Communication is an essential component of any caregiving relationship. Studies have shown that a lack of communication can result in low self esteem and psychological disengagement, and can have a negative impact on the Quality of Life (QOC). This is one area of investigation conducted during a state/federal survey.
When communicating with a resident, the nurse should tell him/her in straightforward language what has to be communicated and ask if the resident understood what was said.
Barriers to good communication can include language differences, hearing problems, hearing aide inefficiency and environmental reasons, such as background noises, loud music and too frequent overhead paging. These barriers need to be corrected. Inservice education should be available on communication skills. Also, caregivers need to recognize residents’ emotional conflicts and how they can affect communication with the residents. During periods of care, discussion on the resident’s previous work, hobbies, family and travel experiences will engage the resident in a meaningful way.
On one occasion a resident remarked to me about a specific caregiver.
She stated the caregiver discussed observations made on the way to work, weather, shopping experiences and interactions with others. The resident said ”I love when she is assigned to me as it gets me out of this room”.
It is very important that the nurse communicates with family frequently pertaining to any changes in the resident’s condition. Good communication goes a long way in alleviating stress and concerns, and helps to decrease any negative perceptions of the care provided by the facility.
When family knows they will be notified timely of any changes or concerns and are encouraged to participate in the resident’s care, they identify a partnership and become more trusting. The family should be notified of all relevant issues pertaining to the resident including changes in condition, medications, treatments and physician visits.
Good communication skills are beneficial when giving reports to the physician. Use of the INTERACT tool SBAR ( Situation, Background, Assessment and Request) should enable the nurse to make a good assessment and have a detailed report available. Physicians frequently say that the nurse did not provide an adequate report, resulting in the resident ‘s transfer to the hospital emergency department for evaluation and treatment.
All nurses should have access to the Minimum Data Set (MDS) which should help increase Interdisciplinary Team (IDT) communication.
All team members should be ready for a discussion of the resident’s condition at the care plan conference. When staff are assigned to work together on a project as an IDT, understanding and communication will be enhanced.
Documentation is the written form of communication. We all have heard the old cliche : “If it wasn’t written down, it wasn’t done.”
Nursing documentation must provide an accurate and timely account of occurrences and must be reflective of observations, be legible and permanent.
Good documents has six important characteristics:
Factual
Accurate
Complete
Current (timely)
Organized
Compliant with standards
The nurse should follow the policies of the facility, especially the appropriate measures for correcting documentation errors. Charting requirements for Medicare residents should be complete and thorough.
If the nurse is unsure that her documentation is satisfactory, she should ask herself, “If another nurse had to take over for me right now, does the charting have enough information for the delivery of safe, competent and ethical care?”
Remember the resident’s record is a legal document. Documentation should provide a chronological record of events so that an ordered sequence or time line is easily recognized. Should the record be reviewed by a legal team, the nurse will be held accountable for lack of clarity. All documentation must be legibly signed and dated.
