Authors: (including presenting author): :
Li KC(1), Lee WSB(1), Lam ST(1), Wong LY(1)
Affiliation: :
(1)Department of Paediatrics & Adolescent Medicine, Princess Margaret Hospital
Keyword 1: :
Nursing Documentation
Keyword 2: :
Verbal communication skills
Introduction: :
Ineffective nursing documentation is a long-standing problem despite various improvement strategies. Besides, a recent trend shows that nurses are often unable to provide a brief account of patients’ conditions verbally or speak up without referring to the medical record or clinical handover notes. A pilot review on nursing documentation in Paediatric department was done in Dec 2023, demonstrated common weaknesses: task-orientated, too many foci and lack of communication element. In 2024, a quality improvement project was conducted to enhance the articulation skills of nurses' verbal communication and identify department-specific foci so that more holistic and individualized care can be delivered to patients and communicated among nursing colleagues.
Objectives: :
1.To build a holistic and individualized nursing care culture.
2.To enhance the confidence of nurses to provide “Precise” & “Concise” verbal communication skills on clinical case presentation.
Methodology: :
A “Pre-test” versus “Post-test” study design was adopted. All nurses working in two general Paediatric wards were recruited in the program. Department-specific crucial foci were developed, e.g. vital signs, hydration status, social condition, discharge plan, etc. Verbal articulation was enhanced through verbalized presentation of the patient’s condition, treatment progress, and plan of care without referring to the medical record. One-on-one staff training was adopted. A staff survey was designed to evaluate staff’s knowledge and level of confidence on articulation and nursing documentation using a six-point Likert scale. Post-staff training questionnaires and compliance assessments were conducted right after the training.
Result & Outcome: :
Total 41 nurses had completed the training from April 2024 to June 2025. Using paediatric-specific criteria, the compliance rate of nursing documentation had been improved from 38% to 74%, while verbal presentation skills improved from 43% to 71% respectively. Besides, the mean score of pre- and post-training staff questionnaire had increased from 3.99 to 5.61. The mean score on staff’s knowledge had been increased from 4.70 to 5.76, and confidence from 3.78 to 5.32. In summary, nursing documentation reflects the quality of care delivered to patients. With a cultural change approach in nursing clinical handover, such as the inclusion of crucial foci in nursing documentation & the enhancement of articulation of presentation skills, a big improvement in nurse performance and confidence can be achieved.
