents duplication of assessment and facilitates transition from one care provider to another as the resident progresses through episodes of care in sequential stages.

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Resident-centred and outcome-based care


The complex health issues that affect people in residential-care settings need to be individually assessed, and realistic goals and individual outcomes of interventions must be planned for each resident. The initial assessment provides the foundation for individual goal-setting and a baseline to monitor progress. The involvement of the resident and family is central to the development of comprehensive care that reflects individual needs. Open discussion between the Clinical pathways increase the involvement of residents and interdisciplinary healthcare team their families in health and and each resident (and his or lifestyle decisionsthus her family) assists in identifying enhancing informed choices. outcomes that enhance the quality of life of the individual. Clinical pathways increase the involvement of residents and their families in health and lifestyle decisionsthus enhancing informed choices. Agreed goals on individual clinical pathways facilitate the planning of activities that enable residents to achieve desired outcomes within an agreed timeframe. Such mutually Care must be taken to avoid agreed goals and outcomes should setting unrealistic goals. reflect the declining abilities of residents, and care must be taken to avoid setting unrealistic goals. The assessment process helps to identify individual abilities and limitations. Involving residents in their care and lifestyle decisions can be quite a challenge if the resident has cognitive impairment (such as that caused by dementia). Involvement of family members is essential if a resident does have severe cognitive impairment that reduces the communication of personal preferences. Many family members are capable and keen advocates for their loved ones. This is particularly true of spouses who have been caring for their partners at home before they enter residential aged care. Clinical pathways in residential aged care encourage family members to provide

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input into the residents nursing care, and thus assist both the resident and family members during the transition from home to residential care. Clinical pathways also improve Clinical pathways improve the care-transition process in progressive the care-transition process illnesses such as dementia. Clinical in progressive illnesses. pathways facilitate increased resident and family involvement in nursingcare planning, and assist in the setting of realistic goals that allow for progressive decline in abilities. Family members thus gain an increased understanding of the progressive nature of cognitive impairment, and are more able to accept the inevitable decline in their loved ones abilities. Clinical pathways in residential aged care also provide families with a record of their loved ones care that they can keep at home and discuss with other family members and friendsthus explaining the holistic care being provided.

Streamlined documentation
Nurses who work in residential aged care often complain that they are so busy making sure that they document care that they do not have enough time to perform actual nursing care. As Brereton (1999, p. 3) has noted, aged-care nurses often feel that:
reams and reams of documentation are required to justify a pittance in funding to employ staff, who, at the end of their more-often-thannot extended unpaid shifts are both physically and mentally exhausted attempting to meet basic care needs for their resident.

Anecdotal evidence suggests that nurses working in residential aged care facilities over-document, and that documentation is guided more by a need to justify funding requirements than by a desire to communicate continuity of care to colleagues. The skill mix among staff in residential aged-care facilities means that guidelines are required to ensure that a consistent level of care is provided by all staff. Similarly, documentation skills vary according to staff training.

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Clinical pathways might be a solution to the documentation challenge currently being faced by nurses in residential aged-care facilities. Clinical pathways guide assessment and care-planning, and provide an evidencebased framework that can be used by clinicians to structure their clinical and managerial decisions.

Staff satisfaction
Clinical pathways can increase morale among members of the interdisciplinary healthcare team by providing them with evidence that their care is consistent with recognised best practice in seeking to achieve the best outcomes for residents. If clinicians working in residential aged-care facilities have access to the appropriate professional tools, nursing care increases and the time spent documenting that nursing care decreases. The documentation Nursing care increases and the time spent documenting that process can be streamlined nursing care decreases. and made consistent across all disciplines and skill levels. All of these factors are likely to increase professional morale in the team.

Evidence-based practice and continuous quality improvement


Evidence-based clinical pathways enable health professionals to review their current practice in relation to accepted best practice. Setting timeframes to guide interventions and achieve outcomes on a clinical pathway in aged care allows monitoring of progress over realistic Clinical pathways in timeframes, and promotes regular residential aged care assist the process of continuous interdisciplinary review of care. quality improvement. Clinical pathways in residential aged care assist the process of continuous quality improvement and promote an approach to patient care that focuses on health outcomes and the principles of best practice.

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Design and implementation of clinical pathways


Regardless of the size of the organisation and the availability of resources, eleven steps are crucial to successful design and implementation of a clinical pathway. These steps are: select a steering committee; select a project coordinator; select a case or procedure; select a design team; perform a study of case histories; perform a literature review; arrange meetings with all disciplines and departments; develop content and design of clinical pathway (first draft); trial (first draft); refine clinical pathway; and select another diagnostic-related group or procedure. Each of these is briefly described below.

1. Select a steering committee


The committee should include key stakeholders from the clinical and management spheresand a consumer representative. The committee should: appoint a chairperson; organise a meeting schedule; clarify goals and objectives for introducing pathways; and set guidelines and clear boundaries for the project.

2. Select a project coordinator


The project coordinator should have a clinical background and have expertise in:

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project management; organisational change; and coordinated care systems. An ongoing education program should be implemented for all staff in the organisationto ensure that the aims, objectives, and progress of the project are understood.

3. Select a case or procedure


A case or procedure should be selected as the basis for designing a pathway.

4. Select a design team


A design team should be selected. The team should include permanent members of the interdisciplinary healthcare team involved in caring for the chosen type of case. The team should: appoint a chairperson; organise a meeting schedule; and clarify goals for introducing the pathway.

5. Perform a study of case histories


A study of case histories identifies current practices for the selected type of case or procedure. Critical events and problems in the process of care should be identified.

6. Perform a literature review


A review of the literature should be performed to determine best practice, based on evidence, for the selected case or procedure.

7. Arrange meetings with all disciplines and departments


Input into the clinical pathway should be encouraged. The content of the clinical pathway will develop through a collaborative process involving meetings with members of the interdisciplinary team involved in the care of the selected type of case.

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Design and implementation of clinical pathways


Regardless of the size of the organisation and the availability of resources, eleven steps are crucial to successful design and implementation of a clinical pathway. These steps are: select a steering committee; select a project coordinator; select a case or procedure; select a design team; perform a study of case histories; perform a literature review; arrange meetings with all disciplines and departments; develop content and design of clinical pathway (rst draft); trial (rst draft); rene clinical pathway; and select another diagnostic-related group or procedure. Each of these is discussed in this section of the text.

8. Develop content and design of clinical pathway (first draft)


The design team should: identify desired outcomes; identify critical events in the process of achieving desired outcomes; identify activities required to accomplish outcomes; chart the events and activities in a sequential manner to form the pathway on one axis (usually vertical) and time (or other indicators of clinical progression) on the other axis; and draft variance-analysis tool and procedures.

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9. Trial (first draft)


A trial of the pathway is conducted with a view to ascertaining whether the pathway accurately represents the sequence of events, the timeframe, and the outcomes expected.

10. Refine clinical pathway


The process of refinement of the clinical pathway through variance analysis is ongoing. The clinical pathway should be reviewed regularly and frequently, and refined drafts should be trialled.

11. Select another diagnostic-related group or procedure


Another diagnostic-related group (DRG) or procedure should be selected for design and implementation of a new clinical pathway. The above process is then repeated. Exclusion of any of these steps increases the risk of clinical pathways not achieving desired outcomes. Design and implementation of clinical pathways is resourceOrganisations need to consider intensive. Before committing to their carefully what they hope to introduction, organisations need to gain and how they are going to consider carefully what they hope to achieve these improvements. gain and how they are going to achieve (and sustain) these improvements.

Conclusion
Clinical pathways enhance the delivery of efficient, quality health care to patients, and they have therefore been adopted by many healthcare services as a standard professional process. The success of clinical pathways in other healthcare settings suggests that residential aged-care facilities have much to gain from their implementation. The advantages are the development of resident-centred, outcome-based aged care, and the implementation of continuous quality-improvement processes. Much can be learnt from the experience of acute and subacute healthcare settings and residential aged-care facilities can modify and utilise this information when designing clinical pathways suitable for their own use.

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Successful implementation of clinical pathways requires organisational commitment to make the changes required. The introduction and implementation of the new process must be carefully planned and managed. Clinical Clinical pathways are powerful pathways that result in a coordinated tools for ensuring the optimal continuum of care are powerful use of resources and the tools for ensuring the optimal use provision of quality care. of resources and the provision of quality care.

Chapter 7

Documenting Behaviour and Emotion


Felicity Humble

Introduction
All nurses experience and observe the behaviour and emotion of those in their care throughout their work day. Whether these behaviours and emotions are expected or unexpected, nurses have a responsibility to observe them carefully and to record accurately what they have observed. Quality resident care depends on the accuracy of these records (Martin et al. 1999). Nurses document their observations on most shifts on most work days. However, in caring for aged and long-term residents in residential settings, nurses can easily slip into automatic note-takingmaking repetitious notes as the behaviours and responses of the residents become almost routine. In some cases it is possible for nurses to see only what they choose to see, and it has been stated that up to 70% of patients who become delirious are never recognised by physicians or nurses as being in a delirious state (Morency et al. 1994, p. 24). This is a serious claim. If true, it is important that nurses involved in aged care take steps to ensure that their recognition and documentation of such behavioural change are improved. It is essential that nurses recognise the nuances

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of human emotion, and the behaviour that comes from the expression of that emotion. They must be alert to behaviour that is inconsistent or unexpected. If disabling conditions such as delirium, depression, and unrecognised pain are to be diagnosed and managed appropriately, nurses have a professional responsibility Nurses must be alert to behaviour to observe emotion and behaviour that is inconsistent or unexpected. astutelyand to document their observations accurately.

Emotion
All behaviours have underlying emotions, and these emotions are very personal experiences. In general, the most reliable way to ascertain what a person might be feeling is to ask him or her. However, if the person is unable to express those emotionsbecause of cognitive impairment from dementia, or because the person is simply not in the habit of discussing feelingsit might be necessary to use other means to understand what he or she is feeling.

Empathy
Observing and understanding emotions requires nurses to put themselves in the situation of the residentto try to empathise with what the person is feeling. In attempting to to put themselves in the situation of empathise, it is sometimes the residentto try to empathise with necessary to take a broader what the person is feeling. perspective of the residents situation. Knowledge of the persons personal, social, and medical history can be very useful in understanding emotional state and changes in behaviour.

Recognising clues
When a person is tense and anxious he or she might experience butterflies in the stomach, sweaty hands, or headaches. When anger or frustration is experienced, a person might experience tightness in the jaw or shoulders,

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feel hot, and perhaps become quite restless. Recognising these clues, and interpreting them as expressions of internal emotional feelings, requires a high level of self-awareness, and other people often notice that a person is upset before that person actually realises it. Many people in the general community live with this lack of awareness of their own emotional feelings, but this lack of awareness is further complicated if a person is cognitively impaired. It is rare for residents with cognitive impairment to identify and express emotions People with cognitive impairment in a verbal or conscious way. experience similar feelings to those Rather, the feelings are likely to experienced by people who are not cognitively impaired. be converted into behavioursand thus expressed unconsciously. It is important for nurses to remember that people with cognitive impairment experience similar feelings to those experienced by people who are not cognitively impaired. The affect, especially the expression on the face, can give clues as to the emotion being experienced by a person. Table 7.1 (page 100) shows examples of changes in facial expression when a person is experiencing anger or anxiety. As shown in the table, the outward appearance of emotion can be misleading and does not necessarily give a clear indication of the emotion underlying the facial expression. Further exploration is required, and the best way is to ask the resident.

Asking questions
In asking questions about feelings, nurses should use simple language that allows the resident to answer in equally simple terms. Some examples of such questions include: You look worried. Are you worried? You dont look happy today. Is there something on your mind? You seem a bit tense. Are you feeling frustrated? These questions seek replies that are simple to express. Putting the question more openly might give rise to more information, but this relies

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Table 7.1 Outward signs of emotion


AUTHORS PRESENTATION

Anger Frowning Clenched teeth Tearfulness Intense focus or staring Tension in jaw Pulsing carotid in neck Flushed or pale face

Anxiety Wrinkled brow Twitching Lip-biting or lip-quivering Sweaty face Dry mouth Trembling or shaking Flushed or pale face

on the person being able to verbalise freely. An example of such a question might be: You dont seem yourself todaycan you tell me how you are feeling? This type of open-ended question cannot be answered with a simple monosyllabic reply. It requires the person to be able to handle concepts, to be aware of differences, and to be open in expressing personal feelings. This sort of question is unlikely to be successful if addressed to people who have a cognitive impairment. Closed questions, such as those outlined above, are more likely to be successful in initiating conversation. Nurses need to be prepared to deal with any answers they receive to these questions. They should also be prepared to deal with their own emotional responses. The ability to utilise empathy can be a very valuable skill, especially in caring for people who have a cognitive impairment and who might therefore have difficulty expressing their feelings. Being able to empathise can give aged-care nurses real insight into the experience of the resident, but it does require nurses to remain objective in making assessments about their own emotions, as well as the emotions of those in their care. If asking questions fails to elicit useful information, the nurse must be astute in observing and assessing the behaviour of the resident.

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Behaviour
Describing behaviour
There are many types of behaviour and it is important to be able to identify and describe behaviours that might be associated with illness. Nurses must be careful not to generalise too Nurses must be careful not often; every person is an individual. It to generalise too often; every is always useful to attempt to gain an person is an individual. understanding of what an individuals behaviour has been like in the past. Family members, friends, and even neighbours are often able to assist in the creation of a profile of the person before his or her admission to the aged-care facility. Figure 7.1 (page 102) lists some of the descriptors of general behaviour. It shows that a range of words can be used to describe any given behaviour. The choice of words is very important in accurate documentationas will be discussed below. These general behaviours can be closely linked to the personality of the person, and knowledge of previous behaviour patterns can help nurses to detect changes. For example, an ageing individual who has lived quite a conventional life might begin to reveal rather eccentric tendencies not previously observed. The change should be noted. Such knowledge Knowledge of previous behavioural patterns can help nurses to can also help nurses to understand understand those in their care. behaviour. For example, a person who has been very controlling in earlier life might, with the onset of dementia, become aggressive and easily irritated over seemingly trivial incidents. Knowledge of previous behavioural patterns can thus help nurses to understand those in their care.

Documenting behaviour
Recording actual behaviour

To provide useful records in nursing notes, descriptive terms of general behaviour (such as those listed in Figure 7.1) should be accompanied by

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Cooperative Sociable Conventional Consistent Busy Isolated In character Independent Controlling

Uncooperative Suspicious Eccentric Unpredictable Idle Intrusive Out of character Passive Aggressive

Figure 7.1 Descriptions of behaviour


AUTHORS PRESENTATION

accurate recording of actual behaviour. Documentation should give other nurses a clear indication of how residents are responding to events around them. Examples of helpful descriptions of general behaviour might be: Mr X began to swear when being assisted with showering; this is out of character with his usual cooperative behaviour; Mrs X showed an aggressive response to assistance with dressing, attempting to pull the nurses hair; Towards evening, Mr X was observed to be deteriorating when walking. He stumbled, but managed to regain his balance and did not fall; or Ms X showed negative body language by turning away from her visiting relative. For ongoing consistent management, it is important to observe, describe, and record such behaviours for the benefit of all nurses involved

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in the care of the residents. Recording what is actually seen and heard creates a picture of the residenta picture with which others can relate.
Recording change

The general behaviour of all residents Recording what is actually should be regularly and frequently seen and heard creates a picture reviewedwith a view to detecting of the residenta picture with any change that requires investigation. which others can relate. For example, it can be quite difficult for those with a cognitive impairment to let nurses know of increased pain. Frequent reviews of behaviour will help to identify pain that might otherwise go undetected. Consideration also needs to be given as to whether behavioural changes occur at particular times of the day. Aged-care nurses need to be aware of the sundowner syndromea term used to describe the phenomenon of people with dementia becoming increasingly confused towards late afternoon or evening. Conditions such as depression can also contribute to a change in emotions and behaviours over Observing and recording variations over time can facilitate diagnosis and the course of a day. People management of dementia, depression, who are depressed can be slow, and other mood-altering conditions. apathetic, and miserable in the morning, but become more energised and lighter in mood as the day progresses. Sometimes this can be reversed, with people starting the day quite normally and then losing their energy and willingness to socialise with others during the afternoon and evening. Observing and recording these variations over time can facilitate diagnosis and management of dementia, depression, and other mood-altering conditions.
Documenting basic functions

The basic functions of eating, drinking, and sleeping should also be carefully observed and recorded. It is very important for nurses to be aware of the eating patterns of residentsincluding consideration of appetite, not simply food and

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fluid intake. A useful way to record such information is to concentrate on how a person eatsthat is, the behaviour associated with eating not merely the end result of how much was eaten. Examples of useful ways to describe eating behaviours include: asked for more food after eating; slow to start eating, but ate the whole meal eventually; ate the entire meal, but in very disorganised manner; picked at food and left most uneatenhas a better appetite at lunch than at evening meal; ate soft foods more easily than unprocessed food; and ate all food brought by relative, but did not eat facility food. If there is a change in a residents eating pattern, this might indicate a problem that requires further investigationsuch as pain, delirium, or depression. The problem might be To be meaningful and helpful as simple as ill-fitting dentures or as for other nurses, documentation serious as a bowel obstruction that of sleep patterns requires more requires urgent treatment. detail than an inadequate To be meaningful and helpful description such as slept well. for other nurses, documentation of sleep patterns requires more detail than an inadequate description such as slept well. Useful information might include: how long the resident slept; the times at which the resident fell asleep; whether the resident took frequent naps during the day; whether the resident could be easily roused; and whether the resident felt rested after sleep. This is relevant and important informationand should be recorded. It will alert others to any alterations in the residents usual behaviour. If changes become evidentsuch as excessively deep sleep during the day, or wakefulness at night that is not easily explainedfurther investigation might be warranted.

Concentrate on how a person eats not merely the end result of how much was eaten.

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The accurate recording of basic behavioural functions such as these is of the utmost importance in professional aged-care nursing documentation.

A case study
This chapter has discussed many aspects of the importance of observing and recording emotions and behaviour in aged care. The story of Doreen (see Box, below) illustrates many of the topics discussed in this chapter.

Doreen
Doreen suffered from dementia and had been in residential care for several months. Her daughter had arranged Doreens admission, but visited only occasionally. Although Doreen rarely spoke, she was normally cooperative with nurses and freely mixed with other residents at mealtimes. One day, a nurse entered Doreens room and found her staring out the window with her cup of tea untouched on her bedside table. The nurse asked her if something was wrong. Doreen turned from the window, looked at the nurse, but said nothing. When the nurse reached to touch her hand, Doreen pulled away. The nurse noticed that Doreen looked paler than usual. She was moistening her lips with her tongue, and her forehead was furrowed. The nurse offered to bring a fresh cup of tea, but again Doreen made no reply. Looking around the room, the nurse noticed the recently vacated bed next to Doreens bed, and recalled that Doreens friend and roommate had been transferred to the local hospital on the previous day. The nurse attempted to smooth Doreens hair and feel her forehead, but she slapped the nurses hand away. Quite concerned at the change in Doreen, who had previously been uncomplicated and cooperative, the nurse returned to the nurses station to review Doreens notes. She read that Doreen had not eaten her breakfast (despite being given her favourite meal of porridge), and that she had been uncharacteristically awake and restless during the night.
(continued)

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Doreen had also been observed to have been in tears during the preceding evening, when her daughter had briey visited. The nurse on the previous shift had said that Doreen was in a bad mood that day. There was no record in Doreens le as to the likely cause of her distress. The nurse sat with Doreen for ten minutes and chatted with her even though Doreen still made no response. The nurse mentioned that she knew that Doreens daughter had visited the day before, but there was no particular reaction from Doreen. The nurse informed Doreen that her roommate would be returning later that day. Her minor operation had been successful, and she had recovered sufciently to return. At this point, the nurse noticed that Doreen was looking at her intently. The nurse again offered to make Doreen a drink. This time she tentatively smiled and held out her hand to the nurse.

In Doreens case, what approach would be most appropriate in attempting to clarify the situation? Ignore the changes in Doreen and get on with other work? Keep checking on Doreen, bringing fresh drinks to her each time? Make some time to sit with Doreen and talk about her daughters visit and the absence of her friend? Telephone Doreens daughter and ask what she had done to upset her mother? The best solution is the third alternative. An astute nurse will have recognised that mentioning the absence of Doreens friend was the stimulus that induced the most significant response from the unhappy old woman. This requires further exploration. However, with the constraints of heavy workloads, poor communication in cognitively impaired people, and insufficient time to accomplish all the tasks associated with aged care, it is not always easy for nurses to follow up these matters as they would wish. There is no doubt that the chances of resolving Doreens situation would be considerably improved by involving Doreen herself in the process, no matter how hard it might be to extract a clear response.

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However it is handled, the case study shows that the astute observation of emotion and behaviour, together with reference to accurate nursing progress notes, make the astute observation of emotion it more likely that Doreens and behaviour, together with accurate problem will be followed nursing progress notes. up in an appropriate and sensitive manner.

Conclusion
To facilitate the most comprehensive and appropriate care for residents in aged-care facilities, it is imperative that emotion and behaviour are observed and recorded accurately and descriptively. Subtle (and notso-subtle) changes in a residents behaviour will then be noted and communicated, and appropriate investigations and management are more likely to ensue. It is important for nurses to know that the onset of delirium can occur over only a few hours, but that a failure to recognise it and investigate it can result in days, weeks, or even months of impaired health or lifethreatening illness. Prompt and accurate observation and documentation facilitate early detection, diagnosis, and treatment.

Documentation of emotion and behaviour


This chapter has considered many aspects of observing and recording emotion and behaviour in an aged-care setting. The main points of the chapter can be summarised as follows. Nurses have a professional responsibility to observe and record the emotions and behaviours of those in their care. Accurate and comprehensive records of changes in emotion and behaviour assist in detecting deterioration in both physical and emotional states. Even if residents are unable to relate what they are feeling, there are often behavioural clues that indicate their emotions. The recording of such information is as important as any other aspect of a residents health status.

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A depressive illness can take weeks (or even months) to become apparent. However, if accurate documentation of residents behaviour is maintained, the nursing notes will reveal clear indications of a gradual deterioration in the persons mood. Residents with cognitive impairment might not be able to explain what is causing these changes, but accurate professional documentation of behaviour and emotion can help to overcome the difficulties associated with these communication difficulties. This is one of the Documentation is one of the greatest challenges of agedgreatest challenges of aged-care nursing, but meeting the challenge care nursing, but meeting the ultimately produces enormous challenge ultimately produces rewards for all concerned. enormous rewards for all concerned.

Chapter 8

Documenting Complementary Therapies


Sue Forster

Introduction
In contemporary nursing practice, especially in the aged-care sector, there has been a tremendous increase in the use and availability of complementary therapies in Western countries in recent decades (McCabe 2001, p. 10). The Nurses Handbook of Alternative & Complementary Therapies makes the following observation about the term complementary therapies (NHACT 1999, p. 3):
The terms alternative, complementary, unconventional, non-traditional, and unorthodox are used interchangeably to denote healing practices that have not traditionally been found in Western medical practice or taught in main stream medical schools.

The application of such complementary therapies in any healthcare setting involves four stages: the planning stage; the organisational stage; the implementation stage; and the evaluation stage.

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The first two stages of complementary therapies in aged carethe planning and organisational stagesare generally included in the position description and role of the person designated as an activities officer or a diversional therapist. In some circumstances, the personnel in these positions are also expected to undertake the third and fourth stagesthe implementation and evaluation of Documentary evidence of the therapiesbut this does not complementary therapies needs to be meet the tenets of true holistic vigorous, denitive, and faultless. care. In such holistic care, the implementation and evaluation stages of complementary therapies should be included in the position descriptions and role statements of all care providersand all of the stages cited above should be clearly documented in such position descriptions and role statements. In all contemporary nursing practices the need for documentary evidence is well established. With respect to complementary therapies, this documentary evidence needs to be vigorous, definitive, and faultless. In any aged-care facility that utilises complementary therapies, the required documentation includes: policies, procedures, and protocols; social profiles and assessments; programs; consents and authorities; care plans; evaluations; and educational records. Each of these is discussed below.

1. Policies, procedures, and protocols


General principles
All policies, procedures, and protocols should reflect current legislative requirementsboth national and regionalin the local jurisdiction. In addition, these policy documents should address ethical considerations,

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the needs of the resident, and guidelines set out by professional nursing bodies and peak group associations. A multidisciplinary team approach to formulating complementary therapy policies, procedures, and protocols ensures commitment to the aims of the policies and successful implementation of A multidisciplinary team approach ensures commitment to the aims of the the procedures and protocols. policies and successful implementation In turn, these should be directly of the procedures and protocols. linked to the organisations vision statement and mission statement. In writing such policies, assistance can be obtained from nurses registration bodies, various nursing associations (including the holistic nurses associations), professional colleges, and complementary therapy associations (Quirk 2003, p. 229).

Practical issues
Practical consideration must be given to a number of issues when preparing policy-related documents. These include (as adapted from Quirk 2003): regimens that will be provided; resources required; qualifications of service providers; accountability of the organisation; and occupational health-and-safety issues. Each of these is discussed below.
Regimens that will be provided There should be a separate policy, There should be a separate procedure, and protocol documented policy, procedure, and protocol for each therapy provided by the documented for each therapy facility. Some aged-care facilities provided by the facility. formulate a directory of services that is made available both internally and externally. This service directory should stipulate contact details, transport availability, and any expenses that might be incurred.

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Resources required

Some equipment and materials that are needed for complementary therapies are expensive. These need to be purchased, and regularly replaced or maintained. Consumable supplies need replenishment. These costings should be documented in the annual budget submissions.
Qualications of service providers

Unqualified personnel should not provide some complementary therapies. The policy document should state which therapies require qualified providers and how currency to practise is assured. Specific insurance requirements should also be documented.
Accountability of the organisation

The policy document should state the responsibilities of the organisation with respect to provision of complementary therapies. This document should state how the organisation meets all relevant legislative requirements and whether it provides insurance cover (or whether this is a responsibility of the resident).
Occupational health-and-safety issues

Most jurisdictions have specific legislation with respect to workplace safety. Such legislation usually includes provisions regarding infection control, manual handling, risk assessment and management, use of chemicals, the use of protective equipment, and so on. All of these matters must be addressed in the policy document.

As was noted in the introduction to this chapter on page 110, the second category of documentation in utilising complementary therapies relates to social profiles and assessments. Before implementing any complementary therapy, documentation begins with a comprehensive assessment. Initially, a social profile should be completed. This social profile should be designed to elucidate sociodemographic data that will assist in deciding whether complementary

2. Social profiles and assessments

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Documentation of complementary therapies


In any aged-care facility that utilises complementary therapies, the required documentation includes: policies, procedures, and protocols; social proles and assessments; programs; consents and authorities; care plans; evaluations; and educational records. A discussion of each of these topics forms the framework of this chapter.

therapies are appropriate in the residents care plan. The information that needs to be obtained and documented in completing a social profile includes: personal detailsname, age, gender, address, social security details, and so on; health statusdiagnoses, disabilities, medications, health behaviours, and so on; social supportrelatives, friends, pets, community groups, church groups, and so on; previous employment and educational achievement; likes and dislikes; leisure activitieshobbies, crafts, social activities, group memberships; lifestyle activitiesironing, cooking, gardening, and so on; cultureplace of birth; other countries of residence; spiritualityreligion, terminal wishes and care, comfort activities; primary and secondary languages;

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sensory abilities or disabilities; and previous and current experiences with complementary therapies. This information should assist the assessor in: conducting any further assessments needed; drawing up referrals to appropriate therapists; and designing a care plan. The social profile must be compiled from information given by the resident or his or her representative. Some organisations have a requirement that a signature must be Consent must be obtained obtained from the informant as proof before commencing any of his or her input into care planning. complementary remedies. Even if the organisation does not require a signature on a social profile, consent must be obtained before commencing any complementary remedies. (For more on this, see Consents and authorities, page 115.) After completing a social profile, more specific assessments can be carried out and documented. These additional assessments might include examination of: behavioural patterns; depression-rating scales; mini-mental examination; communication assessment; special senses appraisal; sleep patterns; mobility and dexterity capabilities; pain assessments; skin condition and wound assessments; and nutritional and hydration status.

3. Programs
As noted on page 110, the third category of documentation required with respect to complementary therapies relates to programs. Programs should

115 Documenting Complementary Therapies

be designed to inform current and potential residents of the various complementary services that are available. An annual and monthly schedule of services should be documented and distributed to residents. Including the annual program in the residents handbook can be a valuable marketing tool for the facility. The programs should document the type of service, the date, time, and duration, and the service providers name. If expenses are to be incurred or if appointments are required, residents should be informed before the therapy is provided. When formulating programs it is It is essential to plan essential to plan therapies around each therapies around each residents routine activities. residents routine activitiessuch as meal times, rest periods, activities of daily living, and social appointments. Individualising programs in this way can be complex and problematic, but effective negotiation skills can assist the planner. All programs should be flexible enough to accommodate any contingency. Programs should offer a variety of activities to maximise individual choice on any given day.

Written consent is a very important component of professional documentation. It provides employees, employers, and the recipients of care with legal protection in any malpractice cases. As Loeb (1992, p. 5) has observed:
Good documentation should give legal protection to you, the patients other caregivers, the health care facility, and the patient. Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a patient.

4. Consents and authorities

For written consent to be valid it must conform with certain requirements. These are listed in the Box on page 116. Authorities are similar to written consents, but the former are usually provided by someone other than the resident. In obtaining authorities, the

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Valid consent
For written consent to be valid it must conform with certain requirements. Such consent must be: voluntarily givennot through coercion; informedthe person consenting needs to be given all relevant details, including desired effects, side-effects, and any known idiosyncratic reactions; given by a person who is deemed to be cognitively intact and competent to give consent; and given by a person who meets the statutory age requirement within the particular jurisdiction.

terms of reference of particular statutory Acts must be observed. Examples of these include: Health Acts; Mental Health Acts; Attorney Acts; and Adult Guardian Acts. Written authorities and consents must be constantly reviewed, upgraded, and renewed. A signed consent obtained upon admission might not be legally valid if the residents condition deteriorates or if a long time elapses from the date of All authorities and consents should be signing. In some jurisdictions consent must be renewed signed, witnessed, and dated. every three months. To prevent exposure to professional liability, explicit information must be provided to the signatory before the consent form is signed. This information should be documented, and a copy should be given to the resident and/or representative. The original should be filed in the residents health record. All authorities and consents should be signed, witnessed, and dated. Following these notations, each signatory should print his or her name

117 Documenting Complementary Therapies

and status (or relationship to the resident). In some organisations, a limited number of nominated persons are authorised to witness legal documents. In these circumstances, these nominated witnesses must provide the signatory with the necessary information to ensure that informed consent is obtained.

5. Care plans
The fifth category of documentation required with respect to complementary therapies (see page 110) relates to care plans. When complementary therapies are incorporated into a residents care plan, specific documentation is essential. There are few qualified complementary therapists employed within the aged-care sector. The majority of staff members have limited knowledge of the intricacies and requirements of the many therapies that fall under the all-encompassing umbrella of complementary therapies. This means that specific documentation of care plans is especially important in complementary therapies. The care plan should include: treatment regimens; recipes and prescriptions (if applicable); objectives of care; methodologies associated with application; required observations; desired effects, side-effects, and known idiosyncratic reactions; reporting criteria; when the therapy should be ceased; and evaluative criteria. The Box on page 118 provides guidelines on how to draw up a care plan for aromatherapy. Guidelines of this sort can be adapted and applied to the drawing-up of care plans for other complementary-therapy modalities.

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Guidelines for aromatherapy care plan


Treatment regimen The name of the essential oils must be documented, together with the method of application (for example, spray, cream, inhaled, or ingested). The times for application, the duration of the course, and the date of review should be included. Recipes and prescription The number of drops of essential oils, and the volume and type of base, should also be written down.The route, dose, frequency, and administration should be recorded. Objectives of care The specic goals should be stipulated utilising a time reference (for example, Mrs A will be less agitated during the night following application of the spray or Mrs A will be free of pruritus in one week). Methodologies associated with application The specic method of massage or application should be clearly stated. This record should take the form of a task analysis. Required observations Any required observations (such as recording vital signs, biochemistry measurements, or the residents condition status) should be documented. The required frequency of such observations should be noted. Desired effects, side-effects, known idiosyncratic reactions Any known reactions should be listed. The action to be taken if these things occur should be notedfor example, continue therapy, reduce frequency, or cease therapy. Reporting criteria The aromatherapist should document any event that should be reported. The reporting criteria should also state whether such an event should be reported to the aromatherapist and/or a senior staff member.
(continued)

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(continued)

The therapy should be ceased if Any events that would lead to immediate cessation of the therapy should be documentedfor example, urticaria, rhinorrhoea, raised blood pressure, increased pulse rate. Evaluative criteria The quantitative evaluative criteria should be citedfor example, pulse rate within normal range, diastolic blood pressure below 85 mm Hg, erythema absent, wound dimensions lessening, volume of sputum diminishing.

6. Evaluation
As noted on page 110, the sixth category of documentation required in utilising complementary therapies relates to evaluation. Effective evaluation of complementary therapies in the aged-care sector is often difficult to achieve because of the altered cognitive ability of many of the residents. Altered cognition in residents can mean that an assessor is presented with various red herrings in evaluating behaviours. A documented framework can be utilised to assess some aspects of a residents involvement in the therapies being implemented. The framework is illustrated in Figure 8.1 (page 120). Effective evaluation of complementary therapies in the aged-care sector is often It uses a numerical scale difcult to achieve because of the altered to indicate a continuum of cognitive ability of many of the residents. reactions. The total score for all five criteria is then calculated. A score of zero (out of a possible total value of twenty points) indicates that the resident is actively participating in the therapy. To measure the actual effectiveness of the complementary therapy being applied, the assessor should refer to the program objectives and timeframes for evaluative criteria. The measurement criteria might include

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0 Understanding Participation Attention span Anxiety level Social abilities Grasps situation Acts on own initiative Attentive No anxiety Cooperative

5
Unable to understand

No interest in participating No attention Too anxious to participate withdrawn

Uncooperative and/or

Figure 8.1 Continuum framework for assessment of resident involvement AUTHORS CREATION

actual physical signs, psychological reactions, and social interactions. These should be documented over a period of 37 days. An extended time period is recommended to minimise unrelated changes If the organisation intends to conduct research in complementary therapies, and thus optimise data it is imperative that a contract for validity. When behavioural participants be signed and witnessed. changes are the goal of the therapy, a useful strategy to use is to make anecdotal progressive entries in the residents notes on a shift-by-shift basis. It is essential to document evaluative data for the purposes of: conducting research; applying industry benchmarking; and planning future educational activities. If the organisation intends to conduct research in complementary therapies, it is imperative that a contract for participants be signed and witnessed. An ethics committee can assist with respect to the confidentiality of data, the right to withdraw, the sharing of results, and the purpose of the research project. All of these matters should be properly documented.

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The last of the items listed on page 110 was education. Documentation of education in complementary therapies should include: the results of a recently completed needs analysis; an educational plan; an educational program; lesson plans; provision of education to staff, volunteers, residents, and their representatives; records of achievement, qualifications, and any current required practising certificates; any competency-based training that is being conducted (internally or externally); a statement of who can plan, implement, and evaluate complementary therapies (and the mandatory qualifications required); a policy related to recognition of prior learning (RPL); and records of attendance at educational presentations conducted internally or externally, whether attended while on or off duty, and whether the participant was paid. Education is effective only if Education is effective only if it is needs driven, if it it is needs driven, if it applies the applies the principles of adult principles of adult learning, and if the anticipated learning is evaluated. learning, and if the anticipated learning is evaluated. Achievement of on-the-job and off-the job competencies should be documentedand should attract recognition in terms of the appropriate credentials and remuneration. Failure to achieve competence should also be documented, and the learner should be precluded from activities related to application of the subject matter. Another documentary requirement related to the topic of education is that the organisation should have anti-discrimination, grievance, and appeal policies in place.

7. Educational records

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Conclusion
The inclusion of complementary therapies in aged-care is essential if the goal of holistic care is to be achieved. In recent times, an increasing number of aged-care residents have experienced the value of complementary therapies before becoming dependent upon service providers. These people value the outcomes of such therapies, and also value being included in decision-making about their care. Moreover, the members of Aged-care nurses are adequately prepared to meet the next generation to receive agedthese important requirements. care will be even more discerning and demanding with respect to their health care than are the current population of residents. The next generation will be used to participating in decision-making about their care. Aged-care nurses will need to plan ahead and be proactive if commercial viability is to be maintained. The documentary requirements might appear to be overwhelming initially. However, as a result of their experience in accreditation processes and continuous quality improvement (CQI) activities, aged-care nurses are adequately prepared to meet these important requirements.

Chapter 9

Documenting Pain Management


Michael Cully

Introduction
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (APS 1992). McCaffery (1968, p. 95) famously defined pain as whatever the experiencing person says it is, existing whenever he [or she] Accompanying the ageing of the population are sharp rises in the says it does. However, in agedincidence of conditions that limit a care nursing, this latter definition persons ability to report pain in a is not always sufficient. Western timely and accurate manner. populations are living longer, with the fastest-growing sector of the community being people over the age of 80. Unfortunately, accompanying this ageing of the population are sharp rises in the incidence of dementia, delirium, depression, and other conditions that limit a persons ability to report pain in a timely and accurate manner. Older adults are twice as likely to experience pain than younger adults, with 2550% of elderly people in the community experiencing pain.

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As many as 85% of elderly people in residential facilities experience pain, and there is a well-documented pattern of under-treatment of that pain (Gaston-Johansson, Johansson & Johansson 1999).

Assessing pain on admission


The management of pain begins with a comprehensive nursing assessment. Asking appropriate questions about the pain provides information that helps to determine whether the resident needs a specific pain-treatment plan. Appropriate questions include: Do you have any ongoing pain problems? Do you have pain now? Where is the pain located? What is the intensity of the pain on a scale of 1 to 10? What is the intensity of the pain now? What is the usual intensity of the pain? What treatment, if any, do you have for your pain? Is your pain satisfactorily controlled now? If the responses to these questions indicate the need for specific treatment, Sometimes residents are reluctant to talk about pain. a nursing-care plan can be drawn up using data from an initial painassessment tool. McCaffery and Pasero (1999) provided an initial painassessment tool to be administered when a resident is first admitted to an aged-care facility. It asks the resident to identify: the location of any pain he or she might have; the intensity of the pain; the quality of the pain; and the onset, duration, variation, or rhythms of the pain. The assessment tool also seeks to establish the residents feelings about expressing pain. Sometimes residents are reluctant to talk about pain. The initial pain-assessment tool also determines what brings relief from the pain, what causes the pain, and the effects of the pain. This gives

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a resident the opportunity to add any additional information that he or she feels might be relevant. A second tool, called the brief pain inventory (McCaffery & Pasero 1999), concentrates on the residents pain experience over the preceding 24 hours and its effect on: general activity; mood; mobility; activities of daily living (ADLs); social relationships; sleep; and enjoyment of life. This inventory uses a 10-point visual analogue scale for most items. Taken together, the initial pain-assessment tool and the brief pain inventory can provide essential information for formulating a plan for pain management. The Box on page 126 provides guidance on how to link an initial pain assessment with documentation.

Rating scales
Numeric rating scale
A numeric rating scale is accepted as having good reliability and validity as a pain-rating tool when used with a resident who has the capacity to understand it. It asks a resident to rate his or her pain on a scale of 1 A numeric rating scale has good reliability and validity when to 5, with 1 being no pain and 5 used with a resident who has the being the worst pain imaginable. capacity to understand it. The scale can be used by the nurse who simply says: Describe how much pain you have by picking a number between 1 and 5, with 1 being no pain, 2 being a little pain, 3 being medium pain, 4 being large pain, and 5 being the worst possible pain.

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Linking initial pain assessment with documentation


1. Location of pain
Suggested questions:

Where is the pain located? Does it radiate or spread elsewhere?


Suggested documentation:

Document with gure drawings. 2. Intensity of pain


Suggested question:

On a scale of 1 to 10, how would you rate your pain now?


Suggested documentation:

Document with pain-rating scale and include description of scale (for example, 1 is no pain, 10 is the worst pain imaginable). 3. Character or quality of pain
Suggested questions:

In your own words, how would you describe the pain? Does anything make the pain better or worse?
Suggested documentation:

Document residents words (burning, stabbing, throbbing, cramping, etc.). 4. Onset and duration of pain
Suggested questions:

When did the pain begin? What were you doing when the pain began? How many days, weeks, or months has the pain been present? How often do the episodes of pain occur? How long do the episodes last?

Suggested documentation:

Document by quoting the resident.


(continued)

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(continued)

5. Associated symptoms
Suggested question:

Are other symptoms associated with the pain?


Suggested documentation:

Document by quoting the resident. 6. Causes of pain


Suggested questions:

Do you know the cause of the pain? Does anything in particular bring the pain on?
Suggested documentation:

Document by recording the residents responses. 7. Effects of pain


Suggested questions:

Are you able to sleep and rest? Are you able to perform your daily activities?
Suggested documentation:

Document by recording the residents responses. 8. Therapy


Suggested questions:

Do you take any pain medications or use pain-relief measures? If pain medications are taken, what is the name, dosage, route, and frequency of the medication? Do they help?
Suggested documentation:

Document by recording the residents responses. 9. Other


Suggested question:

Is there any thing else you would like to add?


Suggested documentation:

Document by recording the residents responses.


ADAPTED FROM BEMIS & ARMSTRONG (2001)

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It is a better idea to use a visual analogue scale that contains the same information, as illustrated in Figure 9.1 (below). The scale can also have ten points, as illustrated in Figure 9.2 (below).

1
No pain

2
Little pain

3
Medium pain

4
Large pain

5
Worst possible pain

Figure 9.1 A 5-point visual analogue scale


AUTHORS CREATION

1
No pain

10 Worst pain

Moderate pain

Figure 9.2 A 10-point visual analogue scale


AUTHORS CREATION

The Australian governments Department of Veterans Affairs (2000) gave the following useful hints on using a numeric rating scale: allow sufficient time to elicit a residents self-reported pain rating; provide an environment that is quiet and free from distractions; have appropriate visual and hearing aids availablefor example, enlarged numeric rating scale charts and enlarged anatomical charts for pinpointing pain location; speak slowly and clearly, and use appropriate volume; involve family members;

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use enlarged copies of a numeric rating scale; teach residents how to use a pain-rating scale; explain the use of the scale each time it is administered; use the same pain-rating scale each time it is administered; ask residents to point to the enlarged scale or anatomical drawing (if they cannot respond verbally but can understand the process); and ask residents to provide a single global estimate of pain intensity. If a resident has known cognitive impairment, nurses should allow 30 seconds for each response, and should repeat the scale at least three times (McCaffery & Pasero 1999). If it is not possible to use a If a resident has known cognitive numeric rating scale, the Wong impairment, nurses should allow 30 seconds for each response, and should Baker faces rating scale can repeat the scale at least three times. be used (Wong 1997). Although this scale was developed for very young children, it has proved to be effective when used with elderly adults who have cognitive or expressive difficulties. The scale is described in the Box below.

WongBaker scale
The WongBaker faces-rating scale (Wong 1997) uses six facial expressionsranging from a face that is smiling broadly to a crying, distressed face. A resident is given the following alternatives: broadly smiling face = no hurt; slight smile, attened eyebrows = hurts a little bit; no smile, mouth a straight line = hurts a little more; mouth beginning to turn down, eyebrows turning down = hurts even more; distinct turning down of mouth and eyebrows = hurts a lot; and clearly distressed, crying face = hurts worst.

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Although this scale has been translated into many languages and is popular with clinicians, some concern has been expressed that an elderly adult might mistake its intention if the scale is not properly explained. The person might believe that the An elderly person might believe that faces scale is measuring his or the faces scale is measuring his or her her mood, not the experience mood, not the experience of pain. of pain. Such a mistake could result in inappropriate treatment, and the clinician must therefore take responsibility for ensuring that the purpose of the scale is clearly understood.

McGill pain inventory


The McGill pain inventory is another pain-assessment scale that is used widely for documentation (Melzack 1987). It includes an extensive questionnaire and body drawings that invite a resident to indicate exactly where the pain is occurring. It is a valid and reliable tool that can be used with cognitively intact residents. Because it is complex and takes longer to administer than other tests, it is less appropriate for residents with impaired cognitive functioning.

Documentation and unrecognised pain


Many residents have difficulty in providing accurate and reliable selfreporting of pain. Nurses should therefore always consult existing documentation to establish whether pain is likely to be present, and whether it requires management. The following matters should be documented: the medical history; patterns of daily activity; sleep patterns; nutrition; mental state; emotional state;

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patterns of wandering; crying out and/or aggression; and changes to the level of social functioning. Nurses should pay particular attention to nursing entries that describe grimacing, sighing, guarding of anatomical areas, and marked changes in activity levels. Late-stage dementia masks facial grimacing, so other signs must be recognised. It should also be remembered that, even in the absence of dementia, behavioural and physiological adaptation to pain often occurs, and this can mask signs of chronic pain (McCaffery & Pasero 1999). When assessing whether pain exists, nurses must therefore make judgments on the balance of probabilitiesand must undertake appropriate investigations accordingly. In the medical history, nurses need to look for documentation of co-existing painful conditions that might not have been the primary reason for the admission. The most common cause of pain in elderly people is osteoarthritis, but other common causes include (Bemis & Armstrong 2001): degenerative joint disease of other types; peripheral vascular disease; and peripheral neuropathies. Nurses should always be alert to the possibility of pain being associated with a range of chronic and acute illnesses. Apart from the above, occult fractures, sprains, and strains are common causes of unrecognised pain in the elderly. Nurses should ask themselves: whether the resident has fallen recently; and whether there has been a sudden change in levels of mobility and activity. These matters should all be carefully documented. Moreover, nurses should be in the habit of checking residents records for any

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notes about these sorts of matters. Such a routine check might lead to an astute nurse detecting a previously ignored problem. If anything of significance is found A routine check of documentation in the records, this might lead to an astute nurse detecting a should prompt further previously ignored problem. investigation.

Common causes of pain in the elderly


Nurses should always keep in mind the most common causes of pain in the elderly. These include: osteoarthritis; degenerative joint disease of other types; peripheral vascular disease; and peripheral neuropathies. Nurses should also be alert to: unrecognised pain associated with a range of chronic and acute illnesses; and unrecognised pain associated with occult fractures, sprains, and strains. Nurses should be in the habit of checking residents records for any notes about these sorts of matters. Such a routine check might lead to an astute nurse detecting a previously ignored problem.

Barriers to effective communication and documentation


Myths
Many myths exist that lead to the under-treatment of pain. Perhaps the most harmful myth is that residents readily report their pain to nurses. In fact, residents often hold beliefs that lead to under-reporting of pain. These include beliefs that pain is: an inevitable part of the ageing process; a sign of the development of life-threatening conditions such as cancer (which activates denial mechanisms);

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likely to cause inconvenience or distress to others; a punishment for past sins, or a purification process; to be preferred to medical treatments that have intolerable sideeffects (including addiction); and to be borne stoicallythat is, without complaint.

Depression and anxiety


Nurses need to be aware that residents might be depressed or anxious. These conditions can diminish a residents ability to communicate his or her pain, while at the same time increasing the experience of pain. Nurses should check existing documentation for evidence of anxiety or depression. This could include reports of social withdrawal, increased sleepiness during the day (or broken sleep at night), changes in appetite, and alterations in elimination patterns.

Barriers to effective documentation


This section of the text discusses various potential barriers that might inhibit accurate detection and documentation of pain. Nurses should always keep the following potential barriers in mind: common myths about pain in the elderly; the possibility that depression and anxiety might be present; a lack of education about pain; difculty in nding the right words to describe pain; and erroneous beliefs held by nurses. Each of these is discussed in this section of the text.

Education
An essential part of any admission is educating residents and their families about the need to identify and ameliorate pain. Such an education plan is also an essential part of pain documentation. The documented plan should address any concerns expressed by the resident, and should outlinein simple, understandable, and culturally appropriate termsthe ways in which the management of pain

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will be approached. Such an education plan forms part of the essential documentation of any pain-management strategy.

Finding the right words


Another barrier to communicating pain levels is that residents can have difficulty in finding the right descriptive word. In these cases, it is perfectly justifiable for nurses to suggest words to describe the painfor example, sharp, stabbing, burning, crushing, throbbing, aching, dull, and so on. Suggestions such as these help the resident to communicate his or her experience. However, if a nurse must help the resident find the right word, this should be recorded in the notes.

Nurses erroneous beliefs


Nurses can also hold unhelpful and incorrect beliefs that interfere with pain reporting. These include: that older residents and cognitively impaired residents have lower levels of pain; that the presence and intensity of pain can be accurately gauged by reference to vital signs; that certain ethnic and cultural groups persistently over-report or under-report pain; and that over-reporting of pain is a diagnostic sign of opioid addiction. Nurses should examine pain documentation for evidence of unhelpful attitudes and beliefs of nurses in the facility. If detected, education plans must incorporate sessions Nurses can hold unhelpful and incorrect on pain management that beliefs that interfere with pain reporting. reflect best practice. These sessions should be based on acceptable levels of evidence and, if appropriate, should include advice on values clarification and cultural awareness.

Procedures for pain documentation


Documentation of pain is obviously a very important aspect of overall nursing documentation. In fulfilling their professional responsibilities in

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this area, there are certain procedures that nurses should follow. Some of these are specific to pain documentation, whereas others are of a more general and standard nature.

Specific procedures for pain documentation


To be comprehensive and effective, documentation of pain must clearly describe: the nature and level of the residents pain; the effect of the pain on the residents biopsychosocial status; a nursing-care plan for the management of the pain; interventions and resident responses; proposed changes to the nursing-care plan in the light of resident responses; communications with other members of the healthcare team; any advocacy undertaken on the part of the resident; and resident and family education on pain controlespecially as part of pre-discharge planning. As a rule, if an elderly resident is too disabled to communicate his or her pain status voluntarily and clearly, the frequency of documentation needs to increase.

Standard documentation procedures


Apart from the specific procedures noted above, documentation of pain should also follow standard documentation procedures. These include: writing legibly in ink; signing all entries with name and designation; ensuring that entries are in the correct chart; correcting errors in a proper mannerdrawing a single line through any error, writing mistaken entry, and initialling the correction; avoiding the use of whiteout or erasers; not making new entries between lines; completing documentation as soon as possible after assessing the residents pain;

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using precise, non-judgmental language; using the residents words wherever possible, utilising quotations; leaving no blank lines in entries; providing clear reasons for interventions (and not expecting the reader to be able to make inferential leaps); and using only acceptable abbreviations.

Conclusion
Nurses must always ask: Is this person pain-free?. If the answer is no, the nurse should then ask: What can I do about it?. One of the essential responses to this latter question is to communicate with other team members through efficient and effective documentation. Nurses should ensure that pain-management documentation is a primary goal in quality-assurance activities. In documenting residents pain experiences, and their In documenting residents pain responses to treatment, nurses experiences, nurses should remember should always remember that that the absence of pain is one of the the absence of pain is one of major determinants of quality of life. the major determinants of quality of life.

Chapter 10

Documenting Restraint
Sue Forster

Introduction
Restraint can be defined as the use of any methodology or apparatus that controls a persons choice to move freely and which cannot be easily removed by that person (Stilwell 1993). Restraint is usually divided into physical restraint and chemical restraint. Physical restraint can be further subdivided into three categories: restraint applied to the residentfor example, lap belts, vests, splints, binders, mitts, wrist ties; restraint applied to the residents immediate environmentfor example, table tops, bed tables, bed rails, wheelchair bars, and deep low chairs; restraint applied to the environment that effects all residents within the areafor example, secure areas or units, electronically operated doors, high fences. Chemical restraint involves the use of medications to control behaviours or mood. It has been suggested that the term restraint should be replaced by the term protective assistance (Lange 1994). The use of this term might

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assist with a paradigm shift in thinking from custodial or controlling care to holistic and participatory care. Furthermore, the use of this term would assist policymakers to become more resident-focused. The use of restraint in an aged-care facility requires the following documentation: policies, procedures, and protocols; assessments; consents and authorities; care plans; other resident documents; evaluation; and educational records. Each of these is discussed below.

1. Policies, procedures, and protocols


General principles
To ensure commitment of all parties to the safe application of restraints, a multidisciplinary team approach to formulating policies, procedures, and protocols is required. This should include consumer input. The documentation should also demonstrate a direct link with the organisations vision statement, mission statement, and other relevant policy documents. Assistance in writing specific restraint policies can be obtained from governmental regulatory authorities, nurses registration bodies, various gerontological nursing associations, professional colleges, and educational bodies. Many of these groups have drawn up specific codes of conduct, policy documents, and guidelines with respect to the use of restraints. All policies, procedures, and protocols should reflect legislative requirements in the local jurisdiction. In addition, the documents should address ethical considerations, the needs of the client, and guidelines set out by professional bodies (medical and nursing) and peak group associations.

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Because the use of restraints is an emotive experience for residents, their representatives, and some staff members, consideration should be given to implementing policies and procedures to produce a restraint-free environment or a minimal-restraint environment.

Documentation of restraint
The use of restraint in an aged-care facility requires the following documentation: policies, procedures, and protocols; assessments; consents and authorities; care plans; other resident documents; evaluation; and educational records. A discussion of these issues forms the framework for this chapter.

Practical issues
Practical consideration must be given to a number of issues when preparing policy documents. These include: resources required; accountability of the organisation; anti-discrimination, grievance, and appeal issues; and occupational health-and-safety issues. These are discussed below.
Resources required Resources required for restraint vary according to the policies and practices of the facility. However, the types of resources required might include electronic security equipment, code pads, fences, gates, belts, sashes, vests, and medications. Some of these are expensive. All of them require maintenance, replacement, or replenishment.

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Any consideration of the documentation of restraint thus involves budgetary costings of these items. These must be clearly documented in annual budget submissions and final budget documents.

Practical issues in restraint policy documents


Practical consideration must be given to a number of issues when preparing policy documents on restraint. These include: resources required; accountability of the organisation; anti-discrimination, grievance, and appeal issues; and occupational health-and-safety issues. Each of these matters is discussed in this portion of the text.

Accountability of the organisation

The use of restraints can have serious legal consequences. Indeed, a senior legal officer has warned that, in certain circumstances, charges of assault and battery might be brought (Wallace 1997). The use of restraints can have serious legal consequences charges of The policy document assault and battery might be brought. should therefore carefully address the responsibilities of the aged-care facility with respect to the use of restraints. This document should state how the organisation meets all relevant legislative requirements.
Anti-discrimination, grievance, and appeal issues

The philosophical, ethical, and practical arguments for and against the use of restraint in aged-care nursing have been the subject of many important studies, articles, and books. This is not the place to explore these issues in any detail. This chapter is essentially concerned with issues of documentationnot a full-scale analysis of the wider arguments for and against the use of restraint. However, with respect to documentation

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issues, the use of restraint has many implications in terms of residents rights and the duty of care of nurses. In drawing up policies, procedures, and protocols on restraint, agedcare facilities must therefore ensure that all relevant statutory and common law requirements are observed with respect to residents rights. These include such rights as: anti-discrimination rights; grievance rights; and appeal rights. These legal and ethical requirements differ from jurisdiction to jurisdiction. It is therefore incumbent upon each organisation to ensure that its documented policies are in accordance with all relevant protocols and guidelines.
Occupational health-and-safety issues

Most jurisdictions have specific legislation with respect to workplace safety and matters of risk. Such legislation usually includes provisions regarding infection control, manual handling, risk assessment and management, use of chemicals, the use of protective equipment, and so on. These issues obviously have implications for any documentation on matters of restraint. All of these topics must therefore be addressed The rights of residents to take in policy documents on restraint. certain risks should be recognised Furthermore, accreditation and included in the documentation on restraint policies. standards and professional nursing bodies often require policy statements regarding the rights of residents to take certain risks (see, for example, NBWA 2004). These rights should be recognised and included in the documentation on restraint policies.

The second category of restraint documentation noted on page 138 referred to assessment documentation. Before implementing any restraint,

2. Assessments

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a comprehensive documented assessment is required. Initially, a resident profile should be completed. This directs the assessor to more specific assessments, as applicable. These additional assessments might include examination of: behavioural patterns; depression-rating scales; mini-mental examination; communication assessment; special senses appraisal; sleep patterns; mobility and dexterity capabilities; and assessment of risk of falls. The resident profile must be compiled from information given by the resident or his or her representative. As noted in the discussion on the documentation of complementary therapies (Chapter 8, page 114), some organisations insist that the informant signs the profile as proof It is mandatory that signed consent is obtained before any of his or input into the planning of form of restraint is instituted. care. Even if the aged-care facility does not insist on such a signature on the resident profile, it is mandatory that signed consent is obtained before any form of restraint is instituted (see below).

The third category of restraint documentation noted on page 138 referred to consents and authorities. Written consent is a fundamental component of professional documentation. Such written consent provides legal protection to employees, employers, and the recipients of care in the event of any allegations of malpractice. For written consent to be valid it must conform with certain requirements. These are listed in the Box on page 143. Authorities are similar to consents, but authorities are usually provided by a person other than the resident. Various statutory Acts contain

3. Consents and authorities

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Requirements for valid consent


For written consent to be valid it must conform with certain requirements. Such consent must be: voluntary; informed; and legalthat is, provided by a person who is legally entitled to provide it. These criteria mean that the person who provides the written consent must be free to do so in an entirely voluntary fashionwith no suggestion of coercion. This person must be provided with all relevant details of the proposed restraint. In particular, he or she must be informed of desired effects, side-effects, and any known risks or idiosyncratic reactions. The person must be legally entitled to provide the consent. If given by a resident, the resident must be cognitively intactand thus competent to give consent. If the person giving consent is a representative of the resident, this person must meet all statutory requirements within the particular jurisdiction.

provisions regarding the rights and responsibilities of persons who can authorise treatment interventions on behalf of othersincluding restraint interventions. Depending on the local jurisdiction, such Acts might include Health Acts, Mental Health Acts, Attorney Acts, and Adult Guardian Acts. As noted in the Box All authorities and consents should above, written authority or be signed, witnessed, and dated. consent is valid only if all relevant information has been explicitly provided to the signatory. The educational information that has been provided should be documented for the record. A copy should be given to the resident and/or representative, and the original should be filed in the residents health record. All authorities and consents should be signed, witnessed, and dated. Following these notations each signatory should print his or her name and status (for example, relationship to the resident). The policies of some organisations mandate that only certain senior staff members have

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the authority to witness legal documents. If such a policy is in place, these designated persons are responsible for ensuring that signatories are provided with all relevant information. Written authorities or consents must be reviewed regularly and frequentlywith a view to upgrading and renewing them as appropriate. If the condition of a resident changes over time, a consent that was obtained at admission might be no longer legally valid. In some jurisdictions consent for restraint must be renewed every three months. In some instances, an aged-care resident (or that persons representative) might actually request that restraint be applied. For example, some residents feel more secure with a lap sash when A resident might actually request that restraint be applied mobilising in a wheelchair. Others Even if these requests are prefer bedrails at night because made freely and spontaneously, they have been used to sleeping they should still be documented. in a double bed and feel insecure in a narrow single bed. Even if these requests are made freely and spontaneously, they should still be documented. Any such arrangements should be reviewed regularly and frequently.

4. Care plans
The introduction to this chapter (page 138) listed several categories of documentation relevant to restraint interventions. The fourth category of restraint documentation referred If restraint is incorporated into to care plans. If restraint is a residents care plan, specic incorporated into a residents care documentation is clearly essential. plan, specific documentation is clearly essential. There are many risks associated with the use of restraints. In many cases, these risks are compounded by inadequate observation and monitoring of restrained residents. This is often due to limited staff numbers with resulting inadequate nurse/resident ratios.

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The care plan should include: the type of restraint to be used; the objectives of care; how the restraint should be applied; the duration of the restraint; required observations and actions; and evaluative criteria. The Box on page 146 contains an example of a suitable care plan involving restraint.

Apart from the nursing-care plan (see page 144), there are other essential documents to keep in the residents record with respect to restraint. These include: an authority to restrain formwith signatories, dates, consent, education provision, and review dates all being clearly noted; a restraint review formwith a record of the times when the restraint was applied and when it was released; a record of any comfort activities undertakenfor example, the resident was offered or given fluids, the resident was mobilised, the resident was taken to the toilet, the resident received a hand massage, the resident had his or her clothes changed, and so on; medication administration formsprescriptions, signed entries of administration, records of all effects; behavioural-assessment formswith a clear description of the behaviour, the duration of the behaviour, what actions were taken, and the results of any actions taken; and any incident reportsnoting the type of injury incurred, actions taken, outcomes, and close-out procedures taken. Other documents that need to be completed and retained by the organisation include: audit results related to the use of restraints; completed hazard-identification forms;

5. Other resident documents

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Care planrestraint
Type of restraint to be used A lap belt will be used when Mrs A is being showered. Objectives of care Throughout her shower, Mrs A will: remain seated be kept comfortable; be kept safe. How the restraint should be applied Once Mrs A is transferred into the shower chair, the lap belt should be applied. Use the adjustment apparatus so that the belt ts snugly around Mrs As hips. The belt should not restrict circulation or access to the underlying skin. Duration of restraint application As soon as Mrs A has been transported back to her chosen area following her shower, the lap belt should be released. Required observations and actions During the shower, observe the skin for any blanching or erythema. Loosen the belt if either occurs. Observe Mrs As behaviour carefully. If she becomes agitated or distressed, cease the procedure, cover her, and talk to her until she calms down. Evaluative criteria Mrs A is comfortable and not distressed. Mrs A has her hygiene needs met. Mrs As skin remains intact and not traumatised. Mrs A is safe throughout the procedure.

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risk assessments and risk analyses that have been conducted; and audits of equipment safety and building safety.

The sixth category of restraint documentation noted on page 138 referred to evaluation. It is essential to document evaluative datawhether these are being used for assessment of It is essential to document clinical effectiveness, research, industry evaluative data. benchmarking, or planning future educational activities. However, effective evaluation of the use of restraints in the agedcare sector is often difficult to achieve. The altered cognitive ability and mood swings of many of the residents makes objective assessment problematical. To measure the actual effectiveness of the use of restraint the assessor needs to refer to the resident-centred objectives and timeframes. Measurement tools might include physical signs, psychological Progressive anecdotal entries in the residents notes on a shift by reactions, and social interactions. shift basis constitute the most These should be documented over useful documentation. a period of 37 days to minimise unintended bias in the data. If behavioural changes or emotional stability are the goals of the interventions, progressive anecdotal entries in the residents notes on a shift by shift basis constitute the most useful documentation. If the organisation intends to conduct research it is imperative that participants sign a contract, and that this be properly witnessed. An ethics committee can assist with documenting such issues as confidentiality of data, the right to withdraw, sharing of findings or results, and the purpose of the research project.

6. Evaluation

7. Education
The final category of restraint documentation noted on page 138 referred to education. Education about restraint should be provided to staff, volunteers, residents, and their representatives.

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Documentation of education with respect to the use of restraints should include: needs analysisa recently completed analysis of educational needs in the facility; educational plana comprehensive educational program (including lesson plans); staff competencerecords of staff members achievements, qualifications, current practising certificates, competency-based training, and recognition of prior learning (RPL); and in-service trainingrecords of attendance at internal or external educational presentations, together with details of whether the participant attended when on duty or off duty, remuneration, expenses, and so on. To be effective, education must be needs driven in meeting the objective gaps and requirements of the facility and its staff. Any educational program should incorporate the principles of adult learning, and must be properly evaluated. All Education must be needs credentials and competencies should be driven in meeting the objective properly documented and recognised gaps and requirements of the with appropriate responsibility and facility and its staff. remuneration.

Conclusion
Restraints (or protective assistance devices) should be used only as needed, and the use of continuous restraint should always be questioned. Residents have the right to be cared for in a dignified manner, and behavioural management techniques are far more appropriate than increasing the distress of already anxious residents by utilising restraints. When considering the possible use of restraint, nurses should ask themselves the following questions: Is this person in danger of self-harm? Is this person putting the safety of others at risk? If the answer to either question is yes, restraint can be justified.

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However, the least restrictive form of restraint should be used, and the duration of its use should be restricted to the duration of the dangerous behaviour. In all aspects of aged-care nursing, documentation must be comprehensive and accurate as proof of the provision of quality care. In the case of restraint, such accurate In law, if its not written and comprehensive documentation is down, it didnt happen. especially important. If legal action ensues, these documents could well be presented in a court of law. Nurses should always be aware of the oftquoted legal axiom: In law, if its not written down, it didnt happen.

Chapter 11

Incident Reports
Adrian Cross

Introduction
The reporting of incidents is a vitally important aspect of nursing documentation. Proper incident reporting makes a significant contribution to the maintenance of high standards of care for residents and improved occupational health and safety for staff. In addition to reporting Proper incident reporting makes incidents, attention must also be a signicant contribution to high standards of care for residents given to recording such reports in and improved occupational an organised fashion that allows health and safety for staff. for review and analysis of all incident reports. Reporting and recording of incidents has many benefits. In particular, accurate reporting and recording of incidents facilitates: the promotion of a higher standard of care for residents; improved occupational health and safety for nurses; more effective management of inventories; and more efficient maintenance for aged-care facilities.

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Before exploring this subject in greater detail, it is important to establish an understanding of the key terms that will be used in this chapter. A glossary of such key terms is presented in the Box below.

Glossary of key terms


Incident reports Incident reports include any reporting by nurses of specic incidentssuch as falls, change of health status, or change of available or desired recreation. In addition to specic incidents, other minor incidents (such as failing to come to meals) should be reported and documented. Staff Apart from nurses, the term staff includes catering, cleaning, laundry, administrative, medical, and paramedical personnel. Residents Residents are the recipients of nursing care in an aged-care facility. Statutory legal requirements Statutory legal requirements are requirements of Acts of Parliament. Common law duty of care Common law duty of care is the duty of care owed by any person to his or her fellow citizens. Because they have received specic training, nurses owe a greater duty of care to the residents in their care. Standard of care The standard of care is a written statement of the aims or intentions of an aged-care facility. These aims or intentions might be detailed in: a mission statementwhat an aged-care facility sets out to do in establishing the facility; a vision statementwhat an aged-care facility sees as needing to be done to full its mission; and a policyhow an aged-care facility intends to achieve its mission and vision.
(continued)

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(continued)

Hazard A hazard is any situation that has the potential to cause harm to people or property. Occupational health and safety Occupational health and safety is the management of illness or injury associated with work activities. This is usually a statutory legal requirement. In some jurisdictions, occupational health and safety includes the health and safety of any people (not just workers) who might be affected by work activities at a workplace. Building and equipment items Building and equipment items include any parts of a building (such as door handles, wash basins, or oor coverings) and any items of equipment (such as furniture, resident-transfer aids, cooking appliances, washing machines, and so on).

Importance of incident reports


The reporting of incidents is an indication of the professional standards of an aged-care facility. Nurses should be attentive to what is happening in the facility, decide what needs to be reported, and pass on the details to Nurses should be attentive to their colleagues. what is happening, decide what needs to be reported, and pass on Nursing in aged care is a the details to their colleagues. continuous activity. The reporting of incidents that are noticed by one nurse on one shift might have an impact on another nurse at a later time. To maintain continuity of care, incident reports are thus an important part of the handover procedure at a shift change. In some jurisdictions, the reporting of incidents by nurses is a statutory legal requirement. Even if there is no statutory requirement,

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the recording of incident reports is an indication of the discharge of the nurses duty of care. Nurses incident reports are also important for the updating of organisational records. To ensure that the reporting and recording of incidents is not impeded, the organisational procedures in aged-care facilities must make the reporting of incidents as straightforward as possible.

Deciding what to report


In all aspects of their professional lives, aged-care nurses are required to apply critical thinking in making decisions about priorities. Such critical thinking is also required in If nurses are in doubt they should deciding what to report when adopt a general policy of reporting an incidents occur. Although some incident, rather than ignoring it. incidents are clearly more important than others, if nurses are in doubt they should adopt a general policy of reporting an incident, rather than ignoring it. Incidents of concern might relate to: residents; nurses; or the aged-care facility itself.

Residents
In assessing incidents involving residents, nurses should be alert to issues that are of special concern to those in their care. These matters can be divided into: lifestyle needs; clinical needs; and community needs. The Box on page 155 lists some of the major concerns under each of these headings.

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Residents concerns
In deciding what to report, nurses should be alert to issues that are of special concern to those in their care. Lifestyle needs Lifestyle needs include: emotional support; independence; issues of privacy and condentiality; leisure interest and activities; cultural and spiritual issues; issues of choice and decision-making; and issues of safety and security. Clinical needs Clinical needs include clinical care, individual nursing care, and other healthrelated care. This broad area includes such specic matters as: medication management; pain management; nutrition and hydration; continence management; behavioural management; assistance with mobility and dexterity; skin, oral, and dental care; assistance with sensory loss; assistance with sleep loss; and palliative care. Community needs Community needs include: assistance with residents rights and responsibilities, access to personal information, and awareness of complaints procedures;
(continued)

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(continued)

ongoing monitoring of support (following an initial or subsequent assessment); care-plan changes; referral arrangements; social and nancial independence; privacy and dignity; awareness of services procedures; and awareness of access to advocacy.

Nurses
In assessing incidents involving nurses, attention should be paid to the issues that are of special concern to nurses. These matters include: regulatory compliance; education and staff development; planning and leadership; human-resources management; inventory and equipment; information systems; and external services.

Aged-care facilities
In assessing incidents involving aged-care facilities, attention should be paid to the issues that are of special concern to the facilities themselves. These matters include: the living environment; occupational health and safety; fire, security, and emergency procedures;

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infection control; and hospitality services (catering, cleaning, laundry, shopping).

Arrangements for reporting


Arrangements for reporting incidents differ from facility to facility, but an easy way for nurses to note and report incidents is to keep a notebook with them at all times in which they can write down the details of any An easy way for nurses to note and report incidents is to keep a incident or change that they notice in the course of their shifts. Critical notebook with them at all times. incidents must obviously be reported immediately, but the remainder of the notations require judgment in deciding what is to be recorded in clinical progress notes and/or incident reports. The organisational procedure for incident reporting must be simple. It is preferable to complete the report soon after the incidentand certainly by the end of the shift. In this way, the time, date, and details of the incident can be recorded and reported at the next handover.

Responsibility for incident reporting


General responsibilities
Aged-care facilities must make arrangements for dealing with the matters listed above. The responsibilities of the facilities lie mainly in the areas of safe practice and hazard control. The nurses professional The nurses professional role is to monitor work practice and role is to monitor work practice environmental safety for themselves and environmental safety for and those in their care. themselves and those in their care. This involves nurses in being aware of the issues involved, being observant, and querying any matters that cause them concern. As part of this process, nurses should report and record hazards and incidents as appropriate.

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Statutory responsibilities
In most jurisdictions, there is a statutory legal requirement to report certain notifiable illnesses suffered by residents or staff members. Statutory legal requirements can also include reporting on any issues that involve fire safety and serious accidents.

Clinical issues
Any clinical change that is a possible indicator of other concernssuch as reduced fluid intakeshould be noted and recorded. This provides other nurses with an opportunity to monitor the change and to respond appropriately if the concern becomes a significant problem. Such reports are an important part of handover arrangements, especially when a large number of nurses is involved, and reports are thus important in ensuring continuity of care for residents. Without this, nursing care can become ineffective, fragmented, and spasmodic.

Collating and analysing reports


Collating incident reports enables an organisation to review records and thus identify any trends in the occurrence of incidents. An individual report of an incident does not Trends or clusters of incidents can be enable this to happen. Trends detected only if the individual reports or clusters of incidents can be are consolidated and organised. detected only if the individual reports are consolidated and organised. For example, a change in the incidence of skin rashes following a change of laundry detergent might be detected after reviewing several reports of such incidents.

Building or equipment maintenance


It is important to report incidents involving building or equipment maintenance. A failure to attend to maintenance requirements can mean that care is compromised if a particular piece of equipment required by nurses is unavailable or fails to function. For example, if resident-transfer aids are not properly maintained, an unsafe environment is created, which

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can result in injuries to nurses and residents. Nurses must therefore put a high priority on reporting equipment and maintenance needs. Consolidating such reports and updating organisational records enables maintenance to be managed in a planned fashion. Planned management of maintenance can significantly improve the standard of care delivered to residents.

Supplies and inventories


Inventories of supplies and specific purchases are arranged at an organisational level, but some nurses have specific responsibilities in this area as part of their duties. As with maintenance requirements, the way in which inventories and purchases are managed can have a significant effect on the standard of care delivered by the facility.

Occupational health and safety


Importance of near misses
Occupational health and safety (OHS) essentially involves detecting work-related hazards and assessing risks. Because the causes of accidents and incidents can be difficult to detect, The so-called safety lag is the tendency for nothing to be done until accident-causation models someone becomes ill or injured. are used. These provide an indication of what to look for in investigating incidents and accidents, and give an indication of whether all the causes of accidents and incidents have been identified. Such models are also useful in proactively identifying hazards before any accidents or incidents have occurred. This reduces the socalled safety lagwhich is the tendency for nothing to be done until someone becomes ill or injured. One such accident-causation model is called the safety triangle. This model aims to identify all causes regardless of whether they are part of any particular accident-causation sequence. In general, it has been found that for every serious injury associated with any given

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hazard there are 10 minor injuries, 30 non-injury incidents, and 300 near misses. This can be expressed as a triangle, as illustrated in Figure 11.1 (below).

1 serious injury

10 minor injuries

10

30 non-injury incidents

30

300 near-miss incidents

300

Figure 11. 1 The safety triangle


AUTHORS CREATION

Most organisations respond to serious injuries with first aid, accident reporting and investigation, medical aid, compensation, and rehabilitation. The safety triangle challenges organisations to adopt a bottomup preventative approach by responding to near misses. If such an approach is adopted, for Examining near misses is likely to every 300 near-miss incidents promote effective control measures. that are controlled, 30 noninjury incidents can be avoided, 10 minor injuries are controlled, and 1 serious injury might be prevented. In contrast to the usual response to serious accidents (which tends to emphasise only a small number of all the possible causes of accidents), examining near misses is likely to promote effective control measures.

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Investigating incidents
Purposes of an investigation

If an illness or injury does occur, this is clear evidence that a hazard exists in the workplace. Information obtained from investigating such situations can be used to prevent further illnesses or injuries. Any investigation has two prime purposes: to determine the circumstances that brought about the illness or accident; and to decide how the situation should be recorded for statistical purposes. In determining the circumstances that brought about the accident, primary factors to be considered include people, materials, and equipment in the work system or environment. As well as these primary factors, second-order (or contributory) factors include such matters as If the circumstances that brought about the accident can be modied the age of the injured person, or eliminated, the chance of a his or her level of experience, similar accident occurring again will and so on. If the circumstances be reduced or eliminated. that brought about the accident can be modified or eliminated, the chance of a similar accident occurring again will be reduced or eliminated. For more on primary and secondary factors, see Sequence of events, below. The second purpose of an investigation is to decide the way in which the situation should be recorded for statistical purposes. It is important to ensure that any information is classified in a way that measures the consequence and the probability of the situation. In addition, steps should be taken to facilitate retrieval of this information for subsequent analysis or research.
Sequence of events

As noted above, the factors involved in producing an accident or incident can be divided into:

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primary factors; and secondary factors By convention, the primary factors contributing to an accident are furher subdivided into two groups: a lack of control by management; and basic or underlying causes. The secondary factors are the immediate (or near) causes of the incident. As shown in Figure 11.2 (page 163), these factors combine to produce an incident. Taken together, the primary factors (a lack of control by management and basic causes) and secondary factors (immediate The primary factors and causes) combine to precipitate a secondary factors combine to precipitate a contact eventthe contact eventthe incident or incident or accident that results in accident that results in harm to harm to people and/or property. people (injury, illness, or death) and/or property (damage or loss). Nurses have a responsibility to recognise and report these primary and secondary factors in aged-care facilities. Eliminating possible causes prevents the accidents and incidents occurringthus diminishing or eliminating the resulting harmand nurses have an important preventative role to play in this regard. The Box on page 164 provides examples of the factors in the sequence of events illustrated in Figure 11.2. The harm or loss is the more visible part of the above sequence. The accident or incident might be visiblealthough it is surprising how varied the descriptions of an accident or incident can be. However, it must be borne in mind that neither the harm nor the contact event, even if visible, are causes. To prevent further accidents or incidents it is necessary to investigate the less-visible parts of the sequence. The focus must be on the earlier factors in the sequence(i) primary causes (loss of control and basic causes) and (ii) secondary causes (immediate causes).

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Primary factors
Lack of control by management Basic causes

+
Secondary factors
Immediate causes

Contact event
Accident or incident

Harm
Personal harm
Injury, illness, death

Property harm
Damage, loss

Figure 11.2 Primary and secondary factors causing a contact event


AUTHORS CREATION

Conducting an investigation In investigating any incident, answers must be sought to the following questions: When and where did the accident occur? What happened and who was injured? What were the contributing factors?

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Examples in the sequence of events


This Box lists some examples of factors in the sequence of events illustrated in Figure 11.2 (page 163). Primary factors Lack of control can include: an inadequate OHS program; inadequate OHS standards; or failure to observe established OHS procedures. Basic causes can include: people factors (such as a lack of knowledge or skill, decreased motivation, health decits); or workplace factors (such as inadequate work systems, inadequate design or maintenance, inadequate purchasing standards, or abnormal wear and tear). Secondary factors Secondary factors (or immediate causes) can include: unsafe acts (such as operating without authority, failure to warn others, operating at an improper speed, improper use of equipment, failure to use personal protective clothing and equipment); or unsafe conditions (such as inadequate guards or protection, defective tools and equipment, dangerous substances, congestion, inadequate warning systems, re and explosion hazards, substandard housekeeping, hazardous atmosphere, excessive noise, or inadequate illumination). Contact events A contact event is an unplanned, unwanted event that causes harm, illness, or injury. Harm Harm includes harm to people and harm to property. This harm or loss might apply to health, output, quality, safety, or security.

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What was the sequence of events? How can a similar accident be prevented from occurring again? Care must be taken not to disturb the accident sceneespecially if the resulting harm is serious. The site might have to be protected with tape, barriers, or staff. Government inspectors, police, or other authorities might require access to the undisturbed site. Safety at the accident scene is also important. In dangerous situations, investigators should take care not to involve more people than are necessary. It is important to take measurements, sketches, photographs, and recordings at the scene. This information should be carefully documented because it might be called as evidence in legal proceedings. Relevant persons should be interviewedpreferably in a quiet and private setting. Eye-witness accounts must be carefully documented. The accounts of other people who were present at the scene, even if they did not actually see the event, are also important. It also is important to interview the ill or injured person. Interviews should be conducted as soon as possible after the accident or incident. When conducting interviews, the interviewer should: reassure the interviewee; state that the interviewer is seeking causes, not attempting to apportion blame; avoid rushing through the interview; use open questions that prompt the interviewee to give explanations and descriptions (rather than yes or no answers); take careful notes; read the record of the interview back to the interviewee; and close the interview by thanking the interviewee.
Statutory requirements Statutory legal requirements with respect to reporting accidents and incidents vary among jurisdictions. However, in general, most statutory requirements have the following objectives:

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to provide information on the nature and extent of illnesses and injuries at workplaces; to provide a comprehensive set of data for the management of OHS in workplaces; to facilitate efficient allocation of resources; to identify appropriate preventative strategies; and to provide data to monitor the effectiveness of preventative strategies.

Building, equipment, inventories, and purchases


Many aged-care facilities take a reactive approach to questions of plant maintenance. However, because this can significantly compromise nursing care, a proactive approach is preferable. Under such a system, plant and equipment is serviced or replaced before it breaks down. Organisational arrangements are required if a proactive system is to be established. There must be proper arrangements for the making of maintenance requests, for filing There must be proper arrangements non-conformance reports, and for for recording nurses documentation recording nurses documentation of incidents relating to building of building and equipment items that require attention. and equipment items that require attention.

Conclusion

Incident reports are an important part of nursing documentation. The incidents to be reported include matters that concern residents, matters that concern nurses, and matters that concern aged-care facilities. These include OHS issues, building and equipment matters, and inventories and purchases. The reporting of incidents requires nurses to: be attentive to what is happening; apply critical thinking in deciding which events are significant; and document accurately to ensure that details are communicated to their colleagues.

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Organisational arrangements should be in place for the recording and review of incident reports. In some jurisdictions there are statutory legal requirements for the reporting and recording of incidents. The reporting and recording of incidents is an important aspect of optimising the safety and wellbeing of residents and staff alike.

Chapter 12

Documenting Evaluative Criteria


Sue Forster

The English word evaluation is derived from the French evaluer (meaning to value), from the Latin valere (be worthy). To place value or worth on something or someone involves making a personal judgment that can be fraught with problems. To minimise or negate these Evaluation is, arguably, the most important phase of care provision. potential problems of subjective judgment, an evaluator should use objective evaluative criteria. Evaluative criteria are measurement parameters that are based upon an accepted rule, standard, or principle. Evaluation is, arguably, the most important phase of care provision. Through evaluation, all aspects of care can be deemed as being either effective and appropriate or ineffective and inappropriate. Evaluation measures care across a continuum that commences with input, traverses throughput, and concludes with output. All of these phases of care need to be clearly documented and evaluated. If the documentary evidence of evaluation is inadequate, all future care actions are in jeopardy of being unsuitable, or even potentially hazardous.

Introduction

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Evaluation methodologies and evaluative criteria should be utilised whenever nurses are documenting their provision of care. Some concepts associated with evaluation include: criterion-referenced vs norm-referenced measurements; formative techniques vs summative techniques; subjective measurements vs objective measurements; reliability and validity; clinical indicators; and continuity. Each of these is discussed below.

1. Criterion-referenced vs norm-referenced measurements


Criterion-referenced measurement
A criterion-referenced measurement is made when a decisive measurable factor is used to ascertain whether the care provided a particular outcome. Examples of criterion-referenced evaluations include: a reduction in diastolic blood pressure following rest in bed; a reduction in the number of falls following supervised mobilisation and the use of a walking aid; a reduction (or absence) of urinary tract infections following ingestion of 2 litres of fluid per 24 hours; and increased participation in activities following implementation of a behavioural-management program. It is important to note that the criterion or outcome must be measurable, and that this measurement must be based upon an accepted rule. The criteria in the above examples include reduced blood pressure, reduced falls, reduced infections, and increased participationwhich can all be measured. The accepted rules in the above examples are that resting reduces cardiac output, that assistance with mobilisation and the use of walking aids prevents falls, that increasing fluid intake reduces urinary stasis (and thus decreases the incidence of infections), and that application

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of appropriate behaviour-modification techniques increases a persons interactions with the environment. All criteria must be documented. If there are no historical data, measurement cannot take place. A record of baseline observations is insufficient for a criterion-referenced evaluationbecause a oneoff event does not prove or disprove an hypothesis. Before any significance can be placed upon the findings, historical data A one-off event does not prove or (including chronological and disprove an hypothesis historical data must be documented. regular measurements) must be documented.

Concepts in evaluation
Some concepts associated with evaluation include: criterion-referenced vs norm-referenced measurements; formative techniques vs summative techniques; subjective measurements vs objective measurements; reliability and validity; clinical indicators; and continuity. A discussion of these concepts forms the framework for this chapter.

Norm-referenced measurements
A norm-referenced measurement is made when the outcomes are indexed against the results of a group. Norm-referenced evaluation includes ranking the members of a group in order of their placement within the group. It is inherently biased. Norm-referenced measurements are based upon the assumption that the concept being measured is distributed along a normal bell-shaped curve. There is no absolute standard in norm-referenced measurement. This is because the standard shifts in accordance with the performance of the group as a whole. If new residents join the group, any statements made about the standard are subject to change.

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Examples of norm-referenced evaluations include: Mrs A calls out more than any other resident; Mr B is the least disruptive; Mrs C falls more often than any other resident; and Miss D requires more nursing-care time than anyone else. It should be noted that every one of the above statements refers to how the person in question compares with everyone else. If new residents join the group, any statements made about the person might have to be changedbecause the overall group norm changes. Norm-referenced evaluations therefore do not The ndings of norm-referenced provide precise individual evaluations are most useful for research information. The findings of purposes and for making decisions norm-referenced evaluations about stafng the organisation. are most useful for research purposes and for making decisions about staffing the organisation. If performed carefully over a period of time, this can be very valuable for strategic planning purposes.

2. Formative vs summative techniques


Formative evaluation
Formative evaluation is based upon a process of informing. It is progressive and assists with planning or redesigning care provision. The first stage of formative evaluation involves documenting daily anecdotes, events, treatment regimens, and investigative findings in the residents health records. The next stage is to analyse the Formative evaluation is a continuous, diagnostic, and corrective dataand then decide whether method. It is a valuable tool for all to continue, discontinue, or care planners and care providers. modify care. The final stage of each analysis is re-evaluation. Formative evaluation is thus a continuous, diagnostic, and corrective method. It is a valuable tool for all care planners and care providers. The resulting documentation serves many purposesboth organisationally and for each individual resident.

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Summative evaluation
Summative evaluation literally means at the end. It is a summary of the outcomes of any event. Examples of summative statements can include certificates (including death certificates), discharge plans, pathology results, and radiological reports. Once a summary of an event Summative evaluation is has been documented, the assessor terminal, nite, and descriptive. must start a new process if care is to be continued. Summative evaluation can best be described as terminal, finite, and descriptive.

3. Subjective measurements vs objective measurements


Subjective evaluation
Subjective evaluation is based on opinionwith few if any objective criteria used. Each persons subjective evaluation is likely to be different from those of others. The findings are therefore unpredictableand the reliability and validity of the results are questionable. This is not to say that subjective evaluation is of little or no use. However, assessors must be alert to the fact that great caution is required when acting upon the gathered data. Examples of subjective evaluations include: Miss A is unnecessarily requesting nursing attention; Mrs B has had a bad day that resulted from her being late for breakfast; and Mr C does not participate in communal activities because he dislikes the other residents in the group. In these examples, opinions are stated. These opinions represent the writers perception of the eventbased on the observers experience. However, even if the opinions come from experienced observers, the statements cannot be classified as statements of established fact. Other assessors might provide other explanations for the residents behaviours.

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Despite these limitations, the use of subjective data is unavoidable when documenting the behaviour, mood, and emotions of residents. To decrease subjective bias, it is often appropriate to write down exactly what was said by the resident. If so, all To decrease subjective bias, it direct quotations should be placed in quotation marks (inverted commas). is often appropriate to write down exactly what was The results of such documentation said by the resident. can prove to be of significant value. For example, analysis of verbatim conversations might lead staff to recognise that a resident is experiencing hallucinations, delusions, suicidal ideation, depression, or delirium. In documenting subjective opinions, nurses should be aware that some words are emotionally laden. Examples include: uncooperative; non-compliant; aggressive; refused; and demanding. It is best to avoid such words. It is better to describe the actual events as objectively as possibleand leave value judgments to the reader. Table 12.1 (page 175) provides examples of actual events and possible value judgments. In each case, the value judgment might be correct. However, it is also possible that there are other valid explanations for the events as described. Making value judgments in documentation can reflect adversely on both the resident and the nurse. For the resident, it can mean that the resident is unfairly labelled as being aggressive or uncooperative and such labels can affect the future care of the resident by adversely influencing the attitudes of other carers. Such residents can be denied their legitimate rights to contribute to decision-making about their care. For the nurse, making repeated value judgments can mean that readers interpret the use of value-judgement words as a reflection of the underlying biased beliefs of the writer.

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Table 12.1 Actual events and possible value judgments


AUTHORS CREATION

Actual events Declines to do something; chooses not to do something; wishes not to do something Biting, grabbing, hitting, swearing Repeating requests, asking for assistance every 510 minutes, yelling out until attended

Possible value judgment Uncooperative; non-compliant; refused Aggressive Demanding

In summary, professional evaluation is better served if nurses describe the actual eventsand leave the value judgments to others.

Objective evaluation
Objective evaluation is criterion-referenced, reliable, valid, and quantitative. Anyone who conducts an objective evaluation should produce the same results as anyone else using the same tool. Examples of objective evaluations include: Mrs A walked a distance of 60 metres this afternoon; Mr Bs vital signs (temperature, pulse, respirations, and blood pressure) have all been within the normal range over the past seven days; Miss C has lost 15 kilograms in weight over the preceding 12 months; and Mrs D sustained a skin tear on her left leg measuring 3 centimetres in length. In the above examples, actual measurements preclude variance in results. Whoever the assessor is, he or she should produce the same results. To make comparisons or demonstrate contrasting results it is crucial that all data are documented. Some facilities have special observation forms that include graphs with upper and lower acceptable limits clearly marked. This allows trends and deviations to be readily recognised and acted upon.

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4.Reliability and validity

Reliability and validity are different concepts. In simple terms: reliability tests the stability of a measurement; whereas validity tests whether an evaluative tool measures what it is supposed to measure.

Reliability
A reliable evaluative tool should perform identically from day to day irrespective of who is using it. In any evaluative tool there is always some error of measurement present, but it should be as small as possible. To increase a tools reliability, an evaluator should therefore take into account the variations in the characteristics being measured, but should exclude unrelated factors as much as possible. For example, it is unreliable to use a variety of scales to establish a residents weight gain. Similarly, it is unreliable to use a variety of sphygmomanometers (manual and electronic) to measure blood pressure. Using the same piece of equipment each time increases reliability.

Validity
As noted above, validity tests whether an evaluative tool measures what it is supposed to measure. To determine the validity of an evaluative tool, the tool needs to be clinically tested. The clinical tests should be documented and the variances taken into account when analysing the gathered data. For example, weight scales should be tested to ensure that they are giving valid weight results, and sphygmomanometers (manual and electronic) should be tested to ensure that they are giving accurate blood pressure results.

Reliability and validity


All evaluations should be both reliable and valid. They should be stable over a period of time and internally consistent. They should also be recorded and interpreted in a manner that ensures that different assessors would agree with the results.

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5. Clinical indicators
Clinical indicators are virtually the same as evaluative criteriain that both are measurement parameters that are based upon an accepted rule, standard, or principle. Examples of clinical indicators include: temperature recordings; pulse and respiratory rates; blood-pressure recordings; urinalysis; blood-glucose levels; biochemistry results; wound assessments; behavioural assessments; psychometric evaluations; elimination recordings; pain assessments; nutritional and hydration assessments; and sensory assessments. If the objective of accurate evaluation is to be achieved, the application of evaluative criteria is mandatory. The use of nebulous or non-definitive statements should be avoided. Some clinical data are easier to measure than others. If a normal If the objective of accurate range is universally accepted, placing evaluation is to be achieved, the application of evaluative individual results above, below, or in criteria is mandatory that normal range is a straightforward nebulous or non-denitive matter. However, some clinical data statements should be avoided. are not so well defined or obvious. The use of such data can compromise the reliability and validity of an evaluation tool. Utilising clearcut clinical indicators or evaluative criteria limits the potential corruption of results. The selection of the appropriate evaluative criteria depends upon what is being evaluated. The evaluator should select the evaluative

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criteria that best measure the outcome nominated in the resident-centred objectives. Table 12.2 (below) provides examples of two resident-centred objectives with some applicable evaluative criteria.
Table 12.2 Resident-centred criteria and evaluative criteria
AUTHORS CREATION

Resident-centred objective Miss A will be pain free

Evaluative criteria Miss A states she is free of pain Pulse and blood pressure within normal parameters Absence of grimacing or guarding Posture relaxed Analgesics not required Mobilising without restriction Weight for height within normal range Healthy skin Skin turgor and mucous membranes normal Eyes not sunken Ingesting a well-balanced diet and completing her meals Fluid balance within normal range and urinalysis normal Bowel motions and patterns normal Biochemistry results normal

Mrs B will be well nourished and achieve optmal hydration

Evaluative criteria can be readily selected by answering the question: Why was the objective formulated? The answer should be that the objective was formulated on the basis that certain evaluative criteria exist for measuring it. For example, if a resident is assessed as being incontinent of urine, the objective might be that the resident will be comfortable. The evaluative criteria should therefore measure the comfort level of the resident. These criteria might include: that the resident is clean and dry; that the perineal area is not red or excoriated; that the resident is not trying to disrobe; that no pruritus is noted; and that the resident is interacting happily with staff, relatives, and other residents.

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All evaluative criteria should be clearly documented and analysed to ensure that future planning and actions are expedient and appropriate.

6. Continuous process
Evaluation is a process that is synonymous with the assessment process. This might, at first, seem to be a surprising statementbecause assessment is usually perceived to be an early stage in the nursing process, whereas evaluation is perceived as being a late stage in the process. However, a model can help to explain the statement that evaluation and assessment are synonymous. The model clearly demonstrates the cyclical process of nursing care.
Assessments Evaluation Analysis

Implementation Objectives

Plan

Figure 12.1 The cyclical nature of nursing care


AUTHORS CREATION

All aspects of care need to be clearly documented. Figure 12.2 (page 180) shows how this is documented on the cyclical model. If the objective has not been met, the plan needs to be adjusted, new actions need to be implemented, and the results need to be evaluated. Documentation of this cyclical process prevents previously trialled and ineffective actions being repeated. It should not be necessary to change the initial assessment, analysis, or resident-centred objective.

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Mr B has not defaecated for 7 days

Assessments

Mr B had his bowels open and his normal pattern of every 2nd day has been re-established

Evaluation

Analysis
Mr B is constipated

Same as plan including: record uid intake; record food intake; record mobility activities; record bowel actions

Implementation

Plan
Offer 120 mL pear juice daily Extra serve of roughage with each meal Offer 200 mL uid per hour Walk 60 m before and after each meal

Objectives
Mr B will evacuate his bowels and have his normal bowel patterns re-established

Figure 12.2 Example of the cyclical nature of nursing care


AUTHORS CREATION

Conclusion
The process of evaluation should be the responsibility of the members of the multidisciplinary team who provide the residents care. Because it is not always possible for all team Meticulous documentation is the members to be present during the linchpin of providing quality care. planning phase, precise and explicit documentation is therefore essential to ensure that accurate analysis is achieved. Care plans should evolve from the analyses, and effective care is reliant upon accurate evaluation. Meticulous documentation is the linchpin of providing quality care.

Chapter 13

Documenting Staff Issues


Sue Forster

Introduction
Issues relating to staff come under the umbrella of human-resource management (HRM). HRM strategies evolved from the realisation that human resourcesstaff membersrepresent an organisations most valuable resource. This has been made even more evident by the decreasing Human resources represent an organisations most availability of trained staff. More than valuable resource. ever before, organisational survival depends upon effective HRM strategies being documented and enacted. All aged-care facilities should therefore have documented HRM policies. These should include policies on: selection and recruiting; affirmative action; equal opportunity in employment; anti-discrimination; occupational health and safety;

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social justice; performance appraisal; complaints (internal and external); and discipline. Each HRM policy should be accompanied by explicit procedural documents. These procedures include: staff selection; staff retention; staff attrition; staff performance appraisals; disciplinary processes; and credentialling. Each of these is discussed below. However, before proceeding to examine these subjects in more detail, it is important to note that modern documentation extends beyond the recording of information on paper. Contemporary documentation also Ambiguity and misinterpretation includes the electronic recording of should be minimised by ensuring data. Such electronic documentation that all documentation is should follow the same principles as specic, accurate, and denitive. traditional hardcopy documentation. It is essential that ambiguity and misinterpretation should be minimised by ensuring that all documentation is specific, accurate, and definitive. Many professionally designed documentsboth hardcopy and electronicare readily available for purchase through suppliers. Once purchased, these documents need to be individualised for the organisation. Purchasing and adapting such documents is both time-effective and costeffective.

1. Staff selection
Once it has been decided to fill a position on staff, the first task is to conduct a job analysis. The results of this job analysis should be reflected

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Framework of the chapter


Each HRM policy should be accompanied by explicit procedural documents. These procedures include: staff selection; staff retention; staff attrition; staff performance appraisals; disciplinary processes; and credentialling. A discussion of these concepts forms the framework for this chapter.

in the position description and duty statement that describe the vacant position. Then, once the position description has been formulated, key selection criteria can be nominated. The next step in the process Advertisements should reect the is to advertise the vacancy. desired image of the organisation, and an effective advertisement is Advertisements should be displayed a valuable marketing tool. internally and posted externally. Internal advertisements ensure that staff members are aware of career opportunities within their own organisation. To attract a wider range of applicants, external advertisements should be posted in the employment section of newspapers, on the Internet, and in industry-specific journals. Advertisements should reflect the desired image of the organisation, and an effective advertisement is a valuable marketing tool. Advertisements should include the following documentation: the vacant position, its level, and its reference number; a description of the organisation; the key selection criteria (KSC); the closing date; the name of the contact person for enquiries; and the address of the organisation.

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Inclusion of remuneration details is optional. All interested people who apply or enquire should receive an information package. The information package should include the following documentation: a letter acknowledging their enquiry; a copy of the full position description; a list of the KSC; the organisations handbook; and relevant time guidelines for the selection process. Once formal applications have been received, the process of culling and short-listing candidates is undertaken. In most jurisdictions there are strict requirements relating to industrial-relations legislation, and it is therefore prudent to document every aspect of this stage. Ideally a properly constituted selection committee should perform these processesso that, in the case of any appeals, the decision-making process withstands public scrutiny. All candidates should receive a letter relating to their application. The letter informs the candidate: that he or she has been short-listed (and the proposed interview date); or that he or she has been unsuccessful at this point in time. Successful applicants should receive a list of possible interview questionsbased upon the KSC. They should be notified that their referees will be contacted, and they should be provided with a choice of interview dates and times. Unsuccessful applicants should receive a brief explanation of why they were not successful. Structured interviews give candidates an equal opportunity to expand upon the information provided in their application. Ideally a panel should conduct the interviews, and each member of the panel should individually record his or her scores on the responses provided by each candidate. Consensus of the panel determines the successful applicant. To ensure that selection is just, it is essential that referees reports are obtained and included in the consensus process.

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Documentation in staff selection


This portion of the text discusses the documents that are required in a staff-selection process. These include: Preparation job analysis position description duty statement key selection criteria Seeking applicants advertisements information package Short-listing and selection process letters to candidates (successful and unsuccessful) accurate (and retained) records of selection committee After selection letters to candidates (successful and unsuccessful) a report of the selection process (if requested) details of available appeal process (if requested) letter of offer of appointment employment contract acceptance of conditions of employment in writing

A report should be provided to any applicant who requests one. Applicants who feel aggrieved after receiving such feedback should be given details of the appeal process. In case of an appeal, it It is essential to keep all documents related to the selection process for is essential to keep all documents the time period stipulated in the related to the selection process local jurisdiction. for the time period stipulated in the local jurisdiction. Because selection is a two-way process, the successful applicant should be sent a letter of offer of appointment. If the position involves

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the signing of an employment contract, a copy of this contract document should be sent with this letter. The successful applicant should be advised to read the documents carefully. The applicant should be asked to accept the conditions of employment in writing, or to decline the offer in writing.

2. Staff retention
With a worldwide shortage of trained staff, retention of staff members is essential for organisational survival. The organisations strategies for staff retention should therefore be clearly and unambiguously documented. Although retention of staff can be expensive for the organisation in terms of money and effort, the costs are offset by the even greater costs of staff attrition. It is essential to document these costings in the organisations annual budget. The methodologies for staff retention can be included in the organisations employee assistance program (EAP). Some of these methodologies are shown in Table 13.1 (page 187). All of these methodologies should be documented in the organisations handbook. The handbook reflects the desired image of the organisation, and a well-designed and professionally produced handbook is a valuable marketing tool.

3. Staff attrition
The term attrition refers to reduction in personnelthrough resignation, retirement, or death. Some managers include a temporary reduction in personnel in this concept. Temporary reduction of personnel includes absenteeism related to holiday breaks, sick leave, long-service The documentation associated leave, maternity leave, leave without with an organisations attrition rates is essential for strategic pay, and study leave. Some reasons planning and budget projections. for absenteeism are predictable, authorised, and expected. The documentation associated with an organisations attrition rates is essential for strategic planning and budget projections. Attrition statistics

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Table 13.1 Methodologies for retaining staff


AUTHORS PRESENTATION

Methodology Effective communications

Features Education Feedback Performance appraisals Non-discrimination Counselling Psychological support services Negotiating work times and hours Job sharing Work contracts Teamwork Equity Consensus in decision-making Reduction in hierarchies Delegation Empowerment Accountability Responsibility Support mechanisms Induction/orientation In-service Traineeships Upgrading qualications Financial support On-site provision Financial assistance Career paths Promotion Bonuses

Flexible rostering systems

Participatory management

Education

Childcare facilities Incentive programs

can be compared with those in similar organisations for benchmarking purposes. Generally, high attrition rates indicate that the morale of the organisation is low. Such high rates indicate that staff would prefer not to be paid, rather than attend work.

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Attrition rates are a summative evaluation (see Chapter 12, page 173). Although they are of value to the organisation, they do little, in themselves, to prevent the loss of personnel. However, if a formative evaluation of the organisation is conducted (see Chapter 12, page 172), the results can be utilised to implement measures to reduce attrition. Such a formative evaluation might be in the form of a staff-satisfaction survey. These surveys should be conducted regularly and frequently, carefully documented, analysed, and acted upon. To ensure valid results, anonymity should be assured. Once the analysis is available, preventive actions to decrease attrition should be documented in the employee-assistance program (EAP).

4. Staff performance appraisals


Performance appraisals are evaluative tools used to measure an individuals functioning within the organisation. These tools should be based upon the key selection criteriawhich served as the blueprint for appointment of the staff member, and which set out what he or she is expected to do in the role. Some organisations have extended these appraisals to include subjective data, a needs analysis, and professional development plans. Most accreditation bodies state that regular staff reviews should be conducted and documented. Furthermore, some regulatory bodies require evidence that unresolved issues or unmet expectations are being addressed. The process of conducting staff appraisals includes examination of the persons education records. The education records should include: attendance; achievement; internal or external provision; mandatory and compulsory requirements; and any contractual arrangements. All of the above documents should be filed in the persons personnel record. This should be stored in a secure area, and access should be limited to authorised persons.

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5. Disciplinary processes
Rigorous documentation is mandatory when conducting disciplinary activities. Most industrial-relations legislation requires that the activities reflect a process referred to as due process. It has often been said that: In law, if its not written down it didnt Detailed documentation of happen. Detailed documentation of each stage of the disciplinary each stage of the disciplinary process process is essential. is essential if this oft-quoted legal criterion is to be met. Documentation includes: a copy of the related policies and procedures; a description of the issue; a written complaint; witness statements; an investigation report; a copy of the letter sent to the staff member being disciplined; a record of consent and agent representation; a complete set of the employees personnel records; full education records; transcripts of interviews conducted; any written responses to the matter being dealt with; copies of warnings undertaken (first, second, and final); progress reports; and the outcome. Disciplining a staff member is an exceedingly difficult task, and this is not the place to explore this complex subject in any detail. However, insofar as documentation of discipline is concerned, rigour is essential. Mischievous and vexatious complaints do occur, and these can be treated as valid if rigorous documentation of all relevant events is not available. Other issues that can occur in disciplinary procedures include discrimination and marginalising of individuals, wrongful

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dismissal, and discriminatory behaviour. All of these can give rise to legal actionsand accurate documentation of all disciplinary procedures is therefore essential.

6. Credentialling
An authorised body usually awards credentials, qualification certificates, diplomas, and degrees. These bodies include schools, nurses registration boards, registered training authorities, educational institutions, and universities. Some health facilities are registered training providers and are authorised to award certificates that are nationally recognised. A list of the documentation required for credentialling is shown in the Box below.

Documentation for credentialling


The documents that are required for staff credentialling include: the organisations accreditation certication with the relevant authority; a full copy of the educational program being conducted; a signed education contract/agreement; a policy on recognition of prior learning (RPL); competency-based assessment tools; a list of resources (personnel and material); educational records; results of evaluation; statements of attendance and achievement; and grievance and appeals policies.

Awarding a credential indicates to others that the recipient is competent in the subject. Indiscriminate provision of awards can lead to dire consequencesincluding prosecution of signatories. An assessor should therefore not certify that a staff member is competent unless the assessor is absolutely sure that the person has demonstrated proficiency.

191 Documenting Staff Issues

Another documentation issue to be addressed with respect to credentialling is the currency and validity of the certifying document. All original qualification documents should be sighted and scrutinised for inaccuracies. If annual certificates are required to practise, these should also be sighted and scrutinised. If there is any doubt, validation of qualifications can be checked with the relevant registration authority.

Conclusion
Human-resource management (HRM) has become increasingly important in the context of the worldwide shortage of trained staff. Aged-care facilities must therefore ensure that they have effective, documented HRM strategies in place. It is essential to have policies Meticulous documentation of and procedures in place on such stafng issues directly affects the vital subjects as staff selection, professional careers and personal retention, attrition, performance livelihoods of the most important appraisals, disciplinary processes, resources that an aged-care facility possessesits valuable staff. and credentialling. As with all documentation, these policies and procedures must be recorded with care and accuracy, and must take account of all relevant statutory requirements. Meticulous documentation of staffing issues is a vital management responsibility because it directly affects the professional careers and personal livelihoods of the most important resources that an aged-care facility possessesits valuable staff.

Chapter 14

Effective Design for Documentation


John Collins

Introduction
This chapter offers practical advice on the design of effective forms for nursing documentation. Well-designed forms are easier to use, but before designing a completely new form nurses should consider whether they are able to adapt an existing one. Familiarity encourages compliance, and if staff members are familiar with a form, they are more likely to use it properly. There are commercially designed forms for aged-care facilities, and nurses should investigate whether these suit their purposes without alteration. If not, the suggestions in this chapter will help nurses to design forms that best suit their purposes.

The purpose of forms


Why do nurses need forms? Among other benefits, well-designed forms: convey a lot of information among people quickly and easily; record, for future reference, what nurses have done; satisfy legal requirements; and give nurses more time to care for residents.

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The more time spent in designing a form, the more effective it will be, the less time will be spent in filling it out, and the easier it will be for others to understand and use the information.

Equipment
Paper
Decisions need to be made on: the grade of paper to be used; and the size of paper to be used.
Grade

The paper that is chosen for a form depends on how often the form is going to be handled. A simple rule to follow is that ordinary photocopy paper (known technically as 80 gsm, or grams per square metre) is sufficiently strong for thirty normal handlings. If the form is likely to be handled more often than this, a stronger paper (such as 90 gsm paper) is needed. Heavier paper can cause problems with smaller non-commercial photocopiers. If the available photocopy facilities cannot use 90 gsm paper, it might be necessary to use commercial printers. This is likely to entail increased costs in printing and storage.
Size

To keep costs down, standard paper sizes should be used. The dimensions of some commonly used paper sizes from the ISO A series are shown in Table 14.1 (below).
Table 14.1 Standard paper sizes
AUTHORS PRESENTATION

Name A3 A4 A5

Dimensions 297 mm x 420 mm 297 mm x 210 mm 297 mm x 148 mm

195 Effective Design for Documentation

All of these paper sizes can be used in the normal upright position (also known as portrait) or sideways (also known as landscape). Using A4 as an example, this is shown in Figure 14.1 (below).

210 mm 297 mm

297 mm

210 mm

Portrait

Landscape

Figure 14.1 A4 paper in portrait and landscape


AUTHORS PRESENTATION

If the information to be included on the form will not fit on one A4 sheet, A3 paper can be used. A landscape A3 is the equivalent of two portrait A4 sheets placed by side by side, as shown in Figure 14.2 (page 196). Alternatively, the information can be spread over the front and back of a folded A3 sheet. This gives the equivalent of four portrait A4 pages, as shown in Figure 14.3 (page 196). In addition to being cheaper, standard paper sizes are also more convenient. Most clipboards, folders, and paper punches are designed to take these sizes. If the files are likely to be stored in ring binders or punched files, the writing on the form should allow for this. Care must be taken to ensure that the writing on the form is not obscured by holes or clips.

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420 mm

297 mm

210 mm
Figure 14.2 Two portrait A4 making one landscape A3
AUTHORS PRESENTATION

210 mm

210 mm

210 mm

297 mm 297 mm

A3 landscape

210 mm

A3 folded making four portrait A4


Figure 14.3 One folded landscape A3 makes four portrait A4
AUTHORS PRESENTATION

197 Effective Design for Documentation

Computer software
Adequate forms for most nursing purposes can be created using common word-processing software. Such programs allow users to choose various typefaces and point sizes, and to arrange information in tables as appropriate. Very complicated forms that involve boxes, lines, colours, symbols, and logos are probably best left to a professional designer using advanced software.

Principles of effective form design


A well-designed form should: be easily identifiable; have a clearly recognisable title; state its purpose; be presented in a fashion that is easy to read and easy to complete; have a clear layout that leaves enough room for written entries to be made clearly and easily; and seek information logically. These features are discussed in more detail below.

1. Identification
In a health service in which many different forms are used, care should be taken to ensure uniformity with other forms that are already in use. If the organisation has a logo, the cut-and-paste function of a wordprocessing program can be used to add the logo to a new form. If this is not possible, the name of the organisation should appear on the Care should be taken to ensure uniformity with other forms formusing the same typeface that are already in use. used on other documents. (For more on typefaces, see page 199.) It is best to have a form that is easily recognised by its shape, colour of the paper, or other colour-coding.

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Principles of effective form design


A well-designed form should: be easily identiable; have a clearly recognisable title; state its purpose; be presented in a fashion that is easy to read and easy to complete; have a clear layout that leaves enough room for written entries to be made clearly and easily; and seek information logically. A discussion of these six features forms the framework for this chapter.

2. Title
All forms should be identified by a title that clearly explains the purpose of the formfor example, Diabetic Treatment Form. The form might also have an abbreviated title by which it is commonly knownfor example, DTS. The form should carry both its full title and its The title should tell readers why the form is important, the nature of the abbreviation. information required, and purpose of If the title of the new collecting the information. form is not obvious, careful consideration should be given to choosing a meaningful title that describes its function. The title should tell readers why the form is important, the nature of the information required, and purpose of collecting the information.

3. Purpose
Unless readers are made aware of the importance of the information being requested, they will not make a significant effort to provide it. If the form is regarded as yet another bureaucratic interference, it will be given little attention and will not be completed properly. To assist readers to understand the purpose of a form, an explanation of the purpose of the form can be given as a subtitle under the main title.

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For example, a form headed Skin Integrity Audit might be subtitled: To assist in patient wellbeing by identifying skin problems related to pressure, excoriation, rashes, etc.. Many of the questions asked A brief paragraph of explanation can be useful in allaying concerns of people who are admitted to and encouraging respondents to residential-care facilities can appear supply information. to be intrusive. A brief paragraph of explanation can be useful in allaying concerns and encouraging respondents to supply information. For example, a nursing home might explain its Social History and Lifestyle admission form in the following terms:
To make your stay as pleasant as possible, we wish to learn about you and your life experiences. By completing this form, you will help us to understand you better and cater for your needs to the best of our ability.

The title (Social History and Lifestyle) clearly identifies the form and the explanation is designed to help the person filling in the form feel comfortable about supplying the requested information.

4. Presentation
Typefaces

Care should be taken in the choice of typeface because some typefaces can be difficult to read. In general, there are two types of typeface. A serif typeface is one with little hooks on the ends of the letters. A common example is Times New Roman. A sans-serif typeface is one without hooks on the ends of the letters. A common example is Arial. The typeface that is chosen should be easy to read, and should be used consistently throughout the form. Serif typefaces are easier to read and are therefore best used in general text. Sans-serif typefaces have a clean modern lookand are therefore commonly used for headings. This convention is followed in the typefaces used in this book. Figure 14.4 (page 200) shows some serif and sans-serif typefaces.

200 Nursing Documentation

Aa Bb Cc
Serif typeface
AUTHORS PRESENTATION

Sans-serif typeface

Aa Bb Cc

Figure 14.4 Serif and sans-serif typefaces

It is best to limit the number of different typefaces used in a document. Too many different typefaces can give a messy and confusing appearance. A good rule is to use a maximum of two different typefaces in one document. Variation can be introduced by using different point sizes to alter the height of the lettersas shown in Figure 14.5 (below).

Times New Roman 14 Point


Times New Roman 12 Point
Times New Roman 10 Point

Arial 14 point
Arial 12 point
Arial 10 point

Figure 14.5 Different point sizes


AUTHORS PRESENTATION

To emphasise particular words or phrases, italics should be used. According to modern publishing convention, bold and underlining are used in headings, but are now less commonly used for emphasis. See Figure 14.6, page 201.
Graphical and pictorial representations

Some information is best recorded in a graphical or pictorial format, and well-designed forms should make allowance for this in recording certain data. For example, graphs of temperature are familiar to nurses as an appropriate way to record and communicate information. Other vital signs and clinical information are also conveniently recorded

201 Effective Design for Documentation

Italics are used to emphasise Bold and underlining are used in headings
Figure 14.6 Use of italics, bold, and underlining
AUTHORS PRESENTATION

on graphs. In designing forms that record this sort of information, it is important to include well-designed blank graphs appropriate to the data to be recordedwith time on the horizontal axis and the vital sign to be measured on the vertical axis. Sometimes the information being sought is subjective. In these cases, a numeric scale can be helpful. A typical example is an assessment of pain. Because there is no objective way to measure pain, nurses ask residents to express how they feel. Numeric scales are used to indicate the residents reported pain intensity on a scale from 1 to 5 (or 1 to 10)with 1 being no pain and 5 (or 10) being the worst pain imaginable. This information can then be recorded on a numeric scale included in the form. For more on the use of these scales, see Rating scales, Chapter 9, page 125. Pictorial representations can also be included in forms. These are useful in two ways: to record subjective data from people who might have difficulty in communicating their feelings; and to save time and words in describing a particular part of the body. An example of the first is the recording of pain intensity in persons who have trouble communicating because they have a cognitive impairment (such as dementia). A faces scale can be useful in recording this information. Such a scale is a pictorial representation of facial expressions that range from a broadly smiling face to a clearly distressed face. However, care must be taken in interpreting these sorts of facial scales. For more on the use of these scales, see Rating scales, Chapter 9, page 129.

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An example of the second use of a pictorial representation is in recording the location of pain. A diagram of the human body can be used to gather the information and to record it. Such a diagram can be Graphs, numeric scales, or shown to a residentwho is asked pictorial representations should be carefully designed for ease of to indicate the location of pain. The use, and clear instructions on nurse can then record the residents their use should be included. response on the diagram and include this in the patients record. If graphs, numeric scales, or pictorial representations are included in forms, they should be carefully designed for ease of use, and clear instructions on their use should be included.
Abbreviations

Abbreviations are best avoided in nursing documentation because they can cause confusion. Such confusion decreases clear communication and, in some cases, this can have legal consequences. However, Nurses should use only approved the reality is that nurses abbreviations. These should be do sometimes need to use explained on the form itselfno abbreviations. Recognising this, matter how self-evident the abbreviation might seem to be. some aged-care facilities have a list of approved abbreviations. In designing a form, nurses should use only approved abbreviations. These should also be explained (at first use) on the form itselfno matter how self-evident the abbreviation might seem to be.
Capitalisation

There is a general policy in modern publishing to minimise the number of capital letters that are used. Text and headings that are written entirely in capital letters can be difficult to read. They also have a heavy, oldfashioned appearance. It is best to use an initial capital for the first word, with the rest of the sentence or heading being in lower case. Capital letters should not be used unless there is a good reason (such as for the formal name of a person or organisation).

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In some cases, a phrase or short sentence in capital letters is useful to emphasise a particular point. However, in modern publishing, the convention is that italics are used to indicate emphasis (rather than capital letters or underlining). Some forms ask people to use BLOCK CAPITALS when they fill in the form. This is to ensure that the entry is easy to readbecause some handwriting can be difficult to decipher. If the form is to be filled out using capital letters, this instruction should be given at the beginning of the form.

Instructions
Clear instructions As previously noted (page 199), a subtitle or explanatory introductory paragraph is useful in assisting people to understand the purpose of a form. In a similar way, any instructions for completing a form should be carefully stated at the beginning. For example, a form might have Any instructions for completing an instruction to use block capitals a form should be carefully (Please use BLOCK CAPITALS in stated at the beginning. completing this form). If the form continues to a second page, an identifying header should be included on the second page, and a note placed on page 1 to indicate that page 2 must also be completed. If a second page is printed on the back of the first page, a note at the bottom of the first page should be includedfor example, Please turn over and complete page 2. However, because people can overlook a page that is printed on the back of another page, some organisations have a policy of never printing on both sides of the page. Dates Different cultures use various formats when writing dates. For example, Americans put the number of the month first and the number of the day second. This variation can cause confusion. If a published form is dated, it is therefore best to express the date in full (using numbers and words) for example, 13 December 2005.

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If the person who fills in the form is required to enter a date, guidance should be provided as to how the date is to be recorded. This should be specified on the form with clear instructions. For example, a form might request that a birthday be filled in as follows:
Date of Birth: ___ (day) ___ (month) ___ (year)

Yes/no answers

Many form questions have a yes/no option as a possible answer. If additional information is required in addition to a yes answer, this should be clearly indicated. For example:
War service? (circle one) No Yes If yes, please give details:

Note that the request for details should immediately follow the yes response option with sufcient space for the response. Allowing too little space can result in important information being omitted. Too much space can result in unnecessary detail being provided. Questions with alternative answers

Some questions request that an answer be chosen from multiple alternativesof which one or more must be selected. The reader should be instructed as to how the Careful consideration should be given selection is to be indicated. to the alternatives that are provided. In most cases this will be by circling the chosen alternative or marking a box. Clear instructions should be given on the formsuch as circle one or tick one. Careful consideration should be given to the alternatives that are provided. Unless care is taken, confusing or ambiguous alternatives might

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be offered. For example, in requesting a respondent to choose an age group, care should be taken to ensure that there is no overlap. Consider the following example:
Age group? (circle one) Under 5 5 to 10 10 to 20 etc.

In this example, the age of 10 years is included in two alternatives. The alternatives should read:
Age group? (circle one) Under 5 5 to 10 11 to 20 etc.

If the multiple alternatives do not encompass every possibility, include an other category. This should be accompanied with the instruction please specify, followed by a suitable space.

5. Layout
The form should not be crowded and difficult to fill in. A crowded form discourages the readerleading to mistakes and omissions. Sufficient space should be left between lines for handwriting. A good test is to look at the form and ask: Is this form user friendly? Would I like to complete this form myself?. There are two obvious ways to avoid cramped formsuse more than one page and/or decrease the number of questions. In considering the number of questions, it is important to ensure that every question earns its place. If a question is asked, the requested information should be information that is really required. Only essential or required information should be requested of the reader.

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6. Seeking information logically


Names Information should be obtained in a logical order. Forms usually start with names. Information should be requested in a way that is acceptable in a multicultural society. It should be remembered that non-Christian people do not have a Christian name and that some Asian people place the family name before the given name. Other cultures do not have a family name and a given name. It is best to ask for a first name and a second name (and perhaps a preferred name). Language spoken The form should ask the reader to indicate what language (or languages) he or she speaks. If the person speaks more than one language, the form can ask the person to indicate the language in which he or she is most fluent. Other information Every form is different, and it is not possible to discuss every possible piece of information that might be required in the many different forms used in residential aged care. Some of these matters (such as dates of birth and age) have been discussed above. Whatever information a logical order that makes sense both for the person who is lling in the is required on particular form and for the person who is compiling forms, care should be taken data and records from the form. to ensure that the information is collected in a logical order that makes senseboth for the person who is filling in the form and for the person who is compiling data and records from the form. Signature If the form requires a signature, sufficient space should be provided for the person to sign his or name. In some cases, it might be necessary to allow room for a witness to the first signature. Space should be allowed for the name of the witness to be entered in block letters beside the signature of the witness. Space should also be allowed for dating any signatures.

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Many forms require the signature of a nurse. There should also be room for nurses to print their name and designation. In many instances this is a legal requirement.
Review date

Nursing knowledge and procedures are not static. A date should be added to the form to show when it was designed. A review date should also be addedto indicate when the form should be checked to ensure that it is accurate and appropriate for its purpose.
Identication

The designers name, and the Forms are covered by copyright. name of the organisation, should It is illegal to reproduce and be included on the form. This use a form without the written information enables other people permission of the copyright owner. to seek permission to use the form if they wish to do so. Forms designed by other people should not be used without permission. As with other created works, forms are covered by copyright. It is illegal to reproduce and use a form without the written permission of the copyright owner.

Trials
It is difficult to design a form perfectly the first time. A few copies should be made and given to nursing colleagues for a trial. Feedback and suggestions should be welcomed and considered carefully. Appropriate amendments should be made to the form. This process might need to be repeated several times. Obtaining a useful form that serves its purpose is worth the time and trouble of getting it right.

Conclusion
Well-designed forms have a number of important benefits. They are easier for staff to useand therefore save time and decrease frustration.

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The information that they contain is easy to read and understand thus improving communication, data collection, and record-keeping. Finally, well-designed forms Well-designed forms enhance general enhance general standards of standards of professional care. professional care.

Chapter 15

A Systems Model for Documentation


Christine Crofton and Gaye Witney

Introduction
Earlier chapters in this book have discussed, in detail, various aspects of nursing documentation. This final chapter takes a broader view of the subject in presenting a systems model for professional nursing documentation in aged care. In This chapter draws together presenting a systematic overview many of the topics considered in of documentation, the chapter earlier chaptersand presents draws together many of the topics them in one coherent model. considered in earlier chaptersand presents them in one coherent model. This final chapter does not attempt to go over everything that has been covered in detail in earlier chapters. However, the model presented here puts many of the topics of earlier chapters into an overall context. In doing so, it provides guidance to clinical nurses and nurse managers in how to go about establishing a comprehensive documentation system that promotes positive attitudes and outcomes with respect to this vital aspect of aged-care nursing. A system is a complex set of connected parts that enables a process to be approached in an ordered and methodical manner. To ensure that

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documentation becomes an integral part of professional nursing practice in an aged-care facility, it is essential to have a well-organised documentation system in place. The existence of such a system gives a clear message to all staff membersthat the The existence of a system gives a organisation is serious about clear message to all staff members professional documentation and that the organisation is serious about positive resident outcomes. Such professional documentation and a system also assists and guides positive resident outcomes. staff in ensuring that residents are managed appropriately and that all relevant aspects of nursing care are recorded. In short, a systems approach ensures that all areas of the organisation are committed to quality documentation with a clear delineation of responsibilities. It takes courage and energy to review the current status of documentation within an organisation and to identify necessary changes. Habitual staff practice will be challenged, and this can cause some discontent in the short term. However, such a review can be of benefit to nursesby identifying the issues that documentation creates for nursing staff. In particular, such a Staff involvement in the review is likely to identify timeprocess can help to ensure management issues and the pressure ownership of the model. that these place on individual nurses. Staff involvement in the process can help to ensure ownership of the model, and the development of clear guidelines and processes that are of benefit to nursing staff and the organisation as a whole. A documentation system integrates an organisational approach to documentationrather than relegating documentation to the status of ad hoc notes that individual nurses write at the end of each shift. Although a systematic approach is complex to establish, it actually simplifies documentation for nurses and clearly delineates their responsibilities in the process. If nurses feel supported in a coherent system of professional documentation, holistic nursing care is enhanced. Nurses working within such a system find it easier to strike the right balance between the demands of documentation and the provision of nursing care. Such a systematic

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model also ensures that all funding requirements are addressed, and that continuous quality improvement is maintained. The documentation model described in this chapter has been developed after many years of research and consultation with professional nursing colleagues. The model moves the responsibility for documentation from the individual nurse to the organisation as a wholewith accountability equitably shared across the many facets of an aged-care facility. It is based on the principles of best practice and integrates many of the philosophical concepts that underpin contemporary nursing practice. The model is shown in Figure 15.1 (page 212), and is described in detail in the rest of this chapter.

Preparatory work
Before establishing a system of documentation in a facility, it is necessary to do some vital preparatory work. This preparatory work involves management and nursing staff addressing the following issues: the place of documentation in the overall clinical governance of the organisation; the importance of evidence-based practice in any documentation system; the overall philosophy of the organisation with respect to documentation; issues of regulatory compliance; the importance of a quality system; policies and procedures; and the role of research. Each of these is discussed below.

Clinical governance and documentation


The culture of an organisation is important in facilitating the successful implementation of clinical governance. The term culture, when used in relation to documentation, can be defined as the developed understanding of what an organisation expects with respect to documentation, and the way

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Clinical governance Evidencebased practice

Preparatory Work
Regulatory compliance Quality systems

Research Policies & procedures

Philosophy

Education

Assessment Tools

Documentation Essentials
Nursing-care plans

Progress notes

Auditing

Assessment

Benchmarking

Publishing
Figure 15.1 CroftonWitney documentation system
AUTHORS CREATION

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in which nurses respond Clinical governance safeguards exemplary to that expectation in their standards and creates an environment in documentation practice. which excellence can ourish. Culture in this sense is what nurses refer to as the way things are done within an organisation the accepted practice and traditions of the organisation. Clinical governance is a framework for best practice. A professional nurse has a responsibility to ensure that documentation practices are contemporary. Clinical governance calls nurses to account. It ensures that ongoing improvement of documentation occursthus safeguarding exemplary standards and creating an environment in which excellence can flourish.

Preparatory work
Before establishing a system of documentation in a facility, it is necessary to do some vital preparatory work. This preparatory work involves management and nursing staff addressing the following issues: the place of documentation in the overall clinical governance of the organisation; the importance of evidence-based practice in any documentation system; the overall philosophy of the organisation with respect to documentation; issues of regulatory compliance; the importance of a quality system; policies and procedures; and the role of research. Each of these is discussed in this section of the text.

In terms of culture and clinical governance, there are four stages in the successful implementation of a comprehensive documentation model: establishing a partnership with residents; ensuring the best-possible record of nursing care in every interaction with a resident;

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learning from experiences by reflecting on documentation practices; and developing documentation practices that increase career options. Each of these is discussed below.
1. Establishing a partnership with residents

This first step involves listening to a resident when undertaking an assessment, talking to family and significant others when gathering information, and informing a resident about options of nursing care. The nurse must then collate the developing a culture of clinical information for a residentgovernance in which the information focused nursing-care plan to be documented is gathered through working collaboratively with collaborative partnerships. residents when developing care plans. This step is thus about developing a culture of clinical governance in which the information to be documented is gathered through collaborative partnerships.
2. Ensuring the best-possible record of nursing care in every interaction with a resident

The second step is concerned with effectiveness when documenting nursing care and nursing management. This involves the identification of the important issues relating to assessment, establishing best practice in documentation, and relating this to nursing care and resident management. All the available evidence should be reviewed to ensure that documentation reflects current nursing practice, and nursing care should be evaluated against resident outcomes. These results should be documented, and the results should be shared and compared with other nursing staff to improve the documentation process. Benchmarking (see page 240) can help to establish how well the organisation is managing in relation to other organisations. Timemanagement issues associated with documentation responsibilities should also be assessed.

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3. Learning from experiences by reecting on documentation practices

This stage in the process is about identifying, and reflecting upon, best contemporary practice in nursing documentation. It involves nurses sharing knowledge about the documentation process, and being responsible for their own learning about documentation requirements. It also involves nurses being change agents by: sharing any new information about documentation with colleagues; managing risks by identifying and avoiding mistakes when documenting; mentoring other nurses to learn this process; and challenging poor practice in documentation to enable colleagues to be proactive (rather than reactive) in dealing with documentation issues.
4. Developing documentation practices that increase career options

This stage involves nurses ensuring that they developboth professionally and personallyrather that remaining stagnant with respect to their understanding of documentation practices. This involves (CGST 2004): participating in professional-development groups; identifying educational needs (both for the individual and the nursing team) to improve documentation; sharing any research and evidence with colleagues within the organisation (and beyond); and encouraging and participating in lifelong learning to ensure that nurses catch the learning bug to enhance their documentation and professionalism.

Evidence-based practice
As can be seen in Figure 15.1 (page 212), the preparatory phase of the CroftonWitney model for documentation moves from clinical governance to evidence-based practice. Evidence-based clinical nursing practice involves decision-making on the basis of the best evidence available, In making clinical decisions,

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nurses must build on their personal professional knowledge and experience by systematically appraising contemporary research findings. This enables

Organisational responsibility for clinical governance


This section of the text has discussed four steps in developing a culture of effective clinical governance with respect to documentation: establishing a partnership with residents; ensuring the best-possible record of nursing care in every interaction with a resident; learning from experiences by reecting on documentation practices; and developing documentation practices that increase career options. Organisations have a responsibility to support nurses in establishing these four steps. As McSherry and Pearce (2002, p. 30) observed: Clinical excellence will ourish in an organisation that proactively responds to incidents, complaints and suggestions. According to these authors, the key attributes of an organisation that actively supports clinical governance are: integrated approaches to documentation processes; leadership in implementing documentation systems and providing ongoing support and resources for that process; processes that encourage evidence-based practice in documentation; innovation in facilitating a sense of documentation being valued and shared; implementation of documentation risk-management systems; a proactive approach to addressing gaps in the documentation system; positive responses to complaints about the documentation system; holding poor performers accountable for their documentation; provision of professional development that is aligned to individual nurses learning needs; and access to high-quality research resources to support the documentation process.

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objective clinical decisions to be maderather than decisions being reactive, emotional, or habitual. If performed conscientiously, such evidence-based appraisal can be a difficult and time-consuming task. Fortunately, there have been numerous advances in evidence processing in recent decades. These include: the production of streamlined guides to aid in critical appraisal of the literature; evidence-based abstraction services; electronic literature searching (both online and in other forms); high-quality systematic reviews (such as the Cochrane Collaboration); and frequently updated textbooks (in hardcopy and electronic formats). Evidence-based practice relating to documentation is a five-step process: defining the documentation issue that needs to be addressed; collecting evidence to address the issue; formally evaluating the evidence gathered (a process known as critical appraisal); integration of the evidence into current practicethus facilitating decision-making to improve documentation; and evaluation of the five-step process with a view to improving it next time. Effective evidence-based practice requires nurses to have evidence that is: accessible and timely; valid, credible, and current; clinically important; and applicable to the documentation system. In undertaking a search for suitable evidence, a nurse needs to assess the time that he or she has available, the availability of databases,

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The importance of critical thinking


Nurses must be able to think critically if they are to decide what and how to document. Such critical thinking involves questioning what is usually taken for granted (Daley, Speedy & Jackson 2000, p. 249). It challenges nurses to investigate assumptions about current information, and to interpret and evaluate arguments with the intention of reaching a conclusion from a new perspective. An inability to ask focused and precise questions can be a major impediment to evidence-based practice. This skill can be improved by: breaking the question down into the stages of documentation(i) assessment; (ii) analysis; (iii) implementation; and (iv) evaluation; and classifying the question into the components of documentation(i) assessment tools; (ii) care plans; (iii) progress notes; and (iv) associated supporting materials. These steps help to clarify issues and avoid questions that are vague and generalised (and therefore difcult to answer). They also provide guidance as to where pertinent evidence might be found.

of evidence desired, and how well the issue lends itself to research. Sources of information and evidence might include colleagues, textbooks, journal articles, guidelines, policies and procedures manuals, government and professional guidelines, and systematic reviews. An excellent example of a structured review database is the Cochrane Collaboration (Cochrane 2004). The studies are analysed using standardised methodology and meta-analysis. The database also includes abstracts of non-Cochrane systematic reviews, a database on methodology for conducting systematic reviews, and the Cochrane handbook (which contains information on how to form review groups, how to do systematic reviews and searches, and how to obtain information about existing groups). Evidence-based abstract services from journals are also useful. The articles are summarised in value-added structured abstracts and have a commentary by content experts. With some services, complete collections

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of structured abstracts and commentaries can be searched by keyword, topic, study type, and year of publication. Medline, produced by the National Library of Medicine in Bethesda, Maryland, USA, is the best-known bibliographic database of biomedical journal literature. Many journals are now available full-text via the website (Medline 2004), complete with charts, tables, graphs, and illustrations. Another online service is that A search of current hardcopy presented by Cinahl Information journals in the eld is still one Systems (Cinahl 2004). A wide range of the best ways to nd newly of current comprehensive healthcare published information. information is available at its website. Apart from such online databases, a search of current hardcopy journals in the field is still one of the best ways to find newly published information.

Philosophy
As can be seen in Figure 15.1 (page 212), the preparatory phase of the model for documentation being discussed in this chapter now moves from evidence-based practice to philosophy. A philosophy is the set of beliefs of an organisation. It is important that an organisation indicates its views on documentation and develops a specific philosophy on the subject. In developing such a philosophy, an organisation needs to consider: basic beliefs and values relating to documentation and documentation practices; management practices that affect documentation; the availability of environmental and human resources to support the documentation process; the ethical considerations linked with documentation; the impact of multidisciplinary teams on documentation outcomes; and an organisational model for documentation.

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Leadership is required to develop a documentation philosophy. Authority and accountability are required at all levels of the organisation. An effective leader must: identify how documentation fits into the organisations goals; clarify documentation requirements and any associated standards, and how to accomplish them; inform nursing staff and provide appropriate supporting resources; provide education when gaps are identified in documentation processes and practices; and review processes to ensure progress towards positive resident outcomes through documentation. Before a philosophy is developed it is important to identify the organisations vision and mission. A vision is the dream for the organisation, whereas a mission Leadership is required to develop a is the implementation of that documentation philosophy. Authority dream in practical terms. Taken and accountability are required at all together, the vision and mission levels of the organisation. of an organisation create a picture of what is expected from all involved within the organisation. The developed philosophy of the organisation flows from this picture. In developing the philosophy, participation by staff is essential. The philosophy should be published and readily available. Staff members will then understand and value their roles within the participatory process, and will appreciate that the organisation values them. The Box A vision is the dream for the on page 221 lists some important organisation a mission is the implementation of that points to be considered by any dream in practical terms. organisation when developing a philosophy of documentation. A consideration of the issues canvassed in the Box will assist in the development (or review) of a documentation philosophy. It is essential for the organisation to have such a documentation philosophyto ensure

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Questions to be addressed
General questions In drawing up a philosophy for documentation, an organisation should address the following general questions. Does the organisation promote the importance of documentation? Is the organisation a facilitator of change in documentation processes? How creative is the organisation when documenting nursing-care issues? Specific questions In more specic terms, the following questions should be addressed. Does the organisation: have a documentation committee? have documentation systems in place to support staff? encourage excellence in documentation? have condence in its own approach to documentation? involve the team in decisions about the documentation? have written guidelines about the documentation required? work to create a learning culture in which staff members can condently learn new documentation skills? present a positive image when speaking about and dealing with documentation issues? tolerate and promote individuality within its documentation systems and within its staff practices?

that a clear indication of the organisations expectations is given to all members of the multidisciplinary team, and to ensure that all members are aware of their individual responsibilities in the process.

Regulatory compliance
The preparatory phase of the CroftonWitney model for documentation (see Figure 15.1, page 212) now moves from the development of an organisational philosophy to the question of regulatory compliance.

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As professionals, nurses are required to uphold a duty of care, and nursing documentation records that duty of care. Apart from a general requirement to practise nursing in a professional manner, certain specific legalities and regulations are As professionals, nurses are associated with the nursing role. required to uphold a duty of Because nursing documentation care, and nursing documentation records nursing care, documentation records that duty of care. can bring the nurse into situations in which legal and regulatory issues need to be considered. Society has expectations of the nursing role and the standards of documentation associated with it, and societys legal and regulatory requirements reflect many of these expectations. In an era in which litigation is common, nurses must be aware of their legal responsibilities under the statutory Acts and common law rulings that govern their practice. All nurses must be aware of relevant legislation and regulations governing nursing practice within their own legal jurisdiction, and must have access to these within the workplace. If an organisation does not physically possess these documents, the organisation should ensure that they are available to nurses through the Internet. Nursing documentation is legal documentation. Even if there are no specific legal requirements with respect to documentation in particular jurisdictions, nurses are obliged to document clearly, concisely, accurately, objectively, and legibly. Entries should be recorded as events happen; entries should not be postponed until the Nursing documentation is end of the shift. All entries should be in legal documentation. chronological order, and there should be no additions or alterations entered at a later date. All entries should have a notation of the date and time, and should be signed with a clear indication of the name and designation of the person making the entry. There should be minimal use of abbreviations and jargonto ensure that there is no confusion as to exactly what the entry means. If an error is made, there should be a clear indication of the change that has been madewith a line through the incorrect entry, a signature, and a date. Erasers or whiteout should never be used.

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If documentation is not maintained, this can imply that something that has not been written down has not been done. Nurses must safeguard themselves against this implication. Something important enough In many ways, traditional nursing to warrant discussion is culture is an oral culture. Nurses also important enough to be talk about care and associated issues recorded in writing. in discussion among themselves during handover or team meetings. It is important that nurses recognise that something important enough to warrant discussion is also important enough to be recorded in writing. Although proper documentation is essential to effective resident care, nurses must also respect issues of confidentiality. As Forrester and Griffiths (2001, p. 76) observed:
[A] breach of professional code of ethics and legislation controlling registration by a health professional may result in the initiation of disciplinary proceedings by the professional regulating body [and] also raises concerns as to the legal implications of third parties having unauthorized access to information.

Nurses thus have an obligation to protect resident records. They must be guided by legislation and the organisations policies with respect to other people requesting information. In these matters it is important that nurses reflect on: the scope of practice in the relevant Nursing Act in their jurisdiction; what the law requires in relation to documentation in general and aged-care standards in particular; requirements under workplace safety legislation regarding incident reporting; privacy legislation and its effect on nursing practice in relation to the collection, use, security, and disclosure of information; and any specific legislation relating to health records and the role of the nurse.

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Comprehensive audits of current procedures dealing with the collection, storage, and maintenance of resident information is essential and must be included in the documentation systems of all organisations. Finally, if there is a documentation committee, it can be useful to have someone on the committee designated as being responsible for continuous monitoring of Comprehensive audits of procedures such regulatory issues to dealing with the collection, storage, and ensure that the organisation maintenance of resident information and nursing staff are must be included in the documentation informed of changes and systems of all organisations. current requirements.

Quality systems
A documentation system must include processes for continually working to improve the standard of nursing care and documentation. These processes constitute a quality A quality system requires systemthe next step in leadership, courage, vision, positivity, the model shown in Figure responsibility, and commitment. 15.1 (page 212). To ensure that a quality system is developed, an organisation requires leadership, courage, vision, positivity, responsibility, and commitment. Contemporary management practice requires organisations to have systems in place to ensure that continuous quality improvement (CQI) occurs. The CQI cycle can be used for improving any stage of the documentation process. The model described here incorporates the Deming principles of plan, do, check, and act (PDCA) (HCi 2004). To improve a documentation system it must first be described and modelled. When the CQI process is implemented it identifies nonproductive phases of the system, which can then be reviewedmaking the overall documentation processes more effective. The PDCA model has seven steps. These are: defining the scope of the documentation system; mapping the documentation system;

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defining the documentation system measures; setting CQI process targets; analysing the CQI process; improving the CQI process; and review. Each of these is described below.

1. Dening the scope of the documentation system This is important for providing a solid foundation for making improvements in the system. In this step, the main purpose and scope of the documentation process are defined. In addition, the stakeholders in the process are identified. 2. Mapping the documentation system A mind map or flowchart provides a shared understanding of how the documentation process operates. It also provides a means for discussing, analysing, and clarifying the processthus allowing opportunities for improvement to be identified. 3. Dening the documentation system measures Qualitative and quantitative measurements are applied to enable data to be collected about the status of the system. The key objective is to establish who does what and whenand then to measure performance in the discharge of those responsibilities. 4. Setting CQI process targets CQI targets are needed to guide the process of improvement in the desired direction. There are two types of performance targets: performance standardsthe raising of standards to a consistent level of excellence across all levels of nursing staff; and performance objectiveswhat is to be achieved once the outcomes of the measures have been analysed. 5. Analysing the CQI process In this step, improvements are identified. The process is analysed from three perspectives:

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the people perspectivethe resources, competencies, and suitability of the organisation to manage a documentation system; the technology perspectivethe adequacy of technical support; and process perspectivethe bottlenecks, non-productive steps, and validated problem areas in the documentation system.
6. Improving the CQI process

This step incorporates the Plan/Do/Check/Act (PDCA) cycle, with a special focus on managing change (especially the human aspects) in the process. The PDCA cycle is also extended by a further step of review whereby the immediate results of an improvement action are reviewed.
7. Review

In this step, the results of the entire CQI cycle are reviewed and its outcomes are communicated to all stakeholders. The next CQI cycle is then initiated.

Policies and procedures


The CroftonWitney model for documentation being discussed in this chapter (see Preparatory work, Figure 15.1, page 212) now moves to the question of policies and procedures.
Policies

A policy is a guide to practice. It is made up of statements of principles that allow staff members to use their discretion while working within accepted boundaries. A documentation policy thus A policy is made up of statements of states the principles that principles that allow staff members have been adopted by an to use their discretion while working within accepted boundaries. organisation with a view to achieving optimum documentation outcomes. Such a policy is derived from the philosophy of an organisation (see page 219). Documentation policies define strategic direction and reflect a systematic approach to the management of contemporary documentation.

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Characteristics of policies
Documentation policies are guidelines that: reect the documentation philosophy of the organisation; clearly spell out documentation responsibilities of the nursing staff; detail prescribed actions to be taken when documenting; state precisely the constraints that are placed on documentation processes; provide direction for decision-making in documentation; reect regulatory compliance; and ensure that documentation is undertaken within the scope of the current practice and designated roles of the nursing staff.

Such policies provide a guide to nurses with respect to documentation practices, and indicate that management has a commitment to quality documentation. They provide for Documentation policies uniformity of actions for all nursing indicate that management staff members associated with has a commitment to quality documentation, promote consistency in documentation. resident management, and encourage ethical documentation practice. Such policies also provide a communication tool that promotes collaboration and cooperation within the team with respect to documentation requirements. This establishes standards of performance expected with respect to documentation. If documentation is inadequate, having definite policies allows for the counselling of staff members on the basis of established principles. Policies must be written down. Before doing so, it is important that management listens to the nursing staff. It is useful to hold brainstorming sessions to collect ideas about the content of the proposed documentation policy. Management should always seek collaboration from the nurses to promote ownership of the developing policy. If nurses are not included in the process in a meaningful way, they can feel that the whole exercise

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is a cynical process of tokenismthus devaluing the whole process. Rather than being agreed and valued, the whole system can be perceived as being imposed and irrelevant, and required standards are unlikely to be achieved if nurses have little or no understanding of the policies. Policies should not be set in concrete. They should be adjusted as changes in documentation requirements occur within the organisation or industry.
Procedures

Documentation policies are implemented through procedures. A procedure is a sequential step-by-step approach that is to be followed to meet the requirements of policy. A procedure thus outlines the individual actions that are to be followed to meet such requirements. It can also specify the standard at which the documentation is to be undertaken. It is essential that an organisation has a clearly established documentation process, and that guidelines describing the process are available and accessible. Procedures are important because they: communicate to staff the expectations relating to documentation; enable a clear approach to be followed; support nurses who are unfamiliar with the facilitythus enabling them to be involved with documentation, rather than regular staff being obliged to undertake it all; promote best practice; and reassure residents and families that quality documentation is occurring. Information regarding the required documentation processes can be passed onto staff in many waysincluding handovers, nursing staff meetings, and appraisals.

Research
The final step in the preparatory phase of the model being discussed (see Figure 15.1, page 212) is research.

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When trying to establish details of current practice in documentation, many nurses are uneasy about library research. Many do not know how or where to start. The research process is basically a process of five steps: defining topics about various aspects of documentation; selecting and using the best research resources; locating the information identified in these resources; evaluating the resources; and documenting and disseminating the findings of the research. Each of these is discussed below.
1. Dening the topic The process begins by clearly mapping-out the concepts to be researched. This identifies the key terms and key concepts to be used when searching electronic databases and print research resources. The researchers understanding of the topic can be clarified by asking the following questions: What level of research does the documentation project require? For example, does the project involve a brief staff presentation or does it involve the writing of a research paper on documentation with a bibliography and footnotes? What is already known about this aspect of documentation? What are the main issues? Does the topic deal with historical or current events, or both? If the research has been requested by the organisation, has the organisation requested that the research include certain types of materialssuch as journals, newspapers, or a particular database? Some background reading should be done to gain various perspectives of the aspect of documentation being researched. This will also generate relevant keywords to use during database searching. Some key resources that will help in gathering this information are: dictionaries and thesaurusesdictionaries provide an alphabetical listing of words and phrases followed by their definitions, whereas thesauruses contain subject headings that list synonyms and related words;

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handbooks and research guidesa handbook is a resource or guidebook to a subject; research guides provide an overview of the research process in a given area; bibliographiesbibliographies contain a systematic list and/or description of the literature on a specific subject (including authorship and publication details). These sorts of resources can often be found in libraries. Handbooks and dictionaries are often shelved in a librarys reference collection. Some libraries produce bibliographies of their major print research Librarians can be very helpful to nurses in seeking out information. resources. Librarians can be very helpful to nurses in seeking out this information. The information collected can be used to create a mind mapa useful method of devising a strategy for finding information in print and electronic research resources.
2. Selecting and using the best research resources
Resources for basic research

Information for projects that do not require in-depth study can usually be found in journal articles or current texts. Using key words or key concepts identified in the mind map discussed above, the library catalogue can be used to find: books and journal titles held at the library; material recommended by experts in documentation; government resources and manuals that have been produced to guide the documentation process; bibliographies of books and articles on documentation; and online help (using search engines).
Resources for advanced research

Indexing publications, abstracting journals, and electronic databases are the major research tools used to locate articles and conference papers that deal with advanced research. These resources provide basic descriptions

231 A Systems Model for Documentation

of articles and enough information for a nurse to see if the material is appropriate. The Internet is an increasingly useful source of information, although quality can vary. Indexing publications (usually referred to as indexes) list basic descriptions of articles and other literature relevant to documentation. These are usually grouped by subject and/or author. Many indexes are now available as electronic databases. Abstracting journals (usually referred to as abstracts) provide similar information to indexes, as well as providing a summary of the article. The abstracts are usually listed numerically, under subject groupings. To find relevant indexes and abstracts, nurses can try an expert keyword searchcombining the subject area with the term abstracts or the term indexes (for example: abstracts AND documentation). The Internet is an increasingly useful source of information, The library should be checked for although quality can vary. abstracts and indexeswhich are often shelved in a separate collection within a library. Some libraries produce bibliographies of their major print research resources. The librarian should be asked about the availability of such resources. Many print indexes and abstracts are now available in electronic formatwhich facilitates quick and easy scanning for information. Some databases now provide the full text of the article. To locate relevant electronic databases, the broad subject area that covers the topic should be selected from the subject page. All subject pages list relevant databases. Guides to searching electronic databases and subjectspecific guides are helpful in researching Internet and print resources. The librarian should be asked about these resources. The Internet provides access to a wide range of information stored in networked computers around the world. Some items are of true value, but they are mixed in with items of little or no valueand finding something useful can involve spending a great deal of time in sifting, sorting, and selecting. Search engines and subject directories are helpful. The broad subject area that covers the topic should be selected, followed by the category

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Internet resources. Alternatively, a direct search of Internet can be undertaken to see if the subject has a bibliography of selected Internet resources. Again, the librarian will often provide useful guidance. Before beginning any search, a research consultation with the librarian can be very useful. Some libraries have subject librarians, and discussions with these people about the focus of the research can help to clarify what is required. Such A research consultation with a a research consultation can librarian can often be the most often be the most effective and effective and efcient method of efficient method of seeking seeking relevant information. relevant information.
3. Locating the information identied in these resources

The library catalogue should be checked to see if the library has the items that have been identified during the searches. If the items are found in the catalogue, their location, call number, and status should be noted. If an item cannot be found but the catalogue indicates that is should be available, the library staff should be consulted. If the catalogue shows the item is already out on loan, arrangements can be made for library staff to make contact when the item is returned. Material from other libraries and tertiary education campuses can be sought using the inter-campus library delivery service to bring the required item to the local library. An electronic application form is usually available.
4. Evaluating the resources
Print resources

Printed material is not always reliableeven if it appears in apparently reputable journals. Critical thinking is required in assessing the information found on a topic. Most Printed material is not always reliable research publications have even if it appears in apparently reputable an editing or peer-review journals. Critical thinking is required in process that helps to verify assessing the information found on a topic. the authority and accuracy

233 A Systems Model for Documentation

of the information presented. Reputable newspapers and magazines also check their facts. However, it is still important to consider such issues as objectivity, currency of the information, and how thoroughly the topic is covered.
Internet resources

Many Internet resources lack the peer-review processes of print journals, and many fail to check basic facts before posting them on the Internet. This means that the user must thoroughly evaluate anything encountered on the Internet before deciding whether it is to be used in the research stage of a documentation project.
5. Documenting and disseminating the ndings of the research

It is important to cite and document all the resources that are used in the researchespecially if the work, ideas, or phrasing of other people are quoted or paraphrased. This includes anything found It is important to cite and on the Internet. If sources are document all the resources that are used in the researchespecially if not properly cited, this can be the work, ideas, or phrasing of other considered plagiarisma serious people are quoted or paraphrased. form of academic dishonesty that can be construed as theft. When photocopying articles that might be used, the bibliographic details should be carefully recorded. This will save a lot of time that would otherwise be spent in trying to track them down later. Depending on the format of the project, it will be necessary to compile a reference list, footnotes, or a bibliographyor a combination of these.

Summary of preparatory work


The initial steps in establishing an effective systems model for documentation (see Figure 15.1, page 212) are therefore: clinical governance; evidence-based practice; philosophy;

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regulatory compliance; quality system; policies and procedures; and research. If these first steps in the systems process are not in place, an organisation will find it difficult to meet documentation requirements. In dealing with documentation In dealing with documentation issues, organisations must issues, organisations must become become proactive, rather proactive, rather than reactive. than reactive.

Education
Having completed the preparatory work, the next stage in developing a comprehensive model of documentation (see Figure 15.1, page 212) is the development of an educational program. An educational program is an essential step in establishing positive attitudes to documentation. In particular, such a program can develop the capacity of nursing staff members to think critically about their documentation practices. Critical thinking involves: reasoning; reaching a conclusion; and forming a mental picture that is different from original perceptions. The critical thinking process is reflective. It involves reasoned thinking about issues with a focus on deciding what to believe and what to dowithout necessarily An educational program is an seeking a specific solution. essential step in establishing positive When applied to documentation, attitudes to documentation. critical thinking challenges nurses to look at assumptions about current documentation practice, and to evaluate arguments with the intention of forming a new perspective.

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Some definitions
Critical thinking Critical thinking is the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions (Bandman & Bandman 1998). Cognitive function Cognitive is an intellectual process by which one becomes aware of, perceives, or comprehends ideas. It involves all aspects of perception, thinking, reasoning and remembering (Como 2002, p. 389).

When developing an educational program that supports critical thinking about the documentation system, the following principles should be kept in mind: staff members should be involved in collaborative decisions; a draft program should be prepared for review; pilots and trials should be conducted; documentation research projects should be established; ongoing evidence-based documentation practice should be promoted; and documentation projects should be benchmarked. Best practice in implementing an educational program includes an analysis of nurses learning needs to identify any gaps in their knowledge, skills, and attitudes with respect to the documentation system. Once these are identified, a program that encourages critical thinking can be developed. Education in documentation should be part of an organisational culture of lifelong education. Such lifelong learning involves educational and life experiences that increase knowledge and skills throughout life. It is a learner-centred process that enhances quality of life and involvement in society through personal growth. Effective educational experiences for nurses involved in documentation enable them to grow personally, as well as professionally.

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Principles of adult learning


When planning an educational program, the principles of adult learning should be utilised. These include: recognising life experiences and prior knowledge related to documentation; acknowledging the values, beliefs, and opinions that nurses bring to their documentation practice; allowing choices and self-direction in the educational exercise; engaging nurses in their learning about documentation; linking new knowledge to previously acquired information and experiences about documentation; treating each nurse as an individual and allowing each nurse to express himself or herself through the educational experience; offering educational exercises that involve practical application and problem-solving; and enhancing lifelong learning with ongoing educational challenges related to documentation.

Documentation essentials
The next stage in the CroftonWitney model of documentation (Figure 15.1, page 212) is the use of the essential documents of nursing practice. This stage involves a consideration of: assessment and nursing diagnosis using nursing-assessment tools; nursing-care plans; and progress notes.

Assessment and nursing diagnosis using nursing-assessment tools


Advantages of assessment tools

Assessment tools are used to identify risk factors that might affect a residents capabilities. Such tools enable the nursing process to be implemented in a professional way. They can be holistic or specialist and

237 A Systems Model for Documentation

enable specific nursing-management strategies to be employed. They improve standards of nursing care by promoting consistency of assessment criteria. Assessment tools are also costAssessment tools can be used in every setting, in every effective because they enable efficient clinical speciality, and in every and effective use of resources aspect of nursing care. and help to determine appropriate equipment allocation. They result in proactive (rather than reactive) nursing care, minimise the occurrence of unrecognised risk factors, and reduce the duration of nursing care. Assessment tools can also be used for validation and auditing purposes, and are useful for protection against litigation. Research activity, education, and communication are all facilitated by assessment tools. Assessment tools can be used in every setting, in every clinical speciality, and in every aspect of nursing care. Assessment tools are especially useful: on admission to establish a baseline; when there has been a change in the situation; and for validation and auditing purposes. All professional nurses who are members of the multidisciplinary healthcare team can use assessment tools. They improve nursing practice by promoting a transparent process, promoting teamwork, and providing consistency of assessment criteria.
Problems with assessment tools

Unfortunately, many nurses have a poor understanding of the nursing process and the vital role of assessment in that process. In particular, many nurses do not have a good understanding of the process of developing an assessment toolresearch, development, implementation, analysis, and evaluation. These deficiencies lead to such problems as: the use of assessment tools that do not cover all aspects of the clinical situation (thus leading to inconsistent or incomplete assessment and re-assessment);

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poor understanding of the role of an assessment tool in the validation and auditing process; and the use of tools with unproven validity and reliability in research projects.

Nursing-care plans
Nursing-care plans (NCPs) are written tools used by nurses to ensure that planned care is carried out after a residents needs have been identified. An NCP must be an accessible, unambiguous, comparable and readable professional tool (Richmond 1997, an accessible, p. 176). It enables planned care to be unambiguous, comparable and undertaken by nurses in a systematic, readable professional tool. measurable way and focuses on the actions nurses must take to address the [residents] identified nursing diagnosis and meet the stated goals (Kozier, Erb & Olivieri 1991, p. 215). For more on NCPs, readers are referred to Chapter 4, page 45.

Progress notes
Once nursing care has been completed, it is important to revisit the NCP to identify if there has been any nursing care that has been different from that envisaged in the NCP and/or to identify new matters to be included in the NCP. A list of the issues should be made, and a decision taken as to whether to record these issues in the progress notes or to add them to the NCP. Short-term or one-off issues can be recorded in the progress notes. Ongoing issues should be added to the NCP. The additional entries (in the progress notes or the NCP) should be initialled and dated. In making entries in the progress notes, a list of the issues should first be made and the list should be prioritised from the most important to the least important. A record should then be made in the progress notes utilising the following format: What is the issue? What is the cause of the issue? What action has been taken or planned to be taken?

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What is the outcome of any actions already undertaken? Who needs to be informed of the changes that have occurred?

Assessment
The next stage in the model being discussed in this chapter (see Figure 15.1, page 212) is assessment.

Auditing
Auditing is the systematic analysis and evaluation of nursing documentation. Auditing provides feedback to management and nursing staff on how successful and relevant nursing documentation has been. Auditing is an essential part of a continuous improvement Auditing is an essential part of a continuous improvement process. process. It ensures that current practice is in accordance with best practice and identifies improvements that might be required. It also identifies gaps in staff knowledge, thus assisting in the planning of nursing education and training. Auditing encourages ongoing collaboration among nursing staff and fosters professionalism. The auditing process begins with initiating an auditing plan, developing an auditing process, and developing an auditing tool. The important steps thereafter are: evaluating audit-compliance risks; developing a compliance plan; and monitoring compliance plan results.
Evaluating audit-compliance risks

This step includes: (i) reviewing all documentation processes for efficiency and effectiveness; and (ii) evaluating and prioritising solutions for at risk processes.
Developing a compliance plan

Included in this step are: (i) assigning nursing staff to specific responsibilities for major non-compliance/at risk processes; (ii) developing

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a detailed work plan with allocated responsibilities, timelines, and due dates; (iii) scheduling periodic reviews of policies and processes; and (iv) developing a system for documenting all decisions and adjustments to policies and processes.
Monitoring compliance plan results

This step involves: (i) reviewing facilities, risk management, and priority compliance; (ii) conducting trials of new policies and processes; (iii) ensuring functioning of incident tracking; (iv) ensuring functioning of complaint tracking and resolution; (v) monitoring results of staff communication and education; and (vi) establishing a process to resolve new issues, questions, and complaints. A suggested audit tool for NCPs is shown in Figure 15.2 (page 241).

Benchmarking
Benchmarking is an ongoing systematic process of rigorous comparison with best practice in other organisations. Benchmarking uses key performance indicators to ensure that all areas of the organisation achieve their full potential in documentation. The key performance indicators provide a picture of the organisation, its performance, Benchmarking uses key performance indicators to ensure that all areas and its future directions. of the organisation achieve their full Benchmarking is thus a potential in documentation. framework for strategic and operational measurement. Benchmarking can be internal or external. Internal benchmarking is conducted within the organisation and aims to obtain data for: (i) trend analysis; or (ii) a comparison among units or sites within the organisation. External benchmarking is conducted outside the organisation and aims to collect data: (i) within the aged-care industry; (ii) within the healthcare system; or (iii) within different industries. Contemporary progressive organisations are encouraged to seek out opportunities for external benchmarking to identify how they compare with their competitors, to identify gaps, and to undertake effective planning and education.

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NCP components
Nursing problem/diagnosis

Yes

No

Comments

Is the nursing problem stated clearly? Is the cause of the problem stated? Are the residents signs and symptoms stated?
Nursing goal

Is there a resident-centred nursing goal? Is the goal realistic? Is the goal understandable? Is the goal measurable? Is the goal behavioural? Is the goal achievable?
Nursing strategies

Do the strategies reect the goal that has been set? Do the strategies reect resident-focused care? Do the strategies reect current practice? Do the strategies reect actual nursing actions? Do the strategies assist others to carry out actions? Do the strategies direct others to carry out nursing actions? Do the strategies support the resident in his or her endeavours to maintain/improve health status? Do the strategies acknowledge the residents strengths? Do the strategies encourage nurse-initiated/doctorinitiated care? Do the strategies encourage the inclusion of all possible nursing interventions?

Figure 15.2 Audit tool for NCPs


AUTHORS CREATION

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NCP components
Nursing strategies

Yes

No

Comments

Do the strategies encourage inclusion of reassessment processes? Do the strategies encourage preventative as well as reactive measures? Do the strategies encourage quantiable/specic language? Do the strategies reect the skill level of the staff? Do the strategies reect documentation requirements? Do the strategies reect standards requirements?
Evaluation

Does the evaluation reect what is to be evaluated? Does the evaluation reect when it is to be evaluated and diarised? Does the evaluation reect how it is to be evaluated? Does the evaluation reect who is going to do the evaluation? Does the evaluation reect what is to be recorded in the progress notes? Does the evaluation reect the system for follow-up and ongoing review?

Figure 15.2 Audit tool for NCPs (continued)

Publishing
The final step in the model being discussed in this chapter is publishing (see Figure 15.1, page 212). Nurses should be encouraged to share their documentation experiences Nurses should be encouraged and achievements with to share their documentation colleagues in the industry experiences and achievements with through journal articles and colleagues in the industry. conference presentations.

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Journal articles
In preparing a journal article, nurses should contact the publisher and seek details of the journals preferred format, style, and submission processes. It is important to establish the nature of the audience and prepare the article with that readership in mind. However, it should not be assumed that every reader is an expert on the topic. In commenting on the work of others, it is important to cite all references and acknowledge the work of others. It is permissible to criticise the work of others, but this criticism should never be derogatory or insulting. The analysis should be sharpened in various drafts of the article, but the author should not become obsessive about small details. It is advisable to ask others to criticise the article before it is submitted. Fair criticism should be accepted constructively. Nurses should realise that authors often have to be persistent if they are to get work published in journals.

Conference presentation
In making a conference presentation, it is important to be passionate about the aspect of documentation to be presented. A clear rationale for the importance of the subject should be offered. However, the presentation can be lightened by the inclusion of humorous comments. The presenter should undertake thorough research and present the subject in a clear and coherent fashion. All key terms should be defined, and the presentation should move from the main point to less important points. Software that supports a conference presentation (such as PowerPoint) should be utilised. If an overhead projector or other audiovisual aid is to be used, it should be tested before the actual presentation. Any slides or other audiovisual materials should be of good quality, simple, and concise. Once the material is collated, the full presentation should be practisedwith special attention to getting the timing correct. Notes should be well organised and readily available at all times during the presentation. However, notes should be used as a promptrather than reading directly from them.

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It is important to speak clearly and at an appropriate volume. If a microphone is available it should be used correctly and effectively. The presenter should not move around too muchunless audience involvement is expected or a roving microphone is available. If audience participation is expected, the presenter must ensure that he or she is well versed in the subject and able to accommodate audience comments and questions. Any such questions or comments should be listened to with care and courtesy. In concluding the presentation, a summary of the key issues and recommendations should be offered. The presentation must be completed within the allocated time, and the audience should always be thanked for their attendance and attention.

Conclusion
A systematic approach to documentation ensures efficiency and effectiveness in the management of residents and promotes best practice within the organisation. A professional documentation system entails many stages, and communication within the organisation is essential. A systematic approach, such as the one discussed in this chapter, ensures that all areas of the organisation are committed to A professional level of documentation quality documentation. It is that is accessible to all ensures best essential that all staff members care of residents and protection of the understand their documentation organisations funding status. requirements if fragmentation is to be avoided. A professional level of documentation that is accessible to all members of the multidisciplinary healthcare team ensures best care of residents and protection of the organisations funding status.

Appendices

Appendix 1

Faecal Incontinence
Janette Williams

Case study
Mrs Green
Presenting problem and history Mrs Green, a 72-year-old resident of an aged-care facility, complained of severe constipation and feeling bloated. She stated she had not had her bowels open properly for several days and was having leakage of faeces although she was unaware when this was happening. Mrs Green had a long history of constipation, passing of hard stools, and straining to open her bowels. She always had a feeling of incomplete emptying. She had no pain but frequently felt bloated. Mrs Green had severe arthritis with limited mobility and limited manual dexterity. There was no history of recent surgery, but Mrs Green had had two total knee replacements and one total hip replacement in the past 10 years. She was classied as requiring a high level of care.
(continued)

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(continued)

Physical examination and investigations The physical examination of Mrs Green revealed: condition of mouthwell-tting dentures; able to chew; abdominal palpationa mass of hard faeces in the lower descending colon; inspection of perineumno skin tags; two external haemorrhoids; faeces around anus; slightly red skin; rectal examinationweakened anal tone with inadequate sphincter contraction; hard faeces in the rectum; one enlarged internal haemorrhoid; and abdominal X-rayfaeces in the descending colon and rectum. Nurses assessment The nurses assessment of Mrs Green revealed: dietinsufcient fruit and vegetables; uid intakepoor (45 cups of tea per day); mobilitypoor; difculty in reaching the toilet easily; activity and exercisereduced (due to arthritis); manual dexteritypoor; difculty in removing clothing easily; medicationsparacetamol (2 tablets 4 times a day) for pain; verapamil for blood pressure; Coloxyl with Senna 23 daily (for more than three years); and other factorstoilet seat not high enough for Mrs Green to sit in a comfortable position to have her bowels open. Problem Chronic constipation with overow incontinence

251 Appendix 1 Faecal Incontinence

Documentation for this case study


Bowel chart
In the case of Mrs Green, nurses should be requested to keep a bowel chart for one week. Documentation on such a bowel chart should include: frequency of defaecation; colour of faeces; consistency of faeces; volume of faeces; degree of incontinence; and faecal smearing.

Assessment tools for constipation


In general, assessment tools for constipation should address the following: recent medical history that might aggravate risk of constipation; diet and fluids; mouth and dentures; medications and use of laxatives; mobility and manual dexterity; toilet facilities; previous bowel habits; inflammatory diseases (such as irritable bowel syndrome); previous bowel surgery; cognitive state; fluid and food chart; bowel diary: frequency; colour; consistency; volume; episodes of incontinence;

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sensation of desire to defaecate: absent; urgent; unaware; normal; physical examination; abdominal palpation (for presence of hard faeces in colon); perineum (skin tags, haemorrhoids, faeces around anus, skin condition); and rectal examination (anal tone, faeces in rectum, ssures, tenderness); other investigation: abdominal X-ray; and colonoscopy (if appropriate).

Management plan
A written management plan for Mrs Green was drawn up. This included the following. Clear the constipation with two glycerine suppositories and a Microlax enema. Increase fluids to 68 glasses per dayincluding prune or pear juice daily (to assist with peristalsis). Reduce caffeine intake. Increase fibre in diet. Discuss with Mrs Green food she likesto assist with the diet changes (such as wholemeal bread, beans, vegetables, and fruits). Work with a physiotherapist to assist with mobility and gentle exercise program. Encourage regular bowel routine by going to the toilet at a regular time every second day. Make use of the gastro-colic reflex (that is, going to the toilet after a meal such as breakfast).

253 Appendix 1 Faecal Incontinence

Discuss medication regimen with medical officer with a view to: changing verapamil to another medication that does not have side-effect of constipation; analgesic alternatives to reduce the number of paracetamol tablets taken each day; and slowly reducing the number of Colyxl and Senna tablets and replacing with bulking agents (such as Normabre or Movicol). Ensure Mrs Green drinks 46 glasses of fluid per day to avoid using irritant laxatives (except intermittently). Toileting arrangements: place toilet seat raiser on the toilet to enable Mrs Green to sit comfortably on the toilet; if she is able, place her feet on a footstool to bring her knees above her hips to reduce the need to strain; and instruct Mrs Green to lean forward on the toilet seat (to reduce the need to strain). Instruct Mrs Green re how to strengthen her anal sphincter tone by performing anal sphincter exercises (same as pelvic-floor exercises, but with emphasis on anal sphincter). Instruct Mrs Green to maintain bowel diary to: monitor for faecal incontinence; and to help prevent further constipation with overow. With the assistance of a nurse, ensure that Mrs Green is able to attend to personal hygiene following bowel action (to prevent skin excoriation). Review management plan after one month.

Appendix 2

Behavioural Management
Robyn Daskein

Case study
Mrs Robinson
Presenting problem and history Mrs Robinson was an 84-year-old resident of an aged-care facility who had been assessed as requiring high-care placement. The psychogeriatricians assessment was that Mrs Robinson had mild dementia, confusion, and verbal behavioural problems (calling out and repetitive communication). Mrs Robinson had been suffering from shingles for the past two months. The doctor had suggested that Mrs Robinsons calling-out was most probably due to the pain of shingles. The doctor had ordered calamine lotion and paracetamol 2 tablets 4-hourly if required. The psychogeriatric team had developed a behavioural modication plan that included time management intervals to manage her inappropriate communication episodes.
(continued)

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(continued)

A medication review by the clinical pharmacist had identied low dosage of pain medication as a problem, and had suggested a review of Mrs Robinsons pain regimen. Relevant investigation A CAT scan of the brain had revealed a lesion (?brain tumour ?CVA) over mobility area of cerebral cortex. Nursing assessment Nursing assessment of Mrs Robinson revealed: communicationbouts of confusion; Mrs Robinson does not always realise where she is; repeats the same words over and over; continually asking for the same thing; repeats requests time and again; continually buzzing for assistance (and when attended, repeats requests); activities of daily livingtwo staff members are required to assist with Mrs Robinsons activities of daily living; can manage her meals independently; takes her medication uncrushed; sight is satisfactory; deaf in both ears; on a continence program; pain assessment (verbal and non-verbal)moderate pain; trends in pain assessment indicated that uncontrolled pain was a contributing factor in the pattern of calling-out; skin assessmentskin dry and thin; shingles lesions on the upper right abdominal quadrant (persistently scratched by resident); nursing behaviour charting assessmentover a 7-day period demonstrated that mild comprehension difculties, periods of withdrawal, feelings of loneliness, confusion, and other inappropriate behaviours were more prominent in the evening and between 0100 hrs and 0400 hrs; a different issue every night; buzzed repeatedly (buzzing starting again as soon as staff members left the room); sleep assessmentcalled out in her sleep; a usual sleep pattern of 68 hours of sleep each night; settled at 2100 hrs following a cup of tea; environmental assessmentroom at the end of the corridor where she had a single room and shared an ensuite;
(continued)

257 Appendix 2 Behavioural Management

(continued)

social and cultural assessmenta strong family background; the centre of attention in her family circle; had been active in community activities; major personal losses included the death of her son (when she was 60 years old) and the death of her husband (one month ago); two daughters visited regularly (Mrs Robinson enjoyed communicating with them); diversional therapist programwhile in activities with the diversional therapist, Mrs Robinson constantly called out if left unattended; her behaviour was the same when she was on bus outings. Problem Verbal behavioural problemscalling out and repetitive communication.

Documentation for this case study


Nursing care plan
On the basis of the above case history, a nursing-care plan for this problem was drawn up in the usual way in three columns. The beginning of the plan is shown below.

Problem

Interventions

Outcomes

Ineffective communication

Establish trust; be reliable Do not argue with Mrs Robinson

Mrs Robinson will be able to communicate her needs more effectively

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The full information on the nursing care plan was as follows.


Column 1 Problem

Ineffective communication (more prominent in the evening and nighttime): confusion; calling out; repetitive communication; and buzzing constantly. Related to: effects of social isolation; and medical condition. As assessed by: behavioural assessmentmild comprehension problems and mild depression; social historyindicates Mrs Robinson is used to having people around her and being the centre of attention.
Column 2 Interventions and actions

Establish trust; be reliable; if you say you will be back, keep your word. Do not argue with Mrs Robinson or tell her she has already told you that. Use reflective listening skills when attending to Mrs Robinson. Maintain adherence to the behavioural management time program. One nurse each shift to care for her and implement the behavioural management strategies as per program. Offer reassurance and comforting words. Encourage Mrs Robinson to express her fears. Clarify what she intended to say to ensure correct communication. Face Mrs Robinson and observe for changes in body language (non-verbal language).

259 Appendix 2 Behavioural Management

Offer an alternative word and wait for a signal from her as to appropriate selection. Respond empathically to the emotional tone of her statements. Provide proactive and appropriate non-drug pain-management interventions. Observe for signs of depression and withdrawal. Use picture family boards and tapes of family interaction to reduce her isolation (as per activities program or when attending to her care). Include Mrs Robinson in the volunteer program in the evening when her calling out and buzzing is most prominent. Include Mrs Robinson when going on outings in the bus. Move her room (with consultation) closer to the nurses station to provide company and visual comfort. Offer her a cup of tea at settling time and when she is awake during the night. Monitor and evaluate the effects of behavioural management interventions and pain interventions. Record triggers and outcomes of interventions. Review Mrs Robinsons behavioural assessment regularly and frequently to identify effective interventions. Case conference regularly and frequently in consultation with her daughters, psychogeriatric team, and doctor to review the outcomes of her pain management, skin condition treatment, and behavioural modification program.
Column 3 Outcome

Mrs Robinson will, to the best of her cognitive ability, be able to communicate her needs more effectively, interact in groups, and participate in group conversations.

Appendix 3

Diabetes
Victoria Stevenson

Case study
Mrs Martin
Presenting problem and history Mrs Martin was a 74-year-old widow with two sons and a daughter. Because her family was unable to care for her, Mrs Martin had resided in a nursing home for four years. She was a very tidy and independent lady who liked things done in a certain way at the right time. This included her meals. She had retired many years previously after working in a cigarette and sweets shop in the city. Her interests included bridge, embroidery, and gardening. Mrs Martin was an ex-smoker who liked a glass of champagne to see in the New Year. Her medical history included: diabetes (type 2) for 15 years; hypertension; coronary artery bypass surgery (10 years previously);
(continued)

262 Nursing Documentation

(continued)

reduced vision; and painful right knee (caused by a fall years ago). Mrs Martins family history revealed that her mother had diabetes and had died from an infection following her second leg amputation. Mrs Martins father had died of a stroke. Mrs Martins medications were glibenclamide 5 mg in the morning, metformin 500 mg in the morning, aspirin 100 mg daily, and perindopril 2 mg daily. Her diabetes regimen had been increased recently while she was in hospital. She had recently been hospitalised for a left fractured femur. While in hospital, her diabetes had become difcult to control and had required insulin for one week. Mrs Martins renal function was satisfactory, and a recent HbA1c was 6.8%indicating effective diabetes control in the previous 23 months. Her blood glucose levels were checked every morning. Over some weeks these results had begun to rise from 512 mmol/L to 1419 mmol/L. The night staff had also documented several episodes of unexplained restless nights. Mrs Martin had needed assistance to change her nightie (due to night sweats) and had been surprised each morning to note the change of clothes. Her meals remained unchanged and she always showed annoyance if there was any fat on the meat. Although she had usually not been keen on afternoon tea, Mrs Martin had recently begun to arrive rst in the diningroom and was heard to complain of being particularly hungry and dizzy. The hunger and dizziness were corrected with extra scones. Her supper was unchangedone chocolate after-dinner mint with a cup of tea. Another recent change to her usual routine was that Mrs Martin had occasionally fallen asleep after breakfast and had missed the beginning of her physiotherapy session. Problem Appears to have unstable blood glucose levels with nocturnal hypoglycaemia.

263 Appendix 3 Diabetes

Documentation for this case study


1. Blood glucose charting
In response to the above, nurses increased the frequency of blood glucose testing and recording. The results were as follows: fasting levels: 1419 mmol/L pre-lunch: 45 mmol/L pre-dinner: 46 mmol/L pre-supper: 3.04.5 mmol/L with night sweats: 2.53.9 mmol/L

2. Nursing diagnosis
The nursing diagnosis was nocturnal hypoglycaemia as evidenced by nocturnal sweats and restless sleep. The blood glucose level of 2.53.9 mmol/L at night confirmed this nursing diagnosis.
Discussion of the nursing diagnosis The nursing diagnosis of hypoglycaemia was based on the nocturnal sweats and restless sleep. Overnight hypoglycaemia can also produce unpleasant dreams and waking with a headache.

Rebound hyperglycaemia can occur in this situation. In Mrs Martins case, her elevated morning blood glucose levels (1419 mmol/L) confirmed that this was happening. The rebound high sugar level is due to stress hormones being releasedcausing glycogen (stored glucose) to be released from the liver into the bloodstream to correct the nocturnal low blood sugar. Her falling asleep after breakfast was most likely due to the effect of the high sugars and (perhaps) a disturbance in her sleep pattern. The likely cause of Mrs Martins nocturnal hypoglycaemia was excessive diabetes medication. Mrs Martin had now recovered from her hip surgery, and the stronger medication regimen adopted in hospital was no longer appropriate. The symptoms of lightheadedness and hunger in the afternoon indicated that she was also suffering from hypoglycaemia at that time of

264 Nursing Documentation

the day (although blood glucose testing was not done at that time). Her recent attendance at afternoon tea and her desire for extra scones was further evidence for this. Testing the blood glucose level before afternoon tea might have shown a level below 3.5 mmol/L.

3. Management plan
The following plan of management was drawn up and documented.
Blood glucose testing

Test pre-meal and bedtime until diabetes becomes stable again (512 mmol/L). Report any blood glucose level below 5 mmol/L. If pre-supper blood glucose level is 6 mmol/L (or lower), give a few biscuits or a glass of milk in addition to her chocolate afterdinner mint.
Medication

Medication is to be to be taken with breakfast and (if required) with the evening meal. Ask medical staff to review medication.
Nutrition and hydration

Mrs Martin likes to eat on time. She follows a diet of high complex carbohydrate, low fat, low sugar, and low salt. She likes an after-dinner mint at supper. She takes sandwiches to her diabetes outpatient appointments. Encourage water or low-calorie cordial with her meals.
Treatment of hypoglycaemia

If conscious: 7 jelly beans (chewed) or 1 glass of normal soft drink or 3 teaspoons sugar in half a glass of water. Do a blood glucose level.

265 Appendix 3 Diabetes

Follow with biscuits, milk, sandwich, or meal (if due). Do a repeat blood glucose level within 15 minutes. Note that any food for hypoglycaemia is in addition to her usual next meal. Ask medical staff to review medication. If unconscious: Roll onto side, clear airway, call an ambulance. Do a blood glucose level and stay with her.
Sleep pattern

Undertake a sleep assessment. Check Mrs Martin regularly and frequently throughout the night for change in sleep pattern.
Safety and risk management

Assist at all times (because of her history of falls). Jelly beans are to left in her bedside drawer (because she is at risk of hypoglycaemia). Normal soft drink (not low-calorie drinks) to be located in a convenient area.

4. Staff education
In a case such as this, it is important to have regular and frequent staffeducation sessions. Encourage staff to attend these sessions. Make relevant journal articles and easy-to-follow guidelines available in the facility, and encourage staff members to read these.

Appendix 4

Nausea
Robyn Millership

Case study
Mrs Green
Presenting problem and history Mrs Green, aged 82, had moved into an aged-care facility two months after her husband had died. Her past medical history included severe arthritis, ischaemic heart disease, obesity, and borderline renal function. Mrs Green had great difculty settling into her new surroundings. She was grieving the loss of her husband of 54 years and of her loved home. She and her husband had built their home and had raised ve children in it. She missed the garden setting and the large living area of four bedrooms, kitchen, dining-room, and lounge-room. For the past three weeks Mrs Green had been complaining of intermittent nausea. This was precipitated by the smell of food as the meals were served. It also occurred on waking in the morning. She had always had a very good appetiteenjoying her meals and frequent treats, including chocolate biscuits. She had now begun to refuse
(continued)

268 Nursing Documentation

(continued)

food because she was afraid that she would vomit. She was not even eating her favourite biscuits. Her family had become worried that she would fade away. They have never known their mother to be off her food. The nursing staff discussed the possible causes of her nausea with the visiting doctor. Treatment Mrs Green was prescribed oral metoclopramide (Maxolon) 10 mg, 6 hourly, as required. After several doses of metoclopramide she was still complaining of nausea. The locum doctor was notied and a telephone order for oral prochlorperazine (Stemetil) 25 mg, 6 hourly, as required, was prescribed. Mrs Greens dietary intake reduced further, and she became tired and lethargic. It was agreed that an objective measurement and description of the nausea was required. An assessment tool was used. This assessment tool recorded the severity of nausea, other symptoms, food intake, and medication. Problem Nausea and reduced food intake.

269 Appendix 4 Nausea

Documentation for this case study


Assessment
The key to successful management of nausea is thorough assessment. A history of the onset and pattern of the nausea should be obtained, together with any associated symptoms. Assessment should therefore include documentation of: onset and pattern of nauseasuch as whether the nausea is related to taking medications, meals, movement, or the sight or smell of food; associated symptomssuch as epigastric pain, pain on swallowing, sore mouth, thirst, hiccoughs, heartburn, or urinary symptoms (frequency or dysuria); usual bowel function patternincluding constipation or diarrhoea. The use of an assessment tool provides a clear picture of the issues and assists in determining the treatment. Such an assessment tool should incorporate: a visual analogue scale; time sequence of the nausea; action taken; and outcome. A suitable nausea assessment tool is shown on page 270.

Treatment
The treatment regimen should, of course, be carefully documented. Antiemetics should be selected on the basis of presenting symptoms. For example: metoclopramide for gastric stasis; haloperidol for general nausea and anxiety; chlorpromazine for hiccoughs; and cyclizine for motion sickness.

270 Nursing Documentation

Nausea Assessment Tool


Visual analogue scale 1 2 3 4 5 6 7 8 9 10

mild

moderate

severe

Key to associated features 1. Pain 2. Anxiety 3. Constipation 4. Lethargy 5. Before food 6. After food 7. After medication

Date

Time

Score

Associated features

Intervention

Outcome score

01 Dec 2006 01 Dec 2006 01 Dec 2006 02 Dec 2006 02 Dec 2006 02 Dec 2006 03 Dec 2006 03 Dec 2006 03 Dec 2006 04 Dec 2006 04 Dec 2006

0900 1400 1750 0600 1130 1730 0600 1200 1800 0600 1200

7 6 7 8 8 5 4 3 2 0 0

2, 5 2, 5 2, 5 2, 4, 5 2, 4, 5 2, 4, 5 2, 7 2, 7 2, 7 0 0

metoclopramide prochlorperazine metoclopramide prochlorperazine metoclopramide metoclopramide metoclopramide, haloperidol metoclopramide metoclopramide, haloperidol metoclopramide, haloperidol metoclopramide, haloperidol

2 5 2 5 3 3 2 1 1 0 0

271 Appendix 4 Nausea

Before changing to another antiemetic, the chosen antiemetic should always be used at a dosage within its therapeutic range. Combination therapy might be necessary for multiple causes of nausea. The underlying cause of the nausea should be treated if possible. For example: steroids for nausea related to raised intracranial pressure, hypercalcaemia, or malignancy; ranitidine for gastric irritation; aperients for constipation; and appropriate medication and/or counselling for anxiety.

Review after intervention


Regular and frequent review after any intervention is vital if the effect of the intervention is to be accurately assessed. A written record helps to establish any pattern of response to various medications or other interventions. This leads to a more systematic management plan and facilitates control of this debilitating problem.

Outcome
After two days the assessment tool record (see page 270) revealed that Mrs Greens nausea was: worse before meals; associated with anxiety; and not responding to prochlorperazine. It was therefore decided to use oral metoclopramide 10 mg 6-hourly strictly during the day. Because anxiety was an associated feature, oral haloperidol 0.5 mg twice daily was added. After two days of the combined regimen, Mrs Green was eating her meals, entering into conversation with other residents, and generally feeling much better. In conversation with her family and other residents, Mrs Green talked about feeling nauseated for weeks after the death of her husband. She also acknowledged her feelings of loss and grief over the move from her family home.

272 Nursing Documentation

Three weeks after this episode, both the metoclopramide and haloperidol were ceasedwith no return of nausea.

Appendix 5

Stomal Care
Heather Hill

Case study
Mrs North
Presenting problem and history Mrs North had been diagnosed as having ovarian cancer two years after her husband of 50 years had died of bladder cancer. Mrs Norths ovarian cancer had led to bowel obstruction, which had been treated with surgery (including a colostomy), radiation, and chemotherapy. Mrs North was 75 years old. Although she had no family, she had many supportive friends and neighbours and had initially managed well. However, following recent rapid deterioration, her doctor had arranged for Mrs North to be admitted to an aged-care facility. Mrs Norths medical problems included diabetes, hypertension, and congestive cardiac failure with pitting oedema. She was obeseweighing 114 kg, although she was only 150 cm tall. Mrs Norths stomal problems were that her appliance had been leaking for three days and the nursing staff had been taping pads around the area
(continued)

274 Nursing Documentation

(continued)

to absorb the drainage. The odour from the leakage, urinary incontinence, and vaginal discharge was terrible. Stomal nursing assessment and management On examination her abdomen was huge as a result of ascites, tumour, and a parastomal hernia. An extra wide hernia belt was tted to provide some support and comfort. With her change in shape, Mrs Norths colostomy had become ush with the skin and oval in shape (5 cm x 2.5 cm). A new template was made to t the stoma. The stoma mucosa was pink and healthy. Mrs Norths skin was excoriated from leaking faecal matter and the tape that had been applied to keep the pad in place. Because of the ascites, her abdomen had been leaking uid, loosening the wafer. The excoriation radiated out beyond the appliance by 1.5 cm. A large exible absorbent hydrocolloid sheet had been applied to help draw the ascitic uid away from the skin. A diagrammatic chart, detailed written instructions, and contact telephone number were left with nursing staff to facilitate care on each shift. The nursing staff and Mrs North were instructed on skin care, a new pouching procedure, hernia belt application, and odour control. Stomal deodorant tablets or uid in the appliance were recommended. Suitable odour-absorbent substances were recommended for Mrs Norths room. Staff members were asked to document any alterations to skin, stoma, leakage, odour control, and emotional status, and to call if there were any further unmanageable issues. As a result of these measures, Mrs Norths remaining two months of life were trouble-free in terms of stomal problems.

275 Appendix 5 Stomal Care

Documentation for this case study

Efficient stomal management depends on precise reporting and the use of consistent terminology. The residents overall physical, psychological, and medical status should be noted. With respect to the stoma itself, a photograph of the stoma and peristomal skin is the best documentation. Serial photographs provide objective evaluation of progress. In addition, the following should be documented.
Item Matters to be documented Document position on body and if any associated problems (such as the stoma being in a skin fold). Should be pink-to-red in colour. Alteration in colour might indicate impaired blood supply. Bleeding from the surface of the stoma often occurs during cleaning, and is not necessarily a problem. Large amounts of blood loss or blood coming from inside the stoma should be reviewed by a specialist or stomal-therapy nurse. Size and shape differs with the type of stoma. An accurate measurement can be obtained by tracing the size onto a clear acetate measuring guide (which are provided free of charge by ostomy companies). Alternatively, a piece of clear plastic can be used to make a template. The stoma should ideally be raised above the skin approximately 1 cm. Recognition of contour variations can help to indicate where future problems might occur with appliances. Nurses should check that peristaltic movement of the stoma is normal. State: (i) the make; (ii) whether two-piece or one-piece; (iii) whether a closed end or drainable; (iv) whether with or without lter. Note what is being used and why (pastes, powders, protective wipes, remover wipes, deodorants, covers).

Stomal appearance
Location Colour Bleeding

Size and shape

Contour

Equipment
Appliance (bag/pouch)

Accessories

(continued)

276 Nursing Documentation (continued)


Item Matters to be documented Note colour (and be aware that bright-red faeces can result from food such as beetroot). Note consistency and volume. This varies with the type of stoma and position in the bowel. Note if any constipation is rare in people with stomas, but can occasionally happen with a sigmoid colostomy. Note if any diarrhoea (but be aware that this can be overow from constipation). Diarrhoea in the elderly should not be ignored because dehydration and electrolyte imbalance can occur quickly and might require urgent treatment. No faecal output can indicate a blockage. If a person with an ileostomy has no faecal output, report immediately and seek help from a stomal-therapy nurse or specialist (the person may have a blockage). State whether present or not. Should be obvious only when changing or emptying an appliance. If atus and/or odour are excessive, consider dietary modication. Report urine colour. Report whether mucus present (this is normal). Report whether odour present. This can caused by foods (especially sh, eggs, and asparagus), but might indicate infection. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes.

Output
Faeces

Flatus Odour Urinary stoma output

Abnormalities
Stenosis

Retraction

Herniation

Prolapse

Mucosal lesions or ulcers

(continued)

277 Appendix 5 Stomal Care (continued)


Item Matters to be documented Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes.

Abnormalities
Oedema or swelling

Skin condition Colour

When an appliance is removed, the red ush usually fades within minutes. If the skin remains an angry red colour, this indicates a problem. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes. Document size, shape, and appearance. Have client reviewed by medical ofcer or stomal-therapy nurse. Document reports, treatment, and descriptive outcomes.

Cellulitis, heat, swelling

Rashes

Lesions/ulcers

Any other changes

Perineal wound
Persistent drainage Odour Skin conditions Document and seek advice. Document treatment and outcomes. Document and seek advice. Document treatment and outcomes. Document and seek advice. Document treatment and outcomes.

Psychological status
Perceptions Feelings Thoughts Document as appropriate. Document as appropriate. Document as appropriate.

Appendix 6

Leg Ulcer Management


Sue Templeton

Case study
Mrs Edwards
Presenting problem and history Mrs Edwards was an 82-year-old woman with a history of obesity, hypertension, osteoarthritis, stripping of varicose veins (35 years ago), and ve pregnancies. Mrs Edwards had sustained a skin tear to her right lower leg from a wheelchair footplate. The skin had been completely removedresulting in a 3 cm x 2.5 cm wound. At the time of the injury, the wound had been cleansed with saline and dressed with parafn-impregnated gauze, a nonadherent dressing, and crepe bandage. The wound had been redressed daily for the rst week, during which time there continued to be a moderate amount of haemoserous exudate. In the following weeks the wound continued to be dressed twice a week with parafn-impregnated gauze and a non-adherent dressing.
(continued)

280 Nursing Documentation

(continued)

A month after the initial injury, the wound size had increased to 4 cm x 3 cm and the base of the wound had become sloughy. Nursing assessment Mrs Edwards wound should now be classied and treated as a chronic leg ulcer because it has not progressed along the expected wound healing processes to produce anatomical integrity. In particular, a wound between the knee and ankle that is unhealed beyond four weeks should be classied as a chronic leg ulcer. Diagnosis and management The cause of delayed healing is likely to be venous insufciency due to obesity, multiple pregnancies, varicose veins, oedematous legs, and limited mobility. This was conrmed by use of the leg-ulcer assessment tool (see page 282). Control of venous insufciency is required for healing to progress. Graduated compression therapy is the recognised treatment for venous ulcers. This corrects venous insufciency through promotion of venous return. Mrs Edwards was commenced on a program of graduated compression therapy using a four-layer bandage system. She was also encouraged to elevate her legs when sitting. Ongoing documentation of the wound demonstrated that, within two weeks, the oedema was controlled. Within four weeks the wound had halved in size and the wound base was no longer sloughy. Within 12 weeks of continuous, graduated compression therapy the wound had healed. Mrs Edwards was then tted for a pair of compression stockings for ongoing control of her venous insufciency and to ensure that skin integrity was maintained.

281 Appendix 6 Leg Ulcer Management

Documentation for this case study


General assessment
A thorough assessment is necessary: to ensure that the aetiology of the wound is correctly identified; to identify factors that might impair healing; and to provide a reference from which wound progress can be monitored. This documented assessment must be used to inform, plan, and monitor appropriate wound interventions.

Leg-ulcer assessment tool


Specific assessment tools can identify underlying pathologies that are impeding healing and can assist in determining the aetiology of a leg ulcer. A leg-ulcer assessment tool (see page 282) provides systematic documentation and can assist the relatively inexperienced practitioner to determine wound aetiology and appropriate management. In particular, such a tool: provides prompts to identify the aetiology of a leg ulcer; allows the practitioner to record a comprehensive baseline assessment of a leg ulcer; and provides links to organisational guidelines that promote evidencebased practice to ensure that interventions will result in optimal client outcomes.

282 Nursing Documentation

ROYAL DISTRICT NURSING SERVICE OF SA INC

LEG ULCER ASSESSMENT TOOL


Allergies/Sensitivities: Nil Known Date of assessment: 11/09/2002 Ulcer site(s)

GENDER: TITLE: SURNAME: FIRST NAME: D.O.B.:

Female Mrs Edwards Glenda 14/07/1920

UR NUMBER 123456

(Afx sticker)

Hospital/Clinic: ........................................ GP/Consultant: Dr Taylor Signature (print name also): Sue Templeton CNC Left leg Right leg

Indicate the site of the ulcer(s) on the appropriate diagram with X. If more than one, number each one.

Condition of ulcer Necrotic (black) Sloughy (yellow) Low exudate Stage 2

Epithelialising (pink) Infected (green) High exudate Stage 3

Granulating (red)

Stage 4

The pattern of ticks may provide an indication of possible contributing risk factors relating to venous or arterial disease, however there may be other causative factors.

Possible indicators of venous hypertension


Ulcer Large, shallow ulcer Poorly dened margins Slow progress Gaiter area: medial/lateral malleolus Associated leg changes Reddish/brown skin pigmentation Dilated and or tortuous supercial veins Vein distention of medial foot Thin, white skin Stasis eczema Limb may be warm Oedema present, especially after standing/sitting for long periods Pain quality Usually at dressing changes When oedema is severe In the presence of infection Pain level (circle)

Possible indicators of arterial insufciency


Ulcer Small deep, possibly multiple ulcers Well dened, punched out margins Rapid progression Dorsum of foot/toes/lateral leg Associated leg changes Foot dusky/pale when elevated > 3 seconds capillary rell time Poor quality, thickened toenails Thin, shiny, dry skin Absence of hair growth Limb may be cool Oedema absent, or may be present when limb inactive or dependent Pain quality Aggravated by exercise May be worse when leg elevated Relieved when leg in dependent position

(no pain)

(worst pain imaginable)

10

283 Appendix 6 Leg Ulcer Management

Possible indicators of venous hypertension


Medical history Deep vein thrombosis Pulmonary emboli Phlebitis Varicose veins Previous trauma to leg(s) Previous surgery to leg(s) Obesity

Possible indicators of arterial insufciency


Medical history Arteriosclerosis Hypertension Angina/myocardial infarction Cerebrovascular accident/TIA Smoking Diabetes mellitus

Other conditions that may delay healing Malignancy Skin cancers Rheumatoid arthritis Connective tissue disease Immune deciency Bowel disease/Malabsorption Other .... Medications that may affect healing .... Observations Pedal pulses Blood pressure 140/80 Left leg Right leg Absent Absent Blood Glucose Reading 5.3 mmol Present Present

Doppler assessment Doppler assessment in the past 12 months? Yes No Unknown If yes, Date performed ........ By whom .... ABPI .......... Doppler assessment should be carried out following assessment of all other factors and only by appropriately trained staff who have completed the Doppler Competencies and attended skills training. Doppler range Left Brachial 140 Dorsalis Pedis 140 Posterior Tibial 135 ABPI 1.0 Right Brachial 140 Dorsalis Pedis 135 Posterior Tibial 140 ABPI 1.0 Date of doppler assessment 12/09/2002 Signature (print name also) Sue Templeton CNC Aetiology of ulcer assessed as: (Refer Nursing Practice Manual 2.CP.66(A) Leg Ulcer Management) Venous Arterial Mixed Other Compression therapy is indicated for ulcers assessed as venous aetiology. Where aetiology is unclear, liaise with CNC or Advanced Wound Specialist. Referral to a vascular specialist is recommended for ulcers of mixed or arterial aetiology. Ulcers of mixed aetiology must be assessed by Doppler prior to instigation of compression. Diagram to scale of ulcer(s) size 1 box= 1cm2

PUBLISHED WITH PERMISSION OF ROYAL DISTRICT NURSING SERVICE, SOUTH AUSTRALIA

Appendix 7

PEG Nutrition
Patsy Montgomery

Case study
Mrs Smith
Presenting problem and history Mrs Smith was an 83-year-old woman who had lived at home for 12 months after suffering a cerebrovascular accident (CVA). Mrs Smith had a left-sided paresis and was unable to speak or swallow. She was able to understand simple directions and seemed to know her relatives. Her main carer was her husband. When he was unable to continue with full-time care, Mrs Smith had been admitted to an aged-care facility. A percutaneous endoscopic gastrostomy (PEG) tube had been inserted 10 days after her CVA. The tube was very long and made of a medical silicon material. The life of such a tube is approximately 12 months. The Yport connector at the end of the tube was leaking. Video uoroscopy undertaken in hospital had indicated an inability to swallow and an inadequate gag reex. Mrs Smith therefore took nothing by mouth. Formula, water, and medications were given via the PEG tube.
(continued)

286 Nursing Documentation

(continued)

Mrs Smith had been seen by a dietitian before leaving hospital.The dietitian had ordered 300-millilitre bolus enteral nutrition of a low-residue formula (of 1 Calorie per millilitre) ve times each day, with 100-millilitre water ushes. This ensured that she was given 2000 millilitres of uid daily. The formula and equipment were ordered from a wholesaler and was subsidised by the Australian government. Mrs Smiths bolus enteral nutrition was given using a catheter-tipped syringe. Because there was a risk of reux and aspiration, the nutrition was given slowly. Nevertheless, Mrs Smith had a very fruity cough. It was not possible to weigh Mrs Smith on admission to the facility. However, over several months, it was apparent that her weight had increased dramatically. Mrs Smith was not ambulant and sat in a chair most of the day. She had diarrhoeawhich consisted of 23 liquid bowel motions daily. (In general, residents who have low-residue formulae have bowel motions twice weekly.) The PEG site was red and irritateddue to constant serous ooze mixed with formula and bile. The site was bathed daily using warm soapy water, and dried. A cortisone cream had been ordered for the red skin, and Betadine was used periodically. Problem Requires assessment and recommendations regarding PEG feeding (with special attention to problem of diarrhoea).

287 Appendix 7 PEG Nutrition

Documentation for this case study


The clinical nurse specialists documented recommendations for this case were as follows.

1. Gastrostomy tube
The following were documented in the progress notes to ensure that staff members knew the status of the tube. The tube could be shortened to a more manageable length approximately 2030 cmand a new Y-port connector should be attached. The tube appears to be working well and probably has another 6 months of life. The tube can be removed at the bedside and replaced with a balloon gastrostomy tube of the same French size (20).

2. Formula
The following information was documented in the progress notes and in the nursing-care plan to ensure that all nurses were aware of the requirements. To decrease and monitor Mrs Smiths diarrhoea: change from a low-residue formula to a fibre formulato assist in providing bulk to the stool; decrease the amount of formula to 200 millilitres (x 5 daily), followed by a flush of 100 millitres (x 5 daily)which will still meet Mrs Smiths recommended dietary intake (RDI); and maintain a fluid balance chart to ensure that all fluid amounts are correctly recorded.

3. Delivery
Bolus feeding is not indicated for clients with a history of reflux and/or aspiration. The following suggestions were therefore documented on the nursing-care plan as a strategy for the management of enteral nutrition:

288 Nursing Documentation

change to gravity feed using a exitainer and gravity-feeding set; or use an enteral pump.

4. Stomal site
Serous ooze and granulation tissue around the site is normal. The amount of leakage around the stoma site will decrease with a lower volume of formula. A wound-management chart (with a cross-reference made in the nursing-care plan) therefore documented the following recommendations. A gauze dressing should be applied only if soiling the clothing. Apply sorbolene and zinc cream to the skin for better protection from the ooze.

5. Other recommendations
The following recommendations were recorded in the progress notes and in the nursing-care plan. Advise referral of Mrs Smith to a dietitian to assess nutritional status. Advise referral of Mrs Smith to a speech therapist for assessment of her swallowing capacity. The clinical nurse specialist to review Mrs Smith in 6 months and change the PEG tube to a balloon gastrostomy tube.

Appendix 8

Wandering
Beverly Smith

Case study
Mrs Elle
Presenting problem and history Mrs Elle was an 80-year-old woman who had lived in an aged-care facility for several years. Before admission to the facility, Mrs Elle had lived with her daughter and granddaughters for ve years. Mrs Elle had been diagnosed with dementia several years previously when she was living alone, widowed, on the family farm. Her confusion and disorientation had increased signicantly in the past 18 months. Admission to the aged-care facility had been precipitated by Mrs Elles absconding from home on a number of occasions. Her absconding had occurred at unlikely times and in an unlikely manner. She was unusually agile and strong for her age, and was able to climb through windows and manipulate fastenings. Once outside, she would sit in the garden or disappearforgetting where she had come from. Although she appeared to have some comprehension, Mrs Elle almost never spoke.
(continued)

290 Nursing Documentation

(continued)

Mrs Elle needed assistance with all aspects of daily living, reminders for toileting and meals, and encouragement to eat and drink. Her daughter had endeavoured to maintain a routine similar to Mrs Elles earlier lifestylewith early-morning rising, prompt completion of household tasks, and gardening and walking on most days. Mrs Elle was much loved and respected by her family. Admission assessment Mrs Elles admission assessment highlighted wandering and restlessness with potential for danger by falling or absconding. A graphical owchart indicated that Mrs Elle usually wandered with some purpose. She was sometimes intrusive and asocial. On occasions she was not amenable to reason. She often became quite opportunistic and belligerentsuch as when she was around the secured front door at busy times. Problem The differential nursing diagnosis was between wandering as a problem and ordinary walking. Nursing care needed to be planned accordingly. Management and documentation The nursing-care plan and documentation is discussed below (see page 291). Family involvement Mrs Elles family members timed their visits to enable them to be with her to sit, talk, and listen to music. Her daughter was able to introduce relaxation massage gradually. Progress Mrs Elles wanderings continued for some weeks after surgery for a fall, then slowed, and eventually stopped as her general health deteriorated. Her balance and stamina became impaired. She was eventually conned to her chair, and then to her bed, prior to her death.

291 Appendix 8 Wandering

Documentation for this case study


Nursing-care plan
A family conference was held at which Mrs Elles care was discussed. Quality of life was the predominant concernand for Mrs Elle that meant freedom. Strategies were implemented to promote dignity and safe mobility. These included: neat clothing and grooming; properly applied footwear; attention to environmental needsincluding clear pathways on her walking routes with appropriately closed doors; minimisation of distractions and interruptions that could deflect her concentration. ensuring that she was occupied or gently redirected at assessed problem timesfor example, by short garden walks. Restraint was not considered to be an option. Mrs Elles full nursing-care plan is shown below.
Date 31 Dec. 2005 Problems and needs Wandering
Potential for absconding Closed-in Refusal to cease walking most of the day Unable to stop Disorientation Maintain safety Maintain mobility Maintain quality of life and freedom Reduce potential for falls Adhere to security measures Monitor whereabouts Use calm approach and maintain a calm environment Monitor carefully for fatigue Encourage use of hand-rail Reduce distractions and obstacles Use sensor mat at night to indicate need for intervention

Goals

Interventions and strategies

(continued)

292 Nursing Documentation (continued)


Date 31 Dec. 2005 Problems and needs Intrusive behaviour
With others belongings Entering rooms Confusion Anxiety Looking for someone Maintain dignity, dressing, and grooming Maintain privacy of others Staff be aware of Mrs Elles whereabouts Staff distinguish problems from safe, casual walking Maintain safety; minimise agitation Ensure staff understand her routine and adhere to it Minimise problem wandering by monitoring whereabouts Attending to daily needs such as toileting, meals, snacks Orientate and trial cues such as family photos Check for comfort such as resettle with toileting or hot drink Encourage Mrs Elle to sit and chat with volunteer or family

Goals

Interventions and strategies

31 Dec. 2005 Restlessness


Prowling Potential danger of injury from falls Potential escalation to other behaviours

References
Preface
ANCI, see Australian Nursing Council. Australian Nursing Council 2000, ANCI National Competency Standards for the Registered Nurse, 3rd edn, ANCI, Dickson, ACT, Australia.

Chapter 1 Understanding Nursing Documentation


ANCI, see Australian Nursing Council. Australian Nursing Council 2000, ANCI National Competency Standards for the Registered Nurse, 3rd edn, ANCI, Dickson, ACT, Australia. Hall, P. 1995, Values Shift, Twin Light Publishing, USA. Norris, J. (ed.) 1994, Mastering Documentation, Springhouse Corporation, USA. Schon, D. 1987, Educating the Reective Practitioner, Jossey-Bass Inc., USA.

Chapter 2 Clinical Reasoning


Aidroos, N. 1991, Use and eectiveness of psychiatric care plans, Journal of Advanced Nursing, 16(2): 17781. Benner, P. 1984, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Addison-Wesley, Menlo Park, California. Brider, P. 1991, Who killed the nursing care plan?, American Journal of Nursing, May: 359. Brosnahan, J. & Tracy, C. 2002, Report on the 3rd Australasian Joanna Briggs Institute Colloquium for Evidence-Based Nursing and Midwifery, Contemporary Nurse, 13(1), 6176.

294 References Greenwood, J. 1998a, Theoretical approaches to the study of nurses clinical reasoning: Getting things clear, Contemporary Nurse, 7(3): 11016. Greenwood, J. 1998b, Establishing an international network on nurses clinical reasoning, Journal of Advanced Nursing, 27(4): 8437. Mason, C. 1999, Guide to practice or load of rubbish? The inuence of care plans on nursing practice in ve clinical areas in Northern Ireland, Journal of Advanced Nursing, 29(2): 3807. Radwin, L.E. 1996, Knowing the patient: a review of research on an emerging concept, Journal of Advanced Nursing, 23(6): 11426.

Chapter 3 Professional Communication


Bennett, V. & Mathieson, I. 2002, Eective Leader: Balance Your Mind, Body and Spirit, Harper Collins, Australia. Masters. D. 2003, How does a consultant become a professional?, Management Today, January/February. Senge. P., Kleiner, A., Roberts, C, Ross, R.B. & Smith, B.J. 1994, The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization, Nicholas Brealey, London. Whitmore. J. 2002, Coaching for Performance, Nicholas Brealey, London.

Chapter 4 Nursing Care Plans


Axford, R. 1995, The Context of Nursing Care Delivery, in Nolan, A. & Hazelton, L. (eds), The Practising Nurse, W.B. Saunders/Baillire Tindall, Sydney. American Nurses Association 1994, Nursing Agenda for Health Care Reform, ANA Publications, Washington D.C. Bonn, K.L. 1999, Partnering with the Resident, Nursing Homes, vol 48 (4), pp 889. Canadian Nurses Association 1988, Health for All Canadians: A call for health care reform, CNA, Ottawa. Caplan, G. 1964, Principles of Preventive Psychiatry, Basic Books, New York. Chiarella, M. 2002, The Legal and Professional Status of Nursing, Churchill Livingston, Edinburgh. Coker, E. 1998, Does Your Care Plan Tell My Story? Documenting Aspects of Personhood in Long-Term Care, Journal of Holistic Nursing, 16: 4, pp 43552. Daly, J.M., Buckwalter, K. & Maas, M. 2002, Written and Computerised Care Plans, Journal of Gerontological Nursing, 28: 9, pp 1426. Grant, N.K 1979, Time to Care, Royal College of Nursing of the United Kingdom, London. International Council of Nurses 1994, in WHO, Partners for Mental Health: The Contribution of Professionals and Non-Professionals to Mental Health, World Health Organization, Geneva. Klitch, B.A. 2000, Stang to Avoid Deciencies, Nursing Homes, 49: 10, pp 1416.

295 References Lewis, S.M., Heitkemper, M.M. & Dirksen, S.R. 2000, Medical Surgical Nursing, Mosby Inc., St Louis. McCoppin, B. & Gardner 1994, Tradition and Reality, Longman Group UK Limited, Melbourne. Meleis, A.I. 1997, Theoretical Nursing: Development and Progress, Lippincott Williams & Wilkins. Neuman, B. & Young, R.J. 1972, A Model for Teaching Total Person Approach to Patient Problems, Nursing Research, 21(3) p. 264. Orem, D.E. 1971, Nursing: Concept of Practice, McGraw-Hill, New York. Roper, N., Logan, W. & Tierney, A. 1996, The Elements of Nursing: A Model for Nursing Based on a Model of Living, 4th edn, Churchill Livingston, New York. Roy, C. 1987, Roys Adaption Model, in R.R. Parse, Nursing Science: Major Paradigms Theories and Critiques, W.B. Saunders, Philadelphia. Royal College of Nursing 1994, Public Health: Nursing rises to the challenge, RCN, London. RCNA 1996, Credentialling Advanced Nursing Practice and Accreditation of Continuing Education Programs: an Exploration of Perspectives, Discussion Paper No. 4, prepared by Gibson, T. & Lawson, D., RCNA, Deakin, ACT. Saunders, R.B. 1999, Said Another Way: Are You an Academic Cowboy?, Nursing Forum, 34: 4, pp 2934. Schulz, S. 1992, Care in the Community, in Cuthbert, M., Dueld, C., Hope, J. (eds), Management in Nursing, Harcourt Brace Jovanovic, Sydney. Schulz-Robinson, S.A. 1997, A Political Imperative: Making Nurses Work Visible by Documentation, in Richmond, J. (ed), Nursing Documentation: Writing What We Do, Ausmed Publications, Melbourne. Wicks, D. 1999, Nurses and Doctors at Work, Allen & Unwin, St Leonards. World Health Organization 1993, Nursing in Action: Strengthening Nursing and Midwifery to Support Health for All, J Salvage (ed.), WHO regional publications, European series, No. 48, World Health Organization, Copenhagen. Yura, H. & Walsh, M. 1973, The Nursing Process: Assessing, Planning, Implementing and Evaluating, Appleton-Century-Crofts, New York.

Chapter 5 Progress Notes


Aged and Community Care Division, Commonwealth Department of Health and Aged Care 1998, Documentation and Accountability Manual: Commonwealth of Australia. RDNS, see Royal District Nursing Service. Richmond, J. 1997 (ed.), Nursing Documentation: Writing What We Do, Ausmed Publications, Melbourne. Royal District Nursing Service 2000, Competent Caring, 2nd edn, Australian Remote and Rural Training Systems.

296 References

Chapter 6 Clinical Pathways


Brereton, L. 1999, Too much documentation in aged care (letter to the editor), Australian Nursing Journal, vol. 6, no. 10, p. 3. Cesta, T. 1993, The Link Between Continuous Quality Improvement and Case Management, Journal of Nursing Administration, vol. 23, no. 6, p. 55. Choong, P.F.M., Langford, A.K., Dowsey, M.M. & Santamaria, N.M. 2000, Clinical pathway for fractured neck of femur: a prospective, controlled study, Medical Journal of Australia, vol. 172, pp 4236. Department of Veterans Aairs 2001, Guidelines for the Provision of Community Nursing Care, Section 2: 37. Dowsey, M., Kilgour, M., Santamaria, N. & Choong, P. 1999, Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study, Medical Journal of Australia, vol. 170, pp 5962. DVA, see Department of Veterans Aairs Falconer, J., Roth, E., Sutin, J., Strasser, D. & Chang, R. 1993, The Critical Path Method in Stroke Rehabilitation: Lessons from an Experiment in Cost Containment and Outcome Improvement, Quality Review Bulletin, vol. 8, no. 16, p. 10. Frink, B. & Strassner, L. 1996, Variance Analysis, in Flarey, D. & Blancett, S. (eds), Handbook of Nursing Case Management: Health care delivery in a world of managed care, Gaithersburg Aspen, USA. Ham, J. 1999, A Literature Review of Critical Pathways in the Health Setting & their Application in Smaller Hospitals in Rural Areas, <www.dhs.vic.gov.au/ahs/qualfund/ litrev.doc>. Ham, J. 2001, Critical Pathways for smaller hospitals in rural areas, Australian Health Review, vol. 24, no. 1, pp 1004. Hampton, D. 1993, Implementing a Managed Care Framework Through Care Maps, JONA, vol. 23, no. 5, pp 217. Shorten, A. & Wallace, M. 1997, Evidence-based practice: when quality counts, Australian Nursing Journal, vol. 4, no. 11, pp 267. Zander, K. & McGill, R. 1994, Critical & Anticipated Recovery Paths: Only the Beginning. Eective Outcome Based Practice Demands Enhanced Knowledge and Skills, Nursing Management, vol. 25, no. 8, pp 3440.

Chapter 7 Documenting Behaviour and Emotion


Martin, A., Hinds, C. & Felix, M. 1999, Documentation practices of nurses in longterm care, Journal of Clinical Nursing, 8, pp 34552. Morency, C.R., Levko, S.E. & Dick, K.L. 1994, Research considerations: delirium in hospitalized elders, Journal of Gerontological Nursing, 20(8), pp 2430.

Chapter 8 Documenting Complementary Therapies


Loeb S. (ed.) 1992, Better DocumentationClinical Skillbuilders, Springhouse Corporation, Pennsylvania.

297 References McCabe P. (ed.) 2001, Complementary Therapies in Nursing and Midwiferyfrom vision to practice, Ausmed Publications, Melbourne. NHACT, see Nurses Handbook of Alternative & Complementary Therapies. Nurses Handbook of Alternative & Complementary Therapies 1999, Springhouse Corporation, Pennsylvania. Quirk L. 2003, Complementary Therapies, in Carmody S. & Forster. S. (eds), Aged Care Nursing: A Guide to Practice, pp 22535, Ausmed Publications, Melbourne.

Chapter 9 Documenting Pain Management


American Pain Society 1992, Principles of Analgesic Use in the Treatment of Acute and Cancer Pain, 3rd edn, Glenview, Illinois. APS, see American Pain Society. Bemis, P.A. & Armstrong, R. 2001, Pain Control at the Bedside, <www.nursing.ceu.com/NCEU/courses/painpb/index.htm>. Department of Veterans Aairs 2000, Take 5: Pain as the Fifth Vital Sign Toolkit, <www.vachronicpain.org/Downloads/pain5th vitalsignv2.PDF>. Gaston-Johansson, F., Johansson, B.S. & Johansson, N. 1999, Undertreatment of Pain in the Elderly: Causes and Prevention, Annals of Long-Term Care, 7[5], pp 1906. McCaery, M. 1968, Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions, UCLA Students Store, Los Angeles. McCaery, M. & Pasero, C. 1999, Pain Clinical Manual, 2nd edn, Mosby, St Louis. Melzack, R. 1987, The Short Form McGill Pain Questionnaire, Pain 30: 1917. Wong, D.L. 1997, Whaley & Wongs Essentials of Paediatric Nursing, 5th edn, Mosby, St Louis.

Chapter 10 Documenting Restraint


Lange, Diana 1994, Queensland Health Protective Assistance Guidelines December 1994, background paper prepared by G. Westwood to replace the provisions of Section 24(5) of the (Nursing Homes) Regulations 1982, circulated January 1995, authorised by Department of Health, Queensland, Australia. NBWA, see Nurses Board of Western Australia. Nurses Board of Western Australia 2004, Guidelines for the Use of Restraint in Western Australia, <www.nbwa.org.au/pdfs/nb_guidelines_restraint.pdf>. Stillwell E.M. 1993, Nurses Education Related to the Use of Restraints, Journal of Gerontological Nursing, 17(2), 2731. Wallace M. 1997, Restraint: some legal implications, Collegian, vol. 4 (2), April 1997, pp 1519, Royal College of Nursing, Australia.

Chapter 15 A Systems Model for Documentation


Bandman & Bandman 1998, in Beanland, C. & Schneider, Z. 1999, Nursing Research, p. 26, Mosby, Sydney.

298 References CGST, see Clinical Governance Support Team. Cinahl 2004, <www.cinahl.com>. Clinical Governance Support Team 2004, <www.cgsupport.nhs.uk>. Cochrane Collaboration 2004, <www.cochrane.org>. Como, D. (ed.) 2002, Mosbys Medical Nursing & Allied Health Dictionary, 6th edn, Harcourt Health Sciences, USA. Daly, J., Speedy, S. & Jackson, D. 2000, Contexts of NursingAn Introduction, MacLennan & Petty, Australia. Forrester, K. & Griths, D. 2001, Essentials of Law for Health Professionals, Harcourt, Australia. HCi 2004, PDCA Cycle, <www.hci.com.au/hcisite2/toolkit/pdcacycl.htm>. Kozier, B., Erb, G. & Olivieri, R. 1991, Fundamentals of Nursing Concepts, Processes and Practice, 4th edn, Addison-Wesley Publishing, USA. Medline 2004, <www.nci.nlm.nih.gov/entrez/query>. Richmond, J. (ed.) 1997, Nursing Documentation: Writing what we do, Ausmed Publications, Melbourne.

Index
abbreviations 6, 15, 65, 74, 136, 198, 202, 222 access to documentation accuracy of documentation
behaviour and emotion 97, 98, 101, 102, 105, 107, 108 clinical pathways 94 design of documentation 207 evaluation 176, 177, 180 incident reports 151, 166 nausea 271 nursing-care plans and 57, 61 pain management 123, 130, 133, 134 professional communication 33 progress notes and 64, 65, 67, 68, 71, 73, 74, 75, 77 restraint 149 sta issues 182, 185, 190, 191 stomal care 275 systems model 222, 232 understanding documentation 3, 5, 8

accountability of documentation

clinical pathways 90 clinical reasoning 23 incident reports 155 nursing-care paths 58, 59 nursing-care plans 58, 59 progress notes 71, 73, 74, 76 sta issues 188 systems model of documentation 216, 217, 222, 223, 228, 231, 238, 244 understanding documentation 6 clinical reasoning and 24, 28 complementary therapies 111, 112 nursing-care plans and 47, 59 professional communication and 43 progress notes and 63, 67 restraint 139, 140 sta issues 187 systems model 216, 220 understanding documentation 13, 16

accreditation 25. 47, 122, 141, 188, 190

activities of daily living 12, 115, 125, 127, 130, 256, 290, 292 activities programs 259 actual behaviour, recording of 1013, 1745 adult learning 121, 148, 236

300 Index

advertisements 183, 185 advocacy 33, 88, 135, 156 aect 99 aged-care nursing, perceptions of
clinical pathways and 85 dierent views of nursing 501 nursing-care plans and 556

assessments (continued)

Alzheimers disease 46 anger 98, 99, 100 anti-discrimination policies 121, 139, 1401, 181, 187 anxiety 25, 46, 52, 56, 98, 99, 100, 120, 133, 148, 269, 270, 271, 292 appeals policies 121, 139, 1401, 184, 185, 190 archives 75 aromatherapy 11718 arthritis 512, 53, 131, 132, 249, 250, 267. 279, 283 assessments (nursing process)
activities of daily living 12, 115, 125, 127, 130, 256, 290, 292 balance 87 behaviour and emotion 12, 87, 100, 101, 114, 142, 145, 177, 256, 258, 259 clinical assessment 12 clinical pathways 85, 867, 88, 90 clinical reasoning 29, 30 communication 114, 142 complementary therapies 110, 112, 113, 114 credentialling and 190 depression 12, 114, 142 elimination 12, 250, 2512, 269 environmental 256 evaluation and 179, 180 falls 87, 142 geriatric assessment 54, 255 hearing 12, 128 hydration 114, 177 incident reports 156 manual handling 12 mini-mental 114, 142

attitudes of sta

mobility 12, 114, 142 nausea 268, 269, 270, 271 nursing-care plans and 31, 46, 47, 48, 56, 57, 60 nutrition 12, 114, 177, 288 pain 12, 114, 12430, 131, 135, 177, 201, 256, 269 PEG feeding 286 physiotherapy 12, 87 progress notes 63, 64, 69, 70, 72, 77 restraint 138, 139, 1412, 145 safety risk 12 sensory 12, 114, 123, 142, 155, 177 sexual health 12 skin 12, 114, 256 sleep patterns 12. 114, 142, 256, 265 social 110, 112, 11314, 257, 258 special senses 114, 142 speech therapy 288 stoma 274 systems model and 212, 214, 218, 2368, 242 ulcer 280, 281, 2823 understanding documentation 12 urinary 178, 269 visual 12 wandering 290, 291 wounds 114, 177 clinical pathways 89, 90 clinical reasoning and 27 nursing-care plans and 56 pain management 134 professional communication 35, 36, 379, 40, 41, 42, 43 reliability 33, 257, 258 systems model and 209, 210, 212, 213, 2278, 234, 235 understanding documentation 4, 15, 1617

attrition of sta 182, 183, 1868, 191 auditing


design of documentation 199

301 Index

auditing (continued)

nursing-care plans 47 professional communication 32, 39, 43 progress notes 64 restraint 145, 147 systems model and 212, 224, 237, 238, 23940, 2412 understanding documentation 10, 11

behaviour and emotion (continued)


restraint 142, 145 sleep patterns 1034 social history 98, 101, 103 sundowner syndrome 103 systems model 241 timeliness 107 wandering 292

balance assessment 87 behaviour and emotion 97108, 2559

accuracy 97, 98, 101, 102, 105, 107, 108 aect 99 anger 98, 99, 100 anxiety 100 asking questions 99100 assessments (nursing process) 12, 87, 100, 101, 114, 142, 145, 177, 256, 258, 259 astute nursing 98, 100, 1067 basic functions 1035 behaviour, describing 101 behaviour, documenting 1013 behavioural management case study 2559 cognitive state 98, 99, 100, 103, 106, 108 complementary therapies 114 delirium 97, 98, 104, 107 dementia 98, 101, 103, 105 depression 98, 103, 104, 108 emotion 98100 empathy 98, 100 evaluation and 170, 171, 174, 177 food intake 1034, 105 individualising care 101 nursing-care plans and 48, 52, 60, 259 nurses emotional responses 100 objectivity 100 pain management 98, 104, 125, 130 professionalism 98, 105, 107, 108 progress notes 77 quality care and 97 recognising clues 989 recording actual behaviour 1013 recording change 103 reliability 98

behavioural-modication programs 170, 257, 258, 259 benchmarking 9, 1011, 120, 147, 187, 212, 214, 235, 240 best practice
clinical pathways 80, 83, 84, 90, 92 clinical reasoning 19, 24, 29, 30 nursing-care paths 58 nursing-care plans 58, 60 pain management 134 progress notes 60, 66 systems model 211, 213, 214, 228, 235, 239, 240, 244 understanding documentation 5, 10, 13

blank spaces and lines 6, 65, 136 blood glucose 177, 2625, 283 blood pressure 119, 170, 175, 176, 177, 178, 250, 283 building maintenance and safety 147, 153, 1589, 166 cancer 46, 132, 273, 283 cardiac failure 53, 273 care pathways see clinical pathways care plans see nursing-care plans change agents 9, 13, 215 charting-by-exception 66, 67, 68, 701, 72 clinical governance 21115, 216, 233 clinical pathways 7995
access 90 accuracy 94 advocacy 88 aged-care nursing, perceptions of 85 assessments (nursing process) 85, 867, 88, 90

302 Index

clinical pathways (continued)

attitudes of nurses 89, 90 best practice 80, 83, 84, 90, 92 cognitive impairment 88, 89 continuity of care 89 denitions of terms 803 dementia 88, 89 depression 87 design and implementation 914 education 81, 92 eective documentation and nursing 79, 81, 83, 86 evaluation 82, 85 evidence-based pathways 79, 81 evidence-based practice 79, 81, 83, 85, 86, 90, 92 falls 87 funding 89 guidelines 823 health outcomes 823 holistic care 86, 89 implementation 58, 82, 83, 84, 85, 86, 91, 92, 93, 94, 95 individualising care 83, 86, 87, 88 interventions 79, 80, 81, 83, 87, 88, 90 management and organisational issues 79, 80, 82, 84, 90, 914, 95 multidisciplinary teams 80, 81, 83, 84, 85, 86, 87, 88, 90, 91, 92, 93 nursing-care plans and 45, 589, 85, 90 objectives and results 834 professionalism 79, 81, 85, 90, 94 qualications of sta 89 quality outcomes and improvement 79, 82, 83, 84, 85, 86, 90, 94 referrals 83, 85, 867 reliability 87 research 92 resident-centred care 80, 82, 83, 85, 86, 889, 94 resident pathway 81 social issues 86 sta satisfaction 85, 86, 90 streamlined documentation 85, 86, 8990

clinical pathways (continued)

clinical reasoning 1930

timeliness 84 validity 81, 87 values and value judgments 81 variance and variance analysis 80, 82, 84, 85, 93, 94

access 23 accountability 24, 28 assessments (nursing process) 29, 30 attitudes of sta 27 best practice 19, 24, 29, 30 communication and 23, 24, 25 conicts with documentation requirements 248 decision theory 20, 21 denition of 19 dementia and 20 diering expectations 278 education 30 eective documentation and nursing 22, 23, 289, 30 evaluation 28, 30 evidence-based practice 26, 28 experience and 19, 20, 21, 22, 23, 24, 25, 26, 27, 29 funding and 24, 28, 29, 30 group experience and 23 implementation 21, 22, 26, 30 individualising care 22, 23, 24, 29, 30 information-processing theory 201 initiative and innovation 28, 29 innovation in documentation 29, 30 interventions 20, 22, 25 legal requirements 28 management and organisational issues 22, 25, 28, 29 nursing-care plans and 21, 247 nursing teams 23, 25, 26, 27 political factors 19, 24, 278 professionalism 19, 25, 27, 28, 29 quality control and improvement 26, 29, 30 regulatory requirements 19, 26, 27, 28, 29, 30

303 Index

clinical reasoning (continued)

coaching 378 Cochrane Collaboration 217, 218 codes of practice


see also ethics, professionalism

skills-acquisition theory 19, 212 social issues 19, 24 sundowner syndrome 20 theoretical plans and clinical experience 247 three theories of 1922 understanding of those in care 20, 21, 224, 29 validity 21, 23, 27

complementary therapies (continued)

cognitive state

codes of conduct 2, 9, 14, 138 codes of ethics 323, 43, 223 codes of professional practice 2, 32, 334, 43, 59

commercially designed forms 182, 193 communication see professional communication complaints 17, 26, 67, 75, 133, 155, 182, 189, 216, 240 complementary therapies 10922
accountability 111, 112 accreditation 122 anti-discrimination 121 appeals 121 aromatherapy 11718 assessments (nursing process) 110, 112, 113, 114 behavioural patterns 114

behaviour and emotion 98, 99, 100, 103, 106, 108, 259 clinical pathways 88, 89 complementary therapies 116, 119 constipation 251 design of documentation 201 nursing-care plans 48 pain management 129, 130, 134 restraint 143, 147 systems model 235 understanding documentation 12

benchmarking 120 care plans 110. 113, 114, 11719 cognitive state 116, 119 communication 114 condentiality 120 consents and authorities 110, 113, 114, 11516, 117 dates and time 115, 116, 118 denition of 109 depression 114 education 110, 113, 120, 121 eective documentation and nursing 115, 119, 121 ethical issues 110, 120 evaluation 109, 110, 113, 117, 11920, 121 evidence-based practice 110 grievances 121 holistic care 110, 111, 122 hydration assessment 114 implementation 109, 110, 111, 112, 119, 121 individualising care 115 legal issues 11011, 11517 management and organisational issues 109, 110, 111, 112, 114, 117, 120, 121 medication 113 mini-mental examination 114 mission statement 111 mobility 114 multidisciplinary teams 111 nutritional assessment 114 occupational health and safety 111, 112 pain assessment 114 planning 109, 110 policies, procedures, and protocols 110 112, 113 professionalism 111, 115, 116 programs 110, 113, 114115, 119 qualications of sta 111, 112, 117, 121 quality improvement 115, 122 referrals 114 regimens 111, 117, 118 research 120

304 Index

complementary therapies (continued)


resident-centred care 111, 115, 122 resources 111, 112 signatures and designations 110, 114, 116117, 120 skin assessment 114 sleep patterns 114 social issues 110, 11214, 115, 120 special senses 114 spiritual issues 113 validity 120 vision statement 111 wound assessment 114, 119 complementary therapies 120 incident reports 155, 156, 165 progress notes 74, 756 restraint 147 systems model 2223 understanding documentation 5, 8 wandering 292

CroftonWitney model for documentation 20944 criterion-referenced evaluation 1701, 175 critical thinking 14, 46, 154, 166, 217, 218, 232, 2345 DAR charting method 70 data

condentiality and privacy

consent

constipation 52, 249, 250, 251, 253, 269, 270, 271, 276 continence programs 256 continuity of care
clinical pathways 89 evaluation and 170, 171, 17980 incident reports 153, 158 nursing-care plans 47, 59, 60 progress notes 64, 66, 67, 68, 73 understanding documentation 3

complementary therapies 110, 113, 114, 11516, 117 disciplinary issues 189 progress notes 74 restraint 138, 1424. 145 validity of 115, 116, 142, 143, 144

dates and time

analysis of 11 assessment of 64 bias in 147 clinical 77 collection of 10, 11, 66, 208, 225, 240 condentiality of 120, 147 databases 217, 218, 219, 229, 230, 231 electronic 182, 219, 229, 230, 231 evaluation of 10, 57, 120, 147, 171, 172, 173, 175, 177, 240 graphical 200, 201 interpretation of 71 objective 69 occupational health and safety 166 omission of 68 organisation of 11, 70 pain assessment 124 recording of 48 sociodemographic 112 subjective 69, 174, 188, 201 validity of 120, 176 variance in 82 complementary therapies 115, 116, 118 design of documentation 2034, 206, 207 incident reports 157 progress notes 65, 238 restraint 143, 145 systems model 222, 238, 240 understanding documentation 5, 6

copyright 207 corrections to documentation 6, 65, 135, 222 counselling 187, 227, 271 credentialling of sta 182, 183, 1901

decision theory 20, 21 delirium 97, 98, 104, 107, 123, 174 dementia

behaviour and emotion 98, 101, 103, 105, 255

305 Index

dementia (continued)

depression

clinical pathways 88, 89 clinical reasoning and 20 nursing-care plans 53, 54 pain management 123, 131, 201 wandering 285

design of documentation 193208

assessment 12, 114, 142 behaviour and emotion 98, 103, 104, 108, 258, 259 clinical pathways 87 complementary therapies 114 evaluation 174 nursing-care plans 46, 54, 59 pain management 123, 133 restraint 142 abbreviations 202 accuracy 207 capitalisation 2023 commercially designed forms 182, 193 computer software 197 copyright 207 dates 2034, 206, 207 graphical and pictorial representations 2002 identication of form 197, 198, 207 language 206 layout 197, 198, 205 legal aspects 193, 202, 207 logic 197, 198, 2067 multiple alternatives 2045 names 206 paper grade and size 1946 presentation 197, 198, 199205 principles of design 197207 professional nursing and 208 purpose of forms 1934, 197, 1989 review dates 207 signatures 2067 title 197, 198 trials 207 typefaces 197, 199200 yes/no answers 204

designation see signatures and designations destruction of records 6 diabetes 198, 2615, 273, 283 discipline of sta 181, 182. 183, 189 90, 191 diversional therapist programs 257 documentation
see also individual index entries

duty of care 3, 5, 10, 14, 68, 74, 141, 152, 154, 222 education and documentation
clinical pathways 81, 92 clinical reasoning 30

behaviour and emotion 97108, 2559 clinical pathways 7995 clinical reasoning 1930 complementary therapies 10922 denition of 2 design of 193208 diabetes 2615 evaluative criteria 16980 faecal incontinence 24953 importance of 3 incident reports 15167 key terms 2 leg ulcer management 27983 nausea 26772 nursing-care plans 4561 pain management 12336 PEG nutrition 2858 praxis 1314 principles of 65 professional communication 3143 progress notes 6377 purposes of 3, 634 restraint 13749 sta issues 18191 stomal care 2737 streamlined documentation 85, 86, 8990 systems model of 20944 understanding documentation 117 wandering 28992

306 Index

education and documentation (continued)

educational programs 11, 64, 92, 121, 148, 190, 2346 eective documentation and nursing

complementary therapies 110, 113, 120, 121 credentialling of sta 182, 183, 1901 diabetes 265 incident reports 156 nursing-care plans 57 pain management 1334, 135 professional communication 30, 31, 40 progress notes 64, 69 restraint 138, 139, 1478 sta issues 187, 189, 190 systems model 212, 215, 220, 232, 2346, 237, 239, 240 understanding documentation 2, 3, 8, 11, 14, 16

errors see corrections to documentation ethics

evaluation and evaluative criteria 16980

codes of ethics 323, 43 complementary therapies 110, 120 nursing-care plans and 60 professional communication 323, 43 progress notes 67, 745 restraint 138, 1401, 147 systems model 219, 223, 227 understanding documentation 2, 67, 8, 17

electronic documentation 76, 182, 217 elimination patterns 12, 48, 133, 177, 178, 180, 250, 2512, 269 emotion see behaviour and emotion empathy 50, 98, 100, 259 employee-assistance programs 186, 188 employment contract 185, 186, 187, 188 environmental assessment 256

clinical pathways 79, 81, 83, 86 clinical reasoning 22, 23, 289, 30 complementary therapies 115, 119, 121 design see design of documentation incident reports 151, 158, 160, 166 nursing-care paths 58 nursing-care plans 47, 51, 57, 58, 61 pain management 129, 1324, 135, 136 professional communication 31, 32, 35, 36, 40, 42, 43 progress notes 63, 64, 65, 76 restraint 147, 148 systems model 214

accepted rules 170 accuracy of documentation 176, 177, 180 actual behaviour, recording of 1013, 1745 assessments (nursing process) 179, 180 behaviour 170, 171, 174, 177, 259 blood glucose 177 blood pressure 170, 175, 176, 177, 178 clinical indicators 170, 171. 1779 clinical pathways 82, 85 clinical reasoning 28, 30 complementary therapies 109, 110, 113, 117, 11920, 121 continuous process 170, 171, 17980 credentialling 190 criterion-referenced evaluation 1701, 175 delirium 174 depression 174 elimination 177, 178, 180 emotions 174 evidence-based practice 169 falls 170, 172 formative evaluation techniques 170, 171, 172, 188 individualising care 172 language and value judgments 1745 mobilisation 170, 178 multidisciplinary team 180 norm-referenced evaluation 1702 nursing-care paths 58

307 Index

evaluation and evaluative criteria (continued)

evidence-based practice (continued)

evaluative criteria see evaluation and evaluative criteria evidence-based practice

nursing-care plans 46, 48, 57, 58, 214, 237, 242, 259 nutrition and hydration 177, 178, 180 objective measurements 169, 170. 171, 173, 174, 175 organisational issues 172 pain assessments 177 performance appraisals 188 professional communication 40, 41, 42, 175 progress notes 69 psychometric evaluations 177 pulse rate 177, 178 quality 180 reliability 170, 171, 173, 175, 176, 177 research 172 respiratory rate 177 restraint 138, 139, 145, 146, 147, 148 sensory assessments 177 stomal care 275 subjective measurements 170, 171, 1735 summative evaluation techniques 170, 171, 172, 173, 180 systems model 214, 217, 218, 229, 232, 233, 234, 237, 239, 242 temperature 177 understanding documentation 10, 11 urinalysis 177 urinary tract infections 170 validity 170, 171, 173, 175, 176, 177 values and value judgments 169, 1745 variances 176 weight 176 wound and skin assessments 177, 178

exercise programs 252 experience of nurses

leg ulcers 281 nursing-care plans 60 pain management 134 professional communication 39 systems model 211, 212, 213, 214, 21519, 233, 235 understanding documentation 5, 10

see also qualications of sta

clinical reasoning and 19, 20, 21, 22, 23, 24, 25, 26, 27, 29 understanding documentation 15, 16

faces-rating (pain) scale 12930, 201 faecal incontinence 24953 falls 52, 87, 102, 131, 142, 152, 170, 172, 262, 265, 290, 291, 292 feedback 21, 23, 32, 389, 185, 187, 207, 239 le management 756 uid and hydration 12, 48, 104, 114, 145, 155, 158, 170, 177, 178, 180, 2513, 264, 276, 287 focus charting 68, 70 food intake and nutrition 12, 48, 103, 104, 114, 130, 155, 177, 178, 180, 264, 2858 formative evaluation techniques 170, 171, 172, 188 fractures and sprains 131, 132 functional needs 48, 51 funding
clinical pathways 89 clinical reasoning and 24, 28, 29, 30 nursing-care plans 45, 56, 60 professional communication 31, 35 progress notes 63, 64, 73 systems model 211, 244 understanding documentation 1, 3, 4, 17

clinical pathways 79, 81, 83, 85, 86, 90, 92 clinical reasoning 26, 28 complementary therapies 110 evaluative criteria 169 incident reports 161

gap analysis 3941 geriatric assessment 54, 255

308 Index

glucose (blood) 177, 2625, 283 government regulation see regulatory requirements graphs 175, 2001, 202, 219, 290 grievance rights 121, 139, 1401, 190 handbooks 115, 184, 186, 218, 230 hazards 145, 153, 157, 159, 160. 161, 164, 169 healthcare teams see multidisciplinary teams hearing assessment 12, 128 holistic nursing practice
clinical pathways 86, 89 complementary therapies 110, 111, 122 professional communication 33, 345 progress notes 71 restraint 138 systems model 210. 236 understanding documentation 9, 12, 17

incentive programs 187 incident reports 15167

human-resource management 181, 191 hydration and uid 12, 48, 104, 114, 145, 155, 158, 170, 177, 178, 180, 2513, 264, 276, 287 immobility see mobility implementation

behavioural management 170, 258 clinical pathways 82, 83, 84, 85, 86, 91, 92, 93, 94, 95 clinical reasoning 21, 22, 26, 30 complementary therapies 109, 110, 111, 112, 119, 121 evaluative criteria 170. 179, 180 nursing-care paths 58 nursing-care plans 45, 48, 57, 58 professional communication 35, 36, 39, 41, 42, 43 restraint 139, 141 sta issues 188 systems model 211, 213, 216, 218, 220, 224, 228, 236, 237 understanding documentation 3, 14 wandering 291

access 155 accuracy 151, 166 advocacy 156 aged-care facilities 156 buildings 147, 153, 15859, 166 clinical issues 158 condentiality and privacy 155, 156, 165 continuity of care 153, 158 critical thinking 154, 166 dates and time 157 deciding what to report 1547 denition 152 duty of care 154 education 156 eective documentation and nursing 151, 158, 160, 166 falls 152 hazards 145, 153, 157, 159, 160. 161, 164 hospitality services 156 importance of 1534 individualising care 155 infection control 156 inventory management 151, 156. 159, 166 investigating incidents 1616 leadership 156 legal issues 152, 153, 158, 167 maintenance 151 management and organisational issues 151, 153, 154, 156, 157, 158, 159, 160, 162, 163, 166, 167 medication 155 mission statement 152 near misses 15960 nurses 156 occupational health & safety 151, 153, 156, 15966 policy 152 professionalism and 153, 154, 157 progress notes 745 quality control and improvement 164 recording reports 151, 158, 167 regulatory compliance 156

309 Index

incident reports (continued)

incontinence 46, 178, 249, 250, 251, 253, 274 individualising care
see also resident-centred care

reporting arrangements 157 research 161 residents 1546 responsibility 1579 restraint 145 risk see risk management safety triangle 160 sleep patterns 155 social issues 156 standard of care 152 understanding documentation 6, 8 vision statement 152

interventions (continued)

inventories 125, 130, 151, 156. 159, 166 jargon 15, 65, 222 language and jargon 15, 65, 99, 113, 136, 1745, 206 layout of documentation 197, 198, 205 leadership
incident reports 156 nursing-care plans 56, 57 professional communication 34, 40, 43 systems model 216, 220, 224 understanding documentation 2, 45, 10, 11, 17

pain management 135, 136 progress notes 67, 70, 71 restraint 143, 144, 147 systems model 241 wandering 2912

information-processing theory 201 initiative and innovation


clinical reasoning 28, 29 professional communication 34, 41, 42 systems model 216 understanding documentation 9

behaviour and emotion 101 clinical pathways 83, 86, 87, 88 clinical reasoning 22, 23, 24, 29, 30 complementary therapies 115 evaluative criteria 172 incident reports 155 nursing-care plans 45, 46, 47, 48, 49, 50, 52, 53, 55, 57, 58, 59, 60 professional communication 38 progress notes 71, 72 understanding documentation 9

leg ulcers 27983 legal issues

integrated progress notes 68, 70, 73 Internet 183, 222, 231, 232, 233 interventions

behavioural management 257, 258, 259 clinical pathways 79, 80, 81, 83, 87, 88, 90 clinical reasoning 20, 22, 25 leg ulcers 281 nausea 270, 271 nursing-care plans 48, 52, 67, 71, 241

legibility 5, 65, 74, 135, 222

clinical reasoning 28 complementary therapies 11011, 11517 consent 74, 110, 113, 114, 11516, 117, 138, 1424. 145 design of documentation 193, 202, 207 duty of care 3, 5, 10, 14, 68, 74, 141, 152, 154, 222 incident reports 152, 153, 158, 165, 167 nursing-care plans 48, 59 professional communication and 32 progress notes 63, 64, 66, 67, 68, 745, 76 restraint 138, 1401, 142, 143, 144, 149 sta issues 184, 185, 189, 190, 191 systems model of documentation 222, 223 understanding documentation 3, 56, 17

maintenance of equipment 139, 151, 1589, 164, 166 management and organisational issues
clinical pathways 79, 80, 82, 84, 90, 914, 95

310 Index

management and organisational issues (continued)

mobility (continued)

manual-handling assessment 12 medication


behavioural management 256 complementary therapies 113 diabetes 262, 263, 264, 265 faecal incontinence 250, 251, 253 incident reports 155 leg ulcer management 283 nausea 268, 269, 270, 271 nursing-care plans 48, 49, 53 pain management 127 PEG nutrition 285 progress notes 71 restraint 137, 139, 145

clinical reasoning 22, 25, 28, 29 complementary therapies 109, 110, 111, 112, 114, 117, 120, 121 costings 478 evaluation 172 incident reports 151, 153, 154, 156, 157, 158, 159, 160, 162, 163, 166, 167 nursing-care plans 45, 478, 50, 51, 55, 56, 60 professional communication 32, 33, 34, 358, 3941, 42, 43 progress notes 63, 64, 66, 70, 74, 756 restraint 138, 139, 140, 141, 142, 143, 145, 147 risk management see risk management systems model 20910, 211, 216, 21921, 2268 understanding documentation 12, 3, 4, 7, 8, 9, 11, 13, 1417

multidisciplinary teams
see also nursingteams

leg ulcers 280 nursing-care plans 46, 52, 53 pain management 125, 131 restraint 142, 144, 146 understanding documentation 12 wandering 291

clinical pathways 80, 81, 83, 84, 85, 86, 87, 88, 90, 91, 92, 93 complementary therapies 111 evaluation and evaluative criteria 180 nursing-care paths 58 nursing-care plans 54, 57, 58, 60 pain management 135, 136 professional communication 31, 33, 34, 40 progress notes 68, 69, 71, 72 restraint 138 systems model 219, 221, 237, 244 understanding documentation 2, 5, 6, 7, 8, 10, 11, 15, 16

narrative progress notes 68, 70, 713 nausea 26772 NCPs see nursing-care plans norm-referenced evaluation 1702 North American Nursing Diagnosis Association (NANDA) 47 numeric rating scales 119, 12530, 2012, 282 nurses and nursing
see also individual entries

mini-mental examination 114, 142 mission statements 111, 138, 152, 220 mobility

assessments (nursing process) 12, 114, 142 behavioural management 256 complementary therapies 114 evaluation 170, 178, 180 faecal incontinence 249, 250, 251, 252 incident reports 155

aged-care nursing see aged-care nursing, perceptions of astute nursing 523, 98, 100, 1067, 132 attitudes of see attitudes of sta documentation see documentation designation 5, 65, 110, 135 dierent views of nursing 501 discipline of sta 181, 182. 183, 18990, 191 emotional responses of 100 erroneous beliefs re pain 133, 134

311 Index

nurses and nursing (continued)

nursing-care plans (NCPs) 4561

holistic care see holistic nursing practice interventions see interventions nursing-care plans see nursing-care plans (NCPs) nursing diagnosis 46 nursing notes 48 nursing problems 46 nursing process 46 nursing teams 23, 25, 26, 27, 34, 40 performance appraisal 181, 182, 183, 187, 188, 191 progress notes see progress notes qualications see qualications of sta registration bodies 111, 138, 141 sta issues see sta issues, documentation of verbal tradition of 47, 49, 222 visibility of work 47, 59 access 58, 59 accountability 47, 59 accreditation 47 accuracy 57, 61 aged-care nursing undervalued 556 anxiety 46 Alzheimers disease 46 arthritis 512, 53 assessments (nursing process) 31, 46, 47, 48, 56, 57, 60 attitudes of sta 56 auditing 47 behaviour and emotion 48, 52, 60 benets of NCPs 478 best practice 58 care pathways 45, 589 cancer 46 cardiac failure 53 clinical audits 47 clinical pathways and 45, 589, 85, 90 clinical reasoning and 21, 247 codes of practice 59 cognitive state 48 communication 48, 57

nursing-care plans (NCPs) (continued)

complementary therapies 110. 113, 114, 11719 constipation 52 continuity of care 47, 59, 60 critical analysis 46 dementia 53 depression 46, 54, 59 dierent views on nursing 501 education 57 eective documentation and nursing 47, 51, 57, 58, 61 elimination patterns 48 emotional state 48, 52, 60 empathy 50 ethical responsibility 60 evaluation 46, 48, 57, 58, 242, 259 evidence-based practice 60 falls 52 uid balance 48 food intake 48 functional independence 48 funding 45, 56, 60 implementation 45, 48, 57, 58 incontinence 46 individualising care 45, 46, 47, 48, 49, 50, 52, 53, 55, 57, 58, 59, 60 interventions 48, 52, 67, 71 leadership 56, 57 legal issues 48, 59 management and organisational issues 45, 478, 50, 51, 55, 56, 60 medication 48, 49, 53 multidisciplinary teams 54, 57, 58, 60 nursing diagnosis 46 nursing notes 48 nursing problems 46 nursing process 46 observations 46 objectivity 48 Parkinsons disease 46 problem-intervention statements 48 problems with NCPs 4850 professionalism 45, 478, 50, 51, 54, 55, 58, 59, 60

312 Index

nursing-care plans (NCPs) (continued)

nutrition and food 12, 48, 103, 104, 114, 130, 155, 177, 178, 180, 264, 2858 objectivity
behaviour and emotion 100 evaluation 169, 170, 171, 173, 174, 175 nausea 268 nursing-care plans 48 pain management 201 progress notes 69 restraint 147, 148 stomal care 275 systems model for documentation 217, 222, 233 understanding documentation 5

progress notes and 67, 71, 72, 77 qualications of sta 49, 50, 53, 57, 60, 61 quality improvement 47, 60 referrals 58 resident-centred care 50, 517, 59 restraint 138, 1445, 146 SOAPIE system 48 social issues 46, 52, 53, 54, 56, 58, 60 sta/resident ratios 50, 57 systematic assessment 46, 48 systems model and 212, 214, 218, 238 temperature 48 understanding documentation 9, 15 urinary tract infection 52, 53 values and value judgments 49, 58 verbal tradition of nurses 47, 49 visibility of nurses work 47, 59

osteoarthritis 131, 132, 279 pain management 12336


accuracy 123, 130, 133, 134 activities of daily living 125 advocacy 135 anxiety 133 assessments (nursing process) 12, 114, 12430, 131, 135, 177, 201, 256, 269 attitudes of nurses 134 barriers to communication and documentation 1324 behaviour and emotion 98, 104, 255, 256, 259 best practice 134 cognitive state 129, 130, 134 complementary therapies 114 corrections 135 denition of pain 123 delirium 123 dementia 123, 131 depression 123, 133 design of documentation 201, 202 diagram of body 202 education about pain 1334, 135 eective documentation and nursing 129, 1324, 135, 136 emotional state 125, 130 erroneous beliefs of nurses 133, 134 evaluation and evaluative criteria 177, 178 evidence-based practice 134 faces-rating scale 12930 faecal incontinence 249, 250 fractures and sprains 131, 132 incidence of pain 1234 interventions 135, 136 language and jargon 136 legibility 135 leg ulcers 282 medication 127 mobility 125, 131 multidisciplinary teams 135, 136 myths 132, 133 nausea 269, 270

observations 46 occupational health and safety

organisational issues see management and organisational issues

complementary therapies 111, 112 incident reports 151, 153, 156, 15966 programs 164 restraint 139, 140, 141 sta issues, documentation of 181 systems model 223

313 Index

pain management (continued)

Parkinsons disease 46 pathways see clinical pathways PEG nutrition 2858 performance appraisal 181, 182, 183, 187, 188, 191 peripheral vascular disease 131, 132 peripheral neuropathies 131, 132 permanency of documentation 5, 63 physiotherapy assessment 12, 87, 252, 262 policies, procedures, and protocols
clinical pathways 80, 84, 85, 91. 92, 93, 94 clinical reasoning 29 complementary therapies 110112, 113, 121 incident reports 145, 152, 153, 154, 155, 156, 157, 164, 165 nursing-care plans 45, 47 occupational health and safety 164 pain management 1346 professional communication 40 progress notes 63, 66, 67, 76 restraint 13841, 1434, 145, 146 systems model and 211, 212, 213, 218, 2268, 234

numeric rating scales 119, 12530, 2012, 282 nutrition 130 objectivity 201 osteoarthritis 131, 132 peripheral vascular disease 131, 132 peripheral neuropathies 131, 132 procedures for pain documentation 1346 professionalism 134 quality control 136 reliability 125, 130 signatures and designations 135 sleep patterns 125, 127, 130, 133 social issues 125, 131, 133, 135 unrecognised pain 1302 validity 125, 130 values and value judgments 134, 136 wandering 131

policies, procedures, and protocols (continued)

political factors 8, 19, 24, 278 privacy see condentiality and privacy problem-intervention statements 48 problem-oriented documentation 689, 70 procedures see policies, procedures, and protocols professional communication 3143
see also professionalism

understanding documentation 8, 10, 14, 16

accountability 43 accuracy 33 advocacy 33 analysis and 32 assessing the system 367, 3841, 43 attitudes of sta 35, 36, 379, 40, 41, 42, 43 auditing and 32, 39, 43 coaching 378 clinical reasoning and 23, 24, 25 codes of ethics 323, 43 codes of professional practice 32, 334, 43 education and 30, 31, 40 eective documentation and nursing 31, 32, 35, 36, 40, 42, 43 ethics 323, 43 evaluation 40, 41, 42 evidence-based practice 39 feedback 389 funding and 31, 35 gap analysis 3941 holistic nursing 33, 345 implementation 35, 36, 39, 41, 42, 43 individualising care 38 initiative and innovation 34, 41, 42 leadership 34, 40, 43 legal requirements and 32 management and organisational issues 32, 33, 34, 358, 3941, 42, 43 nursing-care plans and 48, 57 professional practice 32, 334, 43 progress notes 63, 64, 73 quality control 3941

314 Index

professional communication (continued)

programs (continued)

professionalism

reection and 32 regulatory requirements 40, 43 research and 32, 43 risk management 412 systems model and 32, 33, 34, 35, 3840, 43, 227 timeliness 34 understanding documentation 3, 11 validity 32 values and value judgments 32, 37, 38

see also professional communication

programs

behaviour and emotion 98, 105, 107, 108 clinical pathways 79, 81, 85, 90, 94 clinical reasoning and 19, 25, 27, 28, 29 codes of conduct 9 codes of ethics 323, 43 codes of professional practice 32, 334, 43, 59 communication see professional communication complementary therapies 111, 115, 116 design of documentation 208 evaluation 40, 41, 42, 175 incident reports 153, 154, 157 multidisciplinary teams 31, 33, 34, 40 nursing-care plans and 45, 478, 50, 51, 54, 55, 58, 59, 60, 238 pain management 134 professional practice 32, 334, 43 progress notes 63, 64, 66, 67, 68, 73, 77 restraint 138, 141, 142 sta issues 188, 191 standards of practice 2, 9, 17 systems model 209, 210, 213, 215, 216, 218, 222, 223, 235, 236, 237, 238, 239, 244 understanding documentation 2, 5, 7, 8, 9, 10, 13, 14 activities 259 behavioural modication 170, 257, 258, 259

progress notes 6377

complementary therapies 110, 113, 114 115, 119 continence 256 diversional therapist 257 educational 11, 64, 92, 121, 148, 190, 2346 employee-assistance program 186, 188 exercise 252 faecal incontinence 252 incentive program 187 leg ulcers 280 occupational health and safety 164 quality improvement 10 restraint 148 volunteer program 259 word-processing 197 abbreviations 65, 74 access 66, 71, 73, 74, 76 accountability 63, 67 accuracy 64, 65, 67, 68, 71, 73, 74, 75, 77 archiving 75 assessments (nursing process) 63, 64, 69, 70, 72, 77 audits 64 behaviour and emotion 77 best practice 60, 66 blank spaces 65 charting-by-exception 66, 67, 68, 701, 72 communication 63, 64, 73 condentiality 74, 756 consent 74 continuity of care 64, 66, 67, 68, 73 corrections 65 DAR charting method 70 dates and time 65 education 64, 69 eective documentation and nursing 63, 64, 65, 76 electronic documentation 76 emotional aspects 77 ethical issues 67, 745 evaluation 69

315 Index

progress notes (continued)

protocols see policies, procedures, and protocols

le management 756 frequency and quality 668 focus charting 68, 70 funding 63, 64, 73 holistic nursing care 71 incident reports 745 individualising care 71, 72 integrated progress notes 68, 70, 73 interventions 67, 70, 71 language and jargon 65 legal requirements 63, 64, 66, 67, 68, 745, 76 legibility 65, 74 management and organisational issues 63, 64, 66, 70, 74, 756 medication 71 multidisciplinary teams 68, 69, 71, 72 narrative progress notes 68, 70, 713 nature of 66, 767 nursing-care plans and 67, 71, 72, 77 nursing interventions 67 objectivity 69 principles of documentation 65 problem-oriented documentation 689, 70 professionalism 63, 64, 66, 67, 68, 73, 77 purposes of documentation 634 quality improvement 63, 64, 65 referrals 69 research 76 resident-centred care 63 responsibility for 66 signatures and designation 65, 745, 76 SOAP charting method 68 social issues 77 source-oriented health records 713 spiritual aspects 77 standards of practice 63 storage 66, 756 systems model 212, 218, 2389 timeliness 678, 75 validity 76 values and value judgments 74

publishing 11, 203, 212, 2424 pulse rate 119, 175, 177, 178, 283 qualications of sta
see also education; experience of nurses

quality control and improvement

clinical pathways 89 complementary therapies 111, 112, 117, 121 credentialling of sta 182, 183, 1901 nursing-care plans 49, 50, 53, 57, 60, 61 restraint 148 sta issues 187, 190 understanding documentation 10, 15, 16 behaviour and emotion 97 clinical pathways 79, 82, 83, 84, 85, 86, 90, 94 clinical reasoning 26, 29, 30 complementary therapies 115, 122 evaluation and evaluative criteria 180 incident reports 164 nursing-care plans and 47, 60 pain management 136 professional communication and 3941 programs 10 progress notes and 63, 64, 65 systems model and 211, 212, 213, 2246, 234, 244 understanding documentation 3, 7, 9, 10

reasoning see clinical reasoning records

see also clinical paths; nursing-care plans; progress notes

accessibility 7, 23, 58, 59, 71, 73, 74, 76, 90, 155 accuracy of see accuracy of documentation behaviour and emotion 97, 101, 102, 103, 107, 225 clinical pathways 89 complementary therapies 110, 113, 115, 116, 118, 121 design of documentation 193, 200, 201, 202, 204, 206, 208 destruction of 6

316 Index

records (continued)

referrals

diabetes 263 discipline 189 educational 110, 113, 121, 138, 139, 148, 188, 189, 190 electronic 182 evaluation 171, 172, 176, 177, 180, 242 health 116, 143, 172, 223 incident reports 151, 154, 157, 158, 159, 161, 165, 166, 167 leg ulcer 281 nausea 268, 271 nursing-care plan 238 pain management 127, 131, 132, 134 permanency of 5 personnel 189 progress notes 756, 77, 238, 242 resident 77, 131, 132, 172, 223 responsibility for 66 restraint 138, 139, 143, 145, 148 sta appraisals 188 sta issues 184, 185, 188, 189, 190, 191 sta selection 184, 185 stomal care 287, 288 storage of 6, 66, 756 systems model 210, 213, 214, 216, 222, 223, 233, 238, 242 clinical pathways 83, 85, 867 complementary therapies 114 incident reports 156 leg ulcers 283 nursing-care paths 58 nursing-care plans 58 progress notes 69 SOAP system and 69 stomal management 288

regulatory requirements (continued)

reliability

professional communication and 40, 43 restraint 138 sta issues 188 systems model 211, 212, 213, 2214, 227, 234 understanding documentation 6, 15, 17 behaviour and emotion 98 clinical pathways 87 evaluation and evaluative criteria 170, 171, 173, 175, 176, 177 nurses attitudes 33, 257, 258 pain management 125, 130 systems model 232, 238 clinical pathways 92 complementary therapies 120 evaluation and evaluative criteria 172 incident reports 161 professional communication and 32, 43 progress notes 76 restraint 147 signatures and designations 120 systems model 211, 212, 213, 216, 218, 22834, 235, 237, 238, 243 understanding documentation 3, 10

research

resident-centred care

see also individualising care

reective nursing practice 13, 14, 17, 32, 214, 215, 216, 234, 258 regulatory requirements

clinical reasoning and 19, 26, 27, 28, 29, 30 destruction of records 6 incident reports 156 management issues 15, 17

respiratory rate 175, 177 restraint 13749

clinical pathways 80, 82, 83, 85, 86, 889, 94 clinical reasoning 29, 30 complementary therapies 111, 115, 122 evaluation 178, 179 nursing-care plans 50, 517, 59 progress notes 63 restraint 147 systems model 213, 216, 220, 241

accountability 139, 140 accreditation 141 accuracy 149 anti-discrimination rights 139, 1401

317 Index

restraint (continued)

appeal rights 139, 1401 assessments (nursing process) 138, 139, 1412, 145 auditing 145, 147 authority to restrain 145 behaviour 142, 145 benchmarking 147 building safety 147 care plans 138, 1445, 146 chemical restraint 137 cognitive state 143, 147 comfort activities 145 communication 142 consents and authorities 138, 1424, 145 dates and time 143, 145 depression 142 education 138, 139, 1478 eective documentation and nursing 147, 148 equipment safety 147 ethics 138, 1401, 147 evaluation 138, 139, 145, 146, 147, 148 falls 142 grievance rights 139, 1401 hazard-identication forms 145 holistic nursing practice 138 implementation 139, 141 incident reports 145 interventions 143, 144, 147 legal issues 138, 1401, 142, 143, 144, 149 management and organisational issues 138, 139, 140, 141, 142, 143, 145, 147 medication 137, 139, 145 mini-mental 142 mission statement 138 mobility 142, 144, 146 multidisciplinary teams 138 nurse/resident ratios 144 nurse registration bodies 138, 141 objectivity 147, 148 occupational health and safety 139, 140, 141 physical restraint 137

restraint (continued)

risk management

policies, procedures, and protocols 138 41, 1434, 145, 146 professionalism 138, 141, 142 protective assistance 138, 148 qualications of sta 148 regulatory authorities 138 research 147 resident-centred care 147 resident prole 142 resources 13940 restraint review form 145 risk assessment 141, 144, 147, 148 signatures 1423 sleep patterns 142, 144 social issues 147 special senses 142 vision statement 138 clinical pathways 87 diabetes 265 falls risk 87, 142 injury risk 46 leg ulcers 282 manual-handling risk assessment 12 occupational health and safety 141, 159 PEG nutrition 182 professional communication and 412, 43 restraint 141, 144, 147, 148 risk assessment 12, 412, 87, 112, 141, 142, 143, 147, 148, 159, 240 systems model 215, 216, 236, 237, 239 understanding documentation 12

safety risk assessment 12 sensory assessments 12, 114, 123, 142, 155, 177 sexual health 12, 26 signatures and designations
complementary therapies 110, 114, 116 117, 120 design of documentation 2067 pain management 135 progress notes 65, 745, 76

318 Index

signatures and designations (continued)


research 120 restraint 1423 systems model 222 understanding documentation 5, 6

sta issues, documentation of (continued)

skills-acquisition theory 19, 212 skin assessment 12, 114, 199, 256 sleep patterns

SOAP charting method 68 SOAPIE system 48 social issues

assessments (nursing process) 12. 114, 142, 256, 265 behaviour and emotion 103, 104 complementary therapies 114 incident reports 155 pain management 125, 127, 130, 133 restraint 142, 144 understanding documentation 12

source-oriented health records 713 special senses assessment 114, 142 speech therapist assessment 288 spiritual issues 8, 12, 77, 113, 155 sta issues, documentation of 18191
see also nurses and nursing; experience of nurses; qualications of sta

assessments (nursing process) 110, 112, 11314, 199, 257, 258 behaviour and emotion 98, 101, 103 clinical pathways 86 clinical reasoning 19, 24 complementary therapies 110, 11214, 115, 120 incident reports 156 nursing-care plans 46, 52, 53, 54, 56, 58, 60 pain management 125, 131, 133, 135 progress notes 77 restraint 147 understanding documentation 8, 12

absenteeism 186 accountability 187 accuracy 182, 185, 190, 191 advertisements 183, 185 armative action 181

sta/resident ratios 13, 50, 57, 144 sta-satisfaction surveys 188 standards of practice 2, 9, 17 stomal care 2737 subjectivity 48, 69, 169, 170. 171, 173 5, 188, 201

anti-discrimination 181, 187 appeals 184, 185 attrition of sta 182, 183, 1868, 191 complaints 182, 189 counselling 187 credentialling of sta 182, 183, 1901 discipline of sta 181, 182. 183, 18990, 191 duty statement 183, 185 education 187, 189, 190 electronic documentation 182 employee assistance program 186 employment contract 185, 186, 187, 188 equal opportunity 181 feedback 185, 187 formative evaluation 188 grievances 190 handbook 184, 186 human-resource management 181, 191 information package 184, 185 interviews 184 job analysis 182, 185 job sharing 187 key selection criteria 183, 184, 185, 188 legal aspects 184, 185, 189, 190, 191 morale 187 occupational health and safety 181 performance appraisal 181, 182, 183, 187, 188, 191 position description 183, 185 recruiting sta 181 responsibility 188 retaining sta 182, 183, 186, 187, 191 selecting sta 181, 1826, 191 social justice 182 sta-satisfaction surveys 188 summative evaluation 188

319 Index

summative evaluation techniques 170, 171, 172, 173, 188 sundowner syndrome 20 systems model for documentation 20944

systems model for documentation (continued)

abbreviations 222 accessibility 216, 217, 222, 223, 228, 231, 238, 244 accountability 216, 220 adult learning 236 assessment of the model 212, 23942 assessments (nursing process) 212, 214, 218, 2368, 242 attitudes of nurses 209, 210, 212, 213, 2278, 234, 235 auditing 212, 224, 237, 238, 23940, 2412 benchmarking 212, 214, 235, 240 best practice 211, 213, 214, 228, 235, 239, 240, 244 career options 214, 215, 216 change agents 215 Cinahl information 219 clinical governance 21115, 216, 233 Cochrane Collaboration 217, 218 code of ethics 223 cognitive function 235 complaints 216, 240 condentiality 2223 corrections 222 critical appraisal 217, 218, 232, 2345 documentation essentials 212, 2369 duty of care 222 education 212, 215, 220, 232, 2346, 237, 239, 240 eectiveness of documentation 214 electronic documentation 217 ethics 219, 223, 227 evaluation (of documentation model) 217, 218, 229, 232, 233, 234, 239 evaluation (nursing process) 214, 237, 242 evidence-based practice 211, 212, 213, 214, 21519, 233, 235 feedback 239 funding 211, 244

handbooks 218, 230 holistic practice 210, 236 implementation 211, 213, 216, 218, 220, 224, 228, 236, 237 innovation 216 Internet 183, 222, 231, 232, 233 interventions 241 jargon 222 leadership 216, 220, 224 learning from experiences 214 legal aspects 222, 223 legibility 222 management issues 20910, 211, 216, 21921, 2268 Medline 219 mission statement 220 multidisciplinary teams 219, 221, 237, 244 nursing-care plans 212, 214, 218, 238 nursing team 215 objectivity 217, 222, 233 occupational health and safety 223 philosophy of documentation 211, 212, 213, 21921, 233 policies and procedures 211, 212, 213, 218, 2268, 234 preparatory work 21134 professional communication 32, 33, 34, 35, 3840, 43, 227 professional development 215, 216 professionalism 209, 210, 213, 215, 216, 218, 222, 223, 235, 236, 237, 238, 239, 244 progress notes 212, 218, 2389 publishing 212, 2424 quality system 211, 212, 213, 2246, 234, 244 reection 214, 215, 216, 234 regulatory compliance 211, 212, 213, 2214, 227, 234 reliability 232, 238 research 211, 212, 213, 216, 218, 22834, 235, 237, 238, 243

320 Index

systems model for documentation (continued)

resident-centred care 213, 216, 220, 241 risk management 215, 216, 236, 237, 239 signatures 222 storage 224 understanding documentation and 3 validity 217, 226, 237, 238 values and value judgments 216, 21920, 228, 236 verbal culture of nurses 222 vision statement 220

understanding documentation (continued)

teams see multidisciplinary teams temperature 48, 53, 175, 177, 200 timeliness and time management
behaviour and emotion 107 clinical pathways 84 professional communication and 34 progress notes 678, 75 understanding documentation 5, 15

typefaces 197, 199200

understanding documentation 117


abbreviations 6, 15 access 6 accountability 13, 16 accuracy 3, 5, 8 assessments (nursing process) 12 attitudes of sta 4, 15, 1617 auditing 10, 11 benchmark standards 9, 1011 best practice 5, 10, 13 blank spaces 6 care plans 9 codes of conduct 9 cognitive state 12 communication 3, 11 condentiality 5, 8 continuity of care 3 corrections 6 data analysis 11 data collection 11 dates and time 5, 6

denition of documentation 2 designation 5 destruction of records 6 documentation not performed 15 duty of care 5 education 2, 3, 8, 11, 14, 16 ethics 2, 67, 8, 17 evaluation 10, 11 evidence-based practice 5, 10 food intake 12 funding 1, 3, 4, 17 government regulation 15, 17 holistic nursing practice 9, 12, 17 implementation 3, 14 importance of documentation 3 incident reports 6, 8 indicators 10 individualising care 9 key aspects 10 key terms 2 language and jargon 15 leadership 2, 45, 10, 11, 17 legal issues 3, 56, 17 legibility 5 management and organisational issues 12, 3, 4, 7, 8, 9, 11, 13, 1417 nursing-care plans 9, 15 nursing practice 914 management issues 1417 multidisciplinary teams 2, 5, 6, 7, 8, 10, 11, 15, 16 objectivity 5 permanency 5 praxis 1314 professionalism 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 purposes of documentation 3 qualications of sta 10, 15, 16 quality control and improvement 3, 7, 9, 10 reective nursing practice 13, 17 research 3, 10 responsibility 6, 8, 14

321 Index

understanding documentation (continued)

urinalysis 177, 178 urinary assessments 178, 269 urinary incontinence 274 urinary stoma 276 urinary tract infection 52, 53, 170, 269 validity
clinical pathways 81, 87 clinical reasoning 21, 23, 27 complaints 189 complementary therapies 120 consent 115, 116, 142, 143, 144 credentialling 191 evaluation 170, 171, 173, 175, 176, 177 pain management 125, 130 professional communication 32 progress notes 76 sta-satisfaction surveys 188 systems model 217, 226, 237, 238 understanding documentation 11

scope of practice 10, 15 signatures and designations 5, 6 sleep patterns 12 social issues 8, 12 spiritual issues 8, 12 standards of practice 2, 9, 17 storage 6 system of 3 time management 5, 15 validity 11 values and value judgments 2, 78, 12, 17

variance and variance analysis 80, 82, 83, 84, 85, 93, 94, 175, 176 verbal tradition of nurses 47, 49 visibility of nurses work 47, 59 vision statements 111, 138, 152, 220 visual assessment 12 volunteer programs 259 wandering 131, 28992 weight 175, 176, 178, 273, 286 word-processing programs 197 wound assessment 12, 114, 119, 177, 178, 277, 27983, 288

values and value judgments

clinical pathways 81 evaluation 169, 1745 nursing-care plans 49, 58 pain management 134, 136 professional communication 32, 37, 38 progress notes 74 systems model for documentation 216, 21920, 228, 236 understanding documentation 2, 78, 12, 17

From the extensive list of books from Ausmed Publications, the publisher especially recommends the following as being of interest to readers of Nursing Documentation in Aged Care: A Guide to Practice. All of these titles are available from the publisher: Ausmed Publications, 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: <www.ausmed.com.au>; email: <ausmed@ausmed.com.au>

Aged Care Nursing: A Guide to Practice


Edited by Susan Carmody and Sue Forster
The aged population has grown markedly throughout the world, but there is a shortage of experienced nurses with expertise in the holistic care of the elderly. This book is written to inspire and empower such nurses. Aged Care Nursing: A Guide to Practice is written by clinicians for clinicians. The inclusion of evidence-based and outcome-based practices throughout the book ensures that all readers, be they novices or experts, will have a reliable and comprehensive reference to guide their practice. Each author is a recognised expert in his or her subject area, and all present their topics with a focus that is practical, rather than academic. Available as textbook alone or as audiobooktextbook package.

Dementia Nursing: A Guide to Practice


Edited by Rosalie Hudson
Dementia is one of the major health problems of our ageing society and dementia nursing is one of the most important and highly skilled of nursing specialities. As another volume in Ausmeds growing Guide to Practice series, this is the definitive textbook on dementia nursing. The chapters are written primarily by nurses for nurses. But dementia nursing is essentially an exercise in teamwork, and valuable contributions and insights are offered by other health professionals, carers, artists, and relatives from a variety of backgrounds and countries. The result is a comprehensive international volume on all aspects of dementia nursing. Available as textbook alone or as audiobooktextbook package.

Practical Approaches to Infection Control in Residential Aged Care


Kevin Kendall
For those who work in aged care, this book presents an exceptional opportunity to learn how to protect yourselves, other staff members, and residents from the ever-present dangers of infection. The author believes that infection control polices should be coffee-stained and dog-eared, not shelved and clean!

From the extensive list of books from Ausmed Publications, the publisher especially recommends the following as being of interest to readers of Nursing Documentation in Aged Care: A Guide to Practice. All of these titles are available from the publisher: Ausmed Publications, 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: <www.ausmed.com.au>; email: <ausmed@ausmed.com.au>

Palliative Care Nursing: A Guide to Practice (2nd edn)


Edited by Margaret OConnor and Sanchia Aranda
This second edition of Palliative Care Nursing has been totally revised, rewritten, and redesigned. The result is a comprehensive handsome volume that builds upon the successful formula of the popular first edition. All nurses and other health professionals with an interest in this vital subject will welcome this new edition as an essential addition to their libraries. This is the definitive textbook on palliative-care nursing.

Nurse Managers: A Guide to Practice


Edited by Andrew Crowther
This book addresses the core issues associated with nurse management, and is thus an essential primary text for all nurses as they develop their managerial skills. This book is an innovative and practical text that fulfils a previously unmet need. It provides the evidence-based, practical advice that nurse managers require to undertake their important role with growing confidence and expertise. The book covers such issues as promotion, leadership and motivation, moral management, dealing with unhelpful staff, occupational health and safety, budgets, information technology, and many other vital issues in modern nurse management. In all these areas, the reader is offered a range of solutions and coping strategies for the issues that confront nurse managers every day. Available as textbook alone or as audiobooktextbook package.

Keeping in Touchwith someone who has Alzheimers


Jane Crisp
This book is a resource for ideas about how you, the family member or the professional carer can celebrate and value the lives of those who are affected by dementia. It contains practical ideas for daily living activities and communications.

Nursing documentation is often perceived as a tiresome chore. Although this perception of documentation is understandable, Nursing Documentation in Aged Care: A Guide to Practice is written from a different perspective. The title of the book is carefully chosen. All of the contributors to this book firmly believe that nursing documentation in aged careif performed with pride and professionalismis truly a guide to practice. In striving for the highest standards of professionalism in all that they do, nurses are increasingly recognising that documentation is a wonderful opportunity to record and reflect upon all that is good in nursing. In addition to their ethical and professional responsibilities, caring nurses are aware of the personal satisfaction to be gained from documenting their holistic and reflective nursing practice. As another volume in Ausmeds growing and popular Guide to Practice series of textbooks and audiobooks, Nursing Documentation in Aged Care: A Guide to Practice is an essential text for all aged-care nurses who wish to enhance their documentation skills and deliver higher quality care to the elderly. This book shows how nursing assessments, care plans, and progress notes can allow nurses to share their knowledge, observations, and skillsand thus make a crucial contribution to their own professional lives and to the quality of life of those in their care. This is more than a how-to-do-it workbook. With contributions from a range of experts, this comprehensive evidence-based textbook explores the issues surrounding documentation and reveals the importance of professional communication within multidisciplinary teams.
Christine Crofton Christine Crofton is a registered nurse who has been involved in aged care for many years in a variety of rolesincluding senior management of aged-care facilities. She is currently a nurse educator who believes that older people must be valued, respected, and cared for in accordance with the highest professional standards. If this is to be achieved, Christine believes that documentation must be undertaken effectively and efficiently. If aged-care nurses are empowered and confident in their own abilities, positive resident outcomes and excellence in documentation will be assured.

Gaye Witney Gaye Witney is registered nurse who has had a passionate interest in aged care for longer than she wishes to admit! Her interest in documentation arose from her work with the Australian government on documentation validation and standards accreditation. Gaye is now a nurse educator who encourages her students to take pride in being nursesenthusing them to achieve high standards of documentation in their preparation of nursing assessments, nursing-care plans, and progress notes.