What is the most appropriate approach for a journal entry on patient care?

Selecting a QSEN Competency for Your Patient Care Journal Entry

For a meaningful patient care journal entry, focus on "Teamwork and Collaboration" as it provides the richest framework for demonstrating professional nursing practice while naturally incorporating elements of professionalism, safety, quality, and informatics. 1

Why Teamwork and Collaboration is the Optimal Choice

This competency allows you to showcase the most critical aspects of modern nursing practice through real patient care scenarios. 1 The evidence strongly supports that interprofessional collaborative care directly improves patient outcomes, health-related quality of life, and reduces healthcare complications. 1, 2

Key Elements to Address in Your Journal Entry

Patient-Centered Team Communication:

• Document how you used person-centered language and active listening with both the patient and healthcare team members 1
• Describe specific instances where you elicited patient preferences and beliefs while coordinating with physicians, pharmacists, dietitians, or other team members 1
• Explain how you assessed and addressed barriers to care (literacy, cultural factors, financial concerns) in collaboration with the multidisciplinary team 1

Collaborative Care Planning:

• Detail your participation in formulating a patient-centered care management plan with the team 1
• Describe how treatment goals were established based on individual patient preferences, values, and goals through team discussion 1
• Document how you contributed to ongoing care plan updates as the patient's condition evolved 1

Interprofessional Team Functioning:

• Identify which team members you collaborated with (physicians, nurse practitioners, pharmacists, dietitians, social workers, etc.) 1
• Describe specific collaborative behaviors: sharing knowledge, respectful communication, joint problem-solving 3, 2
• Document how being "on the same page at the same time" improved care delivery efficiency 4

Safety and Quality Integration:

• Explain how team collaboration prevented potential errors or improved patient safety 1, 2
• Describe how coordinated communication at care transitions (shift changes, transfers, discharge) protected patient safety 1
• Document how team-based care reduced healthcare resource utilization or prevented complications 1

How This Naturally Incorporates Other QSEN Competencies

Professionalism is demonstrated through:

• Using ethical communication practices and maintaining patient confidentiality during team discussions 1
• Advocating for patient needs within the team structure 1
• Demonstrating accountability for your nursing role within the collaborative framework 5

Informatics and Technology integration occurs when:

• Describing how you used electronic health records to facilitate team communication 1
• Explaining how you shared patient information through computerized systems while maintaining eye contact and patient engagement 1
• Documenting how technology supported care coordination across team members 1

Common Pitfalls to Avoid

Do not write vague statements like "I collaborated with the team." Instead, provide specific examples: "I initiated a team huddle with the physician, pharmacist, and dietitian to address Mrs. Smith's uncontrolled diabetes, where I shared my assessment of her medication adherence barriers and cultural food preferences." 1, 4

Avoid focusing solely on task completion. Emphasize the relational and communicative aspects of collaboration—how you built psychological safety, resolved conflicts, or adapted the care plan based on team input. 4, 3

Do not ignore the patient's voice in team discussions. Document how you ensured the patient and family were active participants in collaborative decision-making, not just recipients of team decisions. 1

Avoid generic descriptions of "good teamwork." Specify the collaborative behaviors you demonstrated: active listening, knowledge sharing, respectful disagreement, joint problem-solving, or coordinated care transitions. 3, 2

Structuring Your Journal Entry

Begin with a specific patient scenario that required interprofessional collaboration, describing the clinical situation and why team involvement was necessary. 1, 4

Detail your collaborative actions using concrete examples of communication, shared decision-making, and coordinated interventions with specific team members. 1, 3

Analyze the outcomes of collaboration on patient care quality, safety, efficiency, or your own professional development as a team member. 1, 4, 2

Reflect on challenges encountered in the collaborative process and how you addressed them or what you learned for future practice. 4, 5