Findings from this study call for clinical instruction and experiences to take a step further to meet current practice standards and to improve patient safety in the health professions education of nurses.
The aim of the project was to examine the current practice of nursing care documentation and to identify the common errors of nursing care documentation. A prospective cross sectional method was used to evaluate nursing care documents done by the nurses. The project was carried out between January 2014 and 31 March 2014. The project phase was based on the fundamental concepts divided to three phases. Phase 1 was assessment and diagnostic, phase 2: Planning Strategy and Process, and in phase 3: Implementation, Designing tool, Continuous monitoring.First phase started with assessment to diagnose the current practice; therefore baseline auditing was conducted by development of audit tool in documentation based on policy/guidelines, development and initiation of education strategy and finally the evaluation audit conducted to assess the outcome of the project.This project gave depth attention to the standardization of nursing documentation practice and the factors that leading to variation in practice which may cause the flaws in documentation quality. The project identified the barriers and opportunities to improve the efficiency of nursing documentation have been placed. The next stage of this project is to review the effectiveness of the method of documentation through the development and implementation of an audit tool.Alongside this, the plan is to continue regular education related to focus charting in order to fully imbibe this change into daily nursing practice.Nurses in organizations that are struggling with documentation issues can conquer it by using focus note method as it can easily be adapted to different clinical situations. This project also supported the nurses to provide legally prudent information related to patient care and nursing activities performed. There are hopes for the nursing documentation and record audit processes to be developed into electronic and systematic process and used as an aspect of a regular credentialing process in the near future. It is recommended that nursing administration should use a multidisciplinary approach to develop policies and guidelines on nursing care documentation and provide sustained continuing training opportunities for nurses on effectiveness of documentation and also aimed at putting the policy to improve daily use of standardized nursing languages.
Introduction: This paper discussed nurses' resuscitation trainings and their performance in a teaching hospital based on AHA guideline recommendations. The study explored the current standard practices and investigates the nurses' views on the effectiveness of the training, quality of equipment, familiarity and readiness of nurses in performing resuscitation. Methodology: A cross-sectional descriptive study conducted at teaching hospitals which mandate all nurses must be certified with the BLS and attends two code blue drill sessions per year. A self-administered questionnaire examined the support and guidance provided, the availability of resuscitation equipment and their quality/familiarity, the quality of training received in performing the resuscitation actions and finally explored the opinion in improving resuscitation. Results: The study revealed that the organization has established system to prepare the nurses adequately. Based on the 192 nurses, the total mean 2.63 supported that nurses are adequately trained with resuscitation knowledge and skills, 95% (n=171) of nurses were confident in announcing the code blue procedure, 93.3% (n=169) received appropriate training and 90% (n=162) found training instructors utilized standard method of simulation training which 90% (n=161) shared a real-life clinical scenarios are used in the training whilst 90.5% (n=162) stated SBAR is utilized as mode of communication and 66.6% (n=120) practiced post-procedure resuscitation debriefing. However, concerns were raised in three areas: availability of AEDs, cable and pad accessibility and permission to perform defibrillation procedures. In conclusion, study established nurses were well-prepared, trained and supported for resuscitation care.
Nursing documentation is a legal record and a communication for continuity of care. Nurses should understand the implications of incorrect documentation could lead to sentinel events. The study aimed to examine the current practice of nursing care documentation and develop project for improvement. The project conducted from January to March 2014. It was based on the fundamental concepts of assessment; planning; implementation and evaluation. A prospective cross sectional method used to evaluate nursing 'Focus Chart' documents. Two nurses' documentation per unit per day for two weeks was assessed and analyze from all units using the hospital's measurement tool. Findings showed that 980 nurses are providing direct patients care and performing documentation on patients chart. Fifty percent (n= 16) unit has started focus charting and ten units are utilizing narrative and six units using other methods in documentation respectively. Documentation improvement package developed and processes put in place to readdress the documentation concern. The nursing care plan, patient assessment and activity flow sheets were reviewed and recommendation made to nursing administration to use a multidisciplinary approach to develop policies and guidelines on nursing documentation. In addition to provide sustained continuing training opportunities for nurses on effectiveness of documentation.
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