NURS3002: Placement Experience, Nursing Standards, and Reflection

This report analyzes a nursing student's placement experience in the renal ward of Flinders Medical Centre, focusing on record-keeping practices and their alignment with Australian nursing standards. The student reflects on a specific incident where handwritten notes were used instead of official documentation, leading to a critical self-assessment of the importance of accurate and timely record-keeping. The report discusses the implications of this practice on patient care, ethical considerations, and legal compliance, referencing relevant literature and nursing standards. The student identifies areas for professional development, including improved record-keeping skills, understanding handover procedures, and adherence to ethical guidelines. The assignment highlights the significance of decision-making, patient-centered care, and lifelong learning within nursing practice, emphasizing the need for nurses to maintain comprehensive and accurate documentation to ensure patient safety and uphold professional standards. The student concludes with recommendations for future practice and a renewed commitment to upholding nursing standards.

Running head: Nursing practice
Placement Experience and Standards for Practice
Name of the Student
Name of the University
Authors Note

1Placement Experience and Standards for Practice
Introduction
Australian nursing standards are interconnected with each other for treating the
patients with better facilities and proper interventions. Decision making and logical reasoning
are important during treatment and diagnosis of the patient. This assignment will discuss the
professional placement experience that I have experienced during my last placement. My last
placement was in the renal ward of Flinders Medical Centre. Assignment will clearly outline
the appropriate details and analyse the nursing practice relating to the professional placement
experience. This study will focus on the comprehension and reflection of my experience
during my duty hours and will interconnect the treatment facility and decision making with
nursing standards.
Discussion
Critical analysis of Professional Placement experience
Record Keeping and documentation are important aspect of Health and social care.
Nurses should keep the records with accuracy and detailing with proper monitoring and
protection. Well-kept records help a professional to defend herself during the legal procedure
(Thompson, & Wright, 2018). Documentation is one of the most accepted evidence in
professional world and research methodologies. A nurse can keep records by handwritten, in
a Computer Based system or combination of both. Patient’s record can be included with
medical records, nursing notes, medication charge, Lab reports, observational charts
handover and admission forms, checklist of discharge and transfer and different assessment
forms related to evaluation tools (Mutshatshi, Mothiba, Mamogobo & Mbombi, 2018).
Patient assessment forms consist of nutrition, for pressure area or injury records on mental
health care and observational letters which can help her in further treatment procedures. In
my professional experience, I have been diligent in observing the patients, but data were not

2Placement Experience and Standards for Practice
recorded in patient’s chart. Therefore I could not meet the standards of record-keeping as
keeping information in a piece of paper is not a good example of record-keeping. The
records are noted within regular interval of time. However, they cannot be considered as
authentic and consistent in representing the patients' record. The records were handwritten in
my own notes without any initials so, there are possibilities of absence of clarity, spelling
mistakes and lack of additional information related to patient’s condition. As per the
standardised nursing principles, nursing practice should maintain the two-way feedback loop
which consists of assessment, diagnosis, planning, implementation and evaluation with
accurate record-keeping. The record-keeping should maintain six principles such as
factuality , accuracy , completeness, timeliness, organizational and compliance with
standards. Considering the case study, the procedure of keeping all the record in a sheet of
paper helped easy observation but was not compliance to the standards. I would unable to
prove those observations as legal document in court for lack of evidence if any legal
procedures would take place. Moreover, handwritten data can be erased or manipulated by
others and could consist of speculations on unnecessary information (Stevenson-Agren,
Petersson, Israelsson, & Bath, 2017). If the nurse is culturally, different incomprehensive
languages might be present in the notes. Whereas, patient information chart given by
authority helps to keep the data in a specific, accurate and factual way. This event made me
realise my mistake and to be more cautious over small details because as a nurse, we are
dealing life and death of someone’s health.
Reflection on own practice
In this case scenario, I have taken the notes manually which can be manipulated but I
was thinking that noting observations in a sheet of paper is an authentic and would help
me in monitoring process. As I was sincerely collecting the details of the patients the
chances of inaccuracy decrease. According to the Department of Health of Australia,

3Placement Experience and Standards for Practice
Administrative Recordkeeping Guideline explains planning, consistency, communication,
training, modification, technological integration, delegation, responsibility, review are the
most important factors for keeping records in Healthcare Sector
(www1.health.gov.au. ,2020). I should handover rest of the work to another nurse during my
break. Handover of duty helps me to maintain consistent monitoring on the patient. ISBAR
structure of handover maintains the identification of patient current condition and any risk
management related to the deterioration of patient (Whitehair, Hurley, & Provost, 2018). The
process of handover of patients in nursing aims to prevent any kind of deterioration of
patients’ condition and immediate nursing support to the patients with better recommendation
in the break-intervals. Therefore, I could take help of ISBAR or any other handover tool for
monitoring the patients from the beginning of monitoring the patient . In maximum,
hospitals handovers are recorded in electronic medical records so that any kind of breach of
responsibility can be detected easily (Hada, Coyer, & Jack, 2018). In this scenario, I could
have taken the help of handover by verbal reporting as it is a part of procedure and helpful in
appropriate recordkeeping. I might not have all the evidences in the patient documentation
form instead of sheet for secure and accurate records. If the nurse keeps the records in the
official document then privacy of patient could be maintained in a better way. Chances of
breaching dignity of a patient could be reduced and dignity of a patient can be breached by
leakage of information. My decision of noting all the information in a piece of paper was
not a good idea for keeping records as no standard of nursing support the practice of noting
patient’s observational records in an unofficial document.
Link between Professional Placement experience and Nursing standard
Australian nursing standards are aimed to support patient with preventive, curative,
formative, supportive, restorative and Palliative evidence (Cashin et al., 2017). Nursing
standards are established to prevent physical, psychological and developmental abnormality

4Placement Experience and Standards for Practice
by ensuring the best nursing care provision to all patients (Hada, Coyer, & Jack, 2018).
Nursing and Midwifery Board of Australia ensures responsibility and accountability of
registered nurses. In NMBA standards for registered nurses are associated with criteria that
helps to interpret and demonstrate the professional context and duties of nurses in various
aspects ("Nursing and Midwifery Board of Australia - Registered nurse standards for
practice", 2020). In NMBA standards are associated with code of conduct of nurses, National
Framework for development of decision making, supervision guidelines of nursing and
midwifery and other national frameworks or guidelines in Australian Healthcare context
(Russell, Williamson & Hobson, 2017). Nursing standard 1 registered nurses are associated
with variation of thought process and strategy related to logical analysis during clinical
practices (www.nursingmidwiferyboard.gov.au., 2020). This standard supports the evidences
helping in decision making and provision of safe and quality Healthcare facility. This
standard ensures accessibility, analytical ability, quality nursing practice with person centre
and evidence-based nursing practices (www.nursingmidwiferyboard.gov.au. (2020).This
experience has shown that I was failed to maintain the standard quality of care provision and
consistent application of my knowledge while serving the patient. The nurse maintains
accurate and timely documentation for assessment of patient's condition. As a student nurse, I
failed to maintain the aspects related to contribution in quality of facility, improvement of
service and reliable research according to standard one of Australian Nursing Standards as I
forgot to record the details in the official document of the hospital. However, I recorded all
details in a piece of paper which cannot be considered as official documents. According to
standard nursing practice, no documentation means no work has been completed. This
incident was an evidence of poor decision-making and failure to maintain nursing standards
for quality of care. Patient-centred care could not be followed in the situation (Ballard,
2018). I have also shown lifelong learning approach as I am reflecting on my own service.

5Placement Experience and Standards for Practice
As I realised my mistakes which might lead to patient harm and medication error as I did not
record all the details and observation in official format. Additionally, I failed understand
importance of handover in maintaining the observation and to avoid any medication error
during treatment. I was able to understand the role and responsibility and there is always a
chance of development during nursing practices. In this event, I should focus on development
of practice during the service with best of my knowledge, actions and beliefs by keeping all
the records in the provided document by maintaining guidelines of nursing standards during
treatment. I would focus on accuracy of records and avoid late entries. I will take training to
learn different policies and abbreviations regarding nursing record keeping. I will learn to
prioritise the legibility and use different record keeping tools for improving my record
keeping skills. Violations of ethical practices and frameworks has been observed in the
incident. According to Nursing Ethics, quality of patient care, ethical management of
information and proper decision are some mandatory aspects of nursing practice. In addition
to the ethical guidelines of nursing practices will involve autonomy, beneficence, non-
maleficence and justice should be present in treatment. In this case study, beneficence and
confidentiality cannot be maintained along with breach of value statements 1(“quality nursing
care”), 5(“informed decision making”), 6(“culture of safety in nursing”) and 7(“ethical
management of information”) of codes of ethics(ahpra-search.clients.funnelback.com., 2020).
The inter-personal relation and effective communication can be disrupted by the practice due
to lack of information. After handover of patient, delegated nurse could not interpret patients’
condition and will fail to give proper medication because of lack of evidence. The nurse
cannot indulge in effective communication with the patients because no history regarding the
patient could not be found due to poor record-keeping practice. In addition to all the above
aspects, compliances of legislation policy and guidelines of common laws related to
Healthcare provision can be maintained by the nurse with the help of proper record keeping

6Placement Experience and Standards for Practice
(Atkins, De Lacey, Ripperger, & Ripperger, 2020.). However, I could not maintain the legal
compliances regarding record-keeping while noting down the observation. The registered
nurse was also offended by the practice and she ordered me to write all the details as soon as
possible. This will go against me as an evidence of lack of responsibility in court. In context
of the practice, decision making ability of mine is relative and can be questioned by the
supervisors as the official document was not filled up by me. Manual record-keeping has
potential to break ethical consideration and legal Framework sometimes. Therefore, I could
face problem if my notes are manipulated or lost as I did not use the official documents in
keeping the records.
Conclusion
This assignment has put some light on professional practice experience for me and
how I maintained registered nurse standard with professionalism and responsibility. From this
assignment this can be concluded that I have tried to give Healthcare provision in with my
best ability and understanding. Although some mistakes regarding Record Keeping troubled
me. I tried my best to maintain respectful professional relationship with the culture and
experience of patients. Well-kept records help a professional to defend myself during the
legal procedure. In this professional experience that I have experienced, I could have taken
the help of handover process as it is a part of procedure and helpful in appropriate
recordkeeping. Recommendations are also discussed in the assignment. This nursing
reflection helps to understand the importance of nursing standards and other guidelines for
Australian Healthcare context. In my upcoming placements as well as in my whole career, I
would never forget to record what I have already done.

7Placement Experience and Standards for Practice
References
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8Placement Experience and Standards for Practice
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Appendix
Professional Placement Experience
This assignment will focus on my professional placement in the renal ward of
Flinders Medical Centre and the learning experiences during my placement. It was the 2nd
week of my placement and I was assigned to two patients. Most of the patient in the renal
ward had high blood glucose level (BGL) so, strict monitoring of glucose level was done. My
assigned patients also had glucose and ketones charting every 1 hourly. As soon as my duty
commenced, the handover was given and registered nurse supervising me asked me to take
blood glucose level and record it in the patient’s file. Furthermore, a registered nurse also told
me to notify her if it is not in a normal level. I was continuously monitoring and recording in
the documents but later when I went for my break, I forgot to record that in the patient’s file..
I also showed her the small notes where I have written the numbers and she said to complete
documentation before the break if not possible it is always better to handover so, that patient
treatment would not be delayed in every possible way. Furthermore, registered nurse
reviewed me and told me to manage my task with sincerity. Registered Nurse was not
satisfied even after showing the record in my tiny little notes because for nurse
documentation is the sole defence to defend myself, but she did know that I have completed
my task within the accurate time. This event made me realise my mistake and to be more
cautious over the small details. Although, the work has been completed but biggest proof is
written documentation in nursing field.