This essay is going to evaluate the strengths and weakness associated with

Table of Contents

This essay is going to evaluate the strengths and weakness associated with the processes involved in communication and record keeping within nursing. This essay will also assess the motivations and values that help to strengthen the ability to work with others within a range of nursing settings, including hospitals, supported living and many more. Both of these issues are part of the day to day tasks that nurses carry out, especially communication as it is the most fundamental part of a nurse’s job as without this, they may not be able to best help their patients. This essay is going to look at what communication is, looking at both verbal and non-verbal communication. Additionally, this essay will look at the strengths and weaknesses of communication in terms of patient recovery and how this may be affected. I will also evaluate the challenges and barriers associated with communication, such as language barriers and hearing impairments and how these challenges can be resolved, and how barriers can be overcome. Lastly, I am going to evaluate the different strategies of communication and what situations that they are used best in in terms of patient behaviour. The second topic this essay is going to look at is record keeping, I will firstly look at what a record is and the different types of records, such as electronic and paper. I will then evaluate the best ways to keep records safe, the challenges of this and the ways to overcome this. Finally, I will look at how record keeping contributes to care in both positive and negative ways in terms of the accuracy of records and the storage of then. I will look at this in a way whereby I will be able to evaluate the effects of accurate recordkeeping in terms of patient care. CommunicationCommunication can be done verbally and non-verbally. Being able to communicate as a nurse means that we can exchange information, thoughts and feelings through the use of speech and other non-verbal factors such as body language and facial expressions (NCBI,2014). We rely on good communication every day to make our way through life.Verbal Communication is a type of oral communication wherein the message is transmitted through the spoken words. The effectiveness of the verbal communication depends on the tone of the speaker, clarity of speech, volume, speed, body language and the quality of words used in the conversation. (BusinessJargon,2019)Non-verbal communication is any communication made between two or more persons through the use of facial expressions, hand movements, body language, postures, and gestures. (BusinessJargon,2019)Communication is essential between patients and nurses as it is a fundamental part of receiving and relaying information that is usually deemed as important in most circumstances such as how the patient has been feeling for the past few days. This will then allow the nurse and patient to build a relationship of trust whereby the patient may become more open to speaking about their illness and the available treatments whether it be long term or short term. This will allow the nurses to become more empathetic and put themselves in their patient’s shoes which will help then to understand why they may behave the way that they do. This will then allow the nurse to communicate effectively with the patient in a way that they will understand best, this may also include relaying the information to the patients next of kin if applicable, however this must be completed with the permission of the patient to ensure that confidentiality is kept and the patient still feels that they can trust the nurse without the added stress of their information being told to someone who shouldn’t know. Communication additionally assist in the improvement of accurate and consistent nursing creating a sense of satisfaction for the patient as they are consistently obtaining the care, they need at the quality that they expect (NCIB, 2014). In my experience communication can be used in a rage of situations, where you may need to tell the patient information but communication is also a vital part of calming a patient when they have been given life threatening information or when the simply feel that they have had enough of their illness and cannot cope anymore. From my experience this is one of the most difficult parts of communication as it can have two effects, make the situation worse or better, this will then affect the patients outlook on their health and their recovery or coping mechanisms. There are many strengths in communication in terms of patient recovery. This may be as simple as involving the patient in the decision making about the care best suited to them and enabling them to voice their opinion on this matter. Ultimately this will reinforce the patient’s sense of belonging in the sense of that their voice matters and that they are cared for. This is important when treating a patient who may have a history of mental illnesses such as depression, anxiety or low self-esteem. This is also important in older patients, especially those who may have come from a care home or supported living as they are able to feel like they have a sense of control as their opinion, worries and concerns are being listened to and perhaps being resolved if it can be. However, where there are strengths there are also weaknesses whereby there can be consequences for a lack of communication that can negatively affect patient recovery. Poor communication about medication can have a deteriorating effect especially if the patient has been discharged in that the information surrounding their medication and how to obtain it is not properly conveyed to the individual. This can result in the patient being readmitted to the hospital and as a result their condition may have worsened. Poor communication on the patient’s end can also have a negative effect on their recovery as if they withhold information that is deemed as important the best course of treatment may not be apparent to the medical team and therefore it may take longer than expected for the patient to recover. It may also mean that the treatment does not work in the way that it is supposed to because of the factors that have not been conveyed to the team, resulting in the patient’s illness worsening. Communication is not just about relying information to you patient but being able to listen to what you patient wants and how they feel about the situation. In circumstances where there has been a failure to listen to the patient, it can create an atmosphere of mistrust and hatred from the patient’s point of view as they may feel that they don’t matter and that their opinion is not valued. This also takes away the patients right to be able to make their own decision by themselves or with the help of an advocate if needed in regard to their health and the care planned for them. There are many barriers to communication which can make patient care extremely difficult. An example of this is language. If a patient’s first language is not English and they cannot speak English or they speak in broken English, it can make it extremely difficult to obtain and relay information. In this situation a translator would have to be present to try and overcome this barrier but if the patient is going to be admitted it may be difficult to have a translator at all times when you may need to communicate with the patient. In some health care settings it may not be possible to have a translator present or to be able to contact a translator and so the health care professionals must be able to improvise in this situation where by they have to be able to ensure that their patient understands what they are being told and what is going on around them.Another barrier to communication in healthcare is the use of medical jargon, this can impair the patients understanding of their diagnosis, treatment and medication. A way to overcome this barrier would be explaining the information in a way that the patient understands to optimise patient understanding so that they are fully able to give consent. A third barrier may be cognitive ability. This may be a barrier as the patient may have impaired reasoning or memory. This can make it difficult to obtain information vital information due to the patient’s confusion or if they are easily distracted. This barrier may be overcome by talking to the patient in a room where there are no distractions to them to help them to focus on what they are being asked and told. Cultural differences may also lead to a barrier in communication due to different views on different situations. For example, Jehovah witness do not believe in having blood transfusions, so a health care professional may try to push a patient who is part of this religion to have a blood transfusion although it goes against their beliefs. This ultimately leads to a break down in trust and then affects the relationship of the patient and health care professional.Aggressive patients can have a detrimental effect on the health of not only the health care professionals but also the other patients. Aggressiveness towards health care professionals can create an atmosphere of fear within health care settings. Dealing with aggressive patients also takes up a lot of time and so there is a reduced amount of time to spend with other patients. This can also create a feeling of neglect as it is the aggressive patient who is receiving a lot of attention and becoming top priority instead of the patients who are sick. This can result in other patients acting in the same way to receive the same amount of attention. However, seeing how these situations are dealt with by health care professionals can make patients more understanding on some of the hardship’s health care professionals face. From my experience, some patients can feel protective over the health care professional treating them once a relationship has been built.Ultimately both the negatives, positives and the barriers of communication can have a knock-on effect on the health of your patients and how they view health care professionals. These can either improve or negatively affect patient health and recovery during their time within the health care setting but also this can have an effect on their mental health and home recovery progression. In my experience a patient always remembers good interactions with health care professionals, but they also always remember the bad which can cause them not to want to return to a health care setting, especially when they have a bad experience. Record keeping Medical records describe the systematic documentation of a patient’s medical history and care. Medical records contain your basic details like your name and your date of birth. They also contain the results of any tests, treatments, medicines and any notes that have been written about the plan of action regarding your care and your health. These notes are not just about your physical health but also your mental health. There are a range of positives in terms of accurate record keeping. Accurate record keeping is essential for the continuity of care of patients. Accurate records also vital for defending a complaint or clinical negligence claim as they provide information on the clinical judgment and treatment being exercised at the time. (MP, 2019)There are two main types of medical records, written and electronic. Written records are most commonly seen on hospital wards where information about the care provided to the patient is updated every two hours for rounding tools documents and three times a day for care provided. Electronic records are also used within wards but not as frequently as written records from my experience this from is only used weekly to update basic care plans whereby you have to update the patients BMI. In other health care settings, such as district care use electronic records more frequently as it allows them to access the most up to date records and continue to update these on the go. This means that if a patient gets admitted into hospital doctors and nurses will have access to the care that is being provided to them in their own home. This improves the quality of care that the patient will receive as more information about them will be available to those who require it. Electronic records are kept secure by storing them on secure systems and databases. These records are kept secure through the use of passwords, which allows health care professionals to pass through the fire wall and access the medical records. These records are also backed up on to a secure network which allows the information to be shared within the health care setting and those it is in partnership with. For example, GP surgeries and district nurses. Written records are kept secure by lock and key. These records are usually kept in a locked trolley in a locked office. These written records are kept here until they are inputted into the computer where they are stored securely electronically where they are seen to be more secure as they are less likely to be lost. Storing records electronically can create challenges as well as having its positives. Hard drives and data bases can often become corrupt meaning that all of the data is destroyed and often is no longer salvageable due to the information being lost. Viruses can also pose a security breach to patient medical records that are stored electronically. Viruses and worms within computer software can cause a breach in security as they can cause a leak in information because of the weaknesses that they create in the firewall. This allows patient information to be shared across the World Wide Web for anyone to access which completely breaches patient confidentiality. Written records can also create challenges although they hold strong positives. Due to written records being documented on single sheets of paper it can make it easier to lose or misplace information which can be deemed as vital in-patient care. There are also no backups of written records, so if there were to be a fire or a flood where records are stored all of the information will be lost due to the burning or soaking of the paper. There can also be challenges in obtaining accurate information from the patient. Patients often tell an altered story form the truth especially when it concerns their lifestyle choices which in turn makes it very difficult to plan their care. From my experience obtaining accurate records or series of events can be difficult within health care settings. This tends to be more common in patients with substance abuse as they will often tell the health care professional that they have had less of the substance than what they have actually had. This may be due to a fear of having to stay in hospital overnight or for longer if needed, which is seen more commonly in older people. If a patient has dementia, it can also be difficult to obtain accurate records at they may not have full capacity to be able to tell the heath care professional what has happened and so their family may have to be present to be able to do this so that the patient receives the best possible care. Patients family can also create a distorted view of the history of the patient’s health. This is most commonly seen when family accompany patients to appointments with doctors or consultants. This is also seen when a patient’s family is present during an hospital admission where personal questions are asked about the patient’s lifestyle and what their normal is, for example their bowel cycles and if they are continent. These are they type of questions that can be embarrassing for the patient and so they may not want to disclose this information Infront of their family if they are not aware, but it can also be difficult for the patient if their family answers these questions for them and they do not have all of the answers due to this embarrassment. In the past, most medical records were recorded in paper and stored manually. However, more recently there has been a change in how medical record are recorded and stored. The first form of medical records that we know of were written by ancient Greeks whose purpose of documenting medical notes was to simply record successful cures and share what they saw and the symptoms, so that others could learn from this (OTB,2017). In the 1920’s health care professionals found that to improve the diagnosis and treatment of illnesses was to fully document patient observations and actions taken to change this (OTB,2017). All medical records were paper based until around 1960, whereby the development of computers allowed records to be recorded and stored electronically. However, due to the cost of this, there was not many health care settings that’s used this method of medical record storage and so continued to use paper-based records (OTB,2017). It wasn’t until the 1990’s that most health care settings started to use electronic forms of recordings and storing medical records. This was due to the introduction of a database created in the 80’s that was able to be used across all settings. This advance in technology allowed heath care professionals to be able to share and compare medical records and treatments for illnesses (OTB,2017). In the 2000’s the electronic storage of medical records meant that health care professionals were able to make better decisions based on a patient’s medical history, reducing the occurrence of medical error. The introduction of the cloud meant that the network could be widened so that a larger proportion of health care settings could easily access medical records (OTB,2017). Today, electronic records are mostly used with the exception of some observations and care plans still being paper based, however, this depends on the health care setting. In my experience, it is most commonly the documents that need to be updated throughout the day that are recorded in writing. For example, rounding tools need to be updated every two hours so it is best practice to do this on paper instead of electronically. Blood sugar levels are also usually recorded on paper throughout the day; however, district nurses record this electronically on a system called paper light. This means that if a diabetic being seen by district nurses is admitted into hospital, the health care professionals within the hospital can check to see if the patient’s blood sugar is usually low or high and how much insulin the patient usually has throughout the day. Patient care plans are also paper written as this allows them to be completed with the patient as in order to fully know what the patient needs you have to discuss their needs with them and ask them questions about their daily living. There are also online care plans online that are filled out after you have spoken to the patient which are generally updated weekly with information such as their weight or if they have any new needs or they have now gained the ability to do particular things by themselves like not needing assistance to the toilet.