Appendix N. 1: A Case Study
Introduction:
The scenario included in Appendix n.1 shows multiple errors consequently leading to a patient’s deterioration. There was poor communication and record-keeping leading to an incomplete Early Warning Score Chart (EWS) and Fluid Balance Chart, and lack of practical knowledge and skills of the nursing staff in recognizing signs of deterioration of the patient. Furthermore, there is failure to understand the life-saving importance of intravenous antibiotics and the necessity of intravenous access in the case of emergency in acutely ill patients, and failure of the regular review of the patient by the nurses and doctors alike. Identified as the primary issue is the lack of communication and secondary problem an incomplete fluid …show more content…
balance chart, so it is evident that the lack of the communication (verbal and written) lead to a secondary problem and consequently to a deterioration of Mr. Albert.
Essential components in delivering high quality nursing care are good communication and interpersonal skills (Webb, 2011). Nursing and Midwifery Council (NMC, 2010) identified communication as one of the essential skills that students must acquire in order to make progress through their education and training to become qualified nurses. The Department of Health (DH, 2010) initiated The Essence of Care – the government’s strategy to improve the quality of the fundamental aspects of nursing care – which has communication as one of its ten key benchmark areas and stated that staff should communicate effectively with each other to ensure continuity, safety and quality of health care for all. The National Patient Safety Agency (NPSA, 2007) identified communication difficulties as a major factor affecting patient outcomes. Particular concerns included incomplete documentation and nurses not being clear and confident in their reporting. As an outcome of these findings, the essential professional guidelines highlighted health care professional’s legal accountability for the maintenance of accurate and up to date records (NMC, 2008) as poor communication and record keeping can be dangerous, and misunderstanding can lead to misdiagnosis and even medication errors (DH, 2010).
Fluid chart is one of the methods of nursing communication as its correct filling is an essential tool in determining hydration, although many researches indicated another major problem responsible for the poor recording of fluid balance charts. Education, especially life-long continuing professional development, is highly emphasized by DH framework (2004) as an essential feature of maintaining competent professional practice. This is equally supported by The Code (NMC, 2008), as presented in Appendix n.3, which recognizes the importance of appropriate learning and practice activities to maintain and develop the nurses’ competence and performance.
According to NMC guidelines (2008), names mentioned in the assignment are altered as set in the Code for nurses and midwifes to respect people’s right to confidentiality.
Core:
Fluid balance is a term used to describe the balance of the input and output of fluids in the body allowing metabolic processes to function correctly (Welch, 2010) and is influenced by dietary intake, illness and the environment (Scales et al, 2008).
A fluctuation in fluid volume of just 5-10 % can have an adverse effect on health (Sheppard et al, 2006). Scales and Pilsworth (2008) identified three elements for assessing fluid balance and hydration status: clinical assessment, review of fluid balance charts and review of blood chemistry.
The physical symptoms of fluid imbalance as present in Appendix n.2 are part of the clinical assessment and should be never omitted when drawing a picture of overall patient hydration status. McMillen (2011) described the fluid balance chart as a record of a patient’s fluid input and output in 24 hours (Appendix n.1.4, 1.5 and 1.6). Critically ill patients cannot maintain normal water and electrolyte balance due to stress and inflammatory responses, so hourly fluid input and output monitoring is absolutely essential in recognizing fluid balance disturbances (Leach, 2009). Patients falling into the group having fluid balance charts in place are consequently patients who are at risk of dehydration. More than one reason for the importance of the fluid balance chart has been indicated in our case scenario. These were Mr. Albert having intravenous fluids in place because of being ‘nil by mouth’ due to unclear cause of his abdominal pain …show more content…
and vomiting and having actual or potential acute illness due to his recent bowel resection and subsequent Intensive care unit admission.
As proposed in the introduction, accurate record keeping is one of the basics of nursing. According to the NMC (2009), record keeping is an integral part of nursing care, not something to be “fitted in” where circumstances allow. Nursing documentation has received considerable attention in recent years. Essence of Care emphasized many times in the past that record keeping is a fundamental aspect of care because any aspect of the patient’s records can be required as evidence before a coroner’s court, a court of law, or before the professional conduct committee of the NMC (Dimond, 2008). In legal terms, if nursing care is not documented, it is assumed not to have happened. The fluid balance charts are one of the basic records in nursing care to the extent that nurses should view them with the same importance as the prescription charts. Monitoring the patient’s fluid balance chart is a relatively simple task, but its recording is notorious for being inadequately or inaccurately completed (Bennett, 2010). What is the reason behind this and how can it be improved?
The problem often lies as Reid (2004) revealed in the lack of ownership in relation to fluid balance charts, although The Code (NMC, 2008) is clear on this issue. Responsibility lies with the qualified nurse as she is accountable for the care of the patient, so if the task is delegated to the healthcare assistant (HCA), adequate supervision is required. Nevertheless, in the current climate, when we are heading for the support workers mandatory regulation to maximize patient safety, it seems that responsibility will shift to some extent in the future (RCN, 2012). As many times discussed in the past and even more in the present, it is though questionable whether HCA are competent to undertake these multiple and complex interventions. RCN head of policy Howard Catton (Waters, 2012) implied that the need for education and training of support staff is vital to ensure that the task is not separated from knowledge and acquired clinical assessment and decision making. This was sadly demonstrated within this case scenario and it was exacerbated by the lack of good record keeping, which is the mark of a skilled and safe practitioner. The contrary could highlight wider problems with an individual’s practice (NMC, 2009). Blaming culture is though not welcomed in healthcare, as it does not bring any positive change. In author’s opinion, we should instead embrace the approach of recognizing the errors in each malpractice and subsequently learning from them.
Nursing care in these days is multitasked and really complex.
In addition, staff shortages, and service redesigns introduced in the face of budgetary pressures, are putting nurses under immense strain (Sprinks, 2012). It is therefore important to clarify why the fluid balance chart was started in the first place, and in which patients it is beneficial to continue. Everybody should be aware of these patients’ fluid charts and the reasons behind them (Scales et al, 2008). A large proportion of a healthcare professional's daily workload in hospital is devoted to documentation, and nurses can spend a considerable amount of time in recording fluid charts, but doctors seldom look at them due to the inaccurate estimation of the measurements (Chung et al., 2002). The accuracy of fluid intake and output recording is not a new issue. Boylan and Brown (1985) stated that fluid charts were poorly and inaccurately maintained. Eleven years later, Armstrong-Easther (1996) believed that fluid balance charts were the least accurate of all charts. Are the fluid balance charts necessary then? Some researchers go so far as to suggest that it is not possible to assess a patient's hydration state by using a fluid balance chart because of insensible water loss that cannot be measured (Chung et al, 2002), but if that were the case, they should have been perhaps banned years ago. The reason, why they are still important even at the present time, is more likely due to the fact that altered vital signs
and elevated renal chemistry are late signs of dehydration, so careful attention to fluid balance charts could alert staff to fluid imbalances before the symptoms occur (Scales et al, 2008). Although, there are many other techniques to assess fluid balance in individuals, none of them are completely reliable. Scales and Pilsworth (2008) mentioned capillary refill time (CRT) and the colour of the urine. However, CRT assessment can sometimes be misleading, particularly in patients with sepsis, and the colour of urine can be altered by many drugs and give a false indication of urine concentration. Decreased elasticity of skin is another good indicator of fluid deficit, but it can be unreliable in older people as it reduces with age (Sheppard et al, 2006). Measurement of acute changes in body weight after imposed fluid restriction is still relevant in healthcare today, although the body weight can be affected by bowel movements, as well as food and fluid, and would be difficult and unethical to measure in sick, immobile patients (Vivanti et al, 2010). Overall, an accurate fluid balance chart is the best indicator of fluid imbalance in patients, even at the present time, as regular monitoring of urine output can indicate early changes in a patient’s condition, and early treatment can prevent deterioration (NSPA, 2007), so it should not be omitted in any circumstance.
Clinical deterioration can occur at any point in a patient’s illness or care process, but patients are particularly vulnerable following emergency admission to hospital, after surgery, and when recovering from a critical illness (Cullinane et al, 2005). Physiological deterioration precedes critical illness (Goldhill et al, 2005) and an effective early warning score (Appendix n.1.3) needs to be in place to recognize the deteriorating patient early, and to instigate an appropriate response (NICE, 2007). EWS is a numerical scoring system to trigger a response in deteriorating patients and is an integral part of the clinical assessment. It consists of recording the patient’s vital signs including urine output as a deteriorating urine output was recognized as an important indicator of a potential acute problem. In an adult, an hourly volume of 0.5 ml/kg/hour is the minimum acceptable volume (Smith et al, 2011). Looking at the scenario (Appendix n. 1), the failure to identify the poor urine output, and number it according to the EWS score, significantly contributed to the failure to identify the deterioration of this particular patient and to request urgent medical review. However, the effectiveness of EWS has been questioned as it does not have the power to reduce errors linked to documentation and scoring, and consequently it could lead to failure to identify patients who need additional care (Cuthertson et al, 2007). Besides, EWS is not always tailored to the individual patient. Such systems risk being over sensitive, causing too many alerts, and consuming resources inappropriately. Too frequent triggering might reduce appropriate responses and staff may experience ‘trigger fatigue’ that is not acting on a positive alert because there are too many false positives (Beaumont, 2008). Nevertheless, a track and trigger system is a very useful tool in recognizing patient deterioration, but it was suggested that it should be used in line with the nurses’ knowledge and skills. In addition, SBAR (Appendix n.4) was put in place to help communicate the deterioration of the patient with the other members of the multidisciplinary team as it was frequently observed that ineffective communication was one of the main reasons contributing to patient deterioration (Macintosh et al, 2011). As applied to all clinical interventions, EWS should be used with clinical judgment and following decision making after the assessment. One of the highly valued critically ill patients’ assessments recommended by The Resuscitation Council UK (2011) is the ABCDE approach (Appendix n.5).
Plan:
The reason for poor documentation in the case study is reflected in the findings of research undertaken by East Somerset NHS Trust by Jane Reid (2004) and could be replicated internationally. These comprised: inadequate communication within the nursing team regarding a patient’s fluid balance chart, lack of understanding where the responsibility lay for the education and training of ward staff in fluid balance monitoring, lack of accountability for the completion of fluid balance charts, and lack of equipment to enable nurses to accurately record volume input and output. There are however more and more studies which confirm the link between nurse staff levels and care quality, and it seems that staff shortage is significant reason for poor documentation and incomplete fluid charts. Nonetheless, staff shortage is not the only reason to blame for inadequate documentation, as evaluating the author’s experience, the main areas for the improvement of quality of nursing care were also the education, leadership, professional behaviour and attitude, workforce regulation, including healthcare assistants, and the increasing paperwork as highlighted by RCN (Dean, 2012). The most significant and probably the most easily corrected was featured the education deficit. It was suggested equally by The Guideline Development Group, which considered the delivery of education and training of ward staff to be a factor that underpins the correct measurement of physiological variables and the correct response to a patient at risk of clinical deterioration (NICE, 2007). As mentioned before, careful attention to the fluid balance chart and prompt response could have prevented Mr. Albert’s organ failure.
The author’s nursing practical experience has shown that fluid balance charts indeed have been poorly documented. Very often they presented an unclear picture with word such sips, sips++, wet, wet ++, incontinent, OTT, passed urine or even question marks all over. However, such records are vague and do not contribute to the correct fluid balance as they give inaccurate estimation with no evident indication of the amount of urine passed or the amount of fluids drunk (Shepherd, 2011). Another concern was the presence of too many fluid balance charts in place, of which nearly half of them had not been filled in at all, or marked only with occasional information. The burden of increasing paperwork in nursing today with plus adding pressure of staff shortage is frequently discussed in the healthcare literature, so is more critical than ever to clarify which paperwork is essential and which can be omitted (Lomas, 2012), as the presence of unnecessary medical records is time consuming and cost-ineffective. It is a growing concern that nursing staff are being increasingly swamped by bureaucracy and target-chasing (The Telegraph, 2010). A study initiated by excessive use of fluid balance charts revealed the same problem and it seems that nurses were uncertain when to discontinue the fluid chart (Chung et al, 2002). The author observed that the reasons behind it are mostly the fear of litigation, simply following the repeated pattern, and the lack of education. It could be though argued that incomplete or inaccurate fluid balance chart could give more evidence of staff negligence than the discontinued chart. Following the repeated pattern was simply issue of indecision, which mainly proved to be due to lack of training and confidence.
This assignment generally suggested to the author how this problem could be improved and it resulted in the sharing of some of the collected knowledge with the other nursing staff and in that context improving clinical practice in the acute hospital ward. Presentation in any form is an excellent educational opportunity and should be encouraged by the ward managers. It allows the nursing staff to gain the clinical knowledge which can be successfully used in practice to increase the patients’ quality of care. One of the examples is a poster presentation used by the author. Poster presentation is not a new concept and as a learning method it is well recognized within healthcare education, especially in nursing (Akister et al, 2000). Its use is in the raising clinical practice awareness of theoretical assessment; therefore it is a further step in bridging theory and practice. The poster presentations have been effective in disseminating information and in improving relationships between education and clinical staff, and are an effective learning strategy (Utecht et al, 2008). Furthermore, they could be really entertaining and inspiring.
Conclusion:
Nursing records should provide accurate, current, comprehensive and concise information regarding the condition and care of the patient within the standards that govern the whole nursing profession. These standards are set out in the Code of Professional Conduct (NMC, 2008). These include the nurses keeping their knowledge and skills up to date throughout their working life with adequate learning and practice.
Achieving optimal hydration is an essential part of holistic patient care. Maintaining fluid balance is important to avoid complications such as dehydration or accumulating the fluid in the tissues of the body, both of which can have serious clinical consequences. The nurses caring for the particular patients are responsible for ensuring that fluid balance charts are completed with accuracy, and they should always report any significant abnormalities identified in patients’ fluid records, thus resulting in safe and effective nursing care (Shepherd, 2011).
Evaluating the author’s experience, there has been a small improvement in recognizing the importance of the fluid charts and their benefit for particular patients. There was also slight improvement in eliminating the inaccurate estimations in the form of the words as wet, incontinent or sips. With the new housekeeper’s role in this trust, we have been able to improve the more accurate measurement of the fluids given to the patients. When it comes to the output, it is entirely up to the nurses to measure any output as accurately as possible. The weighing scales contribute hugely to accurate measurement of any body fluid output, but the estimations of the amount of body fluid not collected or accidently spilt, is still not fully grasped by the nurses. Time will show how much this acquired skill will improve by the continuous clinical learning and practice of the nurses. Finally, there was a significant improvement in the nurses’ decision when to initiate or discontinue the fluid balance charts depending on the patients’ condition and coexisting diagnosis, which highlighted the clinical importance of the fluid charts still present on the ward. It seems reasonable to assume that the improvement is a consequence of the author’s learning and teaching initiative in the training of all staff included in the patients’ care.
The scenario included in Appendix n.1 shows multiple errors consequently leading to a patient’s deterioration. There was poor communication and record-keeping leading to an incomplete Early Warning Score Chart (EWS) and Fluid Balance Chart, and lack of practical knowledge and skills of the nursing staff in recognizing signs of deterioration of the patient. Furthermore, there is failure to understand the life-saving importance of intravenous antibiotics and the necessity of intravenous access in the case of emergency in acutely ill patients, and failure of the regular review of the patient by the nurses and doctors alike. Identified as the primary issue is the lack of communication and secondary problem an incomplete fluid …show more content…
balance chart, so it is evident that the lack of the communication (verbal and written) lead to a secondary problem and consequently to a deterioration of Mr. Albert.
Essential components in delivering high quality nursing care are good communication and interpersonal skills (Webb, 2011). Nursing and Midwifery Council (NMC, 2010) identified communication as one of the essential skills that students must acquire in order to make progress through their education and training to become qualified nurses. The Department of Health (DH, 2010) initiated The Essence of Care – the government’s strategy to improve the quality of the fundamental aspects of nursing care – which has communication as one of its ten key benchmark areas and stated that staff should communicate effectively with each other to ensure continuity, safety and quality of health care for all. The National Patient Safety Agency (NPSA, 2007) identified communication difficulties as a major factor affecting patient outcomes. Particular concerns included incomplete documentation and nurses not being clear and confident in their reporting. As an outcome of these findings, the essential professional guidelines highlighted health care professional’s legal accountability for the maintenance of accurate and up to date records (NMC, 2008) as poor communication and record keeping can be dangerous, and misunderstanding can lead to misdiagnosis and even medication errors (DH, 2010).
Fluid chart is one of the methods of nursing communication as its correct filling is an essential tool in determining hydration, although many researches indicated another major problem responsible for the poor recording of fluid balance charts. Education, especially life-long continuing professional development, is highly emphasized by DH framework (2004) as an essential feature of maintaining competent professional practice. This is equally supported by The Code (NMC, 2008), as presented in Appendix n.3, which recognizes the importance of appropriate learning and practice activities to maintain and develop the nurses’ competence and performance.
According to NMC guidelines (2008), names mentioned in the assignment are altered as set in the Code for nurses and midwifes to respect people’s right to confidentiality.
Core:
Fluid balance is a term used to describe the balance of the input and output of fluids in the body allowing metabolic processes to function correctly (Welch, 2010) and is influenced by dietary intake, illness and the environment (Scales et al, 2008).
A fluctuation in fluid volume of just 5-10 % can have an adverse effect on health (Sheppard et al, 2006). Scales and Pilsworth (2008) identified three elements for assessing fluid balance and hydration status: clinical assessment, review of fluid balance charts and review of blood chemistry.
The physical symptoms of fluid imbalance as present in Appendix n.2 are part of the clinical assessment and should be never omitted when drawing a picture of overall patient hydration status. McMillen (2011) described the fluid balance chart as a record of a patient’s fluid input and output in 24 hours (Appendix n.1.4, 1.5 and 1.6). Critically ill patients cannot maintain normal water and electrolyte balance due to stress and inflammatory responses, so hourly fluid input and output monitoring is absolutely essential in recognizing fluid balance disturbances (Leach, 2009). Patients falling into the group having fluid balance charts in place are consequently patients who are at risk of dehydration. More than one reason for the importance of the fluid balance chart has been indicated in our case scenario. These were Mr. Albert having intravenous fluids in place because of being ‘nil by mouth’ due to unclear cause of his abdominal pain …show more content…
and vomiting and having actual or potential acute illness due to his recent bowel resection and subsequent Intensive care unit admission.
As proposed in the introduction, accurate record keeping is one of the basics of nursing. According to the NMC (2009), record keeping is an integral part of nursing care, not something to be “fitted in” where circumstances allow. Nursing documentation has received considerable attention in recent years. Essence of Care emphasized many times in the past that record keeping is a fundamental aspect of care because any aspect of the patient’s records can be required as evidence before a coroner’s court, a court of law, or before the professional conduct committee of the NMC (Dimond, 2008). In legal terms, if nursing care is not documented, it is assumed not to have happened. The fluid balance charts are one of the basic records in nursing care to the extent that nurses should view them with the same importance as the prescription charts. Monitoring the patient’s fluid balance chart is a relatively simple task, but its recording is notorious for being inadequately or inaccurately completed (Bennett, 2010). What is the reason behind this and how can it be improved?
The problem often lies as Reid (2004) revealed in the lack of ownership in relation to fluid balance charts, although The Code (NMC, 2008) is clear on this issue. Responsibility lies with the qualified nurse as she is accountable for the care of the patient, so if the task is delegated to the healthcare assistant (HCA), adequate supervision is required. Nevertheless, in the current climate, when we are heading for the support workers mandatory regulation to maximize patient safety, it seems that responsibility will shift to some extent in the future (RCN, 2012). As many times discussed in the past and even more in the present, it is though questionable whether HCA are competent to undertake these multiple and complex interventions. RCN head of policy Howard Catton (Waters, 2012) implied that the need for education and training of support staff is vital to ensure that the task is not separated from knowledge and acquired clinical assessment and decision making. This was sadly demonstrated within this case scenario and it was exacerbated by the lack of good record keeping, which is the mark of a skilled and safe practitioner. The contrary could highlight wider problems with an individual’s practice (NMC, 2009). Blaming culture is though not welcomed in healthcare, as it does not bring any positive change. In author’s opinion, we should instead embrace the approach of recognizing the errors in each malpractice and subsequently learning from them.
Nursing care in these days is multitasked and really complex.
In addition, staff shortages, and service redesigns introduced in the face of budgetary pressures, are putting nurses under immense strain (Sprinks, 2012). It is therefore important to clarify why the fluid balance chart was started in the first place, and in which patients it is beneficial to continue. Everybody should be aware of these patients’ fluid charts and the reasons behind them (Scales et al, 2008). A large proportion of a healthcare professional's daily workload in hospital is devoted to documentation, and nurses can spend a considerable amount of time in recording fluid charts, but doctors seldom look at them due to the inaccurate estimation of the measurements (Chung et al., 2002). The accuracy of fluid intake and output recording is not a new issue. Boylan and Brown (1985) stated that fluid charts were poorly and inaccurately maintained. Eleven years later, Armstrong-Easther (1996) believed that fluid balance charts were the least accurate of all charts. Are the fluid balance charts necessary then? Some researchers go so far as to suggest that it is not possible to assess a patient's hydration state by using a fluid balance chart because of insensible water loss that cannot be measured (Chung et al, 2002), but if that were the case, they should have been perhaps banned years ago. The reason, why they are still important even at the present time, is more likely due to the fact that altered vital signs
and elevated renal chemistry are late signs of dehydration, so careful attention to fluid balance charts could alert staff to fluid imbalances before the symptoms occur (Scales et al, 2008). Although, there are many other techniques to assess fluid balance in individuals, none of them are completely reliable. Scales and Pilsworth (2008) mentioned capillary refill time (CRT) and the colour of the urine. However, CRT assessment can sometimes be misleading, particularly in patients with sepsis, and the colour of urine can be altered by many drugs and give a false indication of urine concentration. Decreased elasticity of skin is another good indicator of fluid deficit, but it can be unreliable in older people as it reduces with age (Sheppard et al, 2006). Measurement of acute changes in body weight after imposed fluid restriction is still relevant in healthcare today, although the body weight can be affected by bowel movements, as well as food and fluid, and would be difficult and unethical to measure in sick, immobile patients (Vivanti et al, 2010). Overall, an accurate fluid balance chart is the best indicator of fluid imbalance in patients, even at the present time, as regular monitoring of urine output can indicate early changes in a patient’s condition, and early treatment can prevent deterioration (NSPA, 2007), so it should not be omitted in any circumstance.
Clinical deterioration can occur at any point in a patient’s illness or care process, but patients are particularly vulnerable following emergency admission to hospital, after surgery, and when recovering from a critical illness (Cullinane et al, 2005). Physiological deterioration precedes critical illness (Goldhill et al, 2005) and an effective early warning score (Appendix n.1.3) needs to be in place to recognize the deteriorating patient early, and to instigate an appropriate response (NICE, 2007). EWS is a numerical scoring system to trigger a response in deteriorating patients and is an integral part of the clinical assessment. It consists of recording the patient’s vital signs including urine output as a deteriorating urine output was recognized as an important indicator of a potential acute problem. In an adult, an hourly volume of 0.5 ml/kg/hour is the minimum acceptable volume (Smith et al, 2011). Looking at the scenario (Appendix n. 1), the failure to identify the poor urine output, and number it according to the EWS score, significantly contributed to the failure to identify the deterioration of this particular patient and to request urgent medical review. However, the effectiveness of EWS has been questioned as it does not have the power to reduce errors linked to documentation and scoring, and consequently it could lead to failure to identify patients who need additional care (Cuthertson et al, 2007). Besides, EWS is not always tailored to the individual patient. Such systems risk being over sensitive, causing too many alerts, and consuming resources inappropriately. Too frequent triggering might reduce appropriate responses and staff may experience ‘trigger fatigue’ that is not acting on a positive alert because there are too many false positives (Beaumont, 2008). Nevertheless, a track and trigger system is a very useful tool in recognizing patient deterioration, but it was suggested that it should be used in line with the nurses’ knowledge and skills. In addition, SBAR (Appendix n.4) was put in place to help communicate the deterioration of the patient with the other members of the multidisciplinary team as it was frequently observed that ineffective communication was one of the main reasons contributing to patient deterioration (Macintosh et al, 2011). As applied to all clinical interventions, EWS should be used with clinical judgment and following decision making after the assessment. One of the highly valued critically ill patients’ assessments recommended by The Resuscitation Council UK (2011) is the ABCDE approach (Appendix n.5).
Plan:
The reason for poor documentation in the case study is reflected in the findings of research undertaken by East Somerset NHS Trust by Jane Reid (2004) and could be replicated internationally. These comprised: inadequate communication within the nursing team regarding a patient’s fluid balance chart, lack of understanding where the responsibility lay for the education and training of ward staff in fluid balance monitoring, lack of accountability for the completion of fluid balance charts, and lack of equipment to enable nurses to accurately record volume input and output. There are however more and more studies which confirm the link between nurse staff levels and care quality, and it seems that staff shortage is significant reason for poor documentation and incomplete fluid charts. Nonetheless, staff shortage is not the only reason to blame for inadequate documentation, as evaluating the author’s experience, the main areas for the improvement of quality of nursing care were also the education, leadership, professional behaviour and attitude, workforce regulation, including healthcare assistants, and the increasing paperwork as highlighted by RCN (Dean, 2012). The most significant and probably the most easily corrected was featured the education deficit. It was suggested equally by The Guideline Development Group, which considered the delivery of education and training of ward staff to be a factor that underpins the correct measurement of physiological variables and the correct response to a patient at risk of clinical deterioration (NICE, 2007). As mentioned before, careful attention to the fluid balance chart and prompt response could have prevented Mr. Albert’s organ failure.
The author’s nursing practical experience has shown that fluid balance charts indeed have been poorly documented. Very often they presented an unclear picture with word such sips, sips++, wet, wet ++, incontinent, OTT, passed urine or even question marks all over. However, such records are vague and do not contribute to the correct fluid balance as they give inaccurate estimation with no evident indication of the amount of urine passed or the amount of fluids drunk (Shepherd, 2011). Another concern was the presence of too many fluid balance charts in place, of which nearly half of them had not been filled in at all, or marked only with occasional information. The burden of increasing paperwork in nursing today with plus adding pressure of staff shortage is frequently discussed in the healthcare literature, so is more critical than ever to clarify which paperwork is essential and which can be omitted (Lomas, 2012), as the presence of unnecessary medical records is time consuming and cost-ineffective. It is a growing concern that nursing staff are being increasingly swamped by bureaucracy and target-chasing (The Telegraph, 2010). A study initiated by excessive use of fluid balance charts revealed the same problem and it seems that nurses were uncertain when to discontinue the fluid chart (Chung et al, 2002). The author observed that the reasons behind it are mostly the fear of litigation, simply following the repeated pattern, and the lack of education. It could be though argued that incomplete or inaccurate fluid balance chart could give more evidence of staff negligence than the discontinued chart. Following the repeated pattern was simply issue of indecision, which mainly proved to be due to lack of training and confidence.
This assignment generally suggested to the author how this problem could be improved and it resulted in the sharing of some of the collected knowledge with the other nursing staff and in that context improving clinical practice in the acute hospital ward. Presentation in any form is an excellent educational opportunity and should be encouraged by the ward managers. It allows the nursing staff to gain the clinical knowledge which can be successfully used in practice to increase the patients’ quality of care. One of the examples is a poster presentation used by the author. Poster presentation is not a new concept and as a learning method it is well recognized within healthcare education, especially in nursing (Akister et al, 2000). Its use is in the raising clinical practice awareness of theoretical assessment; therefore it is a further step in bridging theory and practice. The poster presentations have been effective in disseminating information and in improving relationships between education and clinical staff, and are an effective learning strategy (Utecht et al, 2008). Furthermore, they could be really entertaining and inspiring.
Conclusion:
Nursing records should provide accurate, current, comprehensive and concise information regarding the condition and care of the patient within the standards that govern the whole nursing profession. These standards are set out in the Code of Professional Conduct (NMC, 2008). These include the nurses keeping their knowledge and skills up to date throughout their working life with adequate learning and practice.
Achieving optimal hydration is an essential part of holistic patient care. Maintaining fluid balance is important to avoid complications such as dehydration or accumulating the fluid in the tissues of the body, both of which can have serious clinical consequences. The nurses caring for the particular patients are responsible for ensuring that fluid balance charts are completed with accuracy, and they should always report any significant abnormalities identified in patients’ fluid records, thus resulting in safe and effective nursing care (Shepherd, 2011).
Evaluating the author’s experience, there has been a small improvement in recognizing the importance of the fluid charts and their benefit for particular patients. There was also slight improvement in eliminating the inaccurate estimations in the form of the words as wet, incontinent or sips. With the new housekeeper’s role in this trust, we have been able to improve the more accurate measurement of the fluids given to the patients. When it comes to the output, it is entirely up to the nurses to measure any output as accurately as possible. The weighing scales contribute hugely to accurate measurement of any body fluid output, but the estimations of the amount of body fluid not collected or accidently spilt, is still not fully grasped by the nurses. Time will show how much this acquired skill will improve by the continuous clinical learning and practice of the nurses. Finally, there was a significant improvement in the nurses’ decision when to initiate or discontinue the fluid balance charts depending on the patients’ condition and coexisting diagnosis, which highlighted the clinical importance of the fluid charts still present on the ward. It seems reasonable to assume that the improvement is a consequence of the author’s learning and teaching initiative in the training of all staff included in the patients’ care.