A ward-based writing coach program was piloted to improve the quality of nursing documentation. The program consisted of two 1-hour writing workshops for nurses, followed by one-on-one coaching sessions. The workshops discussed principles of quality documentation and barriers to understanding documentation, such as abbreviations. Nurses were then coached as they wrote documentation to help apply the workshop lessons. The goal was to encourage nurses to critically reflect on documentation practices and make documentation more readable and relevant to diverse readers.
Knowledge and Practice of Documentation among Nurses in Ahmadu Bello Universi...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Use of a standardized nursing language for documentation of nursin.docxjessiehampson
Use of a standardized nursing language for documentation of nursing care is vital both to the nursing profession and to the bedside/direct care nurse. The purpose of this article is to provide examples of the usefulness of standardized languages to direct care/bedside nurses. Currently, the American Nurses Association has approved thirteen standardized languages that support nursing practice, only ten of which are considered languages specific to nursing care. The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical setting, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
Keywords: North American Nursing Diagnosis Association (NANDA); Nursing Intervention Classification (NIC); Nursing Outcome Classification (NOC); nursing judgments; patient care; quality care; standardized nursing language; communication
Citation: Rutherford, M., (Jan. 31, 2008) "Standardized Nursing Language: What Does It Mean for Nursing Practice? "OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1.
Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses' recent implementation of the Nursing Intervention Classification (NIC) (McCloskey-Dochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system. �it is impossible for medicine, nursing, or any health care-related discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process. During the conversation, one nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidence-based outcomes for nursing.
Most articles in the nursing literature that reference standardized nursing languages are related to research or are scholarly discussions addressing the fine points surrounding the development or evaluation of these languages. Although the value of a specific, standardized nursing language may be addressed, there often is limited, in-depth discussion about the applicatio ...
Financial Management Please respond to the following· Explain.docxvoversbyobersby
"Financial Management" Please respond to the following:
· Explain the three methods for calculating credit card interest and your reason for going with a particular method.
· Provide an example of how you can use the power of compounding interest to pay for a future expense.
· Discuss which practical application covered in the chapter you think you will use within the next year and how you think studying this topic will help you make wise financial choices in the future.
ICU Nurses' Oral-Care Practices and the Current Best Evidence
Author: Ganz, Freda DeKeyser, RN, PhD; Fink, Naomi Farkash, RN, MHA; Raanan, Ofra, RN, MA; Asher, Miriam, RN, BA; Bruttin, Madeline, RN, MA; Nun, Maureen Ben, RN, BSN; Benbinishty, Julie, RN, BA
ProQuest document link
Abstract:
The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics.
A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics.
The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care.
While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all ICU nurses to introduce and use evidence-based, oral-care protocols.
Practicing ICU nurses in this survey were often not adhering to the latest evidence-based practice and therefore need to be educated and encouraged to do so in o ...
6410 Application 3 Becoming a Leader in the Translation of Evide.docxtroutmanboris
6410 Application 3: Becoming a Leader in the Translation of Evidence to Practice
Note: Have an APA Level 1 header for each area noted below in blue (a level 1 header is centered, bolded, using upper and lower case letters—see APA manual area 3.03) Follow APA format and include a minimum of 5 scholarly references less than 5 years old.
Include a BRIEF Introduction and Summary in addition to the headers below. DO NOT EXCEED THREE PAGES AND MUST CITE OFTEN THROUGHOUT THE PAPER.
Grading Area
Points Possible
Points Earned
Potential areas for earning points:
Header: Efforts to Increase Finance and Economic Knowledge
How you would continue to increase your knowledge and awareness of financial, economic, and other concerns related to new practice approaches
2
Header: Use of Evidence to Improve Practice
How translating evidence would enable you to affect or strengthen health care delivery and nursing practice
2
Header: Advocating for EBP Policy Change
How you would advocate for the use of new evidence-based practice approaches through the policy arena
2
Potential areas for losing points:
Grammar, Spelling, and APA errors
Up to 2 pt. deduction
Went Over Page Limit (2-3 pages max)
Up to 2 pt. deduction
Improper credit & citation issue
(See Turnitin Report)
1-6 pt. deduction
Late Submission
20% deduction (1.2 pts) per day late (per syllabus)
6 Total Points Possible
Total Points Earned
P.S. Under the first header on “Effort to Increase Finance and Economic Knowledge, please refer to the attached week 6 discussion you did for me, except you did not include specific numbers and statistics. Below is the critique made by the professor on that area. Please read through the critique and try to incorporate it in this portion of this paper.
Dear student: Thank you for your contribution to this week’s discussion. You brought forward potential costs associated with increased mobilization of ICU patients….namely the need for more nurse time. Do you have some hard numbers you can provide on the potential cost of this? Do you have any local or national information on the cost of not mobilizing the patients (longer stays, increased infection, readmission)? Calculating approximate cost associated with the practice change versus the cost of not changing is important. This will help stakeholders see the value in the investment.
DISCUSSION PAPER
Evidence-based practice models for organizational change: overview
and practical applications
Marjorie A. Schaffer, Kristin E. Sandau & Lee Diedrick
Accepted for publication 19 July 2012
Correspondence to M.A. Schaffer:
e-mail: [email protected]
Marjorie A. Schaffer PhD RN
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Kristin E. Sandau PhD RN CNE
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Lee Diedrick MAN RN C-NIC
Clinical Educator
Children’s Hospitals and Clinics of
Minnesota, St. Paul, Minnesota, USA
S C H A F F E R M . A . , S A N D A U K ..
Knowledge and Practice of Documentation among Nurses in Ahmadu Bello Universi...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Use of a standardized nursing language for documentation of nursin.docxjessiehampson
Use of a standardized nursing language for documentation of nursing care is vital both to the nursing profession and to the bedside/direct care nurse. The purpose of this article is to provide examples of the usefulness of standardized languages to direct care/bedside nurses. Currently, the American Nurses Association has approved thirteen standardized languages that support nursing practice, only ten of which are considered languages specific to nursing care. The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical setting, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
Keywords: North American Nursing Diagnosis Association (NANDA); Nursing Intervention Classification (NIC); Nursing Outcome Classification (NOC); nursing judgments; patient care; quality care; standardized nursing language; communication
Citation: Rutherford, M., (Jan. 31, 2008) "Standardized Nursing Language: What Does It Mean for Nursing Practice? "OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1.
Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses' recent implementation of the Nursing Intervention Classification (NIC) (McCloskey-Dochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system. �it is impossible for medicine, nursing, or any health care-related discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process. During the conversation, one nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidence-based outcomes for nursing.
Most articles in the nursing literature that reference standardized nursing languages are related to research or are scholarly discussions addressing the fine points surrounding the development or evaluation of these languages. Although the value of a specific, standardized nursing language may be addressed, there often is limited, in-depth discussion about the applicatio ...
Financial Management Please respond to the following· Explain.docxvoversbyobersby
"Financial Management" Please respond to the following:
· Explain the three methods for calculating credit card interest and your reason for going with a particular method.
· Provide an example of how you can use the power of compounding interest to pay for a future expense.
· Discuss which practical application covered in the chapter you think you will use within the next year and how you think studying this topic will help you make wise financial choices in the future.
ICU Nurses' Oral-Care Practices and the Current Best Evidence
Author: Ganz, Freda DeKeyser, RN, PhD; Fink, Naomi Farkash, RN, MHA; Raanan, Ofra, RN, MA; Asher, Miriam, RN, BA; Bruttin, Madeline, RN, MA; Nun, Maureen Ben, RN, BSN; Benbinishty, Julie, RN, BA
ProQuest document link
Abstract:
The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics.
A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics.
The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care.
While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all ICU nurses to introduce and use evidence-based, oral-care protocols.
Practicing ICU nurses in this survey were often not adhering to the latest evidence-based practice and therefore need to be educated and encouraged to do so in o ...
6410 Application 3 Becoming a Leader in the Translation of Evide.docxtroutmanboris
6410 Application 3: Becoming a Leader in the Translation of Evidence to Practice
Note: Have an APA Level 1 header for each area noted below in blue (a level 1 header is centered, bolded, using upper and lower case letters—see APA manual area 3.03) Follow APA format and include a minimum of 5 scholarly references less than 5 years old.
Include a BRIEF Introduction and Summary in addition to the headers below. DO NOT EXCEED THREE PAGES AND MUST CITE OFTEN THROUGHOUT THE PAPER.
Grading Area
Points Possible
Points Earned
Potential areas for earning points:
Header: Efforts to Increase Finance and Economic Knowledge
How you would continue to increase your knowledge and awareness of financial, economic, and other concerns related to new practice approaches
2
Header: Use of Evidence to Improve Practice
How translating evidence would enable you to affect or strengthen health care delivery and nursing practice
2
Header: Advocating for EBP Policy Change
How you would advocate for the use of new evidence-based practice approaches through the policy arena
2
Potential areas for losing points:
Grammar, Spelling, and APA errors
Up to 2 pt. deduction
Went Over Page Limit (2-3 pages max)
Up to 2 pt. deduction
Improper credit & citation issue
(See Turnitin Report)
1-6 pt. deduction
Late Submission
20% deduction (1.2 pts) per day late (per syllabus)
6 Total Points Possible
Total Points Earned
P.S. Under the first header on “Effort to Increase Finance and Economic Knowledge, please refer to the attached week 6 discussion you did for me, except you did not include specific numbers and statistics. Below is the critique made by the professor on that area. Please read through the critique and try to incorporate it in this portion of this paper.
Dear student: Thank you for your contribution to this week’s discussion. You brought forward potential costs associated with increased mobilization of ICU patients….namely the need for more nurse time. Do you have some hard numbers you can provide on the potential cost of this? Do you have any local or national information on the cost of not mobilizing the patients (longer stays, increased infection, readmission)? Calculating approximate cost associated with the practice change versus the cost of not changing is important. This will help stakeholders see the value in the investment.
DISCUSSION PAPER
Evidence-based practice models for organizational change: overview
and practical applications
Marjorie A. Schaffer, Kristin E. Sandau & Lee Diedrick
Accepted for publication 19 July 2012
Correspondence to M.A. Schaffer:
e-mail: [email protected]
Marjorie A. Schaffer PhD RN
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Kristin E. Sandau PhD RN CNE
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Lee Diedrick MAN RN C-NIC
Clinical Educator
Children’s Hospitals and Clinics of
Minnesota, St. Paul, Minnesota, USA
S C H A F F E R M . A . , S A N D A U K ..
By administering assessments and analyzing the results, targeted aTawnaDelatorrejs
By administering assessments and analyzing the results, targeted and individualized interventions can be determined to best serve the needs of students with disabilities. The actual implementation of the interventions provides teachers opportunities to collect data and gauge the effectiveness of the interventions in addressing documented student needs. Teachers can also gain important skills and knowledge on how to best advocate for practical classroom interventions. Teachers will also be able to collaborate with colleagues and families in mentoring students to take ownership of learning strategies.
Allocate at least 2 hours in the field to support this field experience,
Part 1: Assessment and Interventions
Select at least one student to whom you will administer the informal RTI assessment created in Clinical Field Experience A. Score the assessment and share the results with the student to increase understanding of his or her strengths and areas for improvement.
Collaborate with the certified special education teacher and the student to develop 2-3 interventions based on the student assessment data to support the student’s progress in the classroom. In addition, detail one intervention that can be incorporated at home with family support.
Use any remaining field experience hours to assist the teacher in providing instruction and support to the class.
Part 2: Reflection
In 250-500 words, summarize and reflect upon the following:
· Describe each intervention, including teacher, student, and family roles, where applicable.
· Your experiences administering the assessment, analyzing the results, and providing the student feedback on his or her performance.
· Explain how you expect the interventions you developed to meet the needs of the student, incorporating his or her assessment results in your response.
· Explain how you will use your findings in your future professional practice.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
6
Annotated Bibliography
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
October 7, 2021.
Annotated Bibliography
Ali, H., Ibrahem, S. Z., Al Mudaf, B., Al Fadalah, T., Jamal, D., & El-Jardali, F. (2018). Baseline assessment of patient safety culture in public hospitals in Kuwait. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-2960-x
The researchers conducted a cross-sectional study in 16 public hospitals in Kuwait using the Hospital Survey on Patient Safety Culture (HSOPSC). The study aimed to assess patient safety culture in public hospitals as perceived by hospital staff and relate the findings similar to regional and international ...
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t.
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t.
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t ...
By administering assessments and analyzing the results, targeted aTawnaDelatorrejs
By administering assessments and analyzing the results, targeted and individualized interventions can be determined to best serve the needs of students with disabilities. The actual implementation of the interventions provides teachers opportunities to collect data and gauge the effectiveness of the interventions in addressing documented student needs. Teachers can also gain important skills and knowledge on how to best advocate for practical classroom interventions. Teachers will also be able to collaborate with colleagues and families in mentoring students to take ownership of learning strategies.
Allocate at least 2 hours in the field to support this field experience,
Part 1: Assessment and Interventions
Select at least one student to whom you will administer the informal RTI assessment created in Clinical Field Experience A. Score the assessment and share the results with the student to increase understanding of his or her strengths and areas for improvement.
Collaborate with the certified special education teacher and the student to develop 2-3 interventions based on the student assessment data to support the student’s progress in the classroom. In addition, detail one intervention that can be incorporated at home with family support.
Use any remaining field experience hours to assist the teacher in providing instruction and support to the class.
Part 2: Reflection
In 250-500 words, summarize and reflect upon the following:
· Describe each intervention, including teacher, student, and family roles, where applicable.
· Your experiences administering the assessment, analyzing the results, and providing the student feedback on his or her performance.
· Explain how you expect the interventions you developed to meet the needs of the student, incorporating his or her assessment results in your response.
· Explain how you will use your findings in your future professional practice.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
6
Annotated Bibliography
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
October 7, 2021.
Annotated Bibliography
Ali, H., Ibrahem, S. Z., Al Mudaf, B., Al Fadalah, T., Jamal, D., & El-Jardali, F. (2018). Baseline assessment of patient safety culture in public hospitals in Kuwait. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-2960-x
The researchers conducted a cross-sectional study in 16 public hospitals in Kuwait using the Hospital Survey on Patient Safety Culture (HSOPSC). The study aimed to assess patient safety culture in public hospitals as perceived by hospital staff and relate the findings similar to regional and international ...
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t.
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t.
November-December 2013 • Vol. 22/No. 6 359
Beverly Waller Dabney, PhD, RN, is Associate Professor, Southwestern Adventist University,
Keene, TX.
Huey-Ming Tzeng, PhD, RN, FAAN, is Professor of Nursing and Associate Dean for Academic
Programs, College of Nursing, Washington State University, Spokane, WA.
Service Quality and Patient-Centered
Care
L
eaders of the U.S. Depart -
ment of Health & Human
Services (2011) urge providers
to improve the overall quality of
health care by making it more
patient centered. Patient-centered
care (or person-centered care) refers
to the therapeutic relationship
between health care providers and
recipients of health care services,
with emphasis on meeting the
needs of individual patients. Al -
though the term has been used
widely in recent years, it remains a
poorly defined and conceptualized
phenomenon (Hobbs, 2009).
Patient-centered care is believed
to be holistic nursing care. It pro-
vides a mechanism for nurses to
engage patients as active partici-
pants in every aspect of their health
(Scott, 2010). Patient shadowing
and care flow mapping were used to
create a sense of empathy and
urgency among clinicians by clarify-
ing the patient and family experi-
ence. These two approaches, which
were meant to promote patient-cen-
tered care, can improve patient sat-
isfaction scores without increasing
costs (DiGioia, Lorenz, Greenhouse,
Bertoty, & Rocks, 2010). A better
under standing of attributes of
patient-centered care and areas for
improvement is needed in order to
develop nursing policies that in -
crease the use of this model in health
care settings.
The purpose of this discussion is
to clarify the concept of patient-cen-
tered care for consistency with the
common understanding about pa -
tient satisfaction and the quality of
care delivered from nurses to
patients. Attributes from a customer
service model, the Gap Model of
Service Quality, are used in a focus
on the perspective of the patient as
the driver and evaluator of service
quality. Relevant literature and the
Gap Model of Service Quality
(Parasuraman, Zeithaml, & Leonard,
1985) are reviewed. Four gaps in
patient-centered care are identified,
with discussion of nursing implica-
tions.
Background and Brief
Literature Review
Patient-Centered Care
The Institute of Medicine (IOM,
2001a) and Epstein and Street (2011)
identified patient-centeredness as
one of the areas for improvement in
health care quality. The IOM (2001b)
defined patient-centeredness as
…health care that establishes a
partnership among practition-
ers, patients, and their families
(when appropriate) to ensure
that decisions respect patients’
wants, needs, and preferences
and that patients have the edu-
cation and support they require
to make decisions and partici-
pate in their own care… (p. 7)
Charmel and Frampton (2008)
defined patient-centered care as
…a healthcare setting in which
patients are encouraged to be
actively involved in their care,
with a physical environment
t ...
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
New development in herbals,
Bio-prospecting tools for drug discovery,
Role of Ethnopharmacology in drug evaluation,
Reverse Pharmacology.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2. seven principles of quality nursing documentation (Jefferies et al.,
2010) which ultimately became the local health service policy.
These principles as presented in Table 1. These principles formed
part of the content of the education program.
Following the policy development process, the authors examined
examples of nursing documentation. This examination demonstrated
that problems existed which related to sentence structure, grammar,
and logical presentation of material within the nursing notes. Nurses
were writing in a style of language that could be described as frag-
mented and were using abbreviations extensively throughout their
documentation, (Brous, 2009; Campos, 2009; Griffith, 2004; Jefferies
et al., in press). Although some abbreviations were found on official
abbreviations lists that were developed by each hospital, many
other abbreviations were not and could be open to multiple interpre-
tations making the nurse's documentation ambiguous (Kuhn, 2007).
The use of fragmentary language and unofficial abbreviations made
reading nursing documentation difficult for both nurses and others
outside the profession. One example reported in the literature was
that nurses from Non English Speaking Backgrounds (NESB) found
the use of abbreviations and other examples of fragmented language
made nursing documentation difficult to understand (Deegan and
Simkin, 2010). If other nurses could not understand nursing docu-
mentation, it was unlikely that readers outside the profession would
understand what patient information the nurse was attempting to
communicate. Furthermore, nursing documentation could be judged
as not worth reading (Lawler, 2007). Aspects such as the use of frag-
mentary language and inappropriate use of abbreviations also formed
the content of the education program.
How nurses learn documentation practices could influence the style
of their writing. Anthony Paré makes the point when commenting on
writing education for social workers that values and beliefs about docu-
mentation are passed from generation to generation without a critical
examination of reporting practices (Pare, 2005). It follows that nurses
also learn documentation practices by tradition and these practices are
not given the critical scrutiny that is required for a process of continuous
improvement. As Pare explains, this process of learning documentation
by tradition means that practices that make nursing documentation
difficult for many to understand are simply seen as the ‘way things are
done’ because they have taken on an air of normalcy by the nurse com-
pleting the documentation (Pare, 2005).
With the work of Pare in mind, the authors developed Ward-based
Writing Coach Program. Its aim was to encourage the development of
a sense of critical scrutiny by nurses so that they considered how their
nursing documentation could be improved. This would be achieved by
asking nurses to consider how their audience would react to what
was written in nursing documentation. Campos defines the audience
as being: the nurse documenting their patient's condition and care;
other nurses; other healthcare professionals; the patient, their family
or carers; lawyers and experts when a lawsuit occurs; a judge or magis-
trate; and non-medical and non-legal members of the jury (Campos,
2009). Nurses were asked to critically reflect on current documentation
practices so that they could develop strategies to improve the readabil-
ity of their documentation and make it relevant to all members of the
healthcare team and other potential readers of nursing documentation.
Approach
The program was developed by the authors and was conducted in
two parts: two didactic information sessions followed by one-to-one
coaching of nursing staff over a two-week period. First, nurses on two
busy medical surgical wards in a major metropolitan hospital in Sydney
Australia were asked to attend two one-hour writing workshops; and
second, nurses, who attended the workshops, received one-to-one
writing coaching as they wrote their nursing documentation during
their shift on the ward (See Table 2). The objective of the didactic infor-
mation sessions was to promote an understanding of the purpose of
nursing documentation and how current documentation practices
could impede understanding of readers outside the profession. Once
this is completed, the education program focused on developing strate-
gies to improve the quality of nursing documentation. The coaching
provided an opportunity for nurses to incorporate what was learned
in the didactic sessions into their documentation under the guidance
of the writing coach.
The Attributes of the Writing Coach
The following qualities would enhance the role of the writing coach
in the ward setting. The writing coach should be an experienced regis-
tered nurse who has an interest in nursing documentation. As this is a
program that is designed to fit into the ward routine, the writing
coach should be flexible enough to conduct the didactic sessions as a
part of the ward education program and to organise writing coaching
around the times when nurses are generally completing their docu-
mentation. The writing coach should be willing to work collaboratively
with nurses to improve documentation. Although the writing coaching
helps the nurse improve their documentation, it is the nurse who
knows their patients and who understands the clinical setting. Clinical
nurse educators may be most suitable for this role.
The Workshops
Two didactic workshops were developed by researchers to be pre-
sented to nurses in any clinical setting during their work time. The
duration of each workshop was one hour so that it would easily fit
into the usual education programs conducted at ward level.
The first workshop has three focal points to encourage nurses to
develop skills to scrutinise their nursing documentation. First, the
workshop emphasises how documentation can present a picture of
the patient from admission to discharge that is sensitive enough to
allow all members of the healthcare team to detect changes in the
patient's condition and to be able to plan care accordingly (Johnson
et al., 2010). Asking nurses to consider nursing documentation from
the perspective of being a communication tool that kept all members
of the healthcare team informed about relevant information for the
patient could, potentially, reframe the nurses' concept of nursing doc-
umentation as an important aspect of nursing care.
Second, the likely audience of nursing documentation is discussed
so that nurses could understand the importance of writing in a man-
ner that is meaningful to anyone reading their documentation. Nurses
are asked to consider whether current practices using fragmentary
language or abbreviations that may or may not be found on official
abbreviation lists hampers the ability of readers to understand the pa-
tient information being reported by the nurse. Examples of actual
nursing documentation containing abbreviations and fragments of
language are presented for discussion. One example used is the
following:
Table 1
Principles of quality nursing documentation.
Principle 1 Nursing documentation should be patient centred
Principle 2 Nursing documentation must contain the actual work of nurses
including education and psychosocial support
Principle 3 Nursing documentation is written to reflect the objective clinical
judgment of the nurse
Principle 4 Nursing documentation must be presented in a logical and
sequential manner
Principle 5 Nursing documentation should be written contemporaneously, or as
events occur
Principle 6 Nursing documentation should record variances in care within and
beyond the health care record
Principle 7 Nursing documentation should fulfil legal requirements
2 D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017
3. 14/06/2009 0615 Nursing: Pt. slept well o/night. Afebrile. Sa 02
95% on RA. BSL 4.1 mmol/l this am. Pt given OJ as felt dizzy. Better
after OJ. Returned to sleep. (Name/designation/signature)
An analysis of the language used in this example highlights two
important aspects about current practices in nursing documentation:
first nurses are not using correct sentence structure, and second the
use of abbreviations can lead to ambiguity, especially if the abbrevia-
tions are not found on official abbreviation lists.
The first point leads to a discussion about correct sentence struc-
ture and nurses are reminded that to ensure meaning most sentences
should have a subject, verb and object. The second point is elaborated
by discussing how the abbreviation ‘RA’ in the example can have sev-
eral meanings including room air, right arm and rheumatoid arthritis.
The example is rewritten using correct sentence structure and abbre-
viations from the official abbreviation list:
14/06/2009 0615 Nursing: The patient slept well overnight. He is
afebrile, Sa O2 at 95% on room air and his BSL is 4.4 mmol/l this
am. The patient complained of feeling dizzy and was given orange
juice. He said he felt much better and returned to sleep. (Name/
designation/signature)
The nurses are asked to consider which example is easier to read.
Third, a strategy presenting a more comprehensive picture of the
patient's condition, care and response to care is discussed. Nurses are
encouraged to document in a more systematic manner by assessing
the patient's condition and, if required, recording any intervention
undertaken by the nurse, and the outcome of that intervention. An
example is given to demonstrate how a nurse might use this system
of documentation:
The patient (or Mr …) complained of pain in the left side of his chest
radiating into his jaw and down his left arm. Glyceral trinitrate was
administered sublingually as per the order on the medication chart.
Mr Jones said that he was no longer experiencing chest pain.
This example presents the assessment (the patient has pain), the
intervention (the administration of medication), and the outcome
(the patient is pain free). Although this example only cites one inci-
dent in a patient's admission, nurses were asked to consider how
writing nursing documentation in this particular manner would cre-
ate a more complete picture of the patient's condition, care and re-
sponse to care.
The second workshop places its emphasis on the seven principles
of nursing documentation that we developed in the metasynthesis of
nursing documentation literature (Jefferies et al., 2010).
Each principle is presented to the nurses with an explanation of
how it can be incorporated into current documentation practices.
The first three principles focus on developing a documentation style
that creates a more complete picture of the patient by including the
patient's viewpoint and ensuring that the nursing contribution to pat-
ent care is included in an objective manner. The first principle asks
nurses to make the patient the central focus of their documentation
and suggests that one strategy to achieve this could be to include
any comment made by the patient about their condition, care or
Table 2
Content and participants of ward-based writing coach program.
Activity Duration of activity Number of participants Content of activity
Workshop
1
1 hour and designed to fit into ward education program 16 nurses currently on duty
on the intervention wards
A didactic session covering the following topics:
1. What is the purpose of nursing documentation? To present a
picture of the patient from admission to discharge that is sensitive
enough so that all members of the healthcare team can plan care;
2. To discuss the potential audience that could read nursing
documentation (this includes other nurses, other healthcare
professionals, patients and their carers and members of the legal
profession);
3. How using correct sentence structure and only official
abbreviations make nursing documentation much easier to read by
ensuring that all sentences have a subject, verb and an object;
4. The presentation of a problem solving approach to nursing
documentation that presents a more complete picture of the
patient's condition, care, and response to care-assessment, nursing
intervention and outcome.
Workshop
2
1 hour and designed to fit into ward education program 16 nurses currently on duty
on the intervention wards
A didactic session explaining how the 7 guiding principles of
nursing documentation developed by the authors can be
incorporated into documentation practices. Each principle is
presented with an example of how it is used in nursing
documentation. These could include actual examples of nursing
documentation that demonstrate how the principle is used or not
used in the health care record.
Coaching A Ward-based Writing Coach is available to nurses who have
attended the workshops for a 2 week period as these nurses
complete their nursing documentation.
8 nurses received coaching
on a 1:1 basis during the
2 week trial period.
When a nurse has agreed to participate in a writing coaching
session, the following steps are undertaken:
1. The writing coach asks the nurse to select the records of 2 patients
currently under their care;
2. The coach asks the nurse to discuss each patient's diagnosis, their
current care plan, and current issues;
Each coaching session is approximately 20 minutes in
duration.
3. There is a further discussion about what is happening with the
patient at the current time (current observations, comments the
patient has made about their condition, nursing interventions that
have occurred during the shift and the outcome of that
intervention);
4. The nurse and the writing coach document the patient's
condition, care and response to care ensuring that abbreviations
from the official list and full sentences are used;
5. The writing coach asks the nurse for feedback about the
documentation and the coaching session.
3
D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017
4. response to care. In essence the nurse is asked to write their docu-
mentation from the patient's, rather than the nurses, viewpoint.
The second principle asks nurses to record the actual work of the
nurses. This principle asks nurses to record their own significant con-
tribution to patient care, which the literature tells us is often missing
in the healthcare record. It also provides a point of reference for other
healthcare professionals when they are consulted. The third principle
asks nurses to write objectively and avoid using language that makes
the reader question whether the nurse is making an objective state-
ment. A simple way to explain this notion to nurses is to ask them
not to use words such as ‘appears’ and ‘seems’ when describing
their patient's condition. Again nurses can be reminded that this can
also be avoided if they record what the patient says about any prob-
lem they experience.
The next three principles focus on the content of nursing documen-
tation. Reiterating that nurses will produce a more comprehensive
picture of the patient if they write in a logical and sequential manner,
the fourth principle asks nurses to record the patient's condition, care
and response to care in a systematic manner. We suggest that one
system is documentation via a problem solving approach, such as
discussed above: assessment, intervention and outcome. To ensure
that information is as accurate as possible, the fifth principle asks nurses
to document any incidents, unusual events, as soon as possible after the
event has occurred. If the nurse does not document these events until
the end of the shift, the report of the incident may not be accurate as
recall of these events is not as sharp. The sixth principle asks that nurses
do not fill up nursing documentation with observations or other indica-
tors of a patient's condition that fall in the normal range and are
recorded in other areas of the healthcare record. If nursing documenta-
tion is to be sensitive enough to allow all healthcare professionals to
detect changes in the patient's condition, care and response to care,
only observations or indicators of the patient's condition that present
a change should be recorded in the nursing documentation (Frank-
Stromborg et al., 2001a). The final principle asks nurses to document
according to legal requirements. Of course, legal requirements differ
from country to country and any discussion in a writing coach program
must conform to local needs.
Each principle is illustrated with examples of nursing documenta-
tion and the nurses attending are given opportunities to clarify a
point by asking questions. The workshop closes with an explanation
of the role of the writing coach.
The Process of Writing Coaching in the Clinical Setting
Once the workshops have been completed, the writing coach can
begin the ward-based coaching sessions with nurses who have
attended the workshops. The coaching occurs on a one-to-one basis
on the ward as the nurse completes the nursing documentation. In
order to ensure that the coaching does not disrupt the ward routine,
the coach conducts sessions at times when nurses write major parts
their documentation. Nurses are reminded that events occurring out-
side the period of coaching must be recorded in the nursing docu-
mentation as well.
When the nurse agrees to be coached, the writing coach asks the
nurse to select the healthcare record of two current patients they
are caring for. One is a patient whose condition is stable and whose
care is unchanged, the other is a patient whose condition has changed
and requires changes to their documented care plan. The coach asks
the nurse to discuss each patient focusing on the following topics, di-
agnosis, their care plan, and current issues. Another discussion nar-
rows the focus to what is happening to the patient at the time of
writing. This includes current observations of the patient's condition,
including any relevant comments made by the patient, any nursing
interventions carried out on the current shift; and the outcome of
nursing interventions. Once this discussion is completed the coach
and the nurse document the patient's condition, care and response
to care together ensuring that it is written in full sentences and that
only abbreviations found on the official abbreviation lists are used.
The coach then asks the nurse if the documentation written during
the coaching session is different from the documentation normally
written by the nurse. When the nurse has completed the documenta-
tion on both patients, the writing coach asks the nurse if they have
any comments or questions arising from the session. Another coach-
ing session can be arranged as necessary.
Evaluation of the Writing Coach Program
The effectiveness of the writing coach program can be assessed by
a pre and post program documentation audit. We recommend that
the Nursing and Midwifery Documentation Content Audit Tool
(NMCAT) be used (Johnson et al., 2010). The NMCAT is a designed
audit tool that has 16 criteria relating to the seven principles of qual-
ity documentation and nine criteria relating to the legal requirements
of nursing documentation. Using a time sampling approach, 24-hour
segments of the admission can be audited as necessary. Each audit
takes approximately ten minutes. We suggest that for quality control
purposes, a 24-hour segment of every tenth record is transcribed ver-
batim and all references that could identify any person removed.
These transcripts can be used to evaluate factors such as the use of
fragmentary language or abbreviations and the focus of content.
They can also be used to demonstrate areas for improvement. The
NMCAT does not prescribe a specific system of nursing documenta-
tion but measures whether or not the documentation includes infor-
mation about the assessment of the patient's condition, any
interventions undertaken by the nurse, and the patient's response
to the intervention. This is a tool that can be used to evaluate nursing
documentation in any clinical setting.
This paper has reported an innovative education program
designed to produce a quality improvement in nursing documenta-
tion at the ward level. This is a program that can be conducted on
the ward during the working day with minimal disruption to the
ward routine. The didactic component can easily be slotted into the
regular ward education program. The goal of the program is to give
nurses skills to critically examine their own documentation styles
and strategies to improve their clinical reporting. These skills include
documenting the patient's condition, care, and response to care in a
systematic manner using the three steps of assessment, intervention,
and response. Nurses also ensure that documentation can be read by
all readers though the use of correct sentence structures and employ-
ing abbreviations only found on official abbreviation lists. Emphasis is
placed on nursing documentation containing a complete picture of
the patient's admission that is sensitive enough to enable all health-
care professionals to detect changes in the patient's condition and
care requirements.
Good communication systems are an essential component of patient
safety because they keep all members of the healthcare team informed
about the patient. However to ensure that nursing documentation can
fulfil this function, it must be written so that it is meaningful to a
wide-ranging audience. This innovative education program based on
giving nurses the skills to view their documentation in a critical light
is intended to provide nurses with the skills required to improve their
documentation. The approach may be a new role for the ward-based
clinical nurse educator.
Conflict of Interest
All authors declare that there is no conflict of interest.
Contributors
Study conception and design: MJ, DN, DJ.
Manuscript preparation: DJ, MJ, DN, SL.
4 D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017
5. Critical revisions for important intellectual content: MJ, DN, DJ, SL.
Supervision: MJ, DN.
Funding Statement
This project was made possible by a grant from the Nursing and
Midwifery Office, NSW Department of Health, Sydney, Australia.
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nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017