“Demonstrate the skills needed to record, enter, store, retrieve and organise data essential for care delivery”
This essay will reflect the skills I needed in order to record, enter, store, retrieve and organise data essential for care delivery.
The Gibbs Reflective Cycle (1988) consists of six distinct stages showing the process of reflection: description (describing the incident), feelings (what was I thinking and feeling?), evaluation (what was good and bad about my experience?), analysis (what sense did I make of the situation?), conclusion (what else could I have done?) and the action plan (if situation arose again what would I do?).
In order to protect the patient’s confidentiality the name will be changed in accordance with The Nursing and Midwifery Council’s Code of Professional Conduct NMC (2002).
In preparation for making a visit to Mrs Page’s home (a patient new to the clinic following a recent hip replacement operation) we received certain information from the local hospital, in the form of a fax, where Mrs Page had previously received her operation. The facts enable us to make first contact with the patient agreeing a date and time for the initial visit. A new file is opened and the visit is made.
My first contact with the patient was quite strained, as we were both apprehensive about what to expect off of each other. We were strangers and I was aware that time was needed to build up a trusting nurse/patient relationship. The best way to build up such a relationship is through communication and also is to be able to actively listen. Other social factors also enable good communication, as my mentor had spoken to me prior to the visit in regards to the patients living conditions, that they were not as hygienic as they could have been due to the fact she had pets and was not very hygienic in their care but the patient was happy with the way she lived and the conditions were not detrimental to her health needs.
When we arrived my mentor explained who I was and asked the patient if they were happy for me to come in and help with their dressings, as the patient’s consent must be obtained before treatment may commence. The consent given was verbal and given freely by Mrs Page for my right to examine, treat or provide an act of care based on information, and an understanding of, what is proposed. & Grubb (1994) suggest that in order to give consent, a person must be deemed to be competent Kennedy & Grubb (1994), by obtaining consent previous to any clinical procedure being carried out, this requirement is both a legal and ethical imperative.
I introduced myself to Mrs Page and spoke freely to her asking after her, how she was feeling etc. This helped break the ice and I explained that I needed to ask her a few questions to enable the best care possible to be carried out. I then proceeded to read through her notes to see what the procedure plan was. Correct record keeping enables the next health care professional to be clear on what treatment is required for Mrs Page. The original wound dressing was absent as Mrs Page had removed the dressing and replaced with a rinsed off dishcloth. My apprehension was aroused by this situation because the wound had become infected and Mrs Page did not appear to be concerned about her personal hygiene. Even though Mrs Page’s living environment was unhygienic in my eyes, this was not a valid concern as no more passing of further micro organisms could take place due to this being perfectly normal to Mrs Page’s living environment. As long as we as nurses continue to use the appropriate aseptic techniques in our treatment no further harm can come to Mrs Page.
Mrs Page stated that she had not contacted the clinic earlier because she did not wish to bother us seeing as she thought we would be too busy and did not want to inconvenience us. I explained to Mrs Page that our first concern is the welfare of our patients and we would have come out to her earlier if need be. I explained that we would not have been at all bothered by her call, as it is our duty to see to our patients’ medical needs. I explained this as simply as possible to Mrs Page as I did not wish her to feel that I was reprimanding her.
Once I had removed the dressing and irrigated the wound I redressed the wound, I then explained to Mrs Page that if there was any problems to please contact the clinic. My feelings around such an explanation was to prevent an earlier occurrence. I then continued to record information within her handwritten notes such as her baseline observation i.e. blood pressure, temperature. I explained to Mrs Page that it was important so that we had an idea what her normal ranges were and to enable us to monitor any changes. I told her not to worry as we took all patients’ observations on the initial visit. I also compiled a care plan, which sets out the targets of care over the future weeks/months or as necessary. This level of recording aids other professionals and future nurses in the continuity of care of Mrs Page.
Dyer and Bloch (1987) state that the law recognises that the patients has a right of self determination and that healthcare professionals have a duty of care, and therefore should provide sufficient information to allow patients to make informed choices. Dyer and Bloch (1987)
The Patient’s Charter states a patient’s right to treatment and although Mrs Page may not have realised this, it is our duty both ethically and legally to reinforce the patient’s right to the treatment. This action enabled Mrs Page to be seen promptly and treatment carried out efficiently.
Whilst concluding the evaluation of the visit, it was noted that the use of the dishcloth by Mrs Page in her own care would be integral to advise other professionals in their care of Mrs Page and to make sure that adequate supplies were available to the patient to enable her to improve her own care.
The purpose of communication is to ensure appropriate social contact and professional interaction to meet patients’ needs. Macleod Clark et al. (1991) According to The Nursing & Midwifery Council’s Code of Professional Conduct (2002) all patients have a right to receive information about their condition. You must be sensitive to their needs and respect the wishes of those who refuse or are unable to receive information about their condition. Information should be accurate, truthful and presented in such a way as to make it easily understood. You may need to seek legal or professional advice, or guidance from your employer, in relation to the giving or withholding of consent. Nursing Midwifery Council (2002)
The Human Rights Act came into force on 02 October 2000. This Act followed on from a series of rights in 1950 from the European Convention to include in UK Law. All persons must abide by these laws and nurses have a duty to heed these laws in everyday practice. This will then enable nurses to make the correct choices with regards to duty of care.
Throughout my visit to Mrs Page’s home I felt that because of previous experiences within the community I have improved greatly in my communication to others i.e. patients and their health care needs. I have begun to see patients holistically and understand that they are not to be regarded as tasks. Whilst retrieving the relevant information from Mrs Page I was aware that the information gathered needed to be recorded appropriately and accurately. I was very nervous and my explanation to Mrs Page needed to be reiterated a couple of times, as I did not explain myself very clearly. I sought reassurance from my mentor on several occasions during the visit through body language i.e. a nod or smile. I then spoke with my mentor following the visit and she checked my records before countersigning the paperwork. The value to patients of good communication may be related to the degree of importance that this holds for them in the clinical environment Mallet (1997).
I did learn that I needed to be aware of my limitations within the community, even though my mentor was responsible for my practice, I too am accountable for my actions. During the placement I learnt that keeping good records helps to protect the patient’s continuity of care by aiding the communication between the multi disciplinary team and helping promote high standards of clinical care within the nurse/patient relationship.
The Nursing Midwifery Council’s Code of Professional Conduct (2002) suggests that all information communicated between myself and the patient must be kept confidentially and only used for the purpose of which it is given. NMC (2002)
Using reflective practice is an integral part of nursing as it helps with evaluating the care given and therefore we are able to learn and reassess the patient’s individual needs and keep on improving upon care delivery both regarding ourselves and those within our working environment.
My opinion on the Gibbs Reflective Cycle is that I am able to look back and see the work I have carried out and that it enables me to revaluate my practice and look at it from an objective point of view ensuring further learning and knowledge is improved upon.
The Gibbs Reflective Cycle enables me to reflect upon the work carried out and revaluate my practice, whilst looking at it from an objective point of view, which in turn ensures further learning and knowledge gain is constantly improved upon.
References
Dyer and Bloch (1997) Psychiatry: an impossible profession? Australian and New Zealand Journal of Psychiatry, Australia
Gibbs G, (1988), Learning by doing: A guide to teaching and learning methods, Oxford, Further Education Unit, Oxford Polytechnic.
Human Rights Act (2000), London Station Office
Kennedy & Grubb (1994) Principles of Medical Law, Oxford University Press, Oxford, New York
Macleod, Clark et al (1991) Progression of Counselling. Nursing Times, 20: (87)
Mallet J. (1997) Royal Marsden Hospital Manual of Clinical Nursing Procedures, 5th Edition. London. Blackwell Scientific Publications
Nursing Midwifery Council, (2002), Code of Professional Conduct, London: 23 Portland Place WIB 1PZ
Bibliography
Journal of Community Nursing, (2004), Volume 18, Issue 11
Naidoo J. and Willis J, (2001), Health Studies, 2nd Edition, Hampshire, Palgrave
Nursing Midwifery Council, (2002), Guidelines for Records and Record Keeping, London: 23 Portland Place WIB 1PZ
Tingle J.H. (1998), British Journal of Nursing, Nurses must improve their record keeping skills, 7 (45)
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