Commuincation Paper

Communication is one of the basic survival skills of human and also a fundamental part of nursing. Effective communication would help to promote a positive nurse-client relationship which is crucial for the delivery of quality nursing care (Sheppard, 1993; McCabe 2003).

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

Communication involves information being sent, received and decoded between two or more people (Balzer-Riley 2008) and involves the use of a number of communication skills; which in a nursing context generally focuses on listening and giving information to patients (Weller 2002). This process of sending and receiving messages has been described as both simple and complex (Rosengren 2000 in McCabe 2006, p.4). It is a process which is continually utilised by nurses to convey and receive information from the patient, co-workers, others they come into contact with and the patient’s family.

Effective communication is crucial aspect of nursing yet too often is placed low on the priority list, especially at shift change. Information related to the care of patients is frequently disseminated at a crowded, noisy nurse station with several nurses rushing to leave and others attempting to get the information necessary to plan care and limit the constant distractions. It is this interaction that allows for information vital patient safety information to be communicated including the acuity of patients.

Bedside reporting has the primary function of sharing patient information between nurses, as they change shifts. The nurse ending their shift would report all the changes that have occurred in the state of the patient and all measures which have been taken for the respective patient. This information would be transmitted to the nurse commencing her shift, who would then write and further transmit all patient information occurring during their shift, to the nurse coming to replace them.

Traditionally, nursing shift-to-shift reports were organized methods of communication between only the oncoming and leaving nurse, designated to a location such as the central nursing station or nook of a hallway. Shift reports can be considered the foundation of how the day is going to plan out because it introduces the patient, diagnoses, complications, medications, consults, upcoming test and the entire plan of care. These reports are full of complicated and vital information and while set in certain locations that are vulnerable to interruptions, such as the nursing station, medical errors and miscommunication are more likely to be made. The Joint Commission’s 2009 and 2010 National Patient Safety Goals (Joint Commission, 2015) included two patient safety standards, first to encourage patients to be involved in their health care plan and second, to implement a standardized communication process for handoff reports between providers. Soon after in 2013, The Agency for Healthcare Research and Quality under the United States Department of Health and Human Services introduced a set of strategies to improve patient engagement along with safety and quality in patient care. Within these strategies the new method of nurse bedside shift report was developed, which suggests nurses to conduct shift-to-shift reports at bedside in the room of each patient, rather than out of the room. The benefits of this new method were

Poor communication puts patients in danger because it can lead to medical errors and adverse events. For example, a medication error can occur if a physician’s orders are not updated in time or if the outgoing nurse does not provide the correct time in which a dose was administered last. Thus it is crucial to communicate any recent treatment that has been implemented. In this way, nurses and physicians can facilitate the prevention of errors. Another consequence of ineffective communication is that it can decrease morale and increase work-related stress among members of the healthcare team. If nurses and physicians are not understanding each other’s actions, conflict ensues. It can cause toxic interpersonal relationships. This, in turn, will affect the level of patient care because it is difficult to focus amidst emotional strain and

Hello everyone. My name is John Smith. I am a RN here at the Hospital and I am the Director of Nursing Informatics. As I’m sure all of you know to be successful in the care of our Patients you have to work as an interdisciplinary team and timely COMMUNICATION is key! As you can see I have capitalized communication to emphasize how important it is. As a Nurse on the unit a big part of communication is reporting a patient’s condition after you have

Communication in shift change plays a major role in the nursing practice and role. Appropriate and effective communication is a tool assisting nurses in providing safe, thorough and quality cares about their patients and ensuring there is continued service delivery. Realizing the critical role of their patients and patients’ families in promoting patient safety, nurses need to engage their patients and family members in the whole communication process of exchanging information and planning the care. Nurses need to give their patients chances to participate in the discussion their health conditions, upcoming procedures, medical information, or treatment options. Bedside reporting give nurses opportunities to visualize the physical and psychological needs of their patients. Change of shift reporting is also a situation where the nurses exchange their clinical knowledge, and patients’ condition changes and allow their patients to express their understandings, concerns, and questions. This paper seeks to analyze bedside report and explain its relevance to the nursing practice.

Communication is any form of expressing and receiving of messages between individuals. The importance of Communication in the nursing profession is to maintain high quality care for the patient but also maintain effective collaboration between professionals. Boykins, D (2014) states that the “registered nurse is expected to communicate in various formats and in all areas of practice”. Various formats include speaking to patients and coworkers as well as utilizing appropriate protocols and systems to effectively communicate regards to patient’s status.

Change of shift in the nursing profession is unique (Caruso, 2007). Information is transferred between nurses verbally and through written communication. In many facilities shift report from one shift to another involved sitting down and getting all your orders from a caredex and then talking with the previous nurse face to face going over pertinent information regarding their patients. This type of report usually happens in a report room or sometimes in the hallways or other common

Written communication in healthcare system comprises of care plans, daily reports, handover sheets ,medication sheets in general ,(record keeping). These clinical records are essential skills of communication that a nurse should be able to write as well as extracting vital information from which to provide relevant and precise care. This makes continuity of necessary care possible and fulfils one of NMC’s (2008) core principles of the code of working with others to protect and promote the health and wellbeing of those in nurse’s care and obligation to ensure total and effective information is communicated to your colleagues concerning people in your care (NMC 2010). These records help to increase answerability to the part of the nurse if the nurse is aware of this will be more considerate knowing that any mistake will come around. In addition these records help as the basis for decision –making for nurses and multi-disciplinary team of which the nurse

Each nurse also has specific ideas or beliefs about what information should be communicated during a verbal report. Valuable information may not be provided or may be forgotten (Casey & Wallis, 2011). Writing information down may help a nurse recall the data later, but if there is no consistent format for recording the information, it may be lost regardless. Interruptions, distractions, and the frequency of communications also may negatively effect the communication process and contribute to a nurse forgetting to share important information (Cacolice-Hildebrand, 2008). Active listening, which involves reflecting back a meaningful understanding of one’s message, is one of the most important skills in effective communication.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

Effective communication is of tantamount importance in the scope of a successful nursing practice. It depends heavily upon both verbal and non-verbal methods (AJN). It is inclusive of both behavioral and speech components. Being efficient in both delivering and receiving messages between the nurse and the patient helps initiate and maintain a healthy relationship. Employing both verbal and non-verbal communication between the nurse and the patient will help ensure that the relationship they share remains satisfying to both parties.