Foundations of Nursing for Communication - myassignmenthelp.com

Question: Write about theFoundations of Nursing for Communication and Documentation. Answer: The Australian commission have developed some standards in response to the extensive public and stakeholder consultation. These are recognised as National Safety and Quality Health Service Standards, and ensure the safety and quality of wide variety of health care services. The paper focuses on the sixth standard, which refers to clinical handover. This standard describes the systems and strategies for effective clinical communication whenever accountability and responsibility for a patients care is transferred. The intention of this standard is to ensure relevant clinical handover, on time and in structured manner, that will support the patient care. The purpose of this paper is to outline the nurses responsibilities in regards to effective patient handover, communication and documentation. According to the standard on clinical handover, it is the process of transferring the patients responsibility to another person for some or all aspects of care either temporarily or permanently. The clinical handover may change based on the patients situation. For instance there are different situation of handover such as during patients admission, due to change in shift time, transfer of patient to intra and inter hospital. There are different methods of handover including face-to-face, through written orders, or via telephone or through electronic handover tools. The handover can take place at the patients bedside, in a common staff area, clinic reception or at hospital. Nurses must be highly responsible at the time of clinical handover as the current processes are highly variable. These variations may be unreliable leading to risk for patient safety. Thus, nurses must use standardised process and fit the clinical handover solutions for the purpose. It will increase the likelihood of the critical information to be transferred and acted upon (Bain et al., 2013). To ensure safe transfer of the patient information, the nurses can use the ISBAR tool. It stands for Identify, Situation, Background, Assessment and Recommendation. This tool also allows the accurate identification of the patient and of those participating in hand over. The situation refers to the condition of the patient in current moment. Background informs of the factors that led to the situation. Assessment includes knowing what caused the problem followed by recommending on way to improve the situation (Kitney et al., 2016). As per literature review, this tool has been found effective in safe transfer of patient information in both clinical and non-clinical situation. It acts as teaching tool for the patient and the family to handle the illness. According to Sujan et al., (2015) the tool gives an opportunity for the health care team to discuss with the patients and decide the information that is necessary to be transferred. For instance, loss of excess blood from the surgical pa tient can be mentioned in the hand over. This tool is simple, memorable and logically structured. It prevents poor communication as the tool is designed to collaborate with the medical officers, health mangers, allied health professionals, rural and remote area staff, inpatient staff in addition to nurses and midwifes. Such structured content is necessary to reduce patient clinical management errors (Johnson et al., 2016). According to Kitney et al., (2016) the adaptation to ISBAR involves changes and to manage the change, the nurse can follow the eight steps of John P Kotter. Kotter had put forward eight steps for change management. The principles of change management align with the actions required to introduce ISBAR framework. Most importantly, the nurses must be able to identify the need for clinical communication intervention and know the rationale for intervention. Secondly, the nurse must use the critical thinking skills to identify the leader or cultural influencers so that it becomes easy to use the tool. Good leadership skills are essential to allow the handover to occur at correct time. It is the responsibility of the nurses to use the relevant policies and procedures in the concerned organisation and take an action to maximise the effectiveness of these policies and protocol meant for safe handover. It is the responsibility of the nurse to execute the documented structured process. Nurses must set appropriate location and time for handover, and simultaneously maintain and continue patient care. The nurse must exhibit high level of awareness of the patient needs and the clinical context (Sujan et al., 2015). The result of effective handover is the transfer of accountability and responsibility of care. To ensure effective handover the nurses must regularly evaluate the process of clinical handover and must monitor continuously. Drach?Zahavy Hadid, (2015) argued that collaborative effort on the part of the nurses is required to communicate with the carers, clinician and the patients to review the local processes of clinical handover. Without effective communication s kills, the collaboration would be weak. Nurse may fail to engage other patients and nurses with poor communication skills. Consequently, the transfer of critical information and documentation to the patient is hampered. Nurses must regularly take an action based on the outcomes of reviews. If necessary, nurses must report the outcomes to the executive level of governance. Based on the outcomes of review nurses must take action to increase the involvement of patients and carers. Nurses can take various precautions for effective handover. For effective handover to take place from nurse to nurse, a nurse may start her shift time 15 minutes early and allow the night shift nurse to deliver all the relevant information. When using technical language nurse may invest time to explain, the same to other nurses as well as patients family. Nurses must ensure that the handover occurs at ward office and at bedside to maintain confidentiality and privacy of the patients information. Bedside handover is highly effective then ward office for preventing breach of information (Scovell, 2010). Emotional support can be undermined by use of taped handover and thus must be avoided. Face-to-face handover is considered effective than the taped or written format. The written documentation may be problematic for nurse in the incoming shift to understand. It may not be possible for the new nurse to immediately acquaint with the patient. Similarly, when documenting to the patient, ISB AR tool would be easy to comprehend than any other mode. Therefore passing information from one shift to other must consider the limitations and improve the handover (Tobiano et al., 2015). In conclusion, giving effective handover and documentation cannot be taught. It is the process that a nurse must learn by collaborating with mentors, leaders, peers and clinicians to recognise the handover as a social and emotional support system and teaching tool for nursing care and communicating patient information. Nurses must use the evidenced based process such as ISBAR to handover and documentation to fulfil the purpose of handover. In addition nurses are obliged to follow the policies and other protocol of the organisation to effectively communicate the patient information both to the patient and the other health care professional and ensure safety and quality of care. References Bain, C. 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