Good Clinical Practice (Chapter 23)

Learning Objectives

After completion of this chapter the participant should be able to:

• Know and demonstrate the key features for good communication in clinical practice.

Documentation is really important. It is a way of communicating with our colleagues, remembering important events and monitoring progress. Good documentation prevents errors and protects both the patient and the staff.

It is essential that the mother and baby are treated as one unit. The mother needs to know what is happening to her baby and how she can help. We must make her feel welcome, important and central to the well-being of her baby.

The health workers are a team. We need to communicate with each other, respect and value each other and include the mother in the care of her baby. She is an extended part of the team.

The death of a baby is devastating to the mother and the baby’s family. We must be sensitive to their concern and grief, respectful of religious and cultural beliefs and be prepared to express our sorrow at their loss. Medical diagnoses and treatment given need to be explained to the family. It is important for the family to know that their loss is through no fault of the mother and she should not be blamed

Communicating in Health Care

Who do we need to communicate with?

• Colleagues - seniors/juniors; nurses and doctors, other health staff.
• Parents/guardians – explanations or breaking bad news.
• Children – explanations, reassurance.

When do we need to communicate?

• Morning/evening handover
• Emergency staff to inpatient staff
• Correcting a colleague’s error
• Change of rota
• Seeking assistance from a clinician
• Explaining to a guardian

How do we communicate?

• Verbally – face to face
• By telephone
• In writing
• Documentation in the clinical notes

Poor communication leads to mistakes and to mismanagement. Poor clinical handover can result in:

• Delay in treatment
• Wrong treatment
• Missed or duplicated tests
• Wrong dosage

Communication Styles

Learn to listen; try to understand why and what is being asked. Is your body language welcoming and interested? Don’t stand over a person you are talking to.

1. Is the setting right for this discussion?

The corridor is not the place for discussions. Remember confidentiality! Speak with parents in quiet privacy. Never tell someone off in public.
2. Is the timing right?

If calling for help, do it early rather than too late. If speaking to family, talk to the right members and take time. If a reprimand is needed – don’t delay.
3. Have you got all the data you need?

Do you know the full story? If it is a dispute have you heard both sides? Listen first! If you are reporting about a patient, check the notes, get all the facts.
4. Using a standardised way of communicating.

It helps to present a clinical problem in a standardised way. Many people use the letters ISBAR to remember to say everything.⋆
5. Training helps.

It helps to practice. We often get into bad habits that we are unaware of. A training chapter is a good place to learn good habits and get rid of bad ones.

⋆ISBAR: Standardised format for communicating

Monitoring in Health Care

Anticipating clinical deterioration and possibly stopping it from happening makes good sense. To do this monitoring is critical; it helps us decide when to act to prevent problems and when to call for help.

Nurses are with the patients all the time and measuring, monitoring, and assessing progress is one of their very important tasks.

Vital sign monitoring includes heart rate, respiratory rate, SpO2, temperature, blood pressure, and conscious level. In different circumstances additional monitoring is needed, e.g., when an IV is in place fluid input and output must be monitored; in head injuries, pupil sizes and response are important.

Monitoring means assessing if the child is sucking/drinking, has diarrhoea, or is vomiting.

Is the breathing pattern normal, is it regular, is there chest indrawing or deep acidotic breathing?

Pain assessment is really important. Is the child miserable, in pain or frightened to move? There are various pain scores to help with assessing how severe the pain is.

The mother can help with answering questions and reporting anything that worries her.

Monitoring includes documentation of all the findings. This is best done on a specially designed form. It is not enough to simply record vital signs. Monitoring includes interpreting the findings. Is the temperature high and should it be reported – if so to whom? Is the breathing too fast? Is the baby drowsy (what is the AVPU score)?

Wall charts with the normal range of vital signs at different ages help with interpreting them.

Good monitoring allows the use of what are called early warning systems. They include:

1. A score to indicate the seriousness of the sign.
2. This score leads to an action, such as increasing the monitoring frequency or calling a senior for assistance.
3. There must be a rapid response to that call and
4. Appropriate action must be taken.

Some people call this Track and Trigger.

Monitoring includes knowing how to use and care for equipment. Is the equipment clean? Is it working properly? How often does it need to be serviced or calibrated? Is it stored in an appropriate place and is it easily accessible? (9-13)