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Ticks all the boxes: The rise and rise of defensive nursing

January 21, 2014

How’s this for an example of convenient doublethink? The Under Secretary of State for Health asserted in a parliamentary debate on nursing last week that “Ticking boxes on minimum staffing levels does not equate to good care. As the Berwick review made clear, ticking boxes in relation to minimum staffing levels does not equate to good care.” What he’s really saying is that whatever the merits – or otherwise – of mandatory minimum staffing levels, the Coalition doesn’t want to be tied down to the financial implications of paying for them. But he also raises a wider question: if ticking boxes doesn’t equate to good care, why do nurses spend so much time doing exactly that?

The number of regular (weekly, daily, even hourly) assessments nurses are expected to undertake on every patient in their care has burgeoned in recent years. Although there’s still some variation between Trusts, the list routinely includes nutritional intake, bowel movements (frequency and type), continence, infection screen, catheter care, cannula site, pressure areas, oral mucosa, feet, falls risk, moving and handling…and that’s before you’ve even got started on fluid balance charts, vital signs, intentional rounding, repositioning, ‘fundamental care’ and the nursing kardex itself. Patients’ notes, it sometimes seems, have become miniature temples to the all-conquering tick box.

Completing all this paperwork takes up a lot of nursing time – something which would, perhaps, be justifiable if it resulted in demonstrably improved patient care. But does it? To answer this question, we need to look at why it has been introduced. In his excellent but rather overlooked new book Nursing in Context, Michael Traynor argues that Evidence-Based Practice was ‘a child of its time. It emerged during a period preoccupied with a) risk, b) ambivalence about the status and role of experts…and c) concerned with effectiveness, the following of procedures and the power of the consumer’ (p 92-93). According to this reading, Evidence-Based Practice – despite its undoubted strengths – is not the objective, agenda-free solution that its supporters would have you believe. Rather, it represents a particular workplace response to a particular set of socio-political circumstances.

Wide-ranging and repetitive risk assessment is the deranged little sister of Evidence Based Practice. Originating primarily in Trusts’ need to protect themselves against costly litigation in a risk-averse and consumer-focussed culture, its purpose is to prove that assessment has taken place and appropriate risk-containment strategies instigated. Nursing has been co-opted into acting as the agent through which these counter-balancing instruments of control are enforced. Arguably, this railroading of the profession into largely defensive functions is the single factor that has done most to hold it back: it has effectively cut it off from the pursuit of any distinctive vision of its own.

The only way nursing has been able to retain its credibility in the face of this blatant hijacking is to cloak multiple ongoing tick-boxing in the at least partial respectability of Evidence-Based Practice; but it isn’t Evidence-Based Practice. Take Intentional Rounding (my favourite subject!). Last May, the Nursing Times published an article by Paul Snelling which comprehensively demolished the evidence base for this widely-ridiculed (at least on the wards) ode to the tick box and exposed its widespread adoption as little more than political genuflecting. And it doesn’t stop there. Just last week, the same magazine published an article on Early Warning Systems (EWS) which noted that ‘there is poor evidence behind the use of EWS and further research is needed to validate their use’.

That Trusts continue to insist on compliance with these decidedly shaky initiatives is reason in itself to suspect that sound research backing is not the primary reason for their popularity.Because so much time is now spent policing the risk-averse culture that consumers apparently demand, one answer to those among their number who complain that nurses ‘spend too much time on paperwork’ or ‘lack compassion’ is “actually, you have got exactly  the NHS you wanted – it’s just that advancing this type of health care will inevitably produce other, unanticipated consequences as well.Unfortunately, some of them may be less palatable.”

One of these less palatable consequences is extension of risk aversion out of the realm of physical risks and into the realm of communication. Where nurses’ mindset is conditioned by the prioritising of risk minimisation, fear of upsetting someone by ‘saying the wrong thing’ becomes entirely justifiable. From there, it’s a short step to ducking out of meaningful communication altogether, and taking refuge in ‘this important paperwork I’ve got to get through’. An even bigger problem is that all the box-ticking and form-filling potentially reduces the nurse’s subconscious conceptualisation of the patient to nothing more than an atomised collection of checklists and discourages nurses from original thinking.

But the biggest problem of all is that checklists may not achieve what they have been put in place to do – namely, improve safety. In a highly- recommended 2009 article from The Lancet, Bosk et al warn against the simple adoption of checklists as a solution to health care problems. They argue that ‘widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patients’ safety and to high-quality care’ and conclude that ‘when we begin to believe and act on the notion that safety is simple and inexpensive, that all it requires is a checklist, we abandon any serious attempt to achieve safer, higher quality care…nothing threatens safety so much as the complacency induced when an organisation thinks that a problem is solved’.

Bosk suggests that the most common misconception about checklists is ‘the assumption that a technical solution (checklists) can solve an adaptive (sociocultural) problem’. The sociocultural problem here is how best to preserve the ‘caring’ aspects of nursing in a society obsessed with managing risk. But where nurses fail to grasp the true function of the technical solution, and place the blame for excessive paperwork squarely on the shoulders of ‘haven’t got a clue’ managers, the temptation is to punish those managers by completing the paperwork, but only in a rote or purely mechanistic fashion, with minimal reference to the actual patient.

While of course no one wants patients to come to harm, this uncontrolled growth of the first element of the nursing process has stealthily, and with minimal discussion, altered our focus and distorted our discourse. The time has come to ask whether the pernicious effects of these these sociocultural forces on nursing can be mitigated; but we can only start to do that if we look them squarely in the face and acknowledge what they are.

Traynor, Michael (2013): Nursing in Context: Policy, Politics, Profession. Basingstoke; Palgrave MacMillan

For the Hansard transcript of the Parliamentary debate on Acute Hospital Wards (Staffing), see:

For Paul Snelling’s critique of Intentional Rounding, see:

For the article on Early Warning Systems, see:

For Bosk et al’s article on checklists, see:

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