Effective Communication

Introduction

In a long-term care (LTC) nursing facility, the primary types of communication are documentation and verbal. The physicians and all of the nursing staff have to document every aspect of each patient’s care. Effective documentation provides a legal record of care and how the patient responds to the type of care which they received. By documenting, the physicians and nurses are giving written communication to those who provide follow up care. When the nursing staff begins their shift, the nurse gives a report of their previous shift’s activities. For example; the night nurse gives the day nurse reports on each patient. Without these verbal reports the nurses, Certified Nursing Assistants (CNAs) would need to read each individual patient’s chart to see what happened on the previous shift, this would take away valuable time from the patient and could lead to negative patient care.
By using documentation this type of communication provides a legal record of care for each patient. The LTC facility uses several documents to monitor each resident’s care and the outcomes from the care. Each resident also has a personal medical record (PMR) these record contain the resident’s medical, family, social history, assessments, dietary needs, treatment plans, orders, prescriptions, progress notes, and lab results. With this chart the LTC has a complete and accurate look into each individual resident and their medical history and progression of care.
Included in their record the, Medication Administration Record (MAR) this is used to document the time, dose, how and when it was administered by the nurse. This record also provides communication in regards to new physician orders, which would include changes for a new medication or discontinuation of a medication. The nurse that distributes the medications must chart immediately when the medication is given and the result.
Also in the documentation is the patient’s treatment chart which the nurse records treatments ordered by the physician, these can include something as simple as the use of TED hose to reduce swelling to changing a feeding tube. The importance of this particular documentation of all such treatments must be accurate and up to date. The wound charts which show the location, size, and description of an area on the resident such as scraps, skin tears, pressure sores, or lacerations, are essential for the proper treatment. Without accurate and proper charting, the nurses on the following shifts may not give proper treatment to the area. A new injury may be confused with the one already documented, leading to a treatment error.
For the CNA’s completing activities of daily life (ADLs) for each individual resident is imperative and must be documented during each shift. The ADL flow sheets should include information about personal care, ambulation, toileting schedule, food consumption, and fluid intake during the shift. Each ADL is personalized to the individual resident’s needs and adjusted accordingly, when physician orders change. The majority of these cares are given by the CNA who work with the resident during each shift; charting must be completed by that CNA before after each activity is done and should be completed before the next shift begins. This helps communicate to the following CNA shift what care was given, what care was not done, and any changes in behavior.
At the end of each shift, the Shift reports are done with the shift coming on duty, this is when the nurses share information with other nurses, and CNAs. The information that is shared includes everything needed for the continued proper care of the facility’s residents. This includes, Medication distribution, changes in physicians or treatment orders, dietary changes, special requests from the residents or family members, and anything else that affected the daily operations are to be reported.
Also, during this time shift report is a time to communicate any observation, ideas, and thoughts concerning the residents. For example, Mary Jo fell today, and we are watching her closely for any bruising. The information from the CNAs is valuable to the charge nurse, she is the one that documents and reports changes. CNAs spend a large portion of time with the residents and are usually the ones that first notice, even a subtle change in the residents under their care. Changes in urinary and bowel continence, appetite, behavior, mood, and sleeping habits are first seen by the CNA. Having the ability to communicate observations openly with the nurse is necessary to ensure the residents are receiving the best care.

Communicating by documentation is an effective way for nursing staff, physicians, and other authorized personnel to access the medical information about a resident easily. The information in each resident’s medical record must be accurate, timely, and be read with ease by anyone such as a physician, or other medical authority that inquiries about the resident’s medical information. Errors can take place which can cause confusion, misunderstanding, and lack of, or improper resident care.
One of the most harmful errors can be inaccuracies listed in the MAR. The accurate administration of medication relies on accurate MAR checks by the nurses. All of the medications ordered for a resident must immediately be listed on the MAR, either printed or written in by a nurse during the time between each new MAR print. An incomplete or inaccurate MAR can occur because of a pharmacy error or clarification needs (i.e. abbreviation problems, non-formulary, dosing error, etc.). Other frequent problems that could cause errors can occur when transcribing orders from a resident’s chart to the MAR, could be unreadable handwriting and the use of uncommon abbreviations, for this reason, the nurse must always check the MAR several times for inaccuracies with chart orders.
Another example of ineffective communication is the lack of open communication between shifts this can hinder the care of the residents. Diversity and prejudices can exist between the nurses and CNAs, physicians and nurses, outside consults and nursing home staff; wherever it exists, this can cause obstruction in communication. Many attitudes of superiority can cause subordinates difficulty to communicate the changes in residents for fear of ridicule or disparagement. Empowering workers gives them a sense of ownership and enables open communication, thus providing timely observations and assessments of resident needs to all necessary care staff.
In today’s society, the use of technology has proven to increase efficiency and reduce nursing errors. The electronic medical record (EMR) an electronic version of the resident’s PMR is one technology that has increased efficiency. The EMR automates access to information making it easily accessible. The accuracy and clarity of an EMR greatly reduces the chance of medical errors, reduces duplication of tests and delays in treatment ("Centers For Medicare And Medicaid Services", 2012). Many Long Term Care facilities have successfully implemented EMR systems have reported the improvement and quality of care which showed a significant increase in employee satisfaction, financial benefits in excess of system costs, and the intention of continuing use the technology (Cherry, Ford, & Peterson, 2009).
The Electronic Medication Administration Record (eMAR) technology helps reduce medication errors, because of many physicians illegible handwriting, providing wireless point-of-care access to medical history, enhanced communication between the facility and dispensing pharmacy, electronic documentation at the point-of-care, and electronic submission of new prescriptions and orders (Speed Script, 2010).

Mobile computing workstations offer LTC facility staff a convenient way to provide accurate efficient resident care. Rather than rely on handwritten charts and medical records, nurses can use easily maneuver the workstations into the resident's room, in the hallway, or at the nurses’ station. Mobile computing workstations allow nursing staff to access various types of clinical and medication administration documentation software like the eMAR and EMR no matter his or her location ("It Medical Solutions", 2011).

Conclusion

Today's nursing home is a significantly complex organization. The resident population represents a wide range of clinical conditions that often require care measures that once were deemed sufficiently complex to be treated in hospital settings. The workforce presents diversity in culture and generations represented. The regulatory and legal issues that must be complied with continue to change and grow. (Eliopoulos, RN, MPH, PhD, 2012)
Having open communication is fundamental to providing safe, accurate, and proficient care in an LTC setting. The ability to share information between staff, pharmacies, and outside resources will only be beneficial for the resident’s quality of care. With new technology changing the way the LTC nurses communicate, which provides and improves on new ways of documentation, dispensing medications, and delivering fast more reliable information at the point-of-care. With the new advances along with quality management that empowers staff to assist people and working as a team, will only enable the LTC facilities to achieve unforeseen levels of care.

References
Centers for Medicare and Medicaid Services. (2012). Retrieved from https://www.cms.gov/Medicare/E-Health/EHealthRecords/index.html, July 6, 2012

U.S. Department of Health and Human Services (March 2012) Accelerating Progress on EHR Adoption Rates and Achieving Meaningful Use
Retrieved from http://www.healthit.gov/buzz-blog/meaningful-use/ehr-adoption-rates-and-achieving-meaningful-use/ July 7,2012
Eliopoulos, RN, MPH, PhD, C. (2012). McNight's Long Term Care News. Retrieved from http://www.mcknights.com/ July 6, 2012
IT Medical Solutions. (2011). E-MAR/EMR Retrieved from http://www.itmedicalsolutions.com/emaremr
, July 6, 2012

Speed Script. (2010). Pharmacy Management Systems and Services. Retrieved from http://www.speedscript.com/index.php?bod=55