Documentation: An Essential Nursing Tool - Research Paper Example

? Documentation: An Essential Nursing Tool of the of the Introduction In the field of medical practice, it is extremely important to follow all the rules related to the care and treatment procedure of patients. People working in the field of medicine and nursing have the responsibility to remain alert and balanced while treating their patients. This is because lack of complete commitment, lack of alertness or lack of balance while treating a patient can lead to occurrence of errors which can prove fatal and injurious to the lives and health of patients. Hence, it is extremely important for people in the profession of nursing to remain alert, updated and balanced in their professional life. Nurses need to be aware of the fact that even though the errors committed while patient care are not intentional, they still have a life threatening effect on patient’s life (Croke, 2003, p.54). Sadly, the cases of malpractice against nurses have seen the rising trend. From 253 cases of nurses making payments in malpractice cases in 1998, the number increased to 413 in 2001 (Croke, 2003, p.54). This shows that there is lack of proper understanding about the legal and professional responsibilities and limitations among the people working in the field of nursing. If malpractice cases are to be reduced and if the professional lives of people working in the field of nursing is to remain untarnished, then it is extremely important for them to understand the necessity of following the rules set in the field of practice, with care and complete alertness. However, what is more important is to understand the causes of malpractice as they lie at the roots of malpractice. Hence, to eradicate the possibility of malpractice, it is essential for nurses to understand the core values of nursing because following the core values is the only way to eradicate the root cause of malpractice which is ‘negligence’. Difference between negligence, gross negligence and malpractice Even though negligence, gross negligence and malpractice seem similar to each other, they are different on the basis of the ‘intent’ of the act. Hence, to understand the difference between negligence, gross negligence and malpractice, it is necessary to know their definitions. Negligence In the field of nursing, when an injury is caused to a patient due to a failure on the part of the nurse to fulfill the duty of care, then the act of failure on the part of nurse is called as ‘negligence’ (Sharpe, 1999, p.17). However, the negligence that occurs is a result of carelessness shown by the professional, and is not intentional in nature (Sharpe, 1999, p.17). Also, in case of negligence, the individual does not even believe that the negligence will result in negative consequences (Sharpe, 1999, p.17). When a professional in the field of nursing faces a legal action due to negligence, it results in feeling of shame and denial (Larson & Elliott, 2010, p.154). Hence, it is extremely important for a professional nurse to act with prudence and balance while performing the duty of care (Sharpe, 1999, p.17). Gross Negligence Gross negligence comes under a category of reckless behavior on the part of nursing professional (Sharpe, 1999, p.17). Gross negligence can be called as ‘intentional’ because in this case, the professional nurse shows deliberate disregard to the well-being and rights of patient, even after knowing that his reckless behavior will most likely result in injury to the patient (Sharpe, 1999, p.17). Gross negligence is deliberate deviation from the line of duty where the act in itself shows indifference and carelessness in performing the duty (Sharpe, 1999, p.17). Hence, in case of gross negligence, the act of negligence is evident from the act itself, and one does not have to wait for the consequences to see if it is negligence or not (Sharpe, 1999, p.17). Hence, gross negligence is punishable as the negligence is practiced with complete awareness of the negative consequences of the act (Sharpe, 1999, p.17). Malpractice Malpractice occurs in any profession that deals with psychological, physical or emotional aspects of people. In the field of nursing, malpractice occurs when a professional working in the field of nursing, while performing the course of professional duties, acts with negligence (Sharpe, 1999, p.17). It is important to note here that malpractice is not intentional in nature. It occurs when nurses fail to adhere to and act according to their position related “level of knowledge, technical skills and professional standards” (Sharpe, 1999, p.17). Malpractice also occurs when a professional displays lack of knowledge and skill by failing to foresee the consequences of particular act which results in causing injury to the patient (Sharpe, 1999, p.17). This shows that in the field of nursing, negligence on the part of professional nurses is the root cause of malpractice. From the definitions and the discussion above, it is clear that the difference between the negligence and gross negligence is in the nurse’s awareness of the act. Negligence occurs without the nurse’s conscious knowledge and intention while ‘gross negligence’ occurs due to deliberate and intentional carelessness shown by the nurse towards the duties of care. Also, in case of ‘gross negligence’, the nurse is conscious and completely aware of the harmful consequences of the act but still goes ahead with it. This makes ‘gross negligence’ an intentional act. Hence, malpractice is a form of negligence which occurs in professional setting because even though negligence can occur by anyone, “only those people who are professional are liable and can be sued for malpractice.” Hence, in case of malpractice, it is very important to go in the depth of any case of negligence to see if it is a case of ‘negligence’ or ‘gross negligence’. The Neighborhood Hospital Mishap A newspaper article published a case of mishap at the Neighborhood Hospital where a wrong leg of a 62 year old man called Joseph Benson was amputated. The newspaper has described this mishap as case of negligence. The newspaper is right in its opinion as from the description of the case, it is clear that it is the negligence on the part of professionals that has resulted in a wrong leg being amputated. This is a case of ‘negligence,’ and not the case of ‘gross negligence,’ as there is absence of any motive or intention behind this mishap. The article also says that there was no other complication suffered by Benson. This shows that the operation was conducted by professionals who followed the rules of their duty properly. The only problem was that the wrong leg was amputated. Moreover, there is no complaint of deliberate or reckless behavior by professionals from Mr. Benson. Hence, this mishap was a result of ‘negligence’ as it was unintentional and the staff was not aware of the consequences. If it was a deliberate act by the professionals and intentional reckless behavior by the medical staff treating Mr. Benson, then it would have been a case of ‘gross negligence’. However, it was an unintentional act where the medical staff failed to follow the rules of duty of care. Hence, the mishap at the Neighborhood Hospital is a case of ‘negligence’. Most importantly, it seems to be negligence in regards to documentation. Importance of Documentation Documentation is one of the most important aspects of nursing profession. A reasonably qualified and prudent nurse’s conduct in same or similar situations is considered as a ‘standard conduct’ while judging the actions of a nurse who is facing the charges of negligence (Grant & Ballard, 2011, p. 250). Hence, one of the most important evidence that can help a nurse in case of negligence charges is the documentation that she does while treating the patient. Documentation is a record of all the standard procedures and actions carried out during the treatment of a patient. Documentation can become a strong evidence to prove the charges of negligence wrong, if it accurately reflects the standard nursing process of diagnosis, nursing intervention plan, intervention implementation, evaluation and patient response (Croke, 2003, p.59). Moreover, it is also an important tool in practice as it is primary tool of communication of patient information between the medical professionals who are treating a particular patient (Croke, 2003, p.59). If every minute action about the patient’s medical problem, treatment procedure and progress is not documented accurately, then there are chances of mishaps similar to the one that occurred at the Neighborhood Hospital. Moreover, documentation is not only important as a communication tool but is also important in showing that ethical and standard procedures were applied by the nurse while taking the care of patient (Grant & Ballard, 2011, p. 250). Hence, if nurses are to avoid negligence and negligence related charges, then every case handled by them should be documented accurately, taking in account all the standards and rules of medical practice provided by regulatory mandates (Grant & Ballard, 2011, p. 250). Conclusion The discussion above clearly shows that negligence can be avoided by following the rules and standard procedures given by authoritative bodies. Most importantly, documentation works as a strongest evidence to prove that the nurse has followed standard procedures and rules while providing treatment and care to the patient. Only an accurate documentation can help nurses to protect themselves and their fellow staff from being sued for negligence or malpractice. . References Croke, E.M. (2003). Nurse, Negligence, and Malpractice. American Journal of Nursing, 103(9), 54-63. Grant, P.D. & Ballard, D.C. (2011). Law for Nurse Leaders: A Comprehensive Reference. New York, NY: Springer Publishing Company, LLC. Sharpe, C.C. (1999). Nursing Malpractice: Liability and Risk Management. Westport, CT: Greenwood Publishing Group, Inc. Larson, K., & Elliott, R. (2010). The emotional impact of malpractice. Nephrology Nursing Journal, 37(2), 153-156. Read More