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Nurses have often heard “if it wasn’t documented, it wasn’t done,” but they still struggle to consistently capture documentation that is timely, accurate, and comprehensive. This struggle sometimes emerges when underlying system failures go unaddressed by leadership. To fix this, the director of nursing services (DNS) and other nurse leaders need to improve the processes that are interfering with sound documentation practices and provide education that links a nurse’s skills to the documentation.
To accomplish these goals, the American Association of Directors of Nursing Services (AADNS) recently published the Documentation Toolkit for the Nurse Leader, which contains several helpful tools and resources to make lasting improvements to nursing documentation. Alexis Roam, MSN, RN-BC, DNS-CT, QCP, curriculum development specialist for AADNS, shares some tips for how DNSs and other nurse leaders can use this tool to review their processes and overcome documentation pitfalls.
Revisit the four pillars of documentation
Directors of nursing services (DNSs) and other managers can support and motivate staff in two critical ways: individually and organizationally. Taking the following steps can help staff deal with the anxiety of caring for residents in a pandemic:
Teach staff how to help each other—and themselves
Judy Davidson, DNP, RN, FCCM, FAAN, a nurse scientist at UC San Diego Health and co-chair of the Strength Through Resiliency Task Force at the American Nurses Association, offers the following two stress reduction techniques that DNSs can use themselves and teach staff as well:
* Tap Out and Take a Lap. “If you see someone at work whose anxiety level is rising, you figuratively tap them out and invite them to take a lap of the unit with you. A lap of the unit usually takes about one minute, and that is all it takes to do this stress reduction technique,” says Davidson. “While walking, you coach them through a little breathwork. If they are really panicked, just do four breaths in and four out. Doing that for five cycles will add up to a minute—which is all it takes to break the stress response that the person is under and ground them again so they can get back into the game.”
If the person isn’t totally panicked, “they may be able to tolerate a more complex breathing pattern, four-seven-eight: Breathe in for four, hold for seven, and breathe out for eight. Four to five repetitions of that will give you a minute that you have walked around the unit, and now both you and your colleague are feeling better,” says Davidson. “I recommend anyone to do that for helping out in-the-moment stress.”
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