Holistic care should be provided to the patient in the healthcare facility. For that, the nurse needs to work with experience and reflective process. These practices will help nurses in delivering safe and quality care to the diseased person. Therefore, the reflective process aids nurses in engaging in a therapeutic relationship with the patient which will ultimately enhance the well-being of the patient (Koshy et al 2017).
For my first year of clinical placement, I was placed in a hospital facility. I was working with a registered nurse in the hospital's general ward. My shift started early in the morning and at that time not many nurses were there. My supervisor nurse was very busy with the patients as it was a hectic day due to the number of people present in the ward. So, my supervisor registered nurse assigned me my first case, which was of an Aboriginal patient. The patient was a 35 years old female who complained about the problem in breathing. When I talked to her, I realized that I cannot understand most of the things that she wants to say. However, I understood that she was experiencing this problem from past few days. Therefore, I asked her about how long she has trouble breathing and does she smoke or is exposed to industrial pollution or smoke. I also asked about her being allergic to any substances and that any of her relative or family member have the problem of asthma. I also inquired her occupation and her living condition. While the conversation was going on, I comprehend that she was also not getting what I was trying to say. As a result of which I was not able to do proper documentation of her condition and her background. I was not able to assess her condition properly and also what might have caused her this reaction. Hence, I filled incomplete documentation and reported back to my supervisor nurse who then took the case into her hand. She also told me to observe the communication and documentation style while she talks to the Aboriginal patient.
At the time while I was talking to the Aboriginal patient and I was not able to understand what she was trying to say I felt like I was incompetent to do my job. I realize that as a nurse I should be able to maintain a therapeutic relationship with the patientand at that time I could not do it because of cultural variation. I also felt low about not being able to help the patient who was experiencing discomfort. With that, I was really worried for my future as a registered nurse that how will I be able to talk to my patients and document all the necessary details which are required for the patient diagnosis and treatment. However, after my supervisor registered nurse took the patient case I felt that there are many things which I need to lean in my practice as I am just starting. I also realize that I should not pay more attention to the differences that I might have with the patient but focus on my clinical practice and expertise. I understand the need for having proper knowledge about effective communication and the correct documentation.
In the scenario, the thing that I did well was that I asked the right questions to the patient. I asked her about the condition and try to get more information about it. I also tried to analyze the patient background so that I can know the cause of the problem. This type of initial assessment in nursing is very important because by doing so, the nurse can collect the data about the patient and can sort out the crucial information which would help in analyzing, and documenting the data. It would also help in decision-making which will ultimately benefit the well-being of the patient (Toney-Butler and Unison-Pace 2019). Another thing, which was done right by me, was that I reported my shortcomings to my supervisor nurse so that the patient does not have to face any consequences of my missing documentation skills. According to the Nursing and Midwifery Board APHRA, any process which is below the standard of care must be reported so that patient safety is upheld. With that, the nurse should also provide safe and quality practice to the patient. Therefore, my decision about telling the registered nurse that I lack proper skills for analyzing the patient was a correct step (Nursing and Midwifery Board APHRA 2020).
Things that I can do better while analyzing the patient was that I can make use of better communication skills. I could have made use of an effective communication style so that I can understand the concerns that are put forwards by the patient. Good communication among patients and nurses is significant because it helps in the enhancement of nursing care. It also facilitates in helping the diseased individual who is in need of care. With that, it helps in conveying sympathy and kindness towards the patient. It also assists in maintaining a therapeutic relationship with the patient which will enhance the quality of care (Kourkouta, and Papathanasiou 2014). Another thing which I could have done better was doing the proper or appropriate documentation about the patient and her condition. Documentation in nursing reflects the care quality which is given to the patient. It also enhances effective communication among the patient and the caregiver. With that, it aids in legal processes and helps in decision making. It, therefore, makes sure the safety of the patient and also replicates the complete process of nursing which ranges from assessments to the diagnosis and intervention, implementation and evaluation in the nursing practice. Therefore, if documentation is not done in the right way than implications can occur on the patient quality care and ultimately on her health (Kamil, Rachmah and Wardani 2018).
The main learning that I took from this experience was that I have to work on my communication and documentation skills. Therefore, the strategies that I will undertake to make my communication better will be that I will make use of non-verbal communication with the patient so that better understanding could be achieved. I will also try active listening and would ask the patient multiple questions to gather the data. With that, I would also seek clarification about the statement which I did not understand. I would also gain more knowledge about specific diseases and illnesses so that I can diagnose them early and can help the patient. I would also join workshops which will help me enhance the nurse-patient communication (Kamil, Rachmah and Wardani 2018; Saraswasta and Hariyati 2018). By doing all this, I would upgrade my communication skills. Strategies to work on documentation involve learning about the proper way of documenting the information. I would gain knowledge about the correct ways of documenting the patient's data. With that, I will make use of the reflection process in accessing the patient information. I will be accurate and will make use of correct tools. With that, while documenting I will consult the supervisor registered nurse or the clinician. I will also avoid stereotypes and opinions to get into the way of proper documenting about the patient. In addition to that, I will also focus on unclear information so that it can be clarified and the patient receives the best quality care (Asmirajanti, Hamid and Hariyati 2019).
Asmirajanti, M., Hamid, A.Y.S. and Hariyati, R.T.S., 2019.Nursing care activities based on documentation. BMC Nursing, vol.18, issue.1, pp.1-5.https://doi.org/10.1186/s12912-019-0352-0
Kamil, H., Rachmah, R. and Wardani, E. 2018. What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, vol.9, pp.111-114.
Koshy, K., Limb, C., Gundogan, B., Whitehurst, K. and Jafree, D.J. 2017.Reflective practice in health care and how to reflect effectively. International Journal of Surgery.Oncology, vol.2, issue.6, pp.e20.DOI: 10.1097/IJ9.0000000000000020
Kourkouta, L., and Papathanasiou, I. V. 2014.Communication in nursing practice. Materia Socio-Medica, vol.26, issue.1, pp.65–67. https://doi.org/10.5455/msm.2014.26.65-67
Nursing and Midwifery Board APHRA. 2020. Enrolled nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/enrolled-nurse-standards-for-practice.aspx [Accessed on 25 September 2020]
Saraswasta, I.W.G. and Hariyati, R.T.S., 2018. The implementation of electronic-based nursing care documentation on quality of nursing care: a literature review. International Journal of Nursing and Health Services (IJNHS), vol.1, issue.2, pp.19-31.https://doi.org/10.35654/ijnhs.v1i2.23
Toney-Butler, T.J. and Unison-Pace, W.J. 2019.Nursing Admission Assessment and Examination.StarPearls: United States of America.
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