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ISBN 13: 978-0-273-72867-2 (


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Using a strengths-based approach 8
Person-centred care 9
Holistic care 11
Care planning 14
Care pathways 15
The Caring Model 15
Critical junctures 16
Dignity and privacy 18
Dignity in care 18
Putting ourselves in the patient’s shoes 19
Culturally sensitive healthcare 20
Discrimination 21
Supporting cultural needs 21
Supporting religious needs 22
Background information about some of the
world’s religions 23

Spirituality 29
Reflective practice 31
Clinical supervision 31
Dealing with complaints 32
Incident reporting and analysis 32
Governance 32
Clinical practice benchmarking 33
Keeping a reflective diary 36
Good practice for communicating effectively 40
Active listening 40
Times of silence 40
Tips for verbal handovers 41
Written documentation 41
Common communication problems 42
Assessing communication 43
While every effort has been made to ensure that the content
of this guide is accurate, no responsibility will be taken
for inaccuracies, omissions or errors. This is a guide only.
The information is provided solely on the basis that readers
will be responsible for making their own assessment and
adhering to organisation policy of the matters discussed
herein. The author does not accept liability to any person for
the information obtained from this publication or for loss or
damages incurred as a result of reliance upon the material
contained in this guide.


• Work with colleagues to monitor the quality of your work
and maintain the safety of those in your care
• Consult and take advice from colleagues when appropriate
• Act without delay if you believe that you, a colleague or
anyone else may be putting someone at risk
• Be open and honest, act with integrity and uphold the
reputation of the profession
• Treat people kindly and considerately
• Listen to the people in your care and respond to their
concerns and preferences
• Share with people, in a way they can understand,
the information they want or need to know about their
• Make arrangements to meet people’s language and
communication needs
• Treat people as individuals and respect their dignity
• Respect and support people’s rights to accept or decline
• Ensure that you gain consent before you begin any
treatment or care
• Recognise and respect the contribution that people make
to their own care and well-being
• Act as an advocate for those in your care, helping them to
access relevant health and social care, information and
• Ensure people are informed about how and why
information is shared by those who will be providing care
• Keep your colleagues informed when you are sharing the
care of others

• Demonstrate a personal and professional commitment to

equality and diversity
• Do not discriminate in any way against those in your care
• Inform those in authority if you experience problems with
care provision1
• Make sure that everyone you are responsible for is
supervised and supported
• Give constructive and honest responses to anyone who
complains about the care they receive
• Do not allow someone’s complaint to prejudice the care
you provide for them

Student nurses need to be able to show that they can provide
care that is delivered in a warm, sensitive and compassionate
way2 by:
• Anticipating how the person might feel
• Being attentive and showing sensitivity
• Responding with kindness and empathy to provide
physical and emotional comfort
• Getting to know and value patients as individuals3
• To be compassionate is to understand and to be able to
provide the appropriate support

e.g. you can contact the Nursing and Midwifery Council.
Nursing and Midwifery Council (2007) Essential Skills Clusters, Nursing and
Midwifery Council, London.
Nursing and Midwifery Council (2009) Guidance for the Care of Older People,
Nursing and Midwifery Council, London.

• Anticipating how the person may feel in a given situation

and responding with kindness and empathy
• Providing physical and emotional comfort
• Being sensitive to the person’s needs, choices and
capability and incorporating this into their plan of care4
• Compassion is closely linked with caring and
• In order to be compassionate you need to care and to be
able to communicate effectively.

If you do not know a person’s past, then you cannot

understand their present.5

The Oxford English Dictionary (1990) defines compassion as

being sympathetic, being merciful and to incline one to help.
But to be compassionate you need to be able to anticipate
and understand a person’s needs; if we are unable to do
this we can disable the person. Sometimes we are unaware
that we are doing this.
In 1997 Dr Tom Kitwood published the results of a study
he had made of some care establishments. In this study he
identified 17 elements of harmful attitudes and actions made
by people towards others, and called this ‘malignant social
psychology’. His study showed people labelling others,
treating them like children and deliberately ignoring or
intimidating them rather than accepting and respecting

NMC (2007).
Kerr, D. and Wilkinson, H. (2005) In the Know: Implementing good practice,
Information and tools for anyone supporting people with a learning disability and
dementia, Pavilion, Brighton.

people regardless of their condition or behaviour: in other

words, treating people with unconditional positive regard.6

Unconditional positive regard is accepting people

regardless of their condition and/or their behaviour.

Table 1 The seventeen elements of malignant social

Treachery Using forms of deception and lies to
distract or manipulate and therefore
force a person to comply
Disempowerment Not allowing the person to use their
abilities, or failing to help that person
to complete an action once it has been
Infantilisation Patronising a person, as in how an
insensitive parent may treat a young
Labelling Describing a person through the use
of negative words, e.g. a wanderer
Stigmatisation Treating the person as an object or
Outpacing Providing information or presenting
choices too quickly, so the person
cannot understand, and putting them
under pressure to do things more
rapidly than they are able

Kitwood, T. (1997) Dementia Reconsidered: The person comes first, Open
University Press, Buckingham.

Invalidation Not acknowledging the person’s

feelings or experience
Objectification Treating the person as a dead weight
rather than as a person (e.g. when
moving and handling them)
Banishment Sending the person away or excluding
them physically or psychologically
Ignoring Carrying on a conversation or action in
the person’s presence as if they are
not there
Intimidation Using power threats that cause anxiety
and fear
Imposition Forcing the person to do something
by overriding their desire or denying
their choice
Withholding Refusing to give attention or to meet
the person’s evident needs, treating
them as being invisible
Accusation Blaming a person for actions that have
arisen from the person’s lack of
understanding or ability
Disruption Intruding or disturbing a person’s
actions or thoughts
Mockery Making fun, teasing, humiliating
Disparagement Telling the person they are worthless,
damaging their self-esteem7

Adapted from Kitwood, Tom (1997) and Brooks, Lee (2006) Dementia
Awareness, Tribal Education Ltd, York.


This is about focusing on the person’s abilities and
strengths, so that independence is encouraged.
Self-care becomes more of an achievable goal. It is
about finding out what the person is able to do and
what they are good at doing and then focusing their care
or treatment on these strengths. It helps the person
feel good about themselves, giving them a sense of
well-being. The strengths-based approach helps the
person to identify and use their strengths to achieve
their goals and aspirations.8

Hints: what you can do

Help the person in a constructive way by:
• Identifying the person’s strengths and promoting their
• Tailoring any support to the person’s requirements and
• Finding out what the person’s personal preferences are
• Understanding and valuing the person’s personal
• Breaking tasks into small achievable chunks
• Explaining to the person in a way that they can understand
what you are trying to achieve
• Agreeing goals with the person
• Listening

Adapted from Brooks, Lee (see Footnote 7 above) and Nursing and Midwifery
Council (2007), Essential Skills Clusters, Nursing and Midwifery Council, London.

• Being patient
• Not rushing the person
• Not taking over
• Thinking about how you would feel if your decisions were
made for you.

Person-centred care is about putting the person at the
centre of the care, rather than their illness or condition.
It offers a non-judgemental approach to care in which
the person’s religious belief, personality, intellect,
ethnic origin or other individual characteristics do not
prejudice the delivery of high-quality care. It sees each
person as a unique individual with a unique life history.
The person’s needs and feelings are the focus of that care,
around which all other aspects of the care are geared.9
A person-centred approach is about giving the person
the means to have some control of their treatment. The
person and their family are central in the decision-making
• Actively involving the person in their assessment
and care planning and addressing their needs in
accordance with their known wishes or in the person’s
best interests.10

Brooks, Lee (2006) Dementia Awareness, and Field, L. and Smith, B. (2008)
Nursing Care: An essential guide, Pearson Education, Harlow.
Nursing and Midwifery Council (2007) Essential Skills Clusters, Nursing and
Midwifery Council, London.

How to achieve person-centred care

• Involve patients in the planning of their care
• Ascertain what the needs and feelings of the
person are
• Plan care and treatment around these needs and
• Implement care and treatment ensuring the full
understanding of the patient and their family is
integral to this
• Information regarding treatment options and services
should be available and presented in a way in which
the person is able to understand so that they can make
informed decisions
• Use a whole-team approach that includes all services,
the person and their family

Person-centred care involves taking a ‘whole-person’ or

holistic approach. Each person has individual care needs,
wants and preferences. They can be physical, psychological,
emotional, social, spiritual, cultural and religious. Each of
these will be interconnected and the care approach needs
to address all of these.

Taking a holistic approach

Understand and value the person’s:
• Strengths and ability to participate
• Preferences
• Feelings
• Need for privacy, dignity and control

These are all aspects that you will need to consider to help
you achieve person-centred care.

Holistic care
Holistic care is about seeing that people have a range of
needs and that these needs are not handled in isolation.
The whole person’s needs are considered and attended to.

Aspects of holistic care

• Physical – warmth, shelter, food and drink
• Psychological – well-being
• Emotional – love, happiness, hope, security
• Social – relationships, companionship, interaction
• Spiritual – sense of belonging, being at peace, purpose
• Cultural – customs, languages and ethnicity, preferences
• Religious – being close to one’s God, worship, holy

Nurses need to deliver care that is culturally competent

and free from discrimination, harassment and exploitation.
This means care that takes into account the person’s legal
rights and any differences in cultural traditions, beliefs,
UK legal frameworks and professional ethics when care is

Brooks, Lee (2006) Palliative Care, Tribal Education Ltd, York.
Nursing and Midwifery Council (2007) Essential Skills Clusters, Nursing and
Midwifery Council, London.

We are people who provide care; the care we give to people
will impact on them and on their families. How can we
determine what is good care? We need to be able to improve
care by measuring the quality of it, by analysing and
understanding it. To help us do this we can follow models
of care and undertake initiatives such as clinical practice
benchmarking. The danger is that we explore care but fail
to improve it.
There are three main elements to providing the
fundamentals of care in a safe and effective way:
1. Nurses are:
• Competent
• skilled
• have positive attitudes
• Assertive:
• challenge bad practice
• Reliable and dependable
• Empathetic, compassionate and kind
2. Nurses deliver care by:
• Promoting dignity
• Communication
• Assessing need
• Respecting privacy and dignity
• Working in partnership with the patient and their family,
carers and other colleagues
3. Caring for people in different care environments
• Community
• Hospital

• As appropriate
• Adequate resourced
• Effectively managed.13

How can we make people feel cared for? In order to

understand how to care we need to be aware of how people
can feel and to value these feelings and emotions. These can
include the following:14

Feelings a person may experience

Fear of equipment such as oxygen, intravenous infusions,
hoists, syringe drivers
Being forgotten or left alone in an unfamiliar place, not
knowing what the routine is or what is expected of us
Feeling violated because people are taking control, doing
things to us, for some bringing back distressing memories
of abuse
Helplessness and loss of control, not allowed to make
decisions, being frightened and scared
Loss of identity and not feeling like a person but grouped
together with others with the same disease or condition
Embarrassment and humiliation mixed sex wards,
using commodes by the bedside, people talking over you,
belittling attitudes, disregard of privacy

Adapted from Nursing and Midwifery (2009) Guidance for the Care of Older
People, Nursing and Midwifery Council, London.
Brooks, Lee (2006) Palliative Care, Tribal Education Ltd, York.

• Involves effective assessment
• Care-planning discussion:
• Between the patient and the professional
• Addressing the individual’s full range of needs:
Identifies level of need
Comprehensive patient history
• Focuses on goal-setting
• Gives information
• Supports self-care when possible
• Records the outcome of the care-planning discussion
• Uses a model of care:
• The Roper–Logan–Tierney Model of Nursing: based on
activities of living
• The NHS and Social Care Long-Term Conditions Model
• Assesses risk
• Plans care accordingly, referring:
• To other professionals and agencies
• For investigations
• Specific goals:
• Provision of evidence-based care
• Time limited
• Realistic
• Continuous assessment and evaluation
• Work and plan care/treatment with others who provide
care and treatment for the patient.

• Follows the patient journey from diagnosis through to the
end of an episode of care or treatment or life
• Progressive and identifies steps to achieve outcomes
• Holistic
• Tailored to each individual
• Patient-led not clinician-led
• Collaborative goal-setting
• Action planning
• Problem solving
• Negotiation
• Shared decision making.15


This was developed in 2002 by Sharon K. Dingman as
a result of a study to see if care met the expectations of
the patient and their family. The study found that specific
behaviours had a significant impact on the patient’s
experience, and the daily interactions listed in the
box made a positive experience:16

Adapted from the Department of Health (2009) Your Health, Your Way, HMSO,
Dingman, Sharon K. (2002) The Caring Model TM.
Contact email:

The caring behaviours of The Caring ModelTM

• Staff who introduced themselves and explained
what their role was and what they would be doing
for the person
• Addressing the person by their preferred name
• Sitting with the person (at eye level) for a few minutes
at the beginning of each shift or appointment time
or visit to discus, plan and review the person’s care
and treatment and to determine what the person’s
expectations and priorities were
• Staff who used touch appropriately
• The inclusion of the philosophy of care/treatment
into the planning and implementation of care and

The Caring Model is part of a full programme that creates

an infrastructure of accountability for caregivers to enable
them to implement and support caring behaviours. It was
developed from theory and research on patient/carer
satisfaction. For further information search the Internet.

Critical junctures
A critical juncture is a time when the path or actions that
are chosen influence the resulting care. This can be how
something is expressed or something that is done or not
done. Critical junctures can change a person’s perception
about the care that they receive, and can really make a
difference to the patient’s experience. Sometimes if we
just do that little bit extra or take a little more time and

care we can make a big difference at the critical juncture.

It is important to be able to identify a critical juncture,
because this gives us the opportunity to review and analyse
our behaviour at different stages in our work. A critical
juncture is any time in the care and treatment of a patient
that can make or break their expectations of what is being

Hints: ask yourself

• What are the decision points (the crossroads)?
• What might have made a difference?
• What went well and could be repeated?

What we can do to make a difference

• Be approachable
• Stop writing and greet the patient and their visitors
• Listen to others
• Spend more time with the patient and visitors
• Explain information in a way that the person receiving it
can understand
• If you cannot answer questions find someone who can,
or find the information out yourself and get back to the
• Find out about different religions and cultures – apply
this knowledge to your work
• Assist your colleagues – work as a team

Dingman, Sharon K. (2002) The Caring Model TM (see footnote 16, above).
Field and Smith (2008) Nursing Care, An Essential Guide.


Dignity in care
It is always important that we treat our patients with
dignity, that we respect them and give them the privacy
they need.

Results from the Dignity in Care Survey –

what people want
• Putting the person receiving the care at the centre of
that care by asking them:
• what their specific wants and needs are
• how they want their care to be provided
• Being patient
• Not patronising the person receiving care
• Helping people feel they can rest and relax in a safe
• Making sure people are not left in pain
• Ensuring people do not feel isolated or alone
• Respecting basic human rights:
• privacy
• independence
• Taking into account people’s cultural and religious
• Service made up of smaller, more specialised teams
who get to know the person as an individual18

Department of Health (2006) Dignity in Care Survey, HMSO, London.

Putting ourselves in the patient’s shoes

Lack of dignity is probably one of the most reported
complaints patients have. The next box gives some examples
of how some patients have felt when their dignity was not

• Feeling neglected or ignored

• Being made to feel worthless or a nuisance
• Being treated as an object not as a person
• Feeling their privacy was not respected during intimate
• being forced to use a commode rather than being
taken to the bathroom
• A disrespectful attitude
• addressed in ways the person finds disrespectful
• Being treated as a child
• given a bib rather than a napkin
• Having to eat with fingers rather than being helped to
eat with a fork
• Being rushed
• Not being listened to

Hint: We are often quick to label others, particularly when

they have challenged our ability to care.

Department of Health (2006) Dignity in Care Survey.

Maintaining privacy
• Patients are protected from unwanted public view
• Staff do not enter a patient’s space without first
ascertaining permission from the patient:
• bedside curtains are closed with no gaps, for example
when personal care is given
• Appropriate clothing is available:
• dressing gowns are used over theatre gowns when
transporting patients
• use of blankets/towels to protect the patient’s
• Conversations that need to be kept confidential:
• use a private room if one is available
• ensure aids and equipment to assist hearing are
• friends and relatives should be asked to leave
if this is what the patient wants


We try to deliver health and social care that is suitable
for people living in a multicultural society. As health and
social care professionals we need to be able to give
transcultural care by being aware of others’ cultures and
religions and linking these to the health and social care
that we deliver.

Hint: the person’s cultural, spiritual and religious needs

should be integrated in all care and treatment planning.

In health and social care we are striving towards promoting
health and equal access for all people to services and
treatment. However, discrimination is still prevalent.

Types of discrimination
• Age:
• older adults
• babies, children and young adults
• Gender
• Sexual orientation
• Race
• Religion
• Health
• mental health
• physical health
• Learning disabilities
• Specific learning disabilities
• dyslexia
• autism
• Social
• Financial20

Supporting cultural needs

• Learn about the person’s culture:
• From the person themselves
• From the person’s family and friends
• From national societies
• From a local library
Field and Smith (2008) Nursing Care, An Essential Guide.

• Do not make assumptions:

• A person’s experiences may shape their reactions
• Be sensitive to the person’s past:
• Be aware of your own cultural values
• Be aware of different cultural and community values:
• Use of interpreters
• Language Line 0800 169 2879 (a 24-hour line for over
140 different languages – there is a charge).21

Supporting religious needs

• Assess each person’s religious needs on an individual
• People from the same religion will not always have the
same religious needs
• Talk to the person and their family about their religious
• Prayer
• Hygiene
• Diet
• Respect and make arrangements for sacred practices
such as:
• Fasting
• Anointing with oils
• Quiet, private place to pray
• Baptism
• Contact religious leaders such as priests:
• For advice
• To visit

Adapted from Marie Curie (2009) Spiritual and Religious Care Competencies for
Specialist Palliative Care,

• Have a basic understanding of different religions

particularly with regards to:
• Diet
• Hygiene
• Touch
• Eye contact.22

Background information about some of the world’s


Buddhism – general
• Buddhist faith is centred on the Buddha
(The Enlightened)
• The Buddha is revered as a way of life rather than
as a God
• Buddhists believe in reincarnation and that how
they live their lives will have consequences in the
• it is forbidden to kill any living creature
• Buddhist symbols include:
• the lotus
• the wheel of life
• images of Buddha and the symbolic maps –
• There are schools of Buddhism in the UK (each with its
own traditions)

Adapted from Marie Curie (2009) (see footnote 21 above).
Brooks, Lee (2006) Palliative Care, Tribal Education Ltd, York.

• If a person is dying an image of Buddha should always

be in their view: sometimes a shrine may be created
by the bed
• Buddhists have no preference for male or female
• Visits from the Buddhist minister or religious teacher
• Quiet and privacy are important
• Belief in rebirth
• The state of the mind is very important, particularly
as death approaches
• Sometimes mind-altering drugs such as pain relief
will be refused

• Vegetarianism
• Fasting is done during the afternoon and on
festival days

Christianity – general
There are many different variations, each with its own
distinct church and beliefs and practices
• Anglicanism (Church of England, Church of Scotland):
• belief that those who are baptised will have eternal
• rejects supremacy of the Pope

• accepts authority of the Bible and traditions of the

• many people take holy communion weekly
• anointing seen as a form of spiritual strengthening in
times of distress, sickness, fear
• when death is imminent, vicar or chaplain to
administer Sacrament of the Sick (Holy Unction)
• will welcome visits from vicar, 24-hour on-call system
for the very ill
• Catholicism:
• worships Mary mother of Jesus Christ
• sacraments (bread and wine) symbolic significance
of worship
• accepts authority of Pope (seen as Jesus Christ’s
representative on earth)
• death seen as a step to the ‘fullness of life’
• some Catholics take communion daily
• will welcome visits from priest
• for very ill, priest to visit to administer Sacraments
(Last Rights)
• Free Church includes:
United Reform
• will welcome visits from ministers

Hinduism – general
• Belief in reincarnation – each person being responsible
for how their existing and future life is
• Belief in karma (you sow what you reap)
• Believe that the person should break free from an
imperfect world
• One God who can be seen in different forms
• Hindu women prefer to be treated by female nurses and
• Fresh water must always be provided following use of
bedpan etc.
• Killing of animals forbidden
• Most are vegetarians
• Food should not be served for eating if the plate had
previously had meat on it
• Prefer food to be provided by their family
• Hindu priest is known as a Pandit
• Hindu holy books include the Bhagavad Gita
• Sacred practices include a thread and water from the
River Ganges and the tulsi leaf

Islam – general
• Islam is the Arabic word meaning surrendering oneself
to Allah (God) achieving peace and security
• Allah’s last prophet was Muhammad (he was not a God
but a man to whom Allah revealed his will)
• Jumah Friday prayers
• Qur’an is the Muslim holy book:
• this states that death is the will of God
• people will be judged by the way they live
• Five religious duties:
• pray five times each day
• declare one’s faith
• give alms
• fast during Ramadan
• pilgrimage to Mecca
• Cleanliness very important, hands, feet and mouth are
washed before prayer
• Muslims eat beef from cows killed in accordance with
Muslim ways – Halal
• Eating of pork and birds of prey forbidden:
• includes certain medications such as insulin derived
from pigs
• No alcohol:
• includes medications made from alcohol
• If the person is near to death, bed should face towards
Mecca (the south-east) if possible
• Muslim leader known as an Imam
• When death is imminent, the Creed or the Declaration of
Faith (Shahada) is said

Judaism – general
• Jewish spiritual home is Israel
• Jews worship in a synagogue
• Rabbi is the leader of the Jewish community
• Magen shield (Star of David) is the symbol of
• Living life in accordance with Jewish laws and
• Different types of Judaism include:
• Orthodox
• Ultra-Orthodox
• Conservative
• Hasidic
• Reform Jews
• Shema is a declaration of faith
• Values life and opposes any hastening of death
(even moving a person)
• Can question value of certain medication
• Kosher food (meat slaughtered according to specific
• Pork and shellfish are forbidden
• Milk and milk dishes are not eaten at the same meal as
meat and meat products
• If a person is dying the rabbi may come to pray with the
person – Vidui (deathbed confession)
• A dying person should not be left alone

Sikhism – general
• Gurdwara is the Sikh temple of worship
• Sikh men have a full beard and uncut hair which is worn
in a turban
• A Granthi is a person who understands the Sikh
scriptures and is present at the Gurdwara
• Follow Sikh teachings:
• meditation on God, scriptures and other people
• Adi Granth (Guru Granth Sahib) is the holy book
• Five religious symbols (the five Ks):
• kesh (uncut hair)
• kanga (wooden comb)
• kaccha (baggy underwear, usually white shorts)
• kara (steel bangle)
• kirpin (a short sword)
• Believe in rebirth, death is a step in life and not to be
• Some Sikhs are vegetarians
• Sikhs do not eat beef
• Jatka (one blow to the head) method used for killing
• Alcohol forbidden
• Most Sikh women would prefer to be treated by female
nurses, doctors, therapists and carers
• Amrit (holy water) is given before death

Many people have a spiritual dimension. Spirituality is
whatever gives a person worth and value to their life.
Spirituality is unique to each person; it is what that person

believes in, what is important to them and what provides

them with the means for understanding of their life. For some
spirituality and religion are closely linked, for others this is
not so. Spirituality can be expressed in a number of different
ways depending on each individual; these can include a love
of nature or the arts such as music and painting. It can be
their relationships with others or the key events in their lives.
For some spirituality is linked with culture, tradition and
religion. For many it is what gives life purpose.

Meeting spiritual needs

• Recognise that most people have a spiritual dimension
• Some people will have a religious dimension to their
spirituality, others will not
• Understand how to listen to people
• Know your own boundaries
• Know when to refer on to others with more knowledge
• Be aware of your own spirituality
• Understand the importance of confidentiality and when
to disclose
• Recognise unmet spiritual and religious needs
• Recognise complexity of spirituality, ethnicity and religion
• Plan spiritual needs with the person
• Understand and respond appropriately to conflict within
• Find out about other religions and cultures
• Identify a need for further education and training24

Adapted from Marie Curie (2009) Spiritual and Religious Care Competencies for
Specialist Palliative Care,

Reflective practice is about analysing the care and treatment
that we give and learning from this so that we can constantly
improve and maintain it. Reflective practice is an important
part of continuing professional development.

Learning through reflection

Action learning is thinking about what you are doing,
analysing what happened, why it happened, what could
have been done differently and using the knowledge
gained to develop and improve.

Ways to reflect include:

• Clinical supervision
• Complaints procedures
• Incident reporting and analysing these incidents
• Clinical governance
• Clinical practice benchmarking
• Following models of reflection
• Keeping a reflective diary
• Audit.

Clinical supervision
This can be one-to-one and/or group supervision, putting
aside an allotted amount of time in which people can support
each other to reflect on practice and to act as a sounding
board to initiate changes in their own practice with the
overall aim of improving care and treatment for patients.
The central focus of clinical supervision is to ensure that safe
and accountable care and treatment is given at all times.

Dealing with complaints

There is still a reluctance to admit that there are valid
reasons why patients and their relatives complain. Patients
themselves are often reluctant to make complaints so it is
vital that we recognise the validity of complaints made and
that we actively encourage people to do so. Only then can
we analyse our care and treatment and make the necessary
improvements. We need to encourage openness and honesty
and show that we are willing to make the necessary changes.

Incident reporting and analysis

All incidents, including near misses, must always be reported;
then the situation can be analysed and steps put into place
to ensure this incident is not repeated. Incident analysis can
also be used as a indication to show that there is a need for
different ways of working, such as a change to numbers of
staff on each shift.

Incident reporting
• Incident reporting book
• A clear no-blame culture
• Mistakes, errors, near misses all reported
• Prompt analysis of incidents
• Putting systems in place promptly so as to avoid
repetition of the incident

Governance involves analysing clinical practice to provide
a safe and better health service for patients, and to improve
the quality of care and treatment.

Principles of clinical governance

• To have clear lines of responsibility and accountability
for quality of clinical care
• To give patient satisfaction
• To have clear accessible information
• To develop and follow quality-improvement
• audit
• evidence-based practice
• clinical guidelines
• To follow the risk-management policies that are
in place
• To educate and train
• Identify poor practice and remedy this:
• clinical practice benchmarking
• professional guidelines
• Nursing and Midwifery Council25

Clinical practice benchmarking

Clinical practice benchmarking is used to measure the
quality of services provided to patients and their families.
The aim is to improve the patient experience by examining
and analysing the care given. The Essence of Care
Toolkit (DH 2009) contains the benchmarks and enables
practitioners to measure against the standards that are

Adapted from Scally, G. and Donaldson, L. (2001) Clinical governance and the
drive for quality improvement in the new NHS. BMJ, 317, 61–65.

contained within. Each one gives health and social care

staff the means to take a patient-focused and structured
approach to providing care and treatment. Practitioners can
compare and share practice, working closely with patients
and carers in order to develop action plans of improvement.
The benchmarks are relevant to all health and social care
settings and to all patient and carer groups.

Clinical practice benchmarks

• Bladder and bowel care
• Care environment
• Communication
• Food and drink
• Personal hygiene
• Pressure ulcers
• Promoting health and well-being
• Record keeping
• Respect
• Safety
• Self-care26

Department of Health (2009) Essence of Care: A consultation on the reviewed
original benchmarks, The Stationery Office, London.

Using benchmarking

Stage 1 = identify what aspect of care and/or practice

needs to be improved.

Think about
• Complaints
• Incidents
• Comments from patients, carers, staff
• Local and national surveys

Stage 2 = look at the benchmarks, factors and indicators

to see what people requiring care and carers say needs
to be in place.
• Which benchmarks link with the area of concern?
• What about the benchmark factors? Do they link with
the specific area of concern?
• Look at the indicators to find practical ideas of how
to achieve the factors

Stage 3 = review and change practice and/or care.

• Analyse whether current practice meets the
• If it does not, change practice so that it will

Stage 4 = evaluate practice and or care from perspective

of people who require care, their carers and staff.
Questions to ask:
• Do the people and their carers think that their care has
• Are they happy with the standard of care?
Stage 5 = establish improved practice and care or revise
• Share the improved practice with other teams and

Keeping a reflective diary

The purpose of a reflective diary is for you to be able to
describe, analyse, evaluate and inform your practice by
asking yourself reflective questions and then engaging in
action learning.

Reflective questions
• What am I doing well?
• What will I celebrate?
• What would I change?
• What will it take?
• What is my responsibility in making it change?
• Who do I need help from?
• What is the first step?
• What will I do?

Department of Health (2009) Essence of Care, A consultation on the reviewed
original benchmarks.

Reflective models such as Gibbs’ Reflective Cycle
help you to reflect on incidents that have occurred
in practice. These give structure and help you with
problem solving and action learning.

Whst happened

Adlan Plan l11li110111

the What wereyou
arose again, what thinking and
would you do? faellng?


What wasgood
What 818e could you
and bad about
have done?
the experience?

Whaisellge can
you makB of the

Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods,
Oxford Polytechic, Oxford. Kind permission was granted by Professor Chris
Rust, The Oxford Centre for Staff and Learning Development, Oxford Brookes


Communication is essential to care, patients are

more apt to forgive an unfortunate outcome than
a lack of concern and communication.
(Leadership at the Point of Care, 2001)

To gain entry to the register the nurse needs to be able to

demonstrate that they listen and provide information that is
clear, accurate and meaningful at a level at which the
patient/client can understand.29 This can be achieved by:
• Communicating effectively both orally and in writing by
• the meaning is always clear
• it provides guidance
• it is sensitive
• it uses a range of methods and styles
• it is comprehensive
• it is evidence-based
• records information accurately and clearly
• confirms understanding
• responds appropriately
• Applies principles of confidentiality and data protection by:
• following local policies
• ensuring disclosure is managed appropriately and

Nursing and Midwifery Council (2007) Essential Skills Clusters.

Verbal communication is a two-way process: if you are

giving information you have an obligation to ensure it is given
in such a way that the person intended to receive it can
understand you.

When communicating think about what:

• Method you use
• Is appropriate for that situation
• Barriers there may be to communicating effectively.

Can you tell how someone is feeling from

an email?

Texting and emailing are widely used, but often messages

can be interpreted in more than one way.

Hint: take care, be objective, concise and clear.

Barriers to communication
• The person wants to talk, you don’t
• The person doesn’t want to talk, you do
• The person wants to talk but feels they ought not to.
You do not know how to encourage the person to talk
• The person appears not to want to talk but really needs
to. You don’t know what’s best and don’t want to
intervene in case it makes things worse30

Reid-Searl, K., Dwyer, T., Ryan, J. and Moxham, L. (2006) Student Nurse Clinical
Survival Guide, Pearson Education, Melbourne.


Good practice
Right place – is it too noisy, too quiet? Is there too much
going on around? Can other people hear you?
Right time – have you got enough time to talk and to
listen to what the person wants to tell you? Is the person
frightened or angry?
Body language – yours and the other person’s. What do
your or the person’s facial expressions tell you? What about
their gestures?

Active listening
Active listening is about really listening, not only hearing the
words but understanding the feelings and intent behind the
words spoken. It’s about taking the time to listen.

The skills required to actively listen include:

• Giving the person your full attention
• Using minimal prompts
• Not interrupting
• Reflecting back some of the words
• Listening for hidden fears.

Times of silence
Knowing when not to talk is important, because we need
times of silence in conversations so that we can gather
our thoughts. These times give us the opportunity to think
about what has been said and what we are going to say.

For the person it gives them the opportunity to reflect and

sometimes to open up deeper feelings. It allows time to
interpret what has been said.31

Tips for verbal handovers

Have your essential information prepared before you begin
and include:
• Any changes in the patient’s/family situation that are
• Normal parameters that have deviated
• Doctor rounds – changes in patient’s management, any
new plans of treatment
• Objective (e.g. vital signs) and subjective data that are
• Vicious statements, gossip and personal opinions to be
• Education that you have given to the patient/family
• Relevant and priority care for the next shift/team32

Written documentation
• Check you have the right charts etc.
• Ensure that what you write is accurate
• Focus your documentation on the patient
• Document relevant information only
• Be objective

Brooks, Lee (2006) Palliative Care, Tribal Education Ltd, York.
Reid-Searl et al. (2006) Student Nurse Clinical Survival Guide, Pearson
Education, Melbourne.

• Document contemporaneously
• Avoid documenting in advance
• Don’t document on behalf of someone else
• Write legibly
• Use black ink
• Don’t transcribe
• Use only accepted abbreviations (and avoid using them if
• Date and time
• Sign and give your designation.33

Common communication problems

Dysphasia is problems with communication. It is
characterised by:
• An inability to find the correct word
• Using a similar word
• Using a description e.g. ‘carrying thing’ for bag.

Dysarthia is slurred speech.

Aphasia is an inability to:

• Express language
• Understand the spoken word (especially words that the
person does not commonly use or ones that are highly

Adapted from Reid-Searl et al. (2006) Student Nurse Clinical Survival Guide,
Pearson Education, Melbourne.

Agnosia is the loss of ability to recognise objects, either by

name or by sight.

Apraxia is the loss of ability to form purposeful movements;

this can extend to an inability to remember the patterns
used to form words.

Dyslexia is word and number blindness (visual or abstract


Assessing communication
Can the person:
• Verbalise?
• Understand you?
• do they need an interpreter?
• Hear you?
• refer to Audiology
• check hearing aids are in working order
• is a voice output communication aid needed?
• See you?
• refer to the optician.

Hint: think about the person’s ability to communicate.


Assessing ability level

• Communication is unimpaired
• Has difficulty understanding others but can
communicate to others (with or without aids)
• Has difficulty communicating to others but understands
others’ speech or gestures (with or without aids)
• Has impaired ability to communicate to others and to
understand others’ communication
• Unable to express needs through verbal communication
alone or understand requirements of others but may use
non-verbal communication
• Unable to communicate without the use of an interpreter
• Unable to communicate34

Hint: always take the time to communicate with your

• Listen to what they have to say
• Give your patients opportunities to talk to you
• Include the person at all times in conversations regarding
their care and treatment
• Find ways which help you to interpret what a person is
trying to tell you.

Adapted from the Four Seasons Care and Health Assessment Profile (2008).
Shift roster