Question

Ch. 7 - Documentation

1. How will you be able to remember everything that must be documented during your busy shift caring for 10 - 20 patients.? Share your methods of keeping notes that can keep you organised and ensure all the details are documented later in nurses notes.

2. List the purposes of documentation and consequences of poor documentation.

Ch 8 - Communication

1. Describe the components of the communication process and list three factors that influence the way a person communicates.

2. What are ways to communicate nonverbally. List 3 positive & 3 negative.

Answer 1

Greetings of the day!

Answer:

Ch. 7 - Documentation

1. How will you be able to remember everything that must be documented during your busy shift caring for 10 - 20 patients.? Share your methods of keeping notes that can keep you organised and ensure all the details are documented later in nurses notes.

Types of Record-Keeping Used in Healthcare

• Hand-written records
• Computer-based systems (electronic)
• Some organisations or employers will use a combination of both.

You’ll be expected to be able to comply with whatever requirements your employer or organisation sets for record-keeping. That means you’ll need to:

• Ensure that you are up to date on the information systems and tools in your workplace including their security, confidentiality and appropriate usage;
• Protect any passwords or details given to you to enable your access to any systems;
• Make sure written records are not left in public places where unauthorised people might see them (including any electronic systems or displays);
• Ensure that an entry is made in the patient’s medical record whenever a health professional sees a patient.

Components of a patient’s records include:

• Medical records
• Nursing records/progress notes
• Medication charts
• Laboratory orders and reports
• Vital signs observation charts
• Handover sheets and admission
• Discharge and transfer checklists/ letters
• Patient’s assessment forms, such as nutrition or pressure area care assessment.

Principles of Good Record Keeping

• Some key factors underpin good record keeping. The patient’s records should:

• Be factual, consistent and accurate;
• Be updated as soon as possible after any recordable event;
• Provide current information on the care and condition of the patient;
• Be documented clearly in such a way that the text cannot be erased;
• Be consecutive and accurately dated, timed and all entries signed (including any alterations);
• All original entries should be legible. Draw a clear line through any changes and sign and date;
• Not include abbreviations, slang or jargon as not all workplaces or organisations will use the same terminology;
• Records must be stored securely and should only be destroyed following your local policy;
• Avoid meaningless phrases, speculation and offensive subjective statements/insulting or derogatory language;
• Identify the patient by recording patient’s name, date of birth and hospital number on each page of the record (three approved identifiers) or follow your local policies on how to identify patient’s records;
• Still be legible if photocopied or scanned.

• When caring for a patient, it is important to ensure good record keeping to promote patient care and better communication. Good record keeping is a product of good teamwork and an important tool in developing high-quality healthcare and reinforcing professionalism within nursing.

2. List the purposes of documentation and consequences of poor documentation.

Common Deficiencies in Record Keeping.

Poor record keeping hampers the care that patients receive and makes it difficult for healthcare professionals to defend their practice.

The most common deficiencies in record keeping include:

• An absence of clarity
• Inaccuracies
• Spelling mistakes
• Missing information
• Failure to record action taken when a problem has been identified.

Benefits of Good Record Keeping

Record keeping is a tool for professional practice and one that should help the care process. It is not separate and not an optional extra to be fitted in if circumstances allow.

A record should be made as soon as possible after the patient is seen or the procedure is complete. It’s important that accurate record is made in the patient’s notes and should include interventions and any response to the interventions.

The purposes of good record keeping are:

• Record keeping makes the continuity of care easier;
• Record keeping promotes better communication and dissemination of information between members of the multi-professional team;
• Helps to address complaints or legal processes;
• Supports clinical audit, research, allocation of resources and performance planning;
• Helps to identify risks and enables the early detection of complications;
• Supports patient care and patient-centred communication;
• Supports effective clinical judgement;
• Supports delivery of services;
• Helps improve accountability;
• Shows how decisions were made relating to the patient’s care.

(Jevon 2012)

Legal Issues in Record Keeping

The patient’s records are occasionally required as evidence before a court of law, or to investigate a complaint at a local, organisation level.

Sometimes records may be requested by professional governing bodies when investigating claims related to misconduct (NMC 2010).

Therefore, you must take care about what you write. Not only will you be asked to formally explain your records in the event of, for instance, a complaint from a patient/client, but registered nurses have both a professional and legal duty of care.

It is therefore critical to keep up-to-date with the legal requirements and best practices of record-keeping, proving that:

• A comprehensive nursing assessment of the patient has been undertaken including care that has been provided and planned;
• Relevant information is included together with any actions that have been taken in response to changes in patients’ conditions;
• The duty of care to the patient has been provided and that no acts or omissions have compromised a patient’s safety;
• Arrangements have been made for the ongoing care of the patient.

(Jevon 2012)

Delegation and Countersigning

A registered nurse is accountable for any delegation of record keeping to members of the multi-professional team who are not registered practitioners, such as assistant practitioners (AP), care assistants and nursing students (Jevon 2012).

As with any delegated activity, registered nurses should:

• Provide supervision until the team member is competent at undertaking the activity alone, and then that it is in the patient’s best interests to have record keeping duties delegated;
• Only countersign if they have witnessed the activity or can validate that it took place;
• Always follow local policies around record keeping, delegation and countersigning.

Ch 8 - Communication

1. Describe the components of the communication process and list three factors that influence the way a person communicates.

The Process of Communication

What does communication look like? When you think about communication in its simplest form, the process is really quite linear. There’s a sender of a message—let’s say you—talking. You, the sender, have a thought. You put that thought into words, which is encoding the message.

And then there’s a recipient of a message—in this case your coworker Nikola. The message comes out of your mouth, and then it is decoded, or processed, by the recipient, Nikola, who then decides on the meaning of your words as a result of that decoding process. She hears your words and considers their meaning—put simply, she’s listening. It looks something like this:

But what the sender says isn’t always what the reciever hears. Encoding and decoding don’t always happen seamlessly. In this instance, Nikola might “tune out” and miss some of what you said, or she may hear your words correctly, but misunderstand their meaning. It may even be a concept that is doomed to be misunderstood before your words are even formed, due to existing difference between you and your coworker. When this happens, it’s called noise.

If Nikola is not clear on your message, she may stop you and say, “Wait. You’re saying this. Do I understand you correctly?” This is called feedback.

Your recipient has let you know that you’ve been misunderstood by giving you feedback. At this point you can

• Repeat the message a second time
• Ask some clarifying questions to determine why your recipient didn’t understand what you said, and then address those issues on your next attempt to communicate your idea.

Feedback can come in a variety of forms, too. In this case, Nikola is repeating your statement and asking for confirmation that she heard it correctly. In another case, you may have told Nikola that to find the restroom she needs to head down a hall and turn right. When she heads down the hall and turns left, that, too, is feedback letting you know you’ve been misunderstood.

Often that’s the kind of feedback an organization has to navigate. Organizations issue a communication, perhaps in the form of a memo, and send it out to all their employees. Employees read it. If the message is understood and appropriate actions are taken, all is well. There may have been noise, but it did not get in the way of the message. If employees start firing emails back to the originator of the message, asking questions or clarifying points, they are engaging in feedback. If they take action that is not appropriate, that’s also feedback. The message needs to be reiterated, framed differently, to clarify portions that were not communicated the first time.

This whole process, the steps between a source and receiver that result in the transference and understanding of meaning, is called the communication feedback loop. In an organizational communication feedback loop, we can also consider the channel of communication in the message. The channel is the medium by which the message travels. Newsletters, one-on-one meetings, town halls, video conferencing—all of these are channels of communication.

THE THREE COMPONENTS OF COMMUNICATION

On a daily basis we work with people who have different opinions, values, beliefs, and needs than our own. Our ability to exchange ideas with others, understand others' perspectives, solve problems and successfully utilize the steps and processes presented in this training will depend significantly on how effectively we are able to communicate with others.

The act of communicating involves verbal, nonverbal, and paraverbal components. The verbal component refers to the content of our message‚ the choice and arrangement of our words. The nonverbal component refers to the message we send through our body language. The paraverbal component refers to how we say what we say - the tone, pacing and volume of our voices.

In order to communicate effectively, we must use all three components to do two things:

1. Send clear, concise messages.

2. Hear and correctly understand messages someone is sending to us.

Communication Involves Three Components:

1. Verbal Messages - the words we choose

2. Paraverbal Messages - how we say the words

3. Nonverbal Messages - our body language

These Three Components Are Used To:

1. Send Clear, Concise Messages

2. Receive and Correctly Understand Messages Sent to Us.

SENDING MESSAGES

Verbal Messages

Our use of language has tremendous power in the type of atmosphere that is created at the problem-solving table. Words that are critical, blaming, judgmental or accusatory tend to create a resistant and defensive mindset that is not conducive to productive problem solving. On the other hand, we can choose words that normalize the issues and problems and reduce resistance. Phrases such as "in some districts, people may . . .", "it is not uncommon for . . ." and "for some folks in similar situations" are examples of this.

Sending effective messages requires that we state our point of view as briefly and succinctly as possible. Listening to a rambling, unorganized speaker is tedious and discouraging - why continue to listen when there is no interchange? Lengthy dissertations and circuitous explanations are confusing to the listener and the message loses its concreteness, relevance, and impact. This is your opportunity to help the listener understand YOUR perspective and point of view. Choose your words with the intent of making your message as clear as possible, avoiding jargon and unnecessary, tangential information.

Effective Verbal Messages:

1. Are brief, succinct, and organized

2. Are free of jargon

3. Do not create resistance in the listener

Nonverbal Messages

The power of nonverbal communication cannot be underestimated. In his book, Silent Messages, Professor Albert Mehrabian says the messages we send through our posture, gestures, facial expression, and spatial distance account for 55% of what is perceived and understood by others. In fact, through our body language we are always communicating, whether we want to or not!

You cannot not communicate.

Nonverbal messages are the primary way that we communicate emotions:

Facial Expression: The face is perhaps the most important conveyor of emotional information. A face can light up with enthusiasm, energy, and approval, express confusion or boredom, and scowl with displeasure. The eyes are particularly expressive in telegraphing joy, sadness, anger, or confusion.

Postures and Gestures: Our body postures can create a feeling of warm openness or cold rejection. For example, when someone faces us, sitting quietly with hands loosely folded in the lap, a feeling of anticipation and interest is created. A posture of arms crossed on the chest portrays a feeling of inflexibility. The action of gathering up one's materials and reaching for a purse signals a desire to end the conversation.

Nonverbal Messages:

1. Account for about 55% of what is perceived and understood by others.

2. Are conveyed through our facial expressions as well as our postures and gestures.

Paraverbal Messages

Paraverbal communication refers to the messages that we transmit through the tone, pitch, and pacing of our voices. It is how we say something, not what we say. Professor Mehrabian states that the paraverbal message accounts for approximately 38% of what is communicated to someone. A sentence can convey entirely different meanings depending on the emphasis on words and the tone of voice. For example, the statement, "I didn't say you were stupid" has six different meanings, depending on which word is emphasized.

Some points to remember about our paraverbal communication:

When we are angry or excited, our speech tends to become more rapid and higher pitched.

When we are bored or feeling down, our speech tends to slow and take on a monotone quality.

When we are feeling defensive, our speech is often abrupt.

Paraverbal Messages:

1. Account for about 38% of what is perceived and understood by others.

2. Include the tone, pitch, and pacing of our voice

2. What are ways to communicate nonverbally. List 3 positive & 3 negative.

Ways of nonverbal communication

The many different types of nonverbal communication or body language include:

Facial expressions. The human face is extremely expressive, able to convey countless emotions without saying a word. And unlike some forms of nonverbal communication, facial expressions are universal. The facial expressions for happiness, sadness, anger, surprise, fear, and disgust are the same across cultures.

Body movement and posture. Consider how your perceptions of people are affected by the way they sit, walk, stand, or hold their head. The way you move and carry yourself communicates a wealth of information to the world. This type of nonverbal communication includes your posture, bearing, stance, and the subtle movements you make.

Gestures. Gestures are woven into the fabric of our daily lives. You may wave, point, beckon, or use your hands when arguing or speaking animatedly, often expressing yourself with gestures without thinking. However, the meaning of some gestures can be very different across cultures. While the OK sign made with the hand, for example, conveys a positive message in English-speaking countries, it’s consider offensive in countries such as Germany, Russia, and Brazil. So, it’s important to be careful of how you use gestures to avoid misinterpretation.

Eye contact. Since the visual sense is dominant for most people, eye contact is an especially important type of nonverbal communication. The way you look at someone can communicate many things, including interest, affection, hostility, or attraction. Eye contact is also important in maintaining the flow of conversation and for gauging the other person’s interest and response.

Touch. We communicate a great deal through touch. Think about the very different messages given by a weak handshake, a warm bear hug, a patronizing pat on the head, or a controlling grip on the arm, for example.

Space. Have you ever felt uncomfortable during a conversation because the other person was standing too close and invading your space? We all have a need for physical space, although that need differs depending on the culture, the situation, and the closeness of the relationship. You can use physical space to communicate many different nonverbal messages, including signals of intimacy and affection, aggression or dominance.

Voice. It’s not just what you say, it’s how you say it. When you speak, other people “read” your voice in addition to listening to your words. Things they pay attention to include your timing and pace, how loud you speak, your tone and inflection, and sounds that convey understanding, such as “ahh” and “uh-huh.” Think about how your tone of voice can indicate sarcasm, anger, affection, or confidence.

Negative Body Language

Being aware of negative body language in others can allow you to pick up on unspoken issues or bad feelings. So, in this section, we'll highlight some negative nonverbal signals that you should look out for.

Difficult Conversations and Defensiveness

Difficult or tense conversations  are an uncomfortable fact of life at work. Perhaps you've had to deal with a difficult customer , or needed to talk to someone about his or her poor performance . Or maybe you've negotiated a major contract.

Ideally, these situations would be resolved calmly. But, often they are complicated by feelings of nervousness, stress, defensiveness , or even anger . And, though we may try to hide them, these emotions often show through in our body language.

For example, if someone is exhibiting one or more of the following behaviors, he will likely be disengaged, disinterested or unhappy (see figure 1):

• Arms folded in front of the body.
• Minimal or tense facial expression.
• Body turned away from you.
• Eyes downcast, maintaining little contact.

Figure 1.

Being aware of these signs can help you to adjust what you say and how you say it, so you can make him feel more at ease and receptive to your viewpoint (see figure 2).

Figure 2.

Avoiding Unengaged Audiences

When you need to deliver a presentation, or to collaborate  in a group, you want the people around you to be 100 percent engaged.

Here are some "telltale" signs that people may be bored or disinterested in what you're saying (see figures 3-6):

• Sitting slumped, with heads downcast.
• Gazing at something else, or into space.
• Fidgeting, picking at clothes, or fiddling with pens and phones.
• Writing or doodling.

Figure 3.		Figure 4.
Figure 5.		Figure 6.

When you notice that someone is disengaged , you're in a better position to do something about it. For example, you can re-engage her by asking her a direct question, or by inviting her to contribute an idea of her own.

How to Project Positive Body Language

When you use positive body language, it can add strength  to the verbal messages or ideas that you want to convey, and help you to avoid sending mixed or confusing signals.

In this section, we'll describe some basic postures that you can adopt to project self-confidence and openness.

Making a Confident First Impression

These tips can help you to adjust your body language so that you make a great first impression :

• Have an open posture. Be relaxed, but don't slouch! Sit or stand upright and place your hands by your sides (see figure 7). Avoid standing with your hands on your hips, as this will make you appear larger, which can communicate aggression or a desire to dominate (see figure 8).
• Use a firm handshake. But don't get carried away! You don't want it to become awkward or, worse, painful for the other person. If it does, you'll likely come across as rude or aggressive.
• Maintain good eye contact. Try to hold the other person's gaze for a few seconds at a time. This will show her that you're sincere and engaged. But, avoid turning it into a staring match! (See figure 9.)
• Avoid touching your face. There's a common perception that people who touch their faces while answering questions are being dishonest (see figure 10). While this isn't always true, it's best to avoid fiddling with your hair or touching your mouth or nose, particularly if your aim is to come across as trustworthy.

Figure 7.		Figure 8.
Figure 9.		Figure 10.

Public Speaking

Positive body language can also help you to engage people, to mask presentation nerves , and to project confidence  when you speak in public. Here are a few tips that can help you to do this:

• Have a positive posture. Sit or stand upright, with your shoulders back and your arms unfolded and at your sides or in front of you (see figure 11). Don't be tempted to put your hands in your pockets, or to slouch, as this will make you look disinterested.
• Keep your head up. Your head should be upright and level (see figure 12). Leaning too far forward or backward can make you look aggressive or arrogant.
• Practice and perfect your posture. You'd practice your presentation beforehand, so why not practice your body language, too? Stand in a relaxed manner, with your weight evenly distributed. Keep one foot slightly in front of the other – this will help you to maintain your posture (see figure 13).
• Use open hand gestures. Spread your hands apart, in front of you, with your palms facing slightly toward your audience. This indicates a willingness to communicate and to share ideas (see figure 14). Keep your upper arms close to your body. Take care to avoid overexpression, or people may pay more attention to your hands than to what you're saying.

Figure 11.		Figure 12.
Figure 13.		Figure 14.

Tip:

If you notice that your audience's concentration is starting to slip, try to lean slightly forward while you speak. This suggests that you are taking them into your confidence and will help you to regain their attention.

Interviews, Negotiations and Reflection

Body language can also help you to stay calm in situations where emotions have the potential to run high – a negotiation , for example, or a performance review . Use the following tips to defuse tension and demonstrate openness:

• Use mirroring. If you can, subtly mirror the body language of the person you're talking to. This will make him feel more at ease, and can build rapport . But don't copy every gesture that he makes, as this will likely make him feel uncomfortable, or that you're not taking him seriously.
• Relax your body. It can be difficult to keep emotions at bay, particularly in nerve-wracking situations such as an interview  or appraisal. But you can maintain the appearance of calm by keeping your hands still, and by avoiding fidgeting with your hair or touching your face.
• Look interested. As we suggested above, touching your face or mouth can signal dishonesty. But, it can also demonstrate that you're thinking. So, if you are asked a complex question, it's OK to briefly touch your cheek or stroke your chin. This will show the other person that you're reflecting on your answer before you respond (see figure 15).

Figure 15.

Note:

While the tips covered in this article are a good general guide for intepreting body language, it's important to remember that they won't necessarily apply to everyone. This is particularly the case if someone has a different cultural background  from you, for instance.

Avoid making generalized assumptions. If you're getting mixed signals, check that your interpretation of the person's body language is correct by asking him questions and getting to know him better. After all, the ability to interpret body language is a complementary skill, not a substitute for listening  to and understanding people.

Key Points

Body language refers to the nonverbal signals that you use to communicate your feelings and intentions. It includes your posture, your facial expressions, and your hand gestures.

The ability to understand and to interpret body language can help you to pick up on unspoken issues, problems or negative feelings that other people might have. You can also use it in a positive way to add strength to your verbal messages.

Negative body language includes:

• Folded arms.
• Tense facial expression.
• Body turned away from you.
• Poor eye contact.

Positive body language includes:

• Open body position (arms unfolded).
• Upright posture.
• Relaxed and open facial expression.
• Arms hanging relaxed by the sides.
• Regular eye contact.