Communication and Record Keeping

Introduction

This assignment will be looking at the importance of Communication and Record keeping within the nursing practice. In communication I will be focusing on the important of communication, types of communication, communication barriers, and improving communication within nursing practice. I am also going to look at the National Institute for health and Care Excellence guidelines, Nursing & Midwifery Council code of conduct, past Journals and Books to see what could go wrong, what could be done to make sure that good communication practice are implemented for better effective communication between nurses and patients and how nurses and patients can be affected by miscommunication and the impact it has using references. I am also going to discuss the importance of Record Keeping within nursing practise, looking at the Polices, Documentation, Mental Health Act, the impact of Record Keeping, who can be affected and how good record keeping practice can be implemented to minimize any errors in record keeping. I will also be quoting some of the National Health Service trust policies, government policies, Nursing & Midwifery Council polices, National Institute for health and Care Excellence guidelines as well as World Health Organisation policies on Record keeping

Important of communication,

According to the Nursing & Midwifery Council, it is standard that  all nurses must be able to communicate safely and effective, use a range of communication skills and technologies, Recognise the need of an interpreter, address communication in diversity, Identify ways to communicate and promote Healthy behaviour, respect and protect all confidential information (NMC 2010)Communication is a vast topic, they are so many models and definitions  of communication. Communication can occur when one person transmits a message to another person. DeVito  defines communication as ‘the act, by one or more persons, of sending and receiving messages that distorted by noise, occur within context, and have some effect, and provide some opportunity for feedback’ According to the Nursing & Midwifery Council (2015) Domain 2: All nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory communication. They must take account of individual differences, capabilities and needs. Communication can be divided into many models. The relationship between patients and nurses makes it comfortable to share emotions and information, through the process of caring. (Ferreira

et al

., 2016). Patients and staff often speak out of character because, they might be feeling anxious about their health, about what tests and treatment they might have to undergo and about what the future holds for them according to the Royal College of Nursing. Time is the most precious thing we can give to another person, showing someone that we are willing to put everything aside to pay attention to them. listening to them, showing empathy, understanding how they are feeling can make someone feel better, and build the trust or a bond that will help you and them open up the good channels of communication. For effective interaction and engagement with both the patient and the person behind that label, communication is vital. Care may be compromised if nurses do not communicate well. Such communication must involve: Listening to what patients say; Answering their questions in ways they can understand and process; Relaying information from patients to colleagues, and vice versa. Christopher Barber (2016) Mrs Windsor’s experience illustrates how communication issues have a real effect on patients’ experiences. The NMC Code makes explicit nurses’ responsibility to listen, work with and act on their patients’ concerns and give treatment in a timely manner.

Types Communications

There are different models of communication such as Linier model of communication involves simple tasks that happen in one direction, a massage is transferred without expecting a reply from the receiver. This can also be called a linear model. McCabe and Timmins (2013) cited Berlo (1960) and Miller and Nicholson (1976) The sender needs to adapt the message in the way that it can be received accurately without being misinterpreted and how valid it is (Lucy Webb).The linear model of communication however often struggle to represent the complexity and the interference that inherent in the communication process. Circular model of communication allows the sender to give feedback about the messages they get form the sender. In an example used by (Lucy Webb 2014) ‘the patient hearing doctors concerns about discharge asks the nurse where the discharge is coming from. The nurse then adjusts the message and explain that the doctor is worried that the patient might not cope well at home’ so this type of communication does represent some feedback and adjustments that can be done if required. However, this model does not provide enough information to why the misunderstanding has occurred, although it is better than the linear model. Systematic model of communication acknowledges that the messages to and from sender are subject to interference from the way in which the message is encoded, through the environmental distortion (Lucy Webb 2014).

Barriers to Communication

Communication and assessment can be affected by many barriers in nursing practise. (NMC 2018). There are so many barriers that can compromise patient care (Ballie and Black 2015). Communication can be affected by cultural and religious differences, busy care environment, language barrier, and educational level, and impairments.

Cultural and religious differences

Another boundary to compelling correspondence in nursing practice is cultural boundaries. This is a block to successful attendant patient associations since impression of wellbeing and passing vary among patients from various social foundations. (Kai, 2011; McCarthy, 2013; Tay, 2012). Consequently, the nurses should be mindful when chipping away at patients from various cultures (Aslakson, 2012; Jooste, 2011; Helft, 2011). Culture is mind boggling, and it will be unthinkable for the wellbeing expert to know about the conceivable wellbeing convictions and practices in each culture (Kai, 2011). It is essential for nurses to think about their own encounters while thinking about cultural contrasts (Sibiya, 2018).

Busy care environment

Working on a ward setting has opened my eyes on how often patients can have less quality time with nurses, due to high demand in other aspect of the nursing role. This means that the work load and the amount of time that is available can affect interactions between patients and nurses (Helft, 2011). Working understaffed and the lack of communication between teams can sometimes increase the workload that has to be done within a specific time. This means that some nurses will be isolated in the offices catching up on paperwork, so the patients will have to wait to have discussions with nurses about their concerns. Taking all that into consideration that’s when information becomes inconsistent between nurses, patients and their families (Sibiya, 2018).

language barrier

It becomes a barrier when a nurse or a patient does not share the same language, it can become a problem to their communication and interactions. (Jooste, 2011; Uys, 2017; du Plessis et al., 2010). It becomes very difficult for the nurse to understand a problem that a patient has. vice versa it becomes more difficult for the patient to understand what information or instructions they are being asked to complete. This may have any impact on understand what medication they are being asked to take and how helpful they are to their well-being, when it is being explained to them. During my time as a health care assistant I have witnessed miscommunication between a patient and nurse, when the patient was being informed about the medication they were prescribed to take and why it was important for them to take the medication. The patient found it really hard to understand the nurse as the patient did not understand English, so an interpreter had to be involved to make sure communication was successful.

Disabilities

A lot of are affected by their abilities to understand what is being explained or asked of them, some maybe visually impaired or have hearing, speech impairments. The use of the right channels to communicate between nurses and patients that suffer from any disability is very effective in communication. The education between patients and nurses has to be considered to make sure information is put in a way that can be understood by both. During my placement I learned that there are many ways to communicate with young children with limited speech as well as having learning disabilities. During my time there I noticed that some behaviours that are portrayed by these children were out of frustration as they found it difficult to express their emotions, or when they thought they were not being understood. This gave me an insight to identify their level of understanding and how to communicate with them using chats, boxes and sensory circuits. I learned that the behaviours they were presenting was not because they had challenging behaviours but to try and put their point across so that they can be understood. (Sibiya, 2018) state that stroke or any brain injuries may affect certain areas of the brain that processes information and the ability to speak, so these can also be barriers to communication.

Record Keeping

Record keeping is important in nursing and midwifery practice, magnificent record keeping can help ensure the welfare of patients (Griffiths, 2007). Jeffries et al (2010) includes that a decent standard of nursing documentation encourages progression of care and improves collective consideration. This is praised by having precise and clear records to advance patient wellbeing and care. Record keeping is a multi-disciplinary methodology, which aids the minding procedure, (NMC 2010).

Great record continuing as per the Nursing and Midwifery Council (NMC, 2018) is considered as a vital piece of nursing and maternity care practice which is fundamental to the inventory of protected and successful consideration. It’s anything but a discretionary extra to be fixed in if conditions permit’ (NMC, 2018). Subsequently recordkeeping in human services conditions ought not be underestimated (Independent Nurse, 2016). As indicated by Dimond (2008) recordkeeping is alluded to as ‘a major aspect of the expert obligation of care medical attendants owe to their patients’. The essential goal of recording data in patient’s therapeutic records is to help the arrangement of top-notch care, restorative basic leadership, correspondence between social insurance suppliers and persistent progression of care. Besides, it is a fundamental hotspot for scientific examination, quality confirmation and lucidity of the conveyed care (Zegers et al., 2011). Record keeping additionally assumes a fundamental job in advancing the wellbeing and proceeded with care and bolster given to patients (RCN, 2015).

A wellbeing record is characterized by the Data Protection Act (1998) as one who describes to the physical or psychological wellness of a person which has been made by or for the benefit of a wellbeing proficient regarding the instance of that person. Normal instances of wellbeing records are close to home wellbeing records, radiology and imaging reports, sound and tapes or CDROM, PC databases and extra duplicates of archives (Hywel Dda University board, 2015)

Various consideration experts add to the patient restorative record. Doctors and attendants are the chief patrons of archives assembled and documented in the medicinal record. The idea of the data that can be found in restorative records shows restraint socioeconomics, wellbeing appraisals, social and medicinal narratives, directions of sickness, analyse, medications, test results and post-release care (Ngin, P.M., 1994). It likewise contains nursing reports planned to mirror the consideration patients got from medical caretakers. In any case, it’s a well-known fact that the archives in the medicinal record are utilized by clinic chairmen to review the guidelines of care (Ngin, P.M., 1994). Data protection, how the information will be used, and who has access to the information, patient confidentiality

Documentation

There are many care plans utilized by healthcare establishments in the National Health Service, yet they satisfy three basic roles. To guarantee that the patients are given similar care in any case which suits each individual’s needs from staff is taking care of them, to guarantee that care given is archived and to help the patients to distinguish, oversee and take care of their particular issues. (RCN, 2015). Care plans are composed reports, either electronic or paper-based that are utilized consistently and might be changed over the span of the day. During my placement I learned that following care plans will ensure that all the nurses are giving the care that’s needed. Documentation of risk assessment is also important to identify the risk that can be poised by a patient and how to manage those risk. It could be old or current risk, so a record of those risk will help to ensure staff are working within a safe environment. Not having a risk assessment can have a negative

Two standards of good record keeping from the nursing and midwifery council 2009 propose, all hand setting up must be readable and accounts ought to be precise and recorded so that the importance is clear (NMC, 2009). Powell (2009) concurs that physically set up accounts should have clear penmanship, as clinical records are shared and includes that wellbeing experts read records every day and it is significant that the data in archives is comprehended. Poor penmanship can influence how care is conveyed and can prompt mix-ups and putting a patient in danger. Different sorts of blunders incorporate spelling botches and missing data. The effect of good record keeping is that the care accommodated the patient is proof based and individuals from the multi-disciplinary group know about the patient’s treatment and care. Courtney (2005) clarifies that proof-based care enables medical caretakers to discuss adequately with their patients and with the social insurance group about the justifications for basic leadership and care plans.

Every single patient record are ensured by Act (1998). The Demonstration ensures the privilege of the person in connection to information which is gotten, put away and prepared or provided with respect to them (NMC, 2010). Tolerant records incorporate, transcribed clinical notes, messages, research center reports, x-beams, printouts, episode reports, photos, recordings, chronicles or phone discussions, instant messages and wellbeing reports from different experts.

In recordkeeping there is are a few standards or rules to adjust to by attendants or social insurance experts. The composed or electronic data ought to be clear, neat and entered ineptly into the PC database. All sections must be dated and marked, and the name and occupation title included when it is an expert’s first-time taking records. Neighborhood approaches must administer every single finished passage, and they ought to be exact. The importance of passages ought to be not be contorted to others being taken care of by that patient or the patient (NMC, 2018). The significance of the record ought to be about the patient’s consideration and furthermore to other human services masters associated with thinking about the patient. In certain occurrences, patients may demand to see their therapeutic record, and the data must be justifiable (NMC, 2018). Records ought to be finished at the hour of an occasion or following. Any distinguished dangers or troubles experienced and the measures taken to deal with them must be recorded to guarantee that associates who additionally disparage the records are very much educated. Medical attendants must be mindful so as to guarantee that all records are kept safely, and all information and research discoveries are gathered and put away properly after use (NMC 2018). Records ought to be centered around actualities or individual perceptions not theories by others. Fitting Language ought to be utilized when making passages, and casual Language like languages, shortened forms and short penmanship must be stayed away from (NMC, 2018). During the previous summer occasions, I rendered my temporary position at a network wellbeing focus in East London. I saw that all attendants were readable and clear when recording quiet wellbeing for the afternoon, guaranteeing a smooth changeover when movements change. It helped me to value the substance of recordkeeping for congruity of care to patients. Records ought not be adulterated or adjusted. Prompt and pertinent activities ought to be done in the event that they become mindful that somebody has not kept to these prerequisites (NMC, 2018). Adjustment is permitted when the master has the order to do as such. Any changes should be dated and marked by the expert, giving subtleties of the complete name and occupation position (NMC, 2018).

Great recordkeeping shows proficient responsibility, secure basic leadership strategies, quality measures of care, proof-based consideration, exact specialized techniques, progression of care, consistence to arrangements and methodology, exploring grumblings and capability in lawful procedures by providing the legitimate proof of care (Wood, 2010).

Conclusion

In conclusion all aspects of communication are vital in the nursing industry. It is important for patients and nurses to understand the information being presented to them at any given time It is also important to get feedback to ensure that if there are any areas that may need improving can be improved to ensure effective communication in care environment. Communication and Record keeping cannot be separated as they link to one another. Record keeping is important in the care environment because it ensures that information given is accurate and valid and that the right care is being given to the right patient. It also ensures that staff understand each patients risk before they provide any care to ensure a safe working environment. Record keeping is also important for example if a new nurse who has never worked on a ward comes in if they read the care plans and risk assessment can bring up to date so they don’t feel out of place. It will help them to support each individual with the care they need without the patient noticing any difference in staff change. It also important to know that their rules and policies to make sure information recorded or given or shared between nurses is relevant to what they need to use it for under the data protection act. So, it gives the data subject which are the patients a peace of mind knowing that their information is safe and good practise also ensures that nurses only access the information that will assist them to carry out their duties, without it being shared by irrelevant parties

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