PROFESSIONAL DEVELOPMENT
Written communication: from staff nurse to nurse consultant
Part 7: incident reports John Fowler
© 2014 MA Healthcare Ltd
T
his is the seventh article in the ‘staff nurse to nurse consultant’ series, which is currently discussing the use of written communication by clinically based nurses. Previous articles have explored some core principles when communicating via the written word and how these can be applied to patients’ records, email communications, case studies, literature reviews and reflective writing (Fowler, 2014a–f). This article explores the principles involved in writing incident reports. Take a few moments to reflect on how many incident reports you have written in the past 12 months. How does that compare to the previous 12 months and the year before that? I suspect that you, like many other nurses, are completing more incident reports, not because more incidents are occurring, but because, firstly, as a profession, we are becoming more aware of the litigious nature of our society; and, secondly, because we are acknowledging the benefits of learning from such incidents. This is a huge topic drawing on knowledge and literature from nursing, medicine, law, health and safety, ethics and the professional and union bodies. However, this short article focuses on the language of the written communication used when completing an incident report. Consider the following two sentences: ■■ Mrs Jones appeared to have fallen out of bed. ■■ Mrs Jones was found on the floor by her bed. The first sentence makes the assumption that Mrs Jones ‘fell’. The second is purely factual and makes no assumptions. If you wrote the first statement, it could be interpreted as an admission of liability. These two simple sentences really summarise the principles that need to be kept in mind when writing incident reports. We need to provide purely factual information as to what happened, as opposed to what we think may have happened. Incident reports need to be completed as soon as possible after the incident—this ensures the most accurate recall of events. However, this does not mean they have to be rushed; and no matter how busy you or your
British Journal of Nursing, 2014, Vol 23, No 21
staff are, you should make sure that you take time to think carefully about what is written and how it is written. If necessary, consult with a colleague or your professional body before you commit yourself to paper. Consider the following example, based on the 2001 Department of Health (DH) minimum data set (DH, 2001): ■■ What happened? Mrs Jones was found on the floor by her bed. ■■ Where did it happen? In a single room (number 4), ward 16, surgical unit. ■■ When did it happen? Tuesday 10th November 2014, found at 16.00 hours. ■■ How did it happen? Unknown. ■■ Why did it happen? Mrs Jones stated that ‘I slipped when I was trying to get out of bed and sit in my chair’. ■■ What action was taken (immediate and longer term)? Mrs Jones was initially assessed regarding her consciousness level: she was breathing and communicating well. Pupils were equal and reacting to light. She was assessed visually and verbally for any bleeding, pain or obvious fractures by myself, the senior nurse on duty. Mrs Jones reported no pain. There was no visible bleeding or fractures. I called for healthcare assistant Edwards and we sat Mrs Smith in her chair. We moved her chair nearer the entrance of the room so that she was in visible sight of the desk nurse, and we monitored and recorded her blood pressure and pulse every 15 minutes for 2 hours. The duty doctor was called, who then examined Mrs Smith at 16.25 hours. It was reported to the senior nurse of the unit at 16.15 hours. ■■ What impact did it have? Mrs Jones said, ‘I’m scared I’m going to fall and hurt myself next time’. I sat with Mrs Jones and explained how the call bell worked and that she should press it when she wanted to get back into bed. I also said that I would be asking the occupational therapist (OT) to assess her.
■■ What
factors did or could have minimised the impact of the event? Mrs Jones was assessed by the senior nurse as soon as she was found on the floor and treated accordingly. Mrs Jones was reassured and assessed quickly by medical staff and referred to the OT for mobilisation assessment. This is a simple and not uncommon incident. It is written to give an example of the concise factual style of writing that should be used. You would need to use whatever form or template has been approved by your employers and follow their guidance notes. Future articles in this series will cover; raising concerns, business plans, portfolios, BJN CVs and letters of application.
Department of Health (2001) Building a safer NHS for patients. Implementing an organisation with a memory. http://tinyurl.com/nhwzq33 (accessed 3 November 2014) Fowler J (2014a) Written communication: from staff nurse to nurse consultant. Part 1: core principles. Br J Nurs 23(15): 866 Fowler J (2014b) Written communication: from staff nurse to nurse consultant. Part 2: patient records. Br J Nurs 23(16): 910 Fowler J (2014c) Written communication: from staff nurse to nurse consultant. Part 3: email communication. Br J Nurs 23(17): 958 Fowler J (2014d) Written communication: from staff nurse to nurse consultant. Part 4: case studies. Br J Nurs 23(18): 1004 Fowler J (2014e) Written communication: from staff nurse to nurse consultant. Part 5: literature reviews. Br J Nurs 23 (19): 1046 Fowler J (2014f) Written communication: from staff nurse to nurse consultant. Part 5: reflective writing. Br J Nurs 23(20): 1046
Dr John Fowler is a general and mental health nurse. He has worked as an Educational Consultant to primary care trusts and as a Principal Lecturer in Nursing for many years. He has published widely on educational and professional topics and is series editor of the Fundamental Aspects of Nursing Series and the Nurse Survival Guide Series for Quay Books
1153
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 5, 2015. For personal use only. No other uses without permission. . All rights reserved.
Written communication: from staff nurse to nurse consultant
Part 7: incident reports John Fowler
© 2014 MA Healthcare Ltd
T
his is the seventh article in the ‘staff nurse to nurse consultant’ series, which is currently discussing the use of written communication by clinically based nurses. Previous articles have explored some core principles when communicating via the written word and how these can be applied to patients’ records, email communications, case studies, literature reviews and reflective writing (Fowler, 2014a–f). This article explores the principles involved in writing incident reports. Take a few moments to reflect on how many incident reports you have written in the past 12 months. How does that compare to the previous 12 months and the year before that? I suspect that you, like many other nurses, are completing more incident reports, not because more incidents are occurring, but because, firstly, as a profession, we are becoming more aware of the litigious nature of our society; and, secondly, because we are acknowledging the benefits of learning from such incidents. This is a huge topic drawing on knowledge and literature from nursing, medicine, law, health and safety, ethics and the professional and union bodies. However, this short article focuses on the language of the written communication used when completing an incident report. Consider the following two sentences: ■■ Mrs Jones appeared to have fallen out of bed. ■■ Mrs Jones was found on the floor by her bed. The first sentence makes the assumption that Mrs Jones ‘fell’. The second is purely factual and makes no assumptions. If you wrote the first statement, it could be interpreted as an admission of liability. These two simple sentences really summarise the principles that need to be kept in mind when writing incident reports. We need to provide purely factual information as to what happened, as opposed to what we think may have happened. Incident reports need to be completed as soon as possible after the incident—this ensures the most accurate recall of events. However, this does not mean they have to be rushed; and no matter how busy you or your
British Journal of Nursing, 2014, Vol 23, No 21
staff are, you should make sure that you take time to think carefully about what is written and how it is written. If necessary, consult with a colleague or your professional body before you commit yourself to paper. Consider the following example, based on the 2001 Department of Health (DH) minimum data set (DH, 2001): ■■ What happened? Mrs Jones was found on the floor by her bed. ■■ Where did it happen? In a single room (number 4), ward 16, surgical unit. ■■ When did it happen? Tuesday 10th November 2014, found at 16.00 hours. ■■ How did it happen? Unknown. ■■ Why did it happen? Mrs Jones stated that ‘I slipped when I was trying to get out of bed and sit in my chair’. ■■ What action was taken (immediate and longer term)? Mrs Jones was initially assessed regarding her consciousness level: she was breathing and communicating well. Pupils were equal and reacting to light. She was assessed visually and verbally for any bleeding, pain or obvious fractures by myself, the senior nurse on duty. Mrs Jones reported no pain. There was no visible bleeding or fractures. I called for healthcare assistant Edwards and we sat Mrs Smith in her chair. We moved her chair nearer the entrance of the room so that she was in visible sight of the desk nurse, and we monitored and recorded her blood pressure and pulse every 15 minutes for 2 hours. The duty doctor was called, who then examined Mrs Smith at 16.25 hours. It was reported to the senior nurse of the unit at 16.15 hours. ■■ What impact did it have? Mrs Jones said, ‘I’m scared I’m going to fall and hurt myself next time’. I sat with Mrs Jones and explained how the call bell worked and that she should press it when she wanted to get back into bed. I also said that I would be asking the occupational therapist (OT) to assess her.
■■ What
factors did or could have minimised the impact of the event? Mrs Jones was assessed by the senior nurse as soon as she was found on the floor and treated accordingly. Mrs Jones was reassured and assessed quickly by medical staff and referred to the OT for mobilisation assessment. This is a simple and not uncommon incident. It is written to give an example of the concise factual style of writing that should be used. You would need to use whatever form or template has been approved by your employers and follow their guidance notes. Future articles in this series will cover; raising concerns, business plans, portfolios, BJN CVs and letters of application.
Department of Health (2001) Building a safer NHS for patients. Implementing an organisation with a memory. http://tinyurl.com/nhwzq33 (accessed 3 November 2014) Fowler J (2014a) Written communication: from staff nurse to nurse consultant. Part 1: core principles. Br J Nurs 23(15): 866 Fowler J (2014b) Written communication: from staff nurse to nurse consultant. Part 2: patient records. Br J Nurs 23(16): 910 Fowler J (2014c) Written communication: from staff nurse to nurse consultant. Part 3: email communication. Br J Nurs 23(17): 958 Fowler J (2014d) Written communication: from staff nurse to nurse consultant. Part 4: case studies. Br J Nurs 23(18): 1004 Fowler J (2014e) Written communication: from staff nurse to nurse consultant. Part 5: literature reviews. Br J Nurs 23 (19): 1046 Fowler J (2014f) Written communication: from staff nurse to nurse consultant. Part 5: reflective writing. Br J Nurs 23(20): 1046
Dr John Fowler is a general and mental health nurse. He has worked as an Educational Consultant to primary care trusts and as a Principal Lecturer in Nursing for many years. He has published widely on educational and professional topics and is series editor of the Fundamental Aspects of Nursing Series and the Nurse Survival Guide Series for Quay Books
1153
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 5, 2015. For personal use only. No other uses without permission. . All rights reserved.
