NUR 367 Nursing
Bluebird home is an aged care facility located in a rural township (population 8,000) in NSW. The town is located 50 km from the nearest larger town. The facility provides care for 100 aged residents, many of whom are some distance from their families and friends. The facility is staffed by registered, enrolled nurses and assistants in nursing, kitchen, cleaning and administrative staff. A Director of Nursing, a Deputy Director of nursing and a business manager oversee the operations of the facility. The services of a diversional therapist, a physiotherapist, a pharmacist and several doctors from the local general practice are also employed by the facility.
In response to facility accreditation, the Director of Nursing was compelled to upgrade the facility’s documentation practices. The accreditation team found that entries in each resident’s record were infrequent and contained minimal information. Moreover, each resident’s record was divided between six different folders: a medication folder, a wound care folder, a nursing notes folder, a medical notes folder, an allied health folder and a care plan folder. The lack of integration was identified as creating a risk to the safety and quality of resident care as an holistic and up to date picture of each resident’s health status was impossible to ascertain. Visiting providers often had no knowledge of the residents’ health status or responses to treatment and depended on verbal recounts provided by staff.
The Director of Nursing decided to ask one of the senior registered nurses, Sam, to lead the practice changes required to address the issue. Sam consulted with a friend at another Aged care facility, who gave advice on what to do. Sam decided to merge all of the folders, with the exception of the medication charts, together for each resident (100 folders), which she completed over a weekend. On Monday when staff came to work, they were presented with a memo advising them of the change, specific times for records to be updated, and a sample of the appropriate structure to use when writing a resident’s report.
During that week, episodes of confusion occurred as staff could not access the record when required. Doctors were angry that their own notes were not immediately available and mixed in with others. Nurses were angry that were not getting off work on time as they had to wait until others had finished with the record before they could make their own entries. Some nurses didn’t bother waiting and went home leaving the care undocumented, and were reprimanded by Sam when they returned. The Director of Nursing ordered an audit in response to complaints and found that the notes were more out of date than before, and that the lack of consistency between the sections of the record remained an issue. Furthermore, staff were angry stressed and negative about the change and their lack of involvement. The Director of Nursing regretted not supporting Sam with the change project and resolved to renew the approach she had taken
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