Course content – PFLEGE-16

13. Module 12 · Self-care & documentation

13.2. Application: one step for you, one for your team, one good note

Application

One step for you, one for your team, one good note

This page shows how to turn the ideas of the last pages into actions: a small plan for strain and a short care note. Your organisation’s procedures for records, confidentiality and support apply in every case.

Worked example: Ms Weber

Return to Ms Weber from the start of the module. A colleague, Mr Ali (fictitious), says after the shift: “You seem tired. Do you want a coffee?” She tells him about the death of the resident and that she feels empty. He listens. Together they go through the signs in Figure 12.1: poor sleep, dread of Mondays, cynicism and missing notes.

  1. Name the signs. Ms Weber writes down what she noticed in the last month: waking at 4 a.m., irritability and unfinished records.
  2. Pick one step for herself. She decides to keep her days off free of work messages and to walk for twenty minutes after the early shift.
  3. Pick one step for the team. She asks the team leader for a short debrief about the resident who died, and for the next case discussion to cover the unit’s hardest evening hours.
  4. Ask for help where it belongs. She mentions the rota and the number of residents per night shift to her manager and asks whether the organisation offers supervision or support for staff. The manager agrees to check.
  5. Write one good note. She picks up her records again and writes an entry for a resident who calls out at 5 p.m.: “Calls ‘Mother, mother’ 5 to 5.30 p.m. in the lounge, hands on face. Sat beside her, held her hand, named her mother; calmer after 10 minutes. Try again.”

Notice what happened. Nothing was cured, and no one was blamed. Ms Weber moved from silent exhaustion to a small plan that used three levels (Figure 12.2). If her signs continue or become strong, the next step is to speak to her own doctor or the occupational health service, which is not a failure but good self-care.

Phrases to adapt
SituationYou might say
To a colleague“You seem tired. I have ten minutes. Would you like to tell me what is going on?”
Asking for help“I am at my limit today. Can someone take over the evening round with me?”
To the team leader“Could we have a short debrief about Mr Fischer’s death? Several of us are struggling.”
At handover“At 5 p.m. she calls for her mother. A walk and holding her hand helped for ten minutes.”
Setting a limit“I cannot take extra shifts this month. I need my days off.”
Exercise (voluntary self-check). Read this fictitious note: “Mr Peters was difficult again and refused his shower. He is just stubborn.” What is wrong with this note? Rewrite it in three short sentences: what you saw, what you tried, what helped or what you will try next. Add one thing the team should check before they conclude that he is “stubborn”.
Hint 1
Look at Figure 12.3. “Difficult” and “stubborn” are labels. What did Mr Peters actually do or say, and when?
Hint 2
Remember what resistance can mean: fear, shame, pain, being overwhelmed, cold or loss of control (Module 9). You do not have to know the cause, but you can note what you tried.
Suggested answer
Problem: the note contains labels and an opinion, no observation, no time and nothing the next carer can use. A possible rewrite: “At 7 a.m. Mr Peters stepped back from the bathroom door and said ‘No, not now’. I did not insist and offered a wash at the sink at 10 a.m.; he accepted with a flannel and a towel. Next time: offer the wash at 10 a.m. again and tell him each step.” The team should check pain, fear, shame, his earlier habits and the time of day (life history, Module 5) and ask the nurse in charge whether anything medical could play a part.
In German practice you will hear …
  • Selbstfürsorge – self-care
  • Supervision – guided reflection with an outside facilitator for staff
  • Fallbesprechung – case discussion in the team
  • Übergabe – handover between shifts
  • Pflegedokumentation – care records
  • Pflegeplanung – care planning, including goals and measures
  • Biografiearbeit / Biografiebogen – life-history work / life-history form
  • Gefährdungsbeurteilung – employer’s hazard assessment, which should include psychological strain