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The Land that Time Forgot: Is Rethinking Documentation the Key to Nursing Reform?

June 21, 2013

There is a place where everything that holds nursing back is set down in black and white. There is a kingdom where all the old attitudes – complacency, anti-intellectualism, paternalism – that the move to higher education was supposed to sweep away, still reign supreme. “Where is this land that time forgot?” I hear you cry “Closer than you think” I reply. “You might even have been there today. It’s the nursing notes”.

Nursing documentation has barely changed in thirty years. It is still completed in laborious longhand. It still centres on the care plan, itself based on a nursing model – usually Roper-Logan-Tierney – superimposed on the ‘Nursing Process’. It is the care plan that provides the basis for the ongoing daily (or three-times -daily – once for each shift) ‘evaluation’.

Trained nurses routinely devote hours of every shift to the production of these evaluations and the imperative of getting them finished is a frequently-cited reason for failing to leave work on time. Which makes it all the more tragic that so much of what is written is total, unmitigated garbage – meaningless, formulaic, dehumanising nonsense that is completely unworthy of a graduate profession.

The standard of intellectual rigour showcased by the average set of nursing notes is actually beyond parody. So what follows is not parody; sadly, it’s genuine. Here – in reverse order to ratchet up the tension – is my own general wards nursing notes top ten. It’s by no means exhaustive.

10. Catheter draining satisfactory amounts. As a unit of volume, ‘satisfactory’ (along with ‘good’, ‘poor’, ‘adequate’ and ‘fair’) was considered embarrassingly unscientific when I did my training in the 1980s. Thirty years later, it’s still rare to see exact intake or output measurements recorded in the notes.

9. Tolerating diet and fluid. Is this a reflection on the standard of NHS gastronomy? Or does it just mean ‘eating and drinking’? NB: using the word ‘tolerated’ does not make you sound more medically qualified.

8. No complaints of nausea or vomiting. Why waste time documenting the absence of abnormality?

7. Medication taken as prescribed. As already recorded on the drugs kardex, presumably.

6. Patient appears low in mood. Is it surprising? No one seems to recognise him as an individual. With a name.

5. Incontinent of urine. Nursed in pads. Any idiot can put a patient in a pad. This is not nursing. Nursing is about using evidence-based interventions to promote continence.

4. Confused at times. Orientation provided. Information from the Alzheimer’s Society website: ‘No one likes being corrected all the time – it may simply be irritating, but it can also severely undermine a person’s confidence’. If the general public is thought capable of assimilating this sensible advice, why do nurses continue to give the impression that they are not?

3. Drinking good amounts by mouth. Er…is there some other way of drinking? ​

2. Nursed in a safe environment. A hospital is a safe environment? Are you kidding me? Outside a war zone, it’s possibly the most unsafe environment I can think of: it’s full of germs and people die every day. If you mean you’ve ensured the area around the bed is free from obvious hazards – OK. But don’t forget the Care Quality Commission thought Furness General was ‘a safe environment’.

1. Maintaining own airway. Really? I mean…seriously? The patient is breathing? Have you told the British Medical Association?

The abysmal standard of most nursing documentation is, of course, symptomatic of a much wider malaise. Writing it focuses nurses’ attention not on what matters but on what doesn’t. As a communication tool, it’s not fit for purpose. Despite all the slaving over it, you can still arrive on duty and find, when you ask if a patient is mobile or continent, that no one can tell you. As a legal record, it’s a joke; in a court of law, it would get laughed out or ripped to shreds. The failure to embrace research, the failure to embrace IT, the continuing triumph of ritualistic culture over original ideas and rational actions – all of them are played out every single day across that dark underbelly of nursing, that vast sink of mediocrity, the nursing notes. Never was a workplace system so ripe for root-and-branch reform.

The projected shift to a paperless NHS by 2018 provides an unparalleled opportunity for wholesale re-thinking. What we need here is paradigm shift. Fresh ideas. Re-imagining. What we do not need is the same old rubbish simply transferred to a different data base. So just supposing we were starting out anew, how would we visualise the ideal nursing documentation? Here are a few ideas – again, the list is not exhaustive.

1. Involve the Patient. Whenever possible, patients should document their own progress. This is particularly relevant to problems like pain and nausea/vomiting. Nurses could track the patient’s pain levels, viewing how well and how quickly they respond to analgesia and which activities make them worse.

2. Avoid Repetition and Free Up Nursing Time. Where all data bases are unified, it should not be necessary to repeat in a different format what has already been documented elsewhere. So when a patient’s observations or nursing interventions (for example) have been recorded electronically, there would be no need to re-enter them in the nursing notes.

3. Documentation-in-action. Nursing interventions should be documented at the bedside, as they occur, by the person who carries them out. This will mean nurses no longer have to remember what happened sometimes hours before they come to write about it and will not have to rely on other people’s accounts of events they did not personally witness. In addition, it will make staff more accountable and provide more accurate timelines. If the impulse to bring this about hastens mandatory Health Care Support Worker registration – hooray!

4. Only document what’s important. Changes in the patient’s condition, how they were dealt with, concerns raised by family – these are important. Relaying the news that the patient continues to draw breath is – usually – not.

5. Fluid Balance Charts. Notoriously inaccurate, how about special cup holders that record how much fluid a patient has drunk by weighing it and feeding the results into the database?

6. Ditch Roper-Logan-Tierney. How much use have models ever been to nursing, really? Have they held it back? The only one that has even been generally adopted is Roper-Logan-Tierney, and its premise on a reductionist, Cartesian view of the individual has arguably been more of a hindrance than a help. Time for something more sophisticated.

The current state of much nursing documentation is genuinely scandalous. It demeans patients and infantilises nurses. This hasn’t happened because nurses are dim. It’s happened because the documentation protocol they have to work with is stuck in a time-warp. It is not, however, without consequences; what should us concern is the possibility that the daily reproduction of outmoded values in the nursing notes risks normalising, amongst nurses, a correspondingly outmoded conceptualisation of the nurse-patient relationship. At their most extreme, these concepts, even if  held only subconsciously, could become contributory factors in the evolution of horrors like the one at Stafford Hospital. What is even worse is that no one is talking about it. The nursing press, professional organisations, even the Francis Report – all are strangely silent. Time to lift the lid?

  1. lesley58 permalink

    This is the most common sense article I have read in a long time. The lid definitely needs to be lifted.
    Maybe something Jane Cummings could investigate. We nurses would have more time for
    “compassion” and actually nursing if the documentation process was streamlined.

  2. Hi Lesley, thanks for commenting. The nursing notes fascinate me because of my interest in writing, and I believe language is one of the most intriguing facets of nursing. If I were to conduct research, this is an area I would definitely consider! It’s also ripe for some real leadership, as you say.
    I think there is less tolerance these days of some the more openly derogatory remarks nurses used to make about patients in private handover conversations, but the nursing notes – which are often completed in a hurry, with nurses too tired or harassed to think clearly about what they are writing – are potentially a mine of information about attitudes. I assume students are not taught to document like this, so its persistence in the ward environment, is also an interesting pointer to the socialisation processes. With the growth of IT, things are moving very slowly towards rationalisation, but we must ensure that we don’t end up perpetuating the mistakes of the past, but now in electronic form.

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