The Ethical issues for a survey within a healthcare settings for the Nursing Dissertation

The nursing dissertation in a health care setting is an integral part of documentation. Poor nursing documentation of patient care is identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. Based on the survey in health care unit, a retraining program is recommended to improve structured nursing documentation in a home health agency.



Nursing documentation is an essential function of professional nursing practice. The documentation should be factual, current, and comprehensive to provide consistent information about the assessment, care provided, and evaluation of patient responses to care. Current health care systems require that documentation ensure continuity of care, provide legal evidence of nursing care provided, and support evaluation of quality patient care. To enhance patient outcomes that include patient safety, accurate and complete clinical information is required as a valid and reliable source to be used for communication, quality improvements, research, and policy making.

Some essential characteristics of quality information in patient records include completeness and comprehensiveness. Nursing documentation based on the nursing process facilitates effective care as patient’s needs can be traced from assessment and nurses are empowered in clinical decision-making. Criteria for effective or quality documentation include use of common vocabulary, legible writing, use of authorized abbreviations and symbols. Quality criteria of nursing documentation includes completeness, quantity, legibility, patient identification, chronological report of events, comprehensiveness of description, nursing assessment, objective information, signature, date and timeliness.

Other ethical issues are the incomplete documentation that cannot provide the necessary foundation for provision of quality care, quality improvement or effective decisions on allocation of resources. Therefore, it is crucial that nursing assessments, care plans, implementation of interventions, and evaluation of results should be systematically and accurately communicated through effective documentation. Patient safety has been compromised due to failure of nurses documenting nursing processes effectively and completely. When documentation is inadequate, it reflects substandard care with potential for litigation.

Documentation at health care if poorly done by nursing staff, it affects effective communication of patient status with other clinicians, thereby affecting clinical decision-making and patient outcomes. Poor documentation can negatively affect the effectiveness, quality and visibility of nursing work. Good clinical documentation is a part of quality patient care and shows accountability. Documentation of patient services in home health care is a prerequisite for continuity of care. Nurses use progress notes on patient care to communicate patient care, assess and record patients’ status. Effective documentation shows evidence of care given and patients’ responses, and evaluation of care given[1]. Ineffective documentation may result in patients missing treatments or substandard or inappropriate or delay in treatments. Therefore, there is a need for improvement in the quality of patient care documented in patient records. The importance of effective nursing documentation cannot be overemphasized, as it enhances communication among health care team, clinical decision-making, patient safety, quality of care provided to patients and ultimately promotes better patient outcomes.

Reference

1.      I Holloway, K Galvin - 2016 - books.google.com, Qualitative research in nursing and healthcare