There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.
It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff. To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential. The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.
Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care. The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario. Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.
There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.
Click here to read more on critical thinking.
Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents include:
- Age Related Residential Care (ARRC) contract
- NZS 8134:2008 Health and Disability Services Standards
- Clinical best practice (EBP) guidelines – eg; Lippincott
- The Code of Health & Disability Consumers Services Rights 1996
Clinical documentation errors of any type noted during audits will result in partial attainments at best. This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.
Below are some of the common compliance gaps which relate to clinical documentation:
Missed signatures off notations.
Not signed by the author with a full signature.
No designation written with signature.
Inconsistent structure of resident files.
Unclear or unsecured archiving of documents.
Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.
Not completed within time-frames defined in ARRC.
Baseline recordings at time of admission not recorded.
Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.
Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.
Failure to re-assess for each period of admission eg; respite care.
Assessment not describing risk.
Risk not reflected in care plan interventions.
Lack of risk reviews.
Level of risk noted in interRai assessments not included in care planning
Not recorded in on a shift by shift basis.
Lack evidence of regular registered nurse input.
Writing beyond the bottom line of the page.
Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).
Lack evidence of interventions being implemented.
Lack evidence of RN response to clinical symptoms reported by care staff.
Lack of evidence of rationale for PRN medication administration or the resulting effect.
Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).
24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).
Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.
Not recorded as resolved or transferred to Long Term Care Plan.
Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.
Care Plan (LTCP)
Not reflective of all presenting potential and actual medical / clinical problems.
Not documented within 3 weeks of the date of admission (ARRC requirement).
Not changed at the time of health status / functional change.
Interventions not reflective of each medical diagnosis.
Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.
Frequency of clinical assessment for each actual clinical presentation eg; pain.
Do not clearly indicate the level of function, assistance required for each component of care / support.
Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services for the elderly etc.
Review of care plans not reflecting changes in residents health status as they occur.
Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.
Not completed within ARRC defined time-frames (at least six monthly).
Lack evidence of MDT input into care plan reviews and/or evaluations.
Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.
Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.
Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical consultation notes however not evidenced as having been done.
Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.
Not consistent with service delivery as noted in clinical documentation.
Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.
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When balancing the clinical needs, requests and preferences of each resident in-conjunction with their right to choose, a number of factors need to be taken into consideration. We all recognise that theory and practice can change over time so when I asked Liz Beaglehole (Registered Dietitian) her professional view on this topic is, she offered the following:
The recommendation for older adults with diabetes in aged care facilities with stable diabetes is to provide an unrestrictive diet as much as possible. The notion of a ‘diabetic diet’ is outdated due to the increased risk of hypos and unwanted weight loss.
This is very individual however, a frail 80 year old woman with diabetes will likely have no diet restrictions however an obese 70 year old who may be otherwise stable would benefit from a more restrictive diet. Advice from a dietitian for individuals is recommended.
Overall, guidance from the resident about their wants is probably what determines the diet provided. This may be in accordance with recommendations or not.
Generally, the medications should be fitted to the usual eating pattern of the resident. In aged care facilities there are regular meals and generally balanced carbohydrates over the main meals (assuming good food intake) so usually this is fine. If someone has a reduced food intake, and is on insulin then a unrestrictive diet would be best.
For my menu planning I tend not to plan any special diabetic options on the cycle menus. I may include a low fat / low sugar dessert option if sites request, but generally my philosophy for aged care is not to restrict foods!
Liz is involved with a PEN (practiced based evidence in nutrition) review of the question ‘Do institutionalized, older adults (65 years of age or older) who closely follow a diet prescription have better control of their chronic disease (e.g. diabetes) than those who do not?‘ This is due by the end of March so further practice updates from this review may be available then. Liz noted that generally the evidence suggests there are no benefits with a prescriptive diet vs a more liberal one.
Those of you who are members of the New Zealand Aged Care Association (NZACA) may be aware that we (Healthcare Compliance Solutions Ltd) have been contracted by the NZACA to develop what is known as an Industry Body Customised Food Control Plan (FCP). This is to be approved by the Ministry of Primary Industries (MPI) and made available to all NZACA members. This customised plan comes under section 40 of the Food Safety Act and has been developed with the intention of streamlining audit process for Age Related Residential Care providers to use. There is an extended date for registering under this plan. 31st March was the date noted for registration however for this process, the date for completion of the registration process for use of the Industry Body NZACA FCP will be 31st May 2018.
Instead of registering with the local Council, those members who are taking advantage of the national customised food control plan will register directly with Ministry of Primary Industries. What is being worked towards currently is for this plan then to be audited by your Certification Designation Auditor Agency auditors in conjunction with your other audits. It is our understanding that the deadline for registering with MPI has changed to take the Food Control Plan approval into consideration so please check with NZACA to verify when you need to have your registration completed by.
How far have things progressed currently? We have submitted the draft of the customised plan to MPI for approval. The content of this plan goes beyond the standard Food Control Plan as it will need to also meet Certification and ARRC funding agreement audit criteria. This is designed to be an all in one set of documents so that as noted, it assists with the streamlining of audit. We understand this approval process could take 4 – 6 weeks with a period of refinement if necessary and finalising of the documentation to follow, before a Gazette notice would be published. This notice is necessary to proceed with association members using the Industry Body customised FCP as part of their other certification audit processes.
A huge thank you to Liz Beaglehole (Registered Dietitian) from Canterbury Dietitians who assisted at short notice with the reviewing of documentation contents which form part of the FCP.
There is work to be completed behind the scenes in an attempt to align audit time-frames which are not the same for all providers so while the intent is clear, the reality of achieving what we are setting out to do, is yet to be confirmed.
We support the work of the NZACA and were very pleased to be able to support the age care sector in this way. We undertake to do what we can to support this process to a successful outcome. NZACA will be updating their members as we work through this process. If you are not a member, this may be a good time to join to take advantage of just one of the benefits they offer to support their members.
If you would like further support with the implementation of your Food Control Plan, please feel free to contact us.
April 12th and 13th, 2018 – Christchurch
Gillian Robinson – Bachelor of Nursing, Registered Nurse, Lead Auditor, Management Consultant, Author
Liz Beaglehole – New Zealand Registered Dietitian, with a Post-graduate Diploma in Dietetics (with distinction), Canterbury Dietitians.
Ben Harris – Medical Laboratory Scientist, Honorary Lecturer for the University of Otago
Day One – Thursday 12th April – 9.00am to 4.30pm
- Age-related Residential Care (ARRC) – understanding the DHB funding service specifications
- Quality and Risk Management – striving and achieving excellence
- Clinical Leadership – how to lead the clinical team effectively
- Clinical Documentation – What, when, how and why to document
- Clinical Assessment and Care Planning – bringing it all together for better resident outcomes
- Microbiome – why understanding this is so important
- Multi-Drug Resistant Organisms (MDROs) – the current and pending impact
Day two – Friday 13th April (9.00am start, finish approximately 1.00pm)
- Urinary Tract Infections – to dip or not?!
- Norovirus and Influenza – latest updates
- Food Safety – Food Safety and Nutrition
- Question and Answer session
Attendees will supply their own lunch. Morning and afternoon tea will be provided.
Venue: Chapel Street Centre, Cnr Harewood Road and Chapel Street, Papanui, Christchurch. (Easy access from the airport)
Numbers will be limited so register today.
To register – email email@example.com and supply the names and designations of each staff member attending, and confirmation if they will be attending day one or day two or both days?
The attendance fee for this content filled education is $155 (plus GST per attendee to cover both days), $85.00 plus GST per attendee to cover either day one or day two.
We will respond with confirmation of registrations. Certificates of attendance will be provided.
The Draft Moving and Handling guidelines are currently being finalised with the view to be implemented from December 2017. Developed by Worksafe, they cover Health and Safety at Work Act 2015 (HSWA) duties and risk management for PCBUs in the health care industry and supersede the 2012 guidelines. There are a range of factors noted in these which need to be taken into consideration for those building new facilities or doing refurbishment of existing facilities. There is also a raft of information on Bariatric Care which is an increasing part of the services being provided in residential care.
The draft guidelines include the following:
Please note that there is not a complete consensus on the criteria for classifying a person as bariatric based on weight or Body Mass Index (BMI). However some examples include those people:
– with a body weight greater than 140 kilograms.
– with a BMI greater than 40 (severely obese), or a BMI greater than 35 (obese) with co‑morbidities.
– with restricted mobility, or is immobile, owing to their size in terms of height and girth.
– whose weight exceeds, or appears to exceed, the identified safe working loads (SWLs).
Health risks for bariatric clients
People who have been bariatric for a considerable time face chronic and serious health conditions, many of which should be considered before moving or handling them. Health conditions to take into account include:
– skin excoriation
– rashes or ulcers in the deep tissue folds of the perineum, breast, legs and abdominal areas
– fungal infection
– bodily congestion, including causing the leaking of fluid from pores throughout the body, a state called diaphoresis, which makes the skin even more vulnerable to infections and tearing
– respiratory problems
– added stress to the joints, which may result in osteoarthritis.
Planning for bariatric clients:
The planning process for bariatric clients in order to reduce moving and handling risks should include:
– admission planning
– client assessment
– room preparation
– mobilisation plan
– equipment needs
– space and facility design considerations
– planning for discharge.
Facility and equipment needs for bariatric clients
Health care and other facilities providing care for bariatric clients need to provide adequate spaces for these clients. Some considerations could include:
– ramps and handrails at entrances
– bariatric wheelchairs
– that the facility’s main entrance has sufficient clearance
– adequate door clearance and weight capacity in lifts
It must be remembered that the above comes from a draft but as drafts often end up being very close to the finished document, I felt it timely to share this information. To read more on Health and Safety in the Workplace go here.
HCSL are pleased to announce that from January 2018, you will be able to access clinical online tools for:
- Initial assessment and initial care plan.
- Short term care plans (and evaluations)
- Long term care planning (and evaluations)
- Progress notes
- Restraint/ Enabler restraint management (and evaluations)
All mobile device compatible so you can be with your residents rather than stuck in the office!
HCSL bringing cost effective, specifically designed tools for the New Zealand residential care sector. The Corporates have their tools, why shouldn’t you have the same advantage?!
To find out more and get a no obligation free quote for use contact us here.
Upon reading one policy everything fell neatly into place. I found her documentation to be outstanding. It is very reassuring to know that every policy and procedure is the most up to date and designed to meet audit requirements. All her forms are easily accessible and very user friendly. We can instantly benchmark against others. At the click of a button we can analyse falls, infections and adverse events. Creating graphs and other information for Board reports takes minutes rather than hours.
Having come from a background of many years in QA, HSE and Electronic Document Management in the Oil and Gas Industry, when I entered the aged care sector, it was a huge “eye opener”. After sitting through several handovers and meetings and listening to discussions on medications etc I felt as if I was listening to a foreign language. Oh my goodness I thought and then Gillian’s documentation arrived together with a visit from her shortly after.
Gillian’s enthusiasm and commitment for both the aged care sector and her documentation is contagious. I feel I can now discuss, with the knowledge I have acquired in a few short months, aspects of aged care I never knew existed. Gillian is only a phone call or email away and all queries are always answered promptly, no matter how minor.
Thank you very much Gillian.
Lois Lash – Quality Assurance
Tainui Village – October 2017
As noted previously, I have sold my business. Thanks so much for your fabulous support and encouragement and especially the ‘find me’ conversations we had; so without much ado, I will say ‘cherrio’ and depart quietly.
I wish you the very best going forward with all your ventures and I am sure you have something new on the go as you never seem to sit still….
Owner – Shoal Bay Villa (Northcote, Auckland)