Strategies for Nursing Success: Part 3 of 3 | Documenting and Evaluating to Improve Practice Issues

[Damion Jenkins, MSN, RN]

Since nurses are expected to be self-regulated professionals, we are legally and ethically obligated to identify and make a valid attempt to resolve all practice issues as they arise as a means to minimize potential negative impacts they may have on patients, our fellow colleagues, and daily operations. In part three of this three-part series, we will focus on how to document and evaluate to improve practice issues within our work settings.

Let’s take a look at two strategies we can implement to gain a better understanding of what’s going on, so we can find the best way to resolve practice issues:

Document

It is important to keep personal records of all steps taken to resolve a practice issue. This ensures there is an accurate account of events and that you can use to demonstrate that you’ve met your professional obligations. It is recommended that all communication with managers and other leaders of your organization be noted in your personal communication log. Additionally, it may prove to be helpful to have any discussions or meetings followed up with a summary email. This provides all parties involved with a detailed record of what was discussed and allows for you to highlight specific details, seek further clarification after you’ve thought about it for a while, and to hold other individuals accountable for their contributions to the discussion and/or meeting.

Each board of nursing offers detailed information about the legal and ethical responsibilities relating to reporting and documenting challenging situations within practice. The boards of nursing help to clarify the nurse’s legal and ethical obligation to report incompetent, unethical or impaired practice of a nurse or unethical conduct by any health professional to management, administration and/or the appropriate regulatory body. When documenting any of the above mentioned, be sure to include the following:

1. The practice issue witnessed
2. When the practice issue occurred (specific date and time)
3. Exactly what happened - be sure to remain objective and factual.
4. Describe how the issue has impacted your ability to meet Standards of Practice, Code of Ethics or organizational policies
5. Any other relevant information
6. A request for leadership to follow-up

It is essential to note that the client chart is NOT the place to document discussions regarding a practice issue unless the practice issue had a direct impact on the client. You may also be required to document the practice issue in an incident reporting system. Be sure to know your organization’s policies regarding documentation and/or refer to your state’s board of nursing for more information regarding principles of documentation related to practice issues.

Evaluate

The final step of the nursing process evaluation - and now you must evaluate if the practice issue has been resolved and to determine how your actions may have impacted on the issue itself. If the practice issue was addressed with the support of others, it is important to include them in the evaluation process. Remember that you are never alone in nursing practice - it is always a team effort!

Evaluation helps to ensure that the issue has been addressed and serves as a way to examine what you would do or change in the event of another practice issue. Depending on the severity of the issue, it may not be possible to resolve it immediately and this should be considered during the evaluation process. If your organization’s leadership decides that it is best for them to manage the practice issue without your involvement, it is appropriate to ask that you be informed when it has been addressed or resolved. Be aware that because of confidentiality, the leadership may not be able to provide you with detailed information about how they have resolved the issue. They may only be able to inform you that the issue has been addressed. If you see the practice issue reoccur in the future, it is important to let leadership know and follow the same process as before. You’ll find that as you move through your career, and from one facility to another, things fall between the cracks as individuals leave organizations. It is very likely that an issue that you help to resolve one year, may resurface within the next year or so.

If you’ve determined that the practice issues have not been resolved, take a step back and consider why. Review the process you used by asking yourself the following:

• Did you clearly identify the issue?
• Could you define how and when client care or service was affected?
• Were the right people involved in the discussions and attempts to resolve the issue?
• Is there evidence that your leadership team took steps to address the practice issue?
• What could have been done differently?

Once you have reviewed all of the possibilities, you’ll choose your next steps.

If the practice issue persists you need to continue to take action until it is addressed. Further action could include:

• Request a meeting if you have not yet had a meeting with your leadership team.
• Meet with your direct supervisor again to determine when resolution is likely if you have already met with them and the issue persists.
• Consider discussing the practice issue with the next level of leadership in your organization if your direct supervisor does not provide the support needed for resolution.
• Continue to notify the appropriate people until the issue has been resolved.

In this three-part series, we’ve discussed the six steps in resolving practice issues within nursing practice. The six steps include:

• Identifying Practice Issues
• Fully Exploring the Anticipated Effect and Outcomes of the Practice Issue(s)
• Identifying Resources
• Taking Action
• Documenting
• Evaluating

Does the above list of steps sound familiar? If you guessed - The Nursing Process, you’d be correct! The Nursing Process is always the most important tool that nurses can use to resolve highly complex situations - even major practice issues.

To read the first 2 parts of this series, go to:

Strategies for Nursing Success: Part 1 of 3 - Identifying Practice Issues

Strategies for Nursing Success: Part 2 of 3 - Identifying Resources and Taking Action to Improve Practice Issues

If you have any other tips or suggestions you’d like to share regarding resolving practice issues, please feel free to leave your thoughts in the comments section below!

Best,

Damion

[Queen Tiye, RN]

This is excellent advice. However, in my experience, the manager that you wish to file a grievance against is buddies with the supervisor you need to report her too. Or, leaders get mad when you have no choice but go above their head and you earn a bullseyes on your back and end up having to leave before they fire you.