STANDARDS OF PSYCHIATRIC MENTAL HEALTH NURSING PRACTICE

Standards Of Practice
Standard 1. ASSESSMENT The psychiatric mental health registered nurse collects comprehensive health data that is pertinent the patients health or situation. Rationale The psychiatric mental health registered nurse uses linguistically and culturally effective communication skills, interviewing, behavioral observation, record review and collection of collateral information to make sound clinical assessments. Measurement Criteria The Psychiatric-Mental Health Registered Nurse: Collects data in a systematic and ongoing process. Involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection. Demonstrates effective clinical interviewing skills that facilitate development of a therapeutic alliance. Prioritizes data collection activities based on the patients immediate condition or anticipated needs of the patient or situation. The data may include but is not limited to the patients: Central complaint, focus or concern and symptoms of major psychiatric disorders. History and presentation regarding suicidal, violent, and self-mutilating behaviors to assess level of risk. History of reliability with regard to patients verbal agreement to seek professional assistance prior to engaging in behaviors dangerous to self or others.

 Pertinent family history of psychiatric disorders, substance abuse and other mental health issues. Evidence of abuse or neglect. Stressors, contributing factors and coping strategies. Scope & Standards Draft Revision 2006 1. Demographic profile and history of health patterns, illnesses and past treatments and level of adherence and effectiveness. 2. Actual or potential barriers to adherence to recommended or prescribed treatment. 3. Health beliefs and practices. 4. Religious and spiritual beliefs and practices. 5. Cultural, racial and ethnic identity and practices. 6. Physical, developmental, cognitive, mental status, emotional health concerns and neurological assessment. 7. Daily activities, personal hygiene, occupational functioning, functional health status and social roles, including work, sleep and sexual functioning. 8. Economic, political, legal, and environmental factors affecting health. 9. Significant support systems and community resources including what has been available and underutilized. 10. Knowledge, satisfaction, and motivation to change, related to health. 11. Strengths and competencies that can be used to promote health. 12.Current and past medications, both prescribed and over-the-counter inclusive of herbs, alternative medications, vitamins, or nutritional supplements. 13. Medication interactions and history of side effects and past efficacy.

14. History and patterns of alcohol and substance abuse including type, amount, most recent use and withdrawal symptoms. 15. Complementary therapies used to treat health and mental illness and outcomes. 16. Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data. 17. Uses analytical modes and problem-solving techniques. 18. Ensures that appropriate consents, as determined by regulations and policies, are obtained to protect patient confidentiality and support the patients rights in the gathering. 19.Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances. 20.Uses therapeutic principles to understand and interpret the patients emotion, thoughts and behaviors. 21.Documents relevant data in a retrievable format. process of data

1 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse The APRN-PMH: Employs evidence-based clinical practice guidelines to guide screening and diagnostic activities as available and appropriate. Performs physical and comprehensive mental health assessment. Initiates and interprets diagnostic tests and procedures relevant to the patients current status. Conducts a multigenerational family assessment, including medical and psychiatric history. Assesses the interface among the individual, family, community, and social systems and their relationship to mental health functioning. Standard 2. DIAGNOSIS The psychiatric-mental health registered nurse analyzes the assessment data in determining diagnoses or problems including level of risk. Rationale

Through comprehensive and focused assessment and data analysis the psychiatric mental health registered nurse identifies patient needs related to actual or potential psychiatric disorders, mental health problems, and potential co-morbid physical illnesses. Measurement Criteria The psychiatric mental health registered nurse: Derives the diagnosis or problems from the assessment data, Identifies actual or potential risks to the patients health and safety and/or barriers to mental and physical health which may include but is not limited to interpersonal, systematic, or environmental circumstances. Develops diagnoses or problem statements that conform, or are congruent with, available and accepted classifications systems. Validates the diagnosis or problems with the patient, significant others and other health care clinicians. Documents diagnoses or problems in a manner that facilitates the determination of the expected outcomes and plan.

Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse The APRN-PMH: Systematically compares and contrasts clinical findings with normal and abnormal variations and developmental events in formulating a differential diagnosis. Develops a differential diagnosis derived from the collection and synthesis of assessment data, and applies standardized taxonomy systems to the diagnosis of mental health problems and psychiatric disorders utilizing current DSM & ICD Taxonomy. Utilizes complex data and information obtained during interview, examination and diagnostic procedures in identifying diagnosis. Documents the diagnosis. Identifies long-term effects of psychiatric disorders on mental, physical and social health. Evaluates the health impact of life stressors, traumatic events and situational crises within the context of the family cycle. Evaluates the impact of the course of psychiatric disorders and mental health problems on quality of life and functional status. Assists staff in developing and maintaining competency in the diagnostic process.

Standard 3. OUTCOMES IDENTIFICATION The psychiatric mental health registered nurse identifies expected outcomes for a plan individualized to the patient or to the situation. Rationale

Psychiatric mental health registered nurses provide nursing care to influence positive. patient outcomes including the achievement of individualized mental and physical health goals. 1 Measurement Criteria The psychiatric mental health registered nurse: Derives culturally appropriate expected outcomes from the diagnosis. Involves the patient, family, and other healthcare providers in formulating expected outcomes when possible and appropriate. Considers associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating expected outcomes. Defines expected outcomes in terms of the patient, patient values, ethical considerations, environment or situation with such consideration as associated risks, benefits and costs, and current scientific evidence.Develops expected outcomes that provide direction for continuity of care. Documents expected outcomes as measurable goals. Includes a time estimate for attainment of expected outcomes. Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse The APRN-PMH: Identifies expected outcomes that incorporate scientific evidence and are achievable through implementation of evidence-based practices. Identifies expected outcomes that incorporate cost and clinical effectiveness, patient satisfaction, and continuity and consistency among providers. Supports the use of clinical guidelines linked to positive patient outcomes.

Standard 4. PLANNING The psychiatric mental health registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 1 Rationale 2 A plan of care is used to systematically guide therapeutic interventions and document progress. Measurement Criteria The psychiatric mental health registered nurse: Develops the plan in collaboration with the patient, family, and other health care providers when appropriate. Prioritizes elements of the plan based on the assessment of the patients level of risk for potential harm to self or others and safety needs. Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease. Assists patients in securing treatment or services in the least restrictive environment. Includes an implementation pathway or timeline within the plan. Provides for continuity within the plan. Utilizes the plan to provide direction to other members of the health care team. Documents the plan using standardized language or recognized terminology. Defines the plan to reflect current statutes, rules and regulations, and standards. Develops the plan to reflect the use of available research evidence. Considers the economic impact of the plan. Modifies the plan based on ongoing assessment of the patients response and other outcome indicators.

1 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse The APRN-PMH: Within the plan, identifies assessment, diagnostic strategies, and therapeutic interventions to address mental health problems and psychiatric disorders that reflect current evidence, including data, research, literature, and expert clinical knowledge. Plans care to minimize the development of complications and promote function and quality of life using treatment modalities such as, but not limited to, behavioral therapies, psychotherapy and psychopharmacology. Selects or designs strategies to meet the multifaceted needs of complex patients. Includes synthesis of patients values and beliefs regarding nursing and medical therapies within the plan.

Standard 5. IMPLEMENTATION The psychiatric mental health registered nurse implements the identified plan. Measurement Criteria The psychiatric mental health registered nurse: Implements the plan in a safe and timely manner. Documents implementation and any modifications, including changes or omissions of the identified plan. Utilizes evidence based interventions and treatments specific to the diagnosis or problem. Utilizes community resources and systems to implement the plan. Collaborates with nursing colleagues and others to implement the plan. Manages psychiatric emergencies by determining the level of risk and initiating and coordinating effective emergency care. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse. The APRN-PMH:

Facilitates utilization of systems and community resources to implement the plan. Supports collaboration with nursing colleagues and other disciplines to implement the plan. Incorporates new knowledge and strategies to initiate change in nursing care practices if desired outcomes are not achieved. Implements the plan using principles and concepts of project or systems management. Standard 5 A. COORDINATION OF CARE The psychiatric mental health registered nurse coordinates care delivery. Measurement Criteria The psychiatric mental health registered nurse: Coordinates implementation of the plan. Documents the coordination of care. Additional Measurement Criteria for Psychiatric Mental Health Advanced Practice Registered Nurse The APRN-PMH: Provides leadership in the coordination of multidisciplinary health care for integrated delivery of patient care services. Synthesizes data and information to prescribe necessary system and community support measures, including environmental modifications. Coordinates system and community resources that enhance delivery of care across continuums. Assists patients in getting financial assistance as needed to maintain appropriate care. Standard 5 B. HEALTH TEACHING AND HEALTH PROMOTION The psychiatric mental health registered nurse employs strategies to promote health and a safe environment. Rationale The psychiatric mental health registered nurse, through health teaching, promotes the patients personal and social integration and assists the patient in achieving satisfying, productive, and health patterns of living.

Measurement Criteria The psychiatric mental health registered nurse Uses health promotion and health teaching methods appropriate to the situation, patients developmental level, learning needs, readiness, ability to learn, language preference and culture. Provides health teaching related to the patients needs and situation that may include, but is not limited to, mental health problems and psychiatric disorders, treatment regimen, coping skills, relapse prevention, self-care activities, resources, conflict management, problem-solving skills, stress management and relaxation techniques, a crisis management. Integrates current

knowledge and research regarding psychotherapeutic educational strategies and content. Engages consumer alliances and advocacy groups, as appropriate, in health teaching and health promotion activities. Identifies community resources to assist consumers in using prevention and mental health care services appropriately. Seeks opportunities for feedback and evaluation of the effectiveness of strategies utilized. Provides anticipatory guidance to individuals and families to promote mental health and to prevent or reduce the risk of psychiatric disorders. 1 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse. The APRN-PMH: Educates patients and significant others about intended effects and potential adverse effects of treatment options. Provides education to individuals, families, and groups to promote knowledge, understanding and effective management of overall health maintenance, mental health problems and psychiatric disorders. Uses knowledge of health beliefs, practices, evidence-based findings, and epidemiological principles, along with the social, cultural, and political issues that affect mental health in an identified community to develop health promotion strategies. Synthesizes empirical evidence on risk behaviors, learning theories, behavioral change theories, motivational theories, epidemiology, and other related theories and frameworks when designing health information and patient education.

Designs health information and patient education appropriate to the patients developmental level, learning needs, readiness to learn, and cultural values and beliefs. Evaluates health information resources, such as the Internet, within the area of practice for accuracy, readability, and comprehensibility to help patients access quality health information. Standard 5C. MILIEU THERAPY The psychiatric mental health registered nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with the patients, families and other health care clinicians. Rationale The therapeutic environment consists of the physical environment, social structures, and the philosophy of care and treatment that provides safety at points of crisis and supports the patients ability to use new adaptive coping strategies and available resources. Measurement Criteria The psychiatric mental health registered nurse: Orients the patient and family to the care environment including the physical environment, the roles of different health care team providers in their care. 1 involved in the treatment and care delivery processes, schedules of events pertinent to their care and treatment, and expectations regarding behaviors. Orients the patient to their rights and responsibilities particular to the treatment or care environment. Conducts ongoing assessments of the patient in relationship to the environment to guide nursing interventions in maintaining a safe environment and patient safety. Selects specific activities that meet the patients physical and mental health needs for meaningful participation in the milieu and promoting personal growth. Ensures that the patient is treated in the least restrictive environment necessary to maintain the safety of the patient and others. Informs the patient in a culturally competent manner about the need for the limits and the conditions necessary to remove the restrictions.

Provides the patient with the opportunity to discuss their illness experience with The psychiatric mental health nurse to promote support, validation and prevention of complications. Standard 5 D. PHARMACOLOGICAL, BIOLOGICAL AND COMPLEMENTARY INTERVENTIONS The psychiatric-mental registered nurse uses knowledge of pharmacological, biological and complementary interventions and applies clinical skills to restore the patients health and prevent further disability. Measurement Criteria The psychiatric mental health registered nurse: Applies current research findings to guide nursing actions related to pharmacology, other biological therapies, and complementary therapies. Assesses patients response to biological interventions based on current knowledge of pharmacological agents intended actions, interactive effects, potential untoward effects and therapeutic doses. Includes health teaching for medication management to support patients in managing their own medications, and adherence to prescribed regimen. Educates on information about mechanism of action, intended effects, potential adverse effects of the proposed prescription, ways to cope with transitional side effects and other treatment options, including no treatment. Directs interventions toward alleviating untoward effects of biological interventions. Communicates observations about the patients response to biological interventions are to other health clinicians. Standard 5E. PRESCRIPTIVE AUTHORITY AND TREATMENT The APRN-PMH prescribes or recommends, pharmacological agents for patients with mental health problems and psychiatric disorders based on individual characteristics, such as culture, ethnicity, gender, religious beliefs, age and physical health problems.

Measurement Criteria Conducts a thorough assessment of past medical trials, side effects, efficacy and patient preference. Prescribes or recommends pharmacological agents based on research evidence and knowledge of psychopathology, neurobiology, physiology, expected therapeutic actions, anticipated side effects and courses of action. Prescibes or recommends psychotropic and related medications based on clinical indicators of patient status. Assesses a reasoned balance of risk and benefits, including results of diagnostic and lab tests as appropriate, to treat symptoms of psychiatric disorders and improve functional status. Provides health teaching about mechanism of action, intended effects, potential adverse effects of the proposed prescription, ways to cope with transitional side effects and other treatment options, including no treatment. Educates and assists the patient in selecting the appropriate use of complementary and alternative therapies. Evaluates therapeutic and potential adverse effects of pharmacological and non pharmacological treatments. Evaluates pharmacological outcomes by utilizing standard symptom measurements and patient report to determine efficacy. Adjusts medications based on continual monitoring in collaboration with patient. Standard 5F. PSYCHOTHERAPY The Psychiatric Mental Health Advanced Practice Registered Nurse conducts individual, couples, group, and/or family psychotherapy using evidence-based psychotherapeutic frameworks, interpersonal transactions and nurse-patient therapeutic relationship. Measurement Criteria The APRN-PMH: Uses knowledge of personality theory, growth and development, psychology, neurobiology, psychopathology, social systems small-group and family dynamics, stress and adaptation, and theories and best available research evidence to select therapeutic methods based on the patients needs. Structures the therapeutic contract to include, but not limited to: Purpose, goals, and expected outcomes

 Time, place and frequency of therapy Participants involved in therapy Confidentiality and appropriate written release of information Availability and means of contacting therapist Responsibilities of both patient and therapist Fees and payment schedule Cancellations/alteration in schedule policy Utilizes interventions that promote mutual trust to build a therapeutic treatment alliance. Empowers patients to be active participants in treatment. Applies therapeutic communication strategies based on theories and research evidence to reduce emotional distress, facilitate cognitive and behavioral change and foster personal growth. Uses self-awareness of emotional reactions and behavioral responses to others to enhance the therapeutic alliance. Analyzes the impact of duty to report and other advocacy actions on the therapeutic alliance. Arranges for the provision of care in the therapists absence. Applies ethical and legal principles to the treatment of patients with mental health problems and psychiatric disorders. Makes referrals when it is determined that the patient will benefit from a transition of care or consultation due to change in clinical condition. Evaluates effectiveness of interventions is relation to outcomes using standardized methods as appropriate. Monitors outcomes of therapy and adjusts plan of care when indicated. Therapeutically concludes the nurse-patient relationship and transitions the patient to other levels of care, when appropriate.

Identifies and maintains professional boundaries to preserve the integrity of thetherapeutic process. Standard 5G. CONSULTATION The psychiatric mental health advanced practice nurse provides consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for patients and effect change. Measurement Criteria The APRN-PMH: Synthesizes clinical data, theoretical frameworks, and evidence when providing consultation. Initiates consultation at the request of the consultee. Establishes a working alliance with the patient or consultee based on mutual respect and role responsibilities. Facilitates the effectiveness of a consultation by involving the stakeholders in the decisionmaking process. Communicates consultation recommendations that influence the identified plan, facilitate understanding by involved stakeholders , enhance the work of others, and effect change. Clarifies that implementation of system changes or changes to the plan of care remain the consultees responsibility. Standard 6. EVALUATION The psychiatric mental health registered nurse evaluates progress toward attaining expected outcomes. Measurement Criteria The psychiatric mental health registered nurse: Conducts a systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan and indicated timeline. Involve the patient, family or significant others, and other health care clinicians in the evaluation process.

Documents results of the evaluation. Evaluates the effectiveness of the planned strategies in relation to patient responses and the attainment of the expected outcomes. Uses on going assessment data to revise the diagnoses, outcomes, the plan and the implementation as needed. Disseminates the results to the patient and others involved in the care or situation, as appropriate, in accordance with state and federal laws and regulations. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse: The APRN-PMH: Evaluates the accuracy of the diagnosis and effectiveness of the interventions in relationship to the patients attainment of expected outcomes. Synthesizes the results of the evaluation analyses to determine the impact of the plan on the affected patients, families, groups, communities, and institutions. Uses the results of the evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate Psychiatric Mental Health NursingScope & Standards Draft Revision 2006 STANDARDS OF PROFESSIONAL PERFORMANCE Standard 7. QUALITY OF PRACTICE The psychiatric mental health registered nurse systematically enhances the quality and effectiveness of nursing practice. Measurement Criteria The psychiatric-mental health registered nurse: Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner.Uses the results of quality improvement activities to initiate changes in nursing practice and in the healthcare delivery system. Uses creativity and innovation in nursing practice to improve care delivery.

Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not achieved. Obtains and maintains certification in psychiatric mental health nursing. Participates in quality improvement activities. Such activities may include: Identifying aspects of practice important for quality monitoring. Using indicators developed to monitor quality and effectiveness of nursing practice. Collecting data to monitor quality and effectiveness of nursing practice. Analyzing quality data to identify opportunities for improving nursing practice. Formulating recommendations to improve nursing practice or outcomes. Implementing activities to enhance the quality of nursing practice. Developing, implementing, and evaluating policies, procedures and/orguidelines to improve the quality of practice. Participating on interdisciplinary teams to evaluate clinical care or health services. Participating in efforts to minimize costs and unnecessary duplication. Analyzing factors related to safety, satisfaction, effectiveness, and cost/benefit options. Analyzing organizational systems for barriers Psychiatric Mental Health Nursing Page 36 OF 49 Scope & Standards Draft Revision 2006 Implementing processes to remove or decrease barriers within organizational systems. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse. The APRN-PMH: Obtains and maintains professional certification if available in the area of expertise. Designs quality improvement initiatives.

Implements initiatives to evaluate the need for change. Evaluates the practice environment and quality of nursing care rendered in relation to existing evidence, identifying opportunities for the generation and use of research. Standard 8. EDUCATION The psychiatric mental health registered nurse attains knowledge and competency that reflects current nursing practice. Measurement Criteria The psychiatric mental health registered nurse: Participates in ongoing educational activities related to appropriate knowledge bases and professional issues. Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify learning needs. Seeks experiences that reflect current practice in order to maintain skills and competence in clinical practice or role performance. Acquires knowledge and skills appropriate to the specialty area, practice setting,role, or situation. Maintains professional records that provide evidence of competency and life long learning. Psychiatric Mental Health Nursing Page 37 OF 49 Scope & Standards Draft Revision 2006 Seeks experiences and formal and independent learning activities to maintain and develop clinical and professional skills and knowledge. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse: The APRN- PMH:

Uses current healthcare research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues. Standard 9: PROFESSIONAL PRACTICE EVALUATION The psychiatric mental health registered nurse evaluates his/her own practice in relation to the professional practice standards and guidelines, relevant statutes, rules, and regulations. Measurement Criteria The psychiatric mental health registered nurse: Demonstrates the application of knowledge of current practice standards, guidelines, statutes, rules, and regulations. Provides age appropriate care in a culturally and ethnically sensitive manner. Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas in which professional development would be beneficial. Obtains informal feedback regarding ones own practice from patients, peers, professional colleagues, and others. Participates in systematic peer review as appropriate. Takes action to achieve goals identified during the evaluation process. Provides rationale for practice beliefs, decisions, and actions as part of the informal and formal evaluation processes. Psychiatric Mental Health Nursing Page 38 OF 49 Scope & Standards Draft Revision 2006 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse: The APRN-PMH: Engages in a formal process seeking feedback regarding ones own practice from patients, peers, professional colleagues, and others. Standard 10. COLLEGIALITY

The psychiatric mental health registered nurse interacts with and contributes to the professional development of peers and colleagues. Measurement Criteria The psychiatric-mental health registered nurse: Shares knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentations at formal or informal meetings. Provides peers with feedback regarding their practice and/or role performance. Interacts with peers and colleagues to enhance ones own professional nursing practice and/or role performance. Maintains compassionate and caring relationships with peers and colleagues. Contributes to an environment that is conducive to the education of healthcare professionals. Contributes to a supportive and healthy work environment. Additional Measurement Criteria for the psychiatric mental health advanced practice nurse. The APRN-PMH: Models expert practice to interdisciplinary team members and healthcare consumers. Mentors other registered nurses and colleagues as appropriate. Participates with interdisciplinary teams that contribute to role development and advanced nursing practice and health care. Psychiatric Mental Health Nursing Page 39 OF 49 Scope & Standards Draft Revision 2006 Standard 11: COLLABORATION The psychiatric mental health registered nurse collaborates with patients, family and others in the conduct of nursing practice.

Measurement Criteria The psychiatric-mental health registered nurse: Communicates with patient, family, and healthcare providers regarding patient care and the nurses role in the provision of that care. Collaborates in creating a documented plan focused on outcomes and decisions related to care and delivery of services that indicates communication with patients, families, and others. Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation. Documents referrals, including provisions for continuity of care. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Registered Nurse. The APRN-PMH: Partners with other disciplines to enhance patient care through interdisciplinary activities, such as education, consultation, management, technological development, or research opportunities. Facilitates an interdisciplinary process with other members of the healthcare team. Documents plan of care communications, rationales for plan of care changes, and collaborative discussions to improve patient care. Standard 12: ETHICS The psychiatric mental health registered nurse integrates ethical provisions in all areas of practice. Psychiatric Mental Health Nursing Page 40 OF 49 Scope & Standards Draft Revision 2006 Measurement Criteria The psychiatric mental health registered nurse:

Uses the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice. Delivers care in a manner that preserves and protects patient autonomy, dignity and rights. Maintains patient confidentiality within legal and regulatory parameters. Serves as a patient advocate assisting patients in developing skills for self advocacy. Maintains a therapeutic and professional patientnurse relationship with appropriate professional role boundaries and does not promote or engage in intimate, sexual, or business relationships with current or former patients. Monitors and carefully manages self-disclosure therapeutically. Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and others. Contributes to resolving ethical issues of patients, colleagues, or systems as evidenced in such activities as participating on ethics committees. Reports illegal, incompetent, or impaired practices. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse The APRN-PMH: Informs the patient of the risks, benefits, and outcomes of healthcare regimens. Participates in interdisciplinary teams that address ethical risks, benefits, and outcomes. Standard 13: RESEARCH The psychiatric mental health registered nurse integrates research findings into practice. Psychiatric Mental Health Nursing Page 41 OF 49 Scope & Standards Draft Revision 2006 Measurement Criteria The psychiatric-mental health registered nurse:

Utilizes the best available evidence, including research findings, to guide practice decisions. Actively participates in research activities at various levels appropriate to the nurses level of education and position. Such activities may include: Identifying clinical problems specific to psychiatric-mental health nursing research (patient care and nursing practice). Participating in data collection (surveys, pilot projects, formal studies) Participating in a formal committee or program. Sharing research activities and/or findings with peers and others Conducting research. Critically analyzing and interpreting research for application to practice. Using research findings in the development of policies, procedures, and standards of practice in patient care. Incorporating research as a basis for learning. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse The APRN-PMH: Contributes to nursing knowledge by conducting, critically appraising or synthesizing research that discovers, examines and evaluates knowledge, theories, criteria, and creative approaches to improve healthcare practice. Formally disseminates research findings through activities such as presentations,publications, consultation, and journal clubs. Demonstrates leadership in promoting a culture that consistently integrates the best available research evidence into practice. STANDARD 14. RESOURCE UTILIZATION The psychiatric mental health registered nurse considers factors related to

safety,effectiveness, cost, and impact on practice in the planning and delivery of nursing services.

7 Measurement Criteria The psychiatric-mental health registered nurse: Evaluates factors such as safety, effectiveness, availability, cost and benefits, efficiencies, and impact on practice, when choosing practice options that would result in the same expected outcome. Assists the patient and family in identifying and securing appropriate and available services to address health-related needs. Assigns or delegates tasks, based on the needs and condition of the patient, potential for harm, stability of the patients condition, complexity of the task, and predictability of the outcome. Assists the patient and family in becoming informed consumers about the options, costs, risks, and benefits of treatment and care. Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice Nurse: The APRN-PMH: Utilizes organizational and community resources to formulate multidisciplinary or interdisciplinary plans of care. Develops innovative solutions for patient care problems that address effective resource utilization and maintenance of quality. Develops evaluation strategies to demonstrate quality, cost effectiveness, cost benefit, and efficiency factors associated with nursing practice. STANDARD 15. LEADERSHIP The psychiatric mental health registered nurse provides leadership in the professional practice setting and the profession. Measurement Criteria The psychiatric-mental health registered nurse: Engages in teamwork as a team player and a team builder. Works to create and maintain healthy work environments in local, regional, national, or international communities.

Displays the ability to define a clear vision, the associated goals, and a plan to implement and measure progress. Demonstrates a commitment to continuous, life long learning for self and others. Teaches others to succeed by mentoring and other strategies. Exhibits creativity and flexibility through times of change. Demonstrates energy, excitement, and a passion for quality work. Willingly accepts mistakes by self and others thereby creating a culture in which risk-taking is not only safe, but expected. Inspires loyalty through valuing of people as the most precious asset in an organization. Directs the coordination of care across settings and among caregivers, including oversight of licensed and unlicensed personnel in any assigned or delegated tasks. Serves in key roles in the work setting by participating on committees, councils, and administrative teams. Promotes advancement of the profession through participation in professional organizations. Additional Measurement Criteria for the Psychiatric Mental health Advanced Practice Nurse The APRN-PMH: Utilizes ethical principles to create a system of advocacy for access and parity for mental health problems, psychiatric disorders, and addiction services. Influences health policy to reduce the impact of stigma on services for prevention and treatment of mental health problems and psychiatric disorders. Works to influence decision-making bodies to improve patient care. Provides direction to enhance the effectiveness of the healthcare team. Initiates and revises protocols or guidelines to reflect evidence-based practice, to reflect accepted changes in care management, or to address emerging problems. Promotes communication of information and advancement of the profession through writing, publishing, and presentations for professional or lay audiences.

Designs innovations to effect change in practice and improve health outcomes.

DOCUMENTATION
DEFINITION Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred. Nurses may document information pertaining to individual clients or groups of clients. Individual Clients : When caring for an individual client (which may include the clients family), the nurses documentation provides a clear picture of the status of the client, the actions of the nurse, and the client outcomes. Nursing documentation clearly describes: an assessment of the clients health status, nursing interventions carried out, and the impact of these interventions on client outcomes; a care plan or health plan reflecting the needs and goals of the client; needed changes to the care plan; information reported to a physician or other health care provider and, when appropriate, that providers response; and advocacy undertaken by the nurse on behalf of the client. Groups of Clients When providing service to groups of clients (e.g., therapy groups, public health programs), service records (or an equivalent) are used to document the service provided and overall observations pertaining to the group. Similar to documentation for individuals, documentation for groups reflects the needs assessment, plans, actions taken, and evaluation of the group outcomes.

Documentation of services provided to a group of clients describes: The purpose and goal of the group The criteria for participation Intervention activities and group processes and An evaluation of group outcomes.

NURSINGDOCUMENTATION Pertinent information about individual clients within the group is documented on individual client health records, not on the group service record. When charting on an individual client health record, names of other group members are not identified. REASONSFORDOCUMENTATION To facilitate communication Through documentation, nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. Documentation of this information increases the likelihood that the client will receive consistent and informed care or service. Thorough, accurate documentation decreases the potential for miscommunication and errors. While documentation is most often done by nurses and care providers, there are situations where the client and family may document observations or care provided in order to communicate this information with members of the health care team. To promote good nursing care Documentation encourages nurses to assess client progress and determine which interventions are effective and which are ineffective, and identify and document changes to the plan of care as needed.

Documentation can be a valuable source of data for making decisions about funding and resource management as well as facilitating nursing research, all of which have the potential to improve the quality of nursing practice and client care.

Individual nurses can use outcome information or information from a critical incident to reflect on their practice and make needed changes based on evidence.

To meet professional and legal standards

Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. The nurses documentation may be used as evidence in legal proceedings such as lawsuits, coroners inquests, and disciplinary hearings through professional regulatory bodies. In a court of law, the clients health record serves as the legal record of the care or service provided. Nursing care and the documentation of that care will be measured according to the standard of a reasonable and prudent nurse with similar education and experience in a similar situation.

TOOLS FOR DOCUMENTATION

There are many tools used for client documentation, including worksheets and kardexes, client care plans, flowsheets and checklists, care maps, clinical pathways and monitoring strips. These tools may be written or electronic in format. Regardless of the tool used, pertinent information specific to an individual client resides within the clients health record.

Worksheets and kardexes Nurses use worksheets to organize the care they provide, and to manage their time and multiple priorities.

Kardexes are used to communicate current orders, upcoming tests or surgeries, special diets or the use of aids for independent living specific to an individual client (College of Nurses of Ontario, 2002). If a paper format is used,entries may be erasable as long as the assessment, nursing interventions carried out and the impact of these interventions on client outcomes are documented in the permanent health record.

NURSINGDOCUMENTATION Documentation of the clients care plan, it is kept as part of the permanent record.

Client care plans Care plans are outlines of care for individual clients and make up part of the permanent health record. Care plans are written in ink (unless electronic), up-to-date and clearly identify the needs and wishes of the client.

Flow sheets and checklists Flow sheets and checklists are used to document routine care and observations that are recorded on a regular basis (e.g., activities of daily living, vital signs, intake and output). Flow sheets and checklists are part of the permanent health record, and can be used as evidence in legal proceedings (College of Nurses of Ontario, 2002). Symbols (e.g., check marks) may be used on flow sheets or checklists as long as it is clear who performed the assessment or intervention and the meaning of each of the symbols is identified in agency policy.

Care maps and clinical pathways Care maps and clinical pathways outline what care will be done and what outcomes are expected over a specified time frame for a usual client within a case type or grouping. Nurses

individualize care maps and clinical pathways to meet clients specific needs (e.g., by making changes to items that are not appropriate). If the status of clients varies from that outlined on the care map or clinical pathway at a particular time period, the variance is documented, including the reasons and action plan to address it.

Monitoring strips Monitoring strips (e.g., cardiac, fetal or thermal monitoring; blood pressure testing) provide important assessment data and are included as part of the permanent health record.

INCIDENT REPORTS Agencies often have policies that require nurses to complete incident reports following unusual occurrences, such as medication errors or harm to clients, staff or visitors. Regardless of whether incident reports are used, nurses have a professional obligation to document the actual care provided to an individual in the clients health record. Incident reports are administrative risk management tools to track trends and patterns about groups of clients over time. Incident reports are to be used for quality assurance not punitive purposes. Incident reports completed in hospital based agencies are protected from disclosure in legal proceedings in section 51 of the Evidence Act (2001). Therefore, they are retained separately from the health record and no reference to an incident report is made in the health record to protect the incident report from subpoena. British Columbia Health Care Risk Management Society (2002) recommends the following: Ensure that the facts of the incident are recorded separately from opinions about the cause of the incident and from any quality assurance follow-up information. Some organizations have a two-part incident report with follow-up and recommendations separate from the rest of the report.

Never promise a patient/family a copy of an incident report or of any report arising out of quality assurance investigation - section 51 of the Evidence Act prohibits this.

NURSINGDOCUMENTATION Directives for Documentation Requirements for documentation and the sharing, retention and disposal of this information are drawn from several sources: statutory regulations; Standards of Practice; agency policies and procedures; and legal principles.

STATUTORY REGULATIONS There are no laws in BC stating specifically how and what nurses must document. Agencies generally develop documentation policies which reflect provincial and federal government statutes and/or other relevant documents. The following statutes and documents guide policy in most B.C. agencies: British Columbia Coroners Act Health Professions Act Child, Family and Community Service Act Hospital Act Controlled Drug and Substances Act (Federal) Health Care (Consent) and Facilities Act Electronic Transactions Act Limitation Act Evidence Act Medical Practitioners Act Freedom of Information and Protection of Privacy Act Mental Health Act Health Act Other Relevant Documents

STANDARDSOFPRACTICE
Professional Standards for Registered Nurses and Nurse Practitioners A standard is a desired and achievable level of performance against which actual performance can be compared. Each of the six Professional Standards incorporates one of the characteristics of the profession and provides direction to nurses about documentation. Examples of How Nurses Meet the CRNBC Professional Standards:

Standard 1: Responsibility and Accountability: Maintains standards of nursing practice and professional conduct determined by CRNBC and the practice setting. Examples: Document all relevant data. Ensure that each entry clearly identifies the nurse. Be familiar with and use the documentation method used in the agency. Advocate for agency policies and procedures that are clear and consistent with CRNBC documentation standards. Standard 2: Specialized Body of Knowledge: Bases practice on the best evidence and other sciences and humanities. Example: Understand the purpose of and reasons for accurate and effective documentation. Standard 3: Competent Application of Knowledge: Makes decisions about actual or potential health problems and strengths, plans and performs interventions, and evaluates outcomes. Examples: Document client assessments, interventions and the impact of interventions on client outcomes according to agency policies and the CRNBC Standards of Practice. Individualize care plans to meet the needs and wishes of individual clients.

Standard 4: Code of Ethics: Adheres to the ethical standards of the nursing profession. Examples: Be familiar with agency policies related to confidential information. Safeguard the security of printed or electronically displayed or stored information. Dispose of confidential information in a manner that preserves confidentiality (e.g., shredding). Act as an advocate to protect and promote clients rights to confidentiality and access to information.

Standard 5: Provision of Service in the Public Interest: Provides nursing services and collaborates with other members of the health care team in providing health care services. Examples: Use documentation to share knowledge about clients with other nurses and health care professionals.Regularly update kardex information and ensure that relevant client care information is captured in the permanent health record. Keep the care plan clear, current and useful.

Standard 6: Self-Regulation: Assumes primary responsibility for maintaining competence and fitness to practice. Example: Keep current with changes in the documentation method used.

Practice Standard: Documentation The CRNBC Practice Standard Documentation sets out requirements related to documentation and nurses practice. It also provides direction on how to apply the principles in the Standard to practice.

AGENCY POLICIES AND PROCEDURES Most health care agencies have documentation policies. These policies provide direction for nurses to document the nursing care provided and the process of clinical decision-making in an accurate and efficient manner. Agency policies include: Description of the method of documentation; Expectations for the frequency of documentation; Processes for late entry recording; listing of acceptable abbreviations or the name of a reference text in which acceptable abbreviations are found; Acceptance and recording of verbal and telephone orders; and Storage, transmittal and retention of client information. Agency policies guide nurses in managing each of these specific situations. In situations where policy changes are necessary, nurses advocate for the appropriate changes.

LEGAL PRINCIPLES

Legal standards for documentation have evolved over time and continue to evolve. Many are based on Canadian common law court decisions as illustrated in the following examples: Nurses notes are recognized as documentary evidence. Case: Ares vs. Venner, 1970 Prior to 1970, nurses notes were not considered legal evidence admissible in court unless the nurse was called to testify to the truth of the contents. In 1970, a new law was made in the Ares vs. Venner case when, for the first time, nurses notes were recognized as admissible evidence. Nurses notes were viewed as a record of the nursing care provided to the client. This case set out the conditions in which nurses notes are now admissible (Richard,1995): nurses notes

must be made contemporaneously; nurses notes must be made by someone having personal knowledge of the matter then being recorded; and nurses notes must be made by someone under a duty of care to make the entry or record.

Charting by exception can provide admissible evidence. Cases: Kolesar vs. Jeffries, 1974; Ferguson vs. Hamilton, 1983; Wendon vs. Trikha, 1993 The health record is important both for what is recorded and for what is not recorded. In the case of Kolesar vs.Jeffries (1974), the nurses notes were introduced as evidence and the absence of entries permitted the inference that nothing was charted because nothing was done. However, in a subsequent case, Ferguson vs. Hamilton (1983), the court rejected the submission that the absence of any nurses entry is an indication of failure in care on the part of the nurse(s). In this case, the court concluded that the fact that there was nothing in the nurses notes during a period of time did not necessarily mean nothing was done, provided there was evidence to the contrary and the usual practice was not to chart (Richard, 1995). In the case of Wendon vs. Trikha (1993), the court concluded that omissions in documentation will be interpreted against a nurse unless other credible evidence of nursing care demonstrates that care was given. It means that if charting by exception is an agency policy, and if evidence can be given that care was provided and noted according to this method, then this evidence will be admissible and will provide proof of what was done (Richard, 1995). To meet legal documentation standards, a system of charting by exception must include such supports such as agency documentation policies, assessment norms, standards of care, individualized care plans and flow sheets.

Documentation Methods Most methods of documentation fall into one of two categories: documentation by inclusion and documentation by exception (Coleman, 1997). Documentation by inclusion is done on an ongoing, regular basis and makes note of all assessment findings, nursing interventions and client outcomes. Documentation by exception, on the other hand, makes note of negative findings and is completed when assessment findings, nursing interventions or client outcomes vary from the established assessment norms or standards of care existing within a particular agency. Charting by exception replaces the long held belief of if it was not charted, then it was not done with a new premise, all standards have been met with a normal or expected response unless documented otherwise. Documentation by exception is only appropriate when assessment norms or standards of care are explicitly written and available within the agency. Documentation by exception is never acceptable for medication administration. The documentation method selected within an agency or practice setting needs to reflect client care needs and the context of practice. Some agencies may combine elements of different documentation methods and formats. If an agency decides to change its method or format of documentation and/or expectations, it is important that this be done within a context of appropriate planning and includes the involvement and education of nurses. Regardless of the method used, nurses are responsible and accountable for documenting client assessments, interventions carried out, and the impact of the interventions on client outcomes. Clients who are very ill, considered high risk, or have complex health problems generally require more comprehensive, in-depth and frequent documentation.

Three common documentation methods - focus charting, SOAP/SOAPIER and narrative documentation are described in the following sections. Any of these methods may be used to document on an inclusion or exception basis. FOCUS CHARTING With this method of documentation, the nurse identifies a focus based on client concerns or behaviours determined during the assessment. For example, a focus could reflect: A current client concern or behaviour, such as decreased urinary output. A change in a clients condition or behavior, such as disorientation to time, place and person. A significant event in the clients treatment, such as return from surgery. In focus charting, the assessment of client status, the interventions carried out and the impact of the interventions on client outcomes are organized under the headings of data, action and response. Data: Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention. Action: Completed or planned nursing interventions based on the nurses assessment of the clients status. Response: Description of the impact of the interventions on client outcomes.

Flow sheets and checklists are frequently used as an adjunct to document routine and ongoing assessments and observations such as personal care, vital signs, intake and output, etc. Information recorded on flow sheets or checklists does not need to be repeated in the progress notes.

SOAP/SOAPIE(R)CHARTING SOAP/SOAPIER charting is a problem-oriented approach to documentation whereby the nurse identifies and lists client problems; documentation then follows according to the identified problems. Documentation is generally organized according to the following headings: S = subjective data (e.g., how does the client feel?) O = objective data (e.g., results of the physical exam, relevant vital signs) A = assessment (e.g., what is the clients status?) P = plan (e.g., does the plan stay the same? is a change needed?) I = intervention (e.g., what occurred? what did the nurse do?) E = evaluation (e.g., what is the client outcome following the intervention?) R = revision (e.g., what changes are needed to the care plan?) Similar to focus charting, flow sheets and checklists are frequently used as an adjunct to document routine and ongoing assessments and observations.

NARRATIVECHARTING Narrative charting is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. Data is recorded in the progress notes, often without an organizing framework. Narrative charting may stand alone or it may be complemented by other tools, such as flow sheets and checklists. Use of Technology Technology may be used to support client documentation in a number of ways. If technology is used, the principles underlying documentation, access, storage, retrieval and transmittal of information remain the same as for a traditional, paper-based system. These new ways of

recording, delivering and receiving client information, however, pose significant challenges for nurses, particularly with respect to confidentiality and security of client information. It is important that nurses be supported by agencies in resolving these issues through clear policies and guidelines and ongoing education.

ELECTRONICDOCUMENTATION A clients electronic health record is a collection of the personal health information of a single individual, entered or accepted by health care providers, and stored electronically, under strict security. As with traditional or paper-based systems, documentation in electronic health records must be comprehensive, accurate, timely, and clearly identify who provided what care (College of Nurses of Ontario, 2002). Entries are made by the provider providing the care and not by other staff. Entries made and stored in an electronic health record are considered a permanent part of the record and may not be deleted. If corrections are required to the entry after the entry has been stored, agency policies provide direction as to how this should occur. Most agencies using electronic documentation have policies to support its use, including policies for: Correcting documentation errors or making late entries; Preventing the deletion of information; Identifying changes and updates to the record; Protecting the confidentiality of client information; Maintaining the security of the system (passwords, virus protection, encryption, firewalls); Tracking unauthorized access to client information; Processes for documenting in agencies using a mix of electronic and paper methods; Backing-up client information; and

Means of documentation in the event of a system failure. Guidelines for nurses using electronic health records are as follows: Never reveal or allow anyone else access to your personal identification number or password as these are, infact, electronic signatures; Inform your immediate supervisor if there is suspicion that an assigned personal identification code is being used by someone else; Change passwords at frequent and irregular intervals (as per agency policy); Choose passwords that are not easily deciphered; Log off when not using the system or when leaving the terminal; Maintain confidentiality of all information, including all print copies of information; Shred any discarded print information containing client identification; Locate printers in secured areas away from public access; Retrieve printed information immediately; Protect client information displayed on monitors (e.g., use of screen saver, location of monitor, use of privacy screens); Use only systems with secured access to record client information; and Only access client information which is required to provide nursing care for that client; accessing client information for purposes other than providing nursing care is a breach of confidentiality.

FAXTRANSMISSION Facsimile (fax) transmission is a convenient and efficient method for communicating information between health care providers. Protection of client confidentiality is the most significant risk in fax transmission and special precautions are required when using this form of technology.

Guidelines for protecting client confidentiality when using fax technology to transmit client information are as follows: Locate fax machines in secured areas away from public access; Check that the fax numbers and/or fax distribution lists stored in the machine of the sender are correct prior to dialing; Carefully check activity reports to confirm successful transmission; Include cover sheet warnings indicating the information being transmitted is confidential; also request verification that, in the event of a misdirected fax, it will be confidentially and immediately destroyed without being read; Make a reasonable effort to ensure that the fax will be retrieved immediately by the intended recipient, or will be stored in a secure area until collected; Shred any discarded faxed information containing client identification; and Advocate for secure and confidential fax transmittal systems and protocols. Client information received or sent by fax is a form of client documentation and is stored electronically or printed In hard copy and placed in the clients health record. As the fax is an exact copy of original documentation, Additional notations may be made on the faxed copy as long as these meet the agency standards for Documentation and are appropriately dated and signed. Faxes are part of the clients permanent record and, if relevant, can be subject to disclosure in legal proceedings. Faxed information is written with this in mind. If a physicians order is received by fax, nurses use whatever means necessary to confirm the authenticity of the order.

ELECTRONICMAIL The use of e-mail by health care organizations and health care professionals is becoming more widespread as a result of its speed, reliability, convenience and low cost. Unfortunately the factors that make the use of e-mail so advantageous also pose significant confidentiality, security and legal risks. E-mail can be likened to sending a postcard. It is not sealed, and may be read by anyone. Because the security and confidentiality of e-mail cannot be guaranteed, it is not recommended as a method for transmission of health information. Messages can easily be misdirected to or intercepted by an unintended recipient. The information can then be read, forwarded and/or printed. Although messages on a local computer can be deleted, they are never deleted from the central server routing the message and can, in fact, be retrieved. Having considered these risks and alternative ways to transmit health information, e-mail may be the preferred option to meet client needs in some cases. Guidelines for protecting client confidentiality when using e-mail to transmit client information are as follows: Obtain written consent from the client when transferring health information by e-mail; Check that the e-mail address of the intended recipient(s) is correct prior to sending; Transmit e-mail using special security software (e.g., encryption, user verification or secure point-to-point connections); Ensure transmission and receipt of e-mail is to a unique e-mail address; Never reveal or allow anyone else access to your password for e-mail; Include a confidentiality warning indicating that the information being sent is confidential and that the message is only to be read by the intended recipient and must not be copied or forwarded to anyone else; Never forward an e-mail received about a client without the clients written consent;

Maintain confidentiality of all information, including that reproduced in hard copy; Locate printers in secured areas away from public access; Retrieve printed information immediately; and Advocate for secure and confidential e-mail systems and protocols. From the nurses perspective, it is important to realize that e-mail messages are a form of client documentation and are stored electronically or printed in hard copy and placed in the clients health record. E-mails are part of the clients permanent record and, if relevant, can be subject to disclosure in legal proceedings. E-mail messages are written with this in mind. Similar to physicians orders received by fax, if physicians orders are received by e -mail, nurses use whatever means necessary to confirm the authenticity of the orders.

TELENURSING Giving telephone advice is not a new role for nurses. What is new is the growing number of people who want access to telephone help lines to assist their decision-making about how and when to use health care services. Agencies such as health units, hospitals and clinics increasingly use telephone advice as an efficient, responsive and cost-effective way to help people care for themselves or access health care services. Nurses who provide telephone care are required to document the telephone interaction. Documentation may occur in a written form (e.g., log book or client record form) or via computer. Standardized protocols that guide the information obtained from the caller and the advice given are useful in both providing and documenting telephone nursing care. When such protocols exist, little additional documentation may be required. Minimum documentation includes the following: Date and time of the incoming call (including voice mail messages);

Date and time of returning the call; Name, telephone number and age of the caller, if relevant (when anonymity is important, this information may be excluded); and reason for the call, assessment of the clients needs, signs and symptoms described, specific protocol or decision tree used to manage the call (where applicable), advice or information given, any referrals made,agreement on next steps for the client and the required follow-up. Telenursing is subject to the same principles of client confidentiality as all other types of nursing care. Common Questions about Documentation What information is included in the progress notes? Progress notes (nurses notes) are used to communicate nursing assessments, interventions carried out, and the impact of these interventions on client outcomes. In addition, progress notes are intended to include: Client assessments prior to and following administration of PRN medications; Information reported to a physician or other health care provider and, when appropriate, that providers response; All client teaching; All discharge planning, including instructions given to the client and/or family and planned community follow-up; All pertinent data collected in the course of providing care, including data collected through technology such as monitoring devices (e.g., strips produced during cardiac or fetal monitoring); and advocacy undertaken by the nurse on behalf of the client. What is considered timely documentation?

The timeliness of documentation will be dependent upon the client. When client acuity, complexity and variability are high, documentation will be more frequent than when clients are less acute, less complex and/or less variable. Graphically, this is shown as follows: Low Med High Acuity Complexity Variability Frequency of documentation Who owns the health record? The self-employed nurse or the agency in which the clients health record is compiled is the legal owner of the record as a piece of physical or electronic property. The information in the record, however, belongs to the client. Clients have a right of access to their records and to protection of their privacy with respect to the access, storage, retrieval and transmittal of the records. The rights of clients and obligations of public agencies are outlined in the Freedom of Information and Privacy Act and are often summarized in agency policies. How does the Freedom of Information and Protection of Privacy Act (FOIPPA) affect documentation? The FOIPPA provides the legislative framework for information and privacy rights. This act applies to all public bodies, including hospitals, health authority boards, CRNBC and similar organizations. The legislation gives the public a right of access to records held by one of these public bodies. Individuals have a right of access to personal information about themselves

(including their health records) and a right to request correction of such information. The act also prevents the unauthorized collection, use or disclosure of personal information by a public body. Is the information in the clients health record confidential? Yes. Information in the health record is considered confidential. Client consent for disclosure of this information to agency staff for purposes related to care and treatment is implied upon admission, unless there is a specific exception established by law or agency policy. Client consent is required if the contents of the health record are to be used for research or if any client information is to be transmitted outside the agency. Nursing documentation must be produced according to agency policy when: Clients request access to their personal records; CRNBC, under the Health Professions Act and Regulation needs to inspect or investigate records; a subpoena is provided (e.g., negligence suit); or a statutory mandate requires the release of the information (e.g., reporting communicable diseases or child abuse). Do clients have access to their health record? Yes. The CRNBC Standards of Practice require that nurses provide clients, in appropriate circumstances, with access to their health records or assist them to obtain access to these records. These standards are consistent with the Freedom of Information and Protection of Privacy Act whereby clients can submit written requests for access to their records or for information that might otherwise not normally be provided. Refer to agency policy as to the process to follow when clients request access to their health records. What happens to third party information when information in a health record is to be released?

Nurses may obtain relevant information about a client or an incident from another person, such as the clients family member or friend. Nurses may also learn information about a third party that is relevant to the client. When a clients record has another persons name on it or contains information about another person especially if the information was given in confidence - the record may need to be severed before it is released. This means that some portions of the record are removed and not released to the client requesting the record. For example, if the clients record included the name of a friend of the client or another client, the section of the record that includes this information would need to be removed before releasing the record to the client. How is client information contained in communication books and shift reports communicated? Communication books and shift reports are used to alert the health care team to critical information. These tools are used to direct others to the health record where the pertinent information is recorded in detail. Relevant health information communicated by these tools is documented in the health record (College of Nurses of Ontario, 2002). Should I document incidents where calls are made because of a concern about a specific client, but are not returned? It is important to document only facts on client health records. In cases where calls are made because of a concern about a specific client, a notation of these calls is made in the progress (nurses) notes. A notation is made after each call, regardless of whether the call was returned. If a call is returned, that is noted. Under which circumstances are verbal orders appropriate? Telephone orders Orders accepted over the telephone are generally made without the physicians direct assessment of the clients condition. Decisions are based solely on the nurses assessment of

the client. Any miscommunication or lack of communication could lead to negative implications for the client. Errors in recording telephone orders can also occur and there is always the question of who made the error, the physician in ordering, or the nurse in recording. Despite these concerns, there are times when telephone orders may be the best option for the client .In these cases, the nurse makes himself/herself aware of the agencys policy with regard to accepting and documenting telephone orders. Orders left on answering machines are not acceptable. Documenting Telephone Orders Write down the time and date on the physicians order sheet. Write down the order given by the physician. Read the order back to the physician to ensure it is accurately recorded. Record the physicians name on the physicians order sheet, state telephone order, print your name, sign the entry and identify your status (e.g., RN). On-site verbal orders On-site verbal orders also have the potential for error and are avoided unless in an emergency situation, such as a cardiac arrest. Nurses need to be aware of the agencys policy with regard to accepting and documenting on-site verbal orders. Of nursing staff, only registered nurses take verbal orders (and telephone orders) pertaining to medications. Orders taken verbally and recorded by pharmacists In B.C., pharmacists can accept and record verbal orders from physicians to dispense medications. In these circumstances, nurses can carry out the orders from the label on the dispensed medication. Should chart pages or entries be recopied?

Under no circumstances are chart pages or entries recopied. Errors are corrected according to agency policy. If information is difficult to read, then add information in a note to chart or note to file. How are after the fact notes developed by nurses for potential use in the future handled? There are occasions when nurses write notes after the fact (e.g., one day later, one week later), most often to provide clarification following an incident or an unexpected client outcome. Nurses usually write these notes while the event is current in the nurses memory, in case of an investigation or lawsuit at a later date. It is recommended that nurses do not keep these notes at home but provide them to a supervisor or risk manager within the agency for safe keeping. How long do health records need to be kept? Self-employed nurses and agencies should have policies on the retention of health records and client documentation. Current legislation needs to be considered in the development of these policies. Legislation differs, depending upon the setting. In all settings, records that contain references to blood or blood products must be maintained in perpetuity (MOH communication, 1996/1997). In other words, these records must be kept forever. In acute care hospitals, documents contained in the health record may be considered primary, secondary or transitory. Records are kept for the following time periods (from date of discharge): Primary documents (e.g., physicians orders, nursing admission assessment, consultations, discharge summary, and notice of death) - 10 years Secondary documents (e.g., most diagnostic reports, medication records, flow sheets and nurses notes) six years Transitory documents (e.g., diet report, graphic chart) - one year

Depending upon agency policy, records of minors may be required to be kept longer than the time periods listed above. In community care, public health and mental health settings, client records of adults are generally kept for 10 years and minors for 25 years from the date of service. Some exceptions apply to the timeframes listed above, requiring certain practice settings to have longer retention periods (e.g., forensic mental health). Nurses need to be aware of agency policy and legislation impacting these retention periods. What records are self-employed nurses required to keep? Self-employed nurses must have a documentation system. What is recorded will depend on the type of service offered. Forms can be simple and still address nursing assessment, plans, interventions and client outcomes. The CRNBC Practice Standard Self-Employed Nurse (pub.413) provides direction on documentation requirements for self-employed nurses and is available from the CRNBC website.

Bibliography Ares vs. Venner. 14 D.L.R. (3rd) 4, reversing 70 W.W.R. 96, (S.C.C.) 107, 112, 114, 115, 117, 120, 127 (1970). B.C. Health Care Risk Management Society (2002). Guidelines to Section 51 of the Evidence Act. Victoria: Author. Canadas Health Informatics Association. (2001). Guidelines for the protection of health information. Toronto:Author. Coleman, A. (1997). Where do I stand? Legal implications of telephone triage. Journal of Clinical Nursing, 6, 227-231. College of Nurses of Ontario. (2002). Nursing documentation standards. Toronto: Author. (PAM: Charting) Ferguson vs. Hamilton Civic Hospital. 144 D.L.R. (3rd ed.) 214 (1983). Kolestar vs. Jeffries. 59 D.L.R. (3rd ed.) 367 (1974)

CLINICAL TEACHING
Introduction Clinical area really pose a great challenge to nursing teachers. In nursing, psychomotor skills enjoy a dominant position and professional competency of a nurse is recognized mainly by the demonstration of clinical skills. Developing clinical skills demands more effort from the side of teachers and students compared to teaching and learning theoretical knowledge. Irrespective of the theoretical knowledge, students usually feel insecure and incompetent if they lack adequate clinical skills. Introduction of sophisticated equipments on a regular basis to assist patient care again adds to the complex nature of clinical teaching. Considering the increased mechanization of the patient care, while teaching clinical skills, teacher has to motivate the students to follow the hightechhightouch approach in order to preserve the human component of nursing care. Through

appropriate clinical teaching methods an intelligent teacher always help the student to develop an appreciable level of nursing skills. In the case of studious student, clinical area is a gold mine of learning opportunities and experiences.

OBJECTIVE OF CLINICAL TEACHING:

A well structured clinical teaching will help students to achieve the following objectives;

(a) Understanding of health, illness and health care system, (b) Developing an awareness of own attitudes, values and responses to health and illness. (c) Understanding of the interrelated roles of health care them. (d) Developing clinical competencies like reasoning, psychomotor and

interpersonal and communication skills. (e) Creating an ability to provide a scientific rationale for interventions. (f) Developing self-management skills, especially related to time and work load. (g) Developing ability to process, record and use date effectively. (h) Developing ability to evaluate critically and improve own performance. (i) Developing ability to review and investigate the quality of clinical practice. (j) Develop professional accountability. (k) Acquire commitment to develop and maintain professional competence. L)describe the essentials of clinical teaching methods)discus the functions of clinical teaching method, N)know about the quality of clinical teaching method.

PRINCIPLES OF CLINICAL TEACHING:

1. Clinical teaching is a vital and irreplaceable component in preparing the nursing students for professional practice: This principle underlines the importance of providing adequate clinical experience to students. Infrastructure of nursing institutions should be evaluated on the basis of the clinical facility available for students. If clinical facility is inadequate in the parent hospital, institution head need to arrange facilities through affiliated hospitals. 2. Clinical education should reflect the nature of professional practice: Professional practice requires critical thinking and problem solving abilities, specialized psychomotor and technological skills and a professional value system. Clinical education should assist students to acquire above said qualities in an admirable manner. 3. Clinical teaching is important than classroom teaching: Unlike classroom teaching, clinical teaching provide real life experiences and opportunities for transfer of knowledge to practical situations. Faculty who teach in the clinical setting can help students to achieve objectives in a successful manner. According to Halstead, effective clinical teachers are clinically

competent, know how to teach, have collegial relationships with students and are friendly, supportive and patient. 4. The nursing student in the clinical setting is a learner, not a nurse: The students learn through doing hence opportunity shall be provided for the student to practice various activities to enable effective learning. 5. Sufficient learning time must be provided before performance is evaluated: Most of the teachers perceive their role as to evaluate and majority of the students also perceive the same about teachers. The teacher cannot expect the students to perform competently in their first attempt. Skill acquisition is a complex process that involves making mistakes, learning how to correct and overcoming those mistakes. 6. Clinical teaching must be supported by a climate of mutual trust and respect: To support learning and student growth in clinical practice, the teacher must respect the students as learners and trust their motivation and commitment to the profession. The students must respect the teachers commitment to both nursing education and society. 7. Clinical teaching and learning should focus on essential knowledge skills: and attitudes: Clinical teaching primarily must focus on essential curriculum which includes the knowledge, skill and attitude which are essential for safe and competent practice. Enrichment curriculum which enhances further learning is importance but is secondary. For example, before giving a test does of an antibiotic which may trigger adrenaline is kept ready for emergency use if

needed. Here knowledge about the drug reaction of a particular drug, its dose and action is regarded as essential knowledge and comes under essential curriculum. Whereas the structure of the drug and its metabolism comes under enrichment curriculum. 8. Quality is more important than quantity: The length of time spent in clinical area is no guarantee of the amount or quality of learning that has taken place. The proposed duration may be insufficient for some students and unnecessarily long for others to acquire a particular skill. 9. Nursing students experience stress and anxiety in clinical learning situation: The effective clinical teacher recognizes students need for sportive and collegial relationships and develops in interpersonal style that promotes a conducive learning environment. A safe and stress free learning environment has been created when students feel comfortable in speaking openly. Negative relationship with faculty can contribute to anxiety. Positive relationships are

nurturing and can enhance learning. Caring behaviors and caring environment are essential for reducing the stress of students. Purposes of clinical teaching To provide individualized care in a systematic holistic approach To develop high technical competent skills To practice various procedures To collect and analyze the dada To conduct research To maintain a high standards of nursing practice To become independent enough to practice nursing To develop cognitive, affective, thinking, skills ,attitudes ,and psychomotor skills The students will develop the techniques To meet the needs of the client (TB patients) To improve the standards of nursing practices To develop various methods in delivering care(based on skills differ from person to person) To identify the problems of clients To learn various diagnostic procedure To learn various skills in giving health education techniques to the clients and significant others To keep in investigation of theoretical knowledge into practice

To develop communication skills and to maintain interpersonal relationship To maintain inter-institutional relationship To develop proficiency and efficiency in carrying out various nursing procedures To assist physician in assisting procedures To learn managerial skills To become professionally active member To encounter reality in the practice of nursing ,synthesis learning ,practice

ESSENTIALS FOR GOOD CLINICAL INSTRUCTION The clinical instructor and the head nurse should consider the needs of students to develop the individuals at a higher level of functioning They select the area where opportunities are available for the instructor to teach and the students to learn according to the requirements set by the institution Identify the nursing personnel (head nurse and staff nurse) who are interested in attending and sharing the discussion in nursing care conferences, nursing rounds and other sessions where clinical conditions are discussed. Competent teacher should be available .the head nurse and instructor should cooperate with one another to plan and to provide nursing care practice Conductive environment is essential.

FUNCTIONS OF THE CLINICAL INSTRUCTOR Set the objectives standards for practice Develop evaluation tool Should take permission of the institute Prepare master rotation plan Set up the clinical area in an ideal manner Keep ready equipment in working conditions to provide nursing care. Clinical instructor had the chief responsibility in planning ,direction of instructional programme with in one clinical area of students experience Clinical instructor has to direct and supervise the students in providing clients care Assist in patient care and role model Demonstrate nursing procedure on patients and ask the students to re-demonstrate procedures to develop skills and confidence

 Developing an understanding of research for better patient care. Analyze the difficulties and guiding the students accordingly Maintain high standards of patients care Encourage, motivate and inspire students Supervise and evaluate the performance of students Maintain strict discipline Maintain students record Conduct individual conference with the students to solve any problems arose and to meet their professional and personal needs To attend the lectures which was arranged for students and make arrangement for presentation of topic \supervise assignments like ward teaching class, case study, health talks Has to participate in faculty conferences Focus attentions of the students upon the medical and nursing problems of the client to whom they are assigned To help the students to develop ability to adjust general plans of care to the needs of individual patients Assist the students to preparing teaching planes To demonstrate skillfully the nursing procedure of special importance on the particular area(tracheotomy) To guide the students in acquisition of new skills To direct the students in their use of library resources for writing and preparing clinical assignments of the students To guide the students in conducting research activities To develop potentialities of each student.

QUALITIES OF A CLINICAL INSTRUCTOR She should enjoy bed side nursing She should be an expert in bed side nursing She should have good communication skills and develop good rapport among the nursing personnel She should know methods of delivering the care Should possess adequate theoretical background. She should have good teaching skills

 Good conduct Neat, nicely dressed Should have positive philosophy of life She has to maintain freedom of speech Empathetic and sympathetic in nature She must know teaching and evaluating methods She has to maintain good working relation

DEFINITION It is a science as it is based on systemic body of knowledge and principles of education .it also implies as an art ,as it requires professional skills especially based upon humanitarian approach.

Types of clinical teaching The commonly used clinical teaching methods include 1 .nursing clinic/bedside clinic 2 . nursing rounds 3 . nursing assignments 4 .nursing conferences 5 . morning and afternoon rounds 6 . Team nursing conferences 7 . health team conferences 8 . individual conferences 9 . field visit 10. process recording

1.BEDSIDE CLINIC:

Bedside clinic is an organized clinical instruction in the presence of the patient. Based on the type of topic, bedside clinic can be medical, nursing or combined. This is a teacher centered method meant for a small group of students and can be conducted by a nurse educator, doctor or a ward sister. The purpose of the bedside clinic is to portray nursing problems and to give viva picture of the related nursing care by associating it with specific individual Purpose

To provide a learning experience for nursing student to collect information about the patient with tact and skill To improve the student s ability to solve nursing problems by detailed study and analysis of nursing situation To realize the need for understanding each patient as an individual in order to appreciate his problems and out look It helps the student to do nursing observation in an organized systematic way To be able to work out a nursing care plan to fit the need of individual patient on the basis of his special problems To be able to recognize opportunities for health reaching in the hospitals To understand certain types of apparatus beings used on patients To approve the quality of nursing care

Planning techniques Determine the clinic to whom it is to be conducted ,place ,date and time of clinic to be held and on what topic the student have to become prepared Select a patient for whom student have given the care Secure the patient consent as his co-operation is essential during clinic.

Conducting bedside clinic The clinic should be conducted in the ward or in a class room .which is adjustment to the ward. Physical and mental comfort is provided to the patient Keep the patient at ease The usual duration is 30-45 minutes The number of student should be10-15 in numbers

THREE PHASES INTRODUCTION PHASE This phase serves as acquaint the student with the patient background, presenting nursing care situation the purpose of the clinic significant observation to be made type of question to be asked etc. PATIENT CENTRED DISCUSSION During this phase a few simple questions are asked to obtain the needed information from patient no question should hurt the patient feelings. POST CLINIC PHASE

It offers an excellent opportunities for students to evaluate the patient behavior, ability to solve his own problems and various other aspects. ADVANTAGES Bed side teaching puts the student in an active actual situation Covers a limited group of students Permites evaluation of degree too which educational objectives have been attained Develops qualities off observation and decision taking Ensures closer contact with reality Enables students to develop self confidence Increases variability

DISADVANTAGES Sometimes put the patient in a difficult situation Narrow limits of utilization

2)NURSING ROUNDS

A small group of the staff members not more than five and a lender or teacher visit, the bedside of clients. It is an extension of clinic method.

Purposes:-

To demonstrate important clinical manifestation in clients.

To clarify terminology used and studied.

To demonstrate the effects of drugs. To compare clients reaction to disease.

To learn about disease, pattern of care, treatment.

Procedure:-

Students have to be given information about ward rounds.

The instructor may instruct any nurse in the group to tell what she knows about the client.

The student who is taking care of the patient for a week, present the case to the total group it should be short. For client only 3 4 minutes have to be spent.

Advantages:-

Make classroom discussions more vivid and real response of the patient is more natural.

Disadvantages:-

Requires very careful planning.

A small group of students can be taken at a time.

3)-HEALTH TEAM CONFERENCE Health team conference is a group of professional persons involved in accomplishing common goals for the purpose of interchange of ideas and solving problems which are centered around the client provides a useful tool for building and maintain optimum mental, physical, social health In the hospital , physician will be the leader of the team and followed by the members as follows The clients and his family The graduate staff nurse The social worker The nutritionist The clergy man (priest) The occupational therapist The physical therapist Other allied professional workers

OBJECTIVES To assess the health needs of the client and to solve these needs through comprehensive approaches by contributors of all the members of the team. There must be an objective or purpose that is to be accomplished Adequate preparation by the leaders for all conference expedites fulfillment of expectation for the conference Prior announcement of time ,place purpose and duration of conference to all concerned promotes assembly of a group well prepared and ready to focus attention on the purpose of the conference Obtaining the most recent data available prior to conference assures the leaders that imparted information is pertinent and accurate Information to other members and or client that is paced ,systematic and inclusive allows participants time to assimilate the content and provides them with information necessary functions. Interaction of conferences members on an equal basis encourages active participation and leads to usable solution to the objective. Sharing of feelings through conferences unifies and integrates the membership and allows work to progress. Periodic review conferences held with the members of the team and provide a mechanism for to physician to validate medical care given and maintain quality control. b)-INDIVIDUAL CONFERENCE The individual conference some times described as a conversation with a purpose or more simply as an interview. PURPOSE To guide in teaching To acquire more knowledge To discover the interests. needs and the problems of the individual student To help the student to help herself/himself

TEACHING OF INDIVIDUAL CONFERENCE Teacher should establish good rapport with the students Allow him to talk freely Teacher should not show any prejudice, emotional reactions or bias

PRINCIPLES

Establishment of a definite purpose and specific issues to be covered Knowledge of the student Provide privacy Provide sufficient time Establish good rapport Good listening Positive effect Recording of data

USES It can be used to clarify class materials It helps in supplement instruction It also help to explain answers to questions of individuals It can be used as a means of assisting the individual who is having difficulties in keeping up with the classroom situation. c)-GROUP CONFERENCE This is a small group teaching method, in this group conference a subject of common interest related to the clinical area is discussed under the guidance of the nurse educator. Procedure The subject selected to the group conference should have a clinical orientation and enrich the clinical skills of the students (e.g.)like nursing management, patients with particular disease ,common errors commonly committed by the students in clinical area Ethical and legal issues related to nursing care and other genuine topics or issues by students are teacher can be discussed in the group conference. Discussion should be based on relavent information and directed towards achieving some desirable ends. Students are allowed to participate actively in the discussion. by explaining their own experiences in the clinical area. Nursing teachers has to encourage the students to express their view points and guide them as needed. While discussing problems related to clinical areas the teachers has to motivate the students to come forward with innovate ideas suiting to the problem or situations.

During the discussion the teacher has to assess the pros and cons of suggestions put forward by students before giving opinion. From the suggestion derived from the various group conferences ,those which are related to the ware situations can be put into the notice of the head nurse in a friendly manner .

Advantages: It helps the students to develop the problem solving skills. team building skills, It helps to improve the ability to express oneself assertively by providing an

opportunity to express the innovative ideas and to refine clinical skills, It makes the clinical are a more interesting place for teaching and learning.

d) NURSING CARE CONFERENCE Nursing care conference has all the characteristic of the bed side clinic except the presence of the patient. When the teacher as well as students are well acquainted with the patients features this is the preferred method.

e)TEAM CARE CONFERENCE It is defined as an act of consulting together with in the framework of the nursing team in order to plan for the daily continuity of nursing care that best meet the nursing care. Advantages of the nursing team conference It is used to plan for the daily continuity of nursing care that best meets the patients need As a teaching tool nursing team conference offers valuable opportunities for learning It gives an ablity to observe report and analyse significant findings input to its greatest test as students are confronted with their daily responsibility. OBJECTIVES Identifies the patients nursing problems Recogonize ability and limitations of various team members Helps to communities the ideas information on related nursing care. Utilizes scientific information to influence the cause of nursing care Makes generalization from specific information that is factual.

Helps to report, interpret, channelize and carry out hospital or health care problems Teaches what is required to help team members fulfill their roles Helps to plane nursing care cooperatively with other team members Bring also maximum creative potential of the team

Conference Procedure:

During this period, the planned time is scheduled to ensure that the patience problems are identified and also new strategies and creative ideas are planned through a group of nurses. Notes should be taken about the response of the patients. Using Kardex as a guide, the patients care and objective are taken into consideration. The members who have the contract with the particular patient discuss his response to his care and additional information from the patient or his family Problems are identified by the group a plan is projected for the solution of the problems. The cardex is revised and the objective is altered by the leader The headnurse functions as a resorced person and assist the team leader and the team members identifying nursing problems and developing nursing care plans It is the planning stage for the team and assignment of nursing personal for the following day is developed during and immediately after the conference

4) CASE STUDY Definition Nursing case study is the blue print of nursing care rendered by the nursing students to a selected patients for a particular period by following nursing process approach .with an intention to develop comprehensive nursing care abilities. Guidelines Format and content should ultimately focus on the nursing care issues and all informations related to the patient is expected to serve as a background knowledge for providing comprehensive nursing care. After selecting the patient , student has to give continuous care for a minimum of seven to ten days.

Student can involve patient family in the care and is free enough to seek appropriate help and co-operation from other health team members during the time of care for a better care. Student has to gather information related to the patients disease condition with special reference to nursing care. By the end of stipulated days of care or after the discharge of the patient ,one week time can be taken.

PROCEDURE Continious interaction between the teacher and student is key factor for the fruitful practice for the fruitful practice of the clinical teaching method By he end of the stipulated days of care or after discharge of the patient one week time can be given to the student to submit the care study. Teacher should conduct a discussion on the case study in the class and encourage other students to participate actively If there is time ,students has to present the entire care study before the class mates so that they can actively participate in the discussion. Teacher should direct the discussion in such way that all students should be benefited from the carestudy.

FORMAT OF CASE STUDY There is no prescribed format and content for the case study,but an ideal case study invariably contains Introduction History base line data Chief complaints Present medical history Past medical history Present surgical history Past surgical history Family history Birth history(ammunitions schedule) Socio economic history Nutrition Elimination ,sleeping

Physical examination (head to foot) Investigation Medication Anatomy physiology Disease condition Nursing care plan Assessment Nursing diagnosis Objective Planning Implementation Evaluation

Health education Management plans Follow up in hospital Success of treatment or failure Causes of success or failure Conclusion bibliography

ADVANTAGES Nursing case study provides an opportunity to learn nursing skills through problem solving approach Through case study students lean to identify and define patients problem The process of solving the patients problem will ultimately resuly in meeting the patients needs Case study trains the students to locate gather and process the information required to solve the patients problem. It helps in initiating and maintaining interpersonal relationship It helps to promote positive attitude to the development of nursing skills.

5). FIELD TRIP Field trip is one of the most concrete and most realistic and oldest educational procedures, Definition An educational trip is defined as educational procedure by which the students obtain first hand information by observing places, objects, phenomena or activities and process in their natural settings to future learning. Purpose 1.To provide real life situations for first hand information 2 . To supplement classroom instruction, to secure definite information for a specific lesson. 3. To serve as a preview of a lesson and for gathering instructional materials. 4 . To verify previous information, 5 . To arouse the interest 6 . To create teaching situation to cultivating observation ,keenness and discovery. 7 .To develop positive attitudes values and special skills

Procedure A. preplanning B. Actual conduct of the trip C. Evaluation Preplanning By teachers 1. decide on the trip 2. know the resources 3. obtain administrative sanction of school/ college 4. Dealing with the organization-obtain permission. Date, time 5. arrange transport, prepare the student with theoretical base

Teacher plans with the student 1. Formulate objectives 2. List down specific information to be obtained 3. Formulate questions to be asked to the guide. 4 .If a large group, devide and allot specific jobs 5. Brief them equipments or accessories needed, and time of transport, actual location, set up ,conduct and behavior during the trip, safety precautions to be observed, 6. Evaluate the student.

6). NURSING ASSIGNMENTS:

Definitions:-

The assignment is one of the top most important phases of teaching which gives the instructor an opportunity to guide learning activities by choosing worthwhile objectives and attaining these objectives through selection of proper learning activities based on the principles of learning.

Objectives:-

To give best possible care to the patient.

To develop good managerial skills.

To provide well-rounded educational experience for student nurses.

Principles:-

Assignments should be clear, simple, short and understanding in nature.

Prepare prioritywise in giving assignments.

Assignments should be individualized.

Do not assign same duties for long time.

The Record should be maintained regarding the hours spend on day, different types of leave utilized by students.

Before giving assignments, the instructor has to observe.

The standards and policies of institution.

Individual differences and capabilities.

Objectives of curricular

Duration of experience.

Advantages:-

Maximum learning takes place.

Skill is developed when the work is done repeatedly.

There is less confusion.

Disadvantages:-

More nurses are required.

Individual needs are not considered.

Patient may does not get any security.

07. NURSING CARE STUDY.

Definitions:-

It is an analysis of the nursing problems of an individual patient which grow out of his diagnosis, his physical and mental condition, his medical therapy, and which are influences by his personality makeup and his Socio-economic situations.

Steps:A head nurse or clinical instructed should give a written guide outlining the types of information needed by a nurse outlining the types of information needed by a nurse to analyze the problems of patient to students.

The student collects and write all information regarding the patient according to that written guide.

Identify the patient problems according to the information and try to find the best solution to the problems and make a tentative plan for the patient care.

At last, make a report of nursing care study, either written or oral which includes all the information regarding the patient, his problems and nursing measures for solving such problems, out comes, conclusions sources of information and Bibliography.

08. PROCESS RECORDING:

Definitions:An exact written report of the conversation between the nurse and the patient during the time they were together and or record of the nurses feeling about what was going on at the time and as far as possible, how the patient said what he did.

Purposes:To assist the students in acquiring, understanding of and competitions in interpersonal relationship.

Uses: As a Teaching tool. As on evaluation tool. As a Therapentic tool.

Phases:Prepare the student for process recording Record the nurse patient instructions. Evaluate the nurse patient interactions by the teacher and student.

8. BRAIN STORMING METHOD.

The intellectual capacities of trainees will be utilized in solving and suggesting solutions to problems and make the group to become active and answer the problem among them only.

The instructor will act as referee and give answers for unsolved problems.

For example, the counseling of AIDS, the expert in the field will make some opinion regarding AIDS and make the group into two or more sections.

Each trainee in the group will be given one paper to write opinions and will give 3 minutes time, then ask trainee to read the opinion and give proper explanations.

Then the referee will ask another groups, are they satisfied with that explanation.

If no, trainee is answering correctly for any problems and expert would clarify it.

Here the brain of the trainees will be sharpened and the entire class will participate in discussion, the group will become active.

9. HEALTH TALKS: It is used when teaching for clients and their relation or a mass.

It can be used in hospital and in community.

It can be conducted incidentally and in a planned manner.

10. GROUP DISCUSSION:

A Co-Operative, problem, solving activity which seeks a consensus regarding the solution of a problem.

Purposes:-

To encourages the student to thank for her, to develop critical habits of study.

It gives the student an opportunity to learn how to adjust to social situations.

Leadership skills will be developed.

Outcomes:-

Increase knowledge.

Increased intellectual abilities and skills.

Increased interests.

Increase Co-Operation.

Better personal and social adjustment.

11. DEMONSTRATION METHOD:

Definition:-

It can be defined as visualized explanation of facts, concepts and procedures.

Purposes:-

To demonstrate procedures in the ward (natural setting)

To demonstrate experiments and its use.

To reach the patient a procedure or treatment which he must carry out in home.

Advantages:-

It provides an opportunity for observations learning.

Used as a stronger motivational force.

It correlates theory with practice. It given the teacher an opportunity to evaluate students knowledge of a procedure.

Return demonstration under supervision of the teacher provides an opportunity for well directed practice before the student must use the procedure on the ward.

12. LABORATORY METHOD.

Definition:-

It can be defined as planned learning activity dealing with original data in the solution problems. The original date includes materials obtained experimentally and any other materials resulting from laboratory procedure.

Purposes:It helps the student to acquire scientific attitudes and scientific approach in problem solving. To translate theory into practice. To provide opportunity for teacher to observe the student in action.

Technique:1. Introductory Phase Involves establishment of objectives and a plan of work 2. Work period the student is involved in or first hand experience designed to achieve particular objectives by solving the problem. 3. Culminating Activities After the lab work, the class should meet together for discussion of common problems, for the organization of findings, for the presentation of the results of individual or group problem solving activities.

13. WARD TEACHING:

Purposes:-

To supplement, to integrate and to utilize classroom instruction. To aid the student to make correct applications of scientific principles basic to the particular nursing activity. To inspire the student for self development. Ward class will be conducted based upon current clinical experience of the students for whom the class is planned. Small Group should be planned.

Steps:-

A client is presented to the group.

Permission should be taken from the physician.

Instructor should explain before hand, to the client about the purpose of the client.

Suitable place should be selected.

15. NURSING CARE PLAN

It is used as an excellent clinical teaching method.

Purposes:-

It helps the student to develop basic nursing skills Like:Assessing the patients condition.

Formulating nursing diagnosis. Prioritizing patients needs.

Planning and implementing care with rationale.

Evaluating care.

It helps the students to recognize the importance of delivering continuous and comprehensive care in a systematic way.

It fosters professionalism and creativity among student.

It helps the student to become familiar with the nursing process approach of delivering nursing care.

Steps:-

Before teaching care plan, teachers conduct discussion regarding the new format and content according to NANDA.

Teacher should give sufficient help and guidance to student in preparing and implementing care plans.

Beginning student who are teaching the nursing process need to write simple, short care plan.

After a few weeks of clinical posting, the number and complexity of care plans can be increased gradually.

Conclusion:

Clinical area really faces a great challenge to nursing teachers. Developing clinical skills demands more effort from the side of teacher and students compared to teaching and learning theoretical knowledge. Through appropriate clinical teaching methods, an intelligent teacher always help the student to develop an appreciable level of nursing skills. In the case of a studious student, clinical area is a gold mine of learning opportunities and experiences.

Bibliography:1. B.T.Basavanthappa, NURSING EDUCATION 1st Edition, 2003, Jaypee Brothers Medical Publishers )P) Ltd., New Delhi, Page No.: 359 384. 2. K.P. Neeriya, TEXT BOOK OF NURSING EDUCATION. 1st Education 2003, Jaypee Brothers Medical Publichers (P) Ltd., Page No. 231-241. 3. B.Shankaranarayan, NURSING EDUCATION Brainfill Publishing Company. Page No.: 162- 169. 4. Jean Barrett, WARD MANAGEMENT AND CLINICAL TEACHING. 1st Edition, 1989. Konark Publishers (P) Ltd., Page No. 334 382.