Free Essays - Free Nursing Essays
Nursing Profession
The nurse's day on the ward starts with the ritual of a report. Much of the information shared is routine, often not relevant to care and potentially subjective.
Identify a situation where you have either given or received the change of shift report.
Introduction
The nursing report in one form or another has been around at least since the days of Florence Nightingale. (Carrick P 2000). As the nursing profession has evolved over the years, so have the demands of nursing. (Chaboyer et al. 2001). To a large extent this has been manifested in the various practices that are carried out within the profession.( Meleis A 1997). The nursing report is no exception. As with any practice that involves human intervention, it is rarely perfect and its standard can vary from excellent to appalling. (RCN2003) The thrust of this essay is to examine the best practice in this area.
The particular nursing report that is seminal to this essay was given when I was working on a geriatric ward in an NHS hospital. It has remained fixed in my mind as it was a good example of how not to present a report. It was given by a staff nurse who clearly wanted to get away quickly, who probably had had a bad day on the ward, who was fed up and apparently did not care a great deal about what happened on the ward after she had gone home. (Bryant P 2005). The result of this was that I did not have a clear idea of the various ongoing problems with the patients and it gave me no insight into the needs of the various patients as people. I felt as if they were being regarded as cattle - which was clearly very unprofessional. (Sugarman J & Sulmasy 2000). The report itself was very task orientated and actually did little more than list the various tasks that were still outstanding which the nurse who was giving the report, simply didn't have the time to get round to doing herself.
The report itself was given in a rushed manner, the actual items that were included were not presented well nor actually communicated clearly, and there were a number of colloquial references which were, frankly, rather judgmental and not terribly professional. At the end of the report, I actually confronted the nurse who had given it and told her of my misgivings, but as she was rather more senior to me, it was not therefore easy to become assertive in this matter. Over the intervening weeks I have had the opportunity to reflect on this matter (Gibbs 1988) and have made a number of observations, evaluations and come to a number of conclusions (see on)
Discussion
Academic work in this particular area is not very prolific. What there is, seems to be foreign in origin and not very recent. The two definitive studies directly on the subject, however, (Kihlgren et al 1992) (Ljukkonen A 1992), are actually very revealing.
The Kihlgren study was particularly well structured with several seperate elements of study contained within it. It assessed the quality of the reports studied over a three month period. It then assessed the quality of reports given for a further three months after a spell of intensive training on the issues involved. It then sought to measure whether the patient care was improved to any degree. It also assessed the receiving nurses' assessment of the quality of the report both before and after the intervention. In general terms, it found that the pre-intervention reports tended to be:
highly task oriented and the staff often discussed the patients' reaction in vague and general terms.
The study also found that the steps of the nursing process did not appear to be consistently used.
After training, the authors noted that reports were different in as much as they could detect that:-
more messages were given per report after the intervention compared to the control ward and the messages with psychosocial content had doubled.
Possibly as a result of this the authors also noted that the nurses who were receiving the report also expressed less dissatisfaction and more noticeable collaboration between the different working groups on the ward. (Adams et al 1998)
The study pointed to the key elements of the report which echo the writings of Orlando (et al 1989) (see on ). The training that was given was not clearly specified, but it did cover areas of both prioritisation, communication and presentation skills together with instruction of the important ingredients of the actual nursing report.
Ljukkonen A 1992 produced a similar study in the same year. This went into greater detail regarding the actual content of the nursing report. It is particularly relevant as it was carried out in a geriatric setting where there was a low turnover of patients and those that were there were becoming progressively more disabled and therefore the nursing staff needed constant updating on their condition. Rather like the Kihlgren study, this study found that most of the reports were:-
concerned daily activities and medical care. Some of the discussions fell within the categories of "patients' opinions" and "mood". Information was situation related
This certainly related to my experience. There is a further dimension to the issues pertaining to a poor nursing report, and that has been mentioned tangentially already. One of the aspects of the function of a nursing report is to encourage the concept of a nursing team. (Chaboyer 2001). There are few situations where the nursing team on a busy ward, will actually have the opportunity to discuss issues and bond. The nursing report is therefore important in this respect as well. (Parahoo et al 2004). To be able to interact and both hear and express opinions relating to the patients on the ward, is a vital part of the nursing process (Roper et al 1983)
The third paper on the issue is by Kuhlmey (et al 1988). It has to be said that this study is not as user friendly as the other two, but there are still some very relevant findings. They found that there was a tendency, if the staff could not think of anything constructive to report, to pass comment on the patient's emotional state. This clearly, although peripherally useful, does not contribute much to the future management of the case. (Henderson 1960). The same study found that training did make measurable differences to both the structure and quality of the nursing report.
This then begs the question - what are the constituent components of an ideal nursing report. They can be categorised into three main headings, namely:
Prioritising care and patient needs. Communication Skills. Non-Judgemental Approach.
(Orlando, I. J., & Dugan, A. B. 1989).
Orlando's ideals came from a belief that the nurses role was to ascertain and priorities the patient's needs for help. (Orlando 1987). Clearly each nurse who interacts with a patient will bring their own perception of the patient's needs into the clinical domain. Having ascertained these needs, the nurse can then prioritise them and these can be either immediately actioned or charted for future action and, as such, presented as a vital component of the nursing report.
Communication skills are paramount in this area. There is the issue of communication between patient and nurse, and also the issue of the inter-nurse communication during the process of the nursing report. (Arnold et al 2004)
Communication skills are included amongst the six core constituents for an effective nurse manager. (ICN 1998) viz:
Personal integrity.
Strategic vision and action orientation.
Team-building and communication skills.
Management and technical competency.
People skills, such as networking and working collaboratively.
Personal survival skills, such as political sensitivity and candour.
It is clearly of no value to the nursing team for the nursing manager to have important information and yet not be able to communicate this clearly and effectively to the other members of the team. (Burgio et al 2001). This is effectively demonstrated by the first two of the studies that we have already commented upon. There are some nurses who instinctively appear to have the ability to communicate clearly and concisely, but for the majority, it is a skill that has to be both learned acquired and practised. (Davies et al 2002)
The study referred to above (Burgio 2001) actually measured the effects of communication between the various nursing workers on a geriatric ward. The authors found that , with appropriate facilitation, good channels of communication actually increased the amount of useful time that was spent with nurses involving themselves with positive and productive interactions with patients. They also commented on the increase in staff cohesiveness which is an American term for team bonding.
A very recent study by Heinmann-Knoch (2005) was on the same type of format as the Burgio study, insofar as it considered the implications of poor communication within the nursing team. The authors set up a study which was in two groups (one being the control) and they instituted both training and instruction in one group and then measured the outcome. From their results, it is clear that they were able to demonstrate that the art of effective presentation and communication can be both learned and practised.
There is of course the basic need to be able to converse in everyday English which may be a problem with some of our ethnic minority colleagues, (Veitch RM 2002), but with the advent of language proficiency standards being introduced, this is hopefully a thing of the past. (Casey & Hoy 1997).
Part of the key to effective communication, is the clear presentation of key ideas which should, ideally be prepared earlier, and listed in a prioritised fashion (King I 1991). It is advised that the presenter should organise the presentation in some fashion. It can either be in order of priority, or as more often the case in the classical nursing report, patient by patient, with the same pattern of presentation in each case (Newell and Simon. 1972)
The non-judgemental approach is also clearly important. Comments that I remember from the nursing report that I recalled from earlier, were both judgmental and, to me, frankly offensive. Comments relating to the fact that Mrs A. is being awkward and Mrs B. is being a nuisance may be true, but really have no place in a professional report. The reality of the situation is that the professional nurse should really try to ascertain just why it is the Mrs A. feels the need to be awkward and that Mrs B. is being a nuisance. (Henderson 1960)
It could just be that by understanding the reasons behind the actions then the nurse may well be able to rectify the situation rather than simply comment on it as a matter of fact (Marks-Moran & Rose 1996).
It is comparatively easy for the nurse to become depersonalised on a busy ward and to come to think of patients as cases or numbers. Hopefully we should never loose sight of the fact that they are people with their own thoughts, needs and rights who are deserving of the professional nurses' respect. (Veitch RM 2002)
On this note we should consider the fact that it is actually appropriate for the nursing report to not only relate to issues that pertain to the patient. The nursing process should also cover the interactions and dynamics between the patients relatives and carers and the nurses. (Hertzberg et al 2000). The carers and relatives of the patient must also be allowed to have a voice and a say in the dealings with the patient. This may not be apparent to the nurse who is working only with the patient and who may not have actually met the carer. Such information is therefore potentially of paramount importance in the management plan of the patient, and should therefore also have a place in the good nursing report.
Conclusions
Form the evidence that I have found, not only from my own personal experience, but in the literature as well, it is clear that the nursing report, as a nursing tool, has the ability to serve a very useful purpose. It can inform and educate, as well as being a model for how a ward should be run. (Clark 1997). It acts as a forum for constructive comments for the various nursing professionals, who may have an input to the potential welfare of each individual patient. (Adams et al 1998)
I have used the particular experience that I had as a model for reflection (Gibbs, G 1988) and I have come to a number of conclusions.
Rather than simply relating the various task-orientated processes, which are obviously important to the running of a modern hospital ward, a good nursing report should also address the patient's basic human needs as well as those needs that are purely related to their disease process (Ljukkonen A 1992).
One final paper that I should pass comment on is the one by Voutilainen (et al 2004) this study looked at the effectiveness of the nursing report with a particularly fine set of parameters. It sought to determine whether, as the result of a nursing report, that the following arbitrary criteria had been met:-
(i) Individual needs were assessed, the goals for nursing care were set, and the nursing interventions were determined;
(ii) If the patients' needs were met
(iii) If goal achievement is regularly evaluated by including comments made in the nursing report.
The paper itself is both long and detailed, but, in essence, it was able to conclude that where these criteria were met, the patient care was demonstrably better.
It is clear to me that the best forms of nursing report that I have heard, are the ones that are obviously thought about and prepared beforehand rather than just being read as a series of disjointed comments. They include the various needs of the patient, both medical and nursing, as well as those needs that are perhaps less easily defined such as social or perhaps psychological. (Kuhse & Singer 2001). I believe that proper delivery of a nursing report is a skill that can be learned and practised. It is not something that should just be approached casually by a nurse in a hurry. (Johnson 1990)
From the knowledge that I now have, I feel more able to challenge poor practice in this area. I have always been a firm believer that explanation and encouragement are better tools to effect change than are compulsion and blind insistence. (Marinker M.1997)
I started this essay by commenting on the changes from the time of Florence Nightingale. One can only hope that her ideals and aspirations for the increasing professionalism of the nursing staff in her hospitals (Nightingale 1859) will continue, not least in the form of good communication and nursing reports.
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