On #NHSChangeday I committed to visiting front-line services – back to the floor if you will – to make sure I had the widest understanding possible of the challenges people face and how informatics could help. I have enjoyed my #nhschangeday activities so far. Over the last couple of weeks I have also visited Barts Health NHS Trust and Leeds and York Partnership NHS FT.
What have remained with me, since these visits, are some thoughts about record keeping.
When I do my clinical practice on the wards I work on an elderly rehabilitation ward. I find the documentation on the ward a real challenge. Each patient has an A4 folder for the nursing record and to my eye is full of assessment forms and I struggle to work out exactly what needs to be done for any one patient. For me an essential purpose of the record is to enable the best communication so that anyone supporting the patient’s needs can quickly understand how they can help. I thought it might be just me but after a CQC visit recently the trust, as part of their action plan, is doing lots of work to revise their nursing documentation.
Barts was interesting, as a large university hospital and for me personally it is a more familiar environment than many of the other places I have visited so far. They have a large Electronic Patient Record deployment and I was impressed by their informatics strategy – it is ambitious and focussed on sharing. I was, however, quite surprised to see how little structured nursing documentation it seemed to contain. It may be that I just went to the wrong places (it’s a big place) but in terms of consistent nursing content across different areas of the hospital that’s not what I saw or heard and I suspect this is part of their plans and the journey they are travelling – I hope so.
Then last week I had a great experience going to visit a forensic mental health ward. Other than it being a great learning experience for me, I am a general nurse with limited mental health experience, the record keeping took my breath away; reams and reams of narrative, with a few structured forms. I know this is likely to reflect the different cultures between the more assessment orientated general and nursing and mental health but the contrast was stark!
The Nursing and Midwifery Council Record Keeping Guidance states that record keeping is an integral part of nursing and midwifery practice. There are two key reasons for good quality record keeping; the first to ensure the delivery of safe and effective care and the second as a legal record of the care delivered. It is an essential asset if we are to deliver care across teams and organisational boundaries, making sure that patients don’t experience a ‘bumpy ride’ as they transfer care across individuals, teams and services. We also need good records for audit and research so we can assess outcomes and look at the contribution that nursing makes to the care of people. The RCN produced a document relating to this called ‘Making Nursing Visible’ which makes the point that if we have accurate electronic nursing records we can measure the impact of nursing practice on patient outcomes.
Over the last year record keeping has continued to be debated with many people seeing nurses being burdened by data collection systems. We need to find ways to make sure information is collected once, at the point of care, and used many times for other purposes, with the patient’s permission if it is required.
But the diversity of types and content of records is alarming. I have been listening to people talking about a standard language for nursing records for a few years and we never seem to make any progress; I’m not convinced that it isn’t a holy grail.
So what can we do? We know that nurses like narrative and see record keeping as a burden rather than a task they want to do. We know that we have to cope with the diversity of nursing settings that I continue to see when I visit sites. I’m not sure I know the answer but I do know that nurses and midwives need to be the ones who step up to meet this challenge. The worst thing that we can do is let someone tell us how to ‘do’ our record keeping and what we should be recording and how. We also are unlikely to be able to continue with paper record keeping in many settings. Compromise is also likely to be part of any solution – a willingness to focus on the patient rather than the history and culture of nursing and finally to accept that perhaps we need to change.
Informatics can help if nurses engage to make sure that systems are implemented well, with good clinical content that focuses on patients and working in partnership both with patients but also the multi-disciplinary team. It’s a leadership challenge for nurses with many people walking away from this issue in the past and as a result we often end up with systems that do not reflect what our patients or we need.
There are also emerging technologies on the horizon that might help. The developments in the field of Natural Language Processing is likely to enable us to be less focussed on drop down boxes and radio buttons but it will still mean we have to seek agreement over the use of some aspects of our record keeping. Barts Health are starting to explore and take steps on this journey. It may mean we talk less about ‘forms’ but may mean we need to think about the language we speak in, the words we use to describe particular aspects of care and that when, for example, we say ‘Pressure Ulcer, Grade 3’ we all mean the same thing. I think this is still about standards but perhaps different to the conversations we have had so far – I’m looking forward to watching this story unfold.
anniecoops 
When I was a general nurse we had the kardex in two a4 files either on the desk or in the office (old double nightingale ward (how I would miss them if working now), a fluid balance chart and a temp / obs chart and the drug Kardex at the end of the bed. The kardex gave plenty of space for the narrative of the shift.
Midwifery mutated into hand held notes for the pts (this was early 90’s) .
This is one of the issues of NHS Informatics for me – everyone seems to be doing their own thing, in their own silo and usually without consulting the patient.
Why can’t there be a tablet by every patient’s bedside? Nurses could put the data in there from observations, pts could see when tests are scheduled (I hated it when I was an inpt and the porter would roll up with the chair unannounced) , HCP could either add the narrative of the shift there or at the desk, Dr’s could pull up the results of tests on ward rounds – they could even be adapted to monitor things like BP, hr etc if necessary and that monitoring would be immediately added to the pts record (maybe even photographs of wounds, sores so that some analysis could be done on them to see how they are healing). I don’t think its a complex issue really, all the stuff is around, it just needs to be put together and then rolled out.
In 1992, Drs at Hope Hospital SCBU now Salford Royal Hospital were collecting real time monitoring information into an electronic record of the babies in intensive care, we had to key in tasks that were done so they would know when they looked at the record , what was happening. Yes, 1992.
Why are we still discussing this issue as something that ‘should’ be implemented?
(Btw any jobs going 😉 )
:0)
Thanks Mandy – your observations are right and I am starting to see some movement and change – I have seen some great uses of mobile technology. But everyone thinks their version of a record is ‘right’ and few involve the patient. I have seen many, many different versions of essentially the same ‘form’. We have to collectively move past this if we want to really get the best out of new technology. The most consistent documents I think are medication forms.
But then you are relating your experiences to the acute sector. My point is partly – its more diverse than that!
I know, Annie – but that was where I was focused for much of my relatively short career as a nurse (but it obviously made a huge impact on me – sometimes I long to be back there but then I recover my senses 😉 ) . I did like the handheld notes that came into midwifery – I felt that when either we were in the community, at a clinic, or in a labour room, we asked the woman where are *your* notes, made them part of the process. But I see that sort of autonomy has stopped at the edges – just pregnant women and children involved. Not even diabetics are allowed to be *that* involved with their care (in England anyway). Surely this should be an approach used with at least all chronic illness sufferers. What about the idea of asking sufferers of depression to write what they are feeling down into some sort of jointly owned record? Joint electronic access to these records could be a great way to engage patients actively with their care.
A lingering side effect of this is when ever I go to visit someone if its a close relative, I ask them if can have a look at the notes that are at the end of the bed to see how they are doing. (sometimes getting a couple or more looks from any nurse wandering by)).
I have always strongly believed that narratives can give a better ‘feeling’ of what is happening with the client than just a series of obs. I knew that I was really quite poorly earlier in the year because my BP was normal, but the nurse recorded it as fine and doubtless she didn’t record my comments. I tried always to give my pts a chance to talk about how they were feeling. I remember when I was a night nurse on a surgical ward (first job). There was a regular who was in for some treatment of her bladder tumour. I had a talk with her one night as she was restive and she reported that she didn’t feel ‘right’ and i noticed that her sclera were just a bit yellow. reported that both in the kardex and on handover and went on nights off. When I came back, she was terminal and died either that night or certainly very shortly afterwards. My comments had prompted them to look more closely at her on the ward round, gave her an uss and saw that she had advanced liver secondaries. I also remember being given a handover and being told about a pt who’d had a fairly major operation who was up already despite being just post op and doing really, really well. I had a look at the pts name, and sighed. The day nurse didn’t know this guy and she thought he was doing really great. However what she didn’t know was that this same guy who had had a GA earlier in the year actually had a very rare side effect of anaesthesia – he went psychotic. No one picked that up except me. Bang on 2 am we had an entertaining time when it hit big style… Not only do we have to have the narrative but nurses have to be taught how to interpret this along with what the quantittive material is saying. Is this taught in Schools of Nursing anymore?
Isn’t this being taught anymore in schools of nursing?
I’ve always found it a little odd that different hospitals have different forms, but then again I was once told by a Nursing officer in a hospital that she wouldn’t allow the nursing protocols of that hospital be shared on a HA (ie the same one the hospital was part of) because well they ‘belonged’ to that hospital & therefore part of the IP of that hospital. This is despite the fact most likely they were based on national evidence.
I’d hoped that this attitude had been done away with . Its inefficiency writ loud, imho, all these people in various different hospitals reinventing the wheel at the same time. Why can’t NHSE take control, set staff free with the project, give them a timeline, design the system (flexible enough to fit 95-99% of situations where nursing is done) and then roll it out?
Glad you enjoyed your visit!
My first thoughts are that to say that some of what happens in documentation in mental health nursing is proscribed by other disciplines, mostly notably psychology and psychiatry. Risk assessment in mental health ( which we do an awful lot of) is an especially fertile ground for large amounts of narrative – HCR-20 is a good example of this. The one it replaced was RAMAS, which was even longer and wordier! We do have a lot of complex, legal paperwork stuffed into our MDT files which must be there to keep the patient detained. Then there’s the CQUIN targets which can increase our file paperload. Patient led paperwork (My Shared Pathway, WRAP and Recovery Star) are also very narrative, though structured, assessment documents.
There is a lot of non-numerical data in mental health and there’s a lot of words -capturing the patient’s state of mind – what they say and what they do and how they feel – encourages the ‘reams’ you identified!
I’m not sure what the answer is for mental health. I would encourage you to go to an acute open unit, like Becklin next to SJUH and see what differences you notice.
Interestingly, my most developed skill in recent years is that I’ve become a fast typist……..
I think we could use tablets for real time mental health observations. I think I may have wittered on about this before.
Hi Anne, Very interesting post and I’m pleased that you enjoyed your visit. We certainly loved having you with us for the afternoon.
Forensic MH is not particularly my area of expertise, so I’m generalising a bit, as there are variations across different areas of mental health. However, that said, I think that the reason why we write so much in mental health is because I think we tend to be less medical in our assessments, as we have to base our assessments predominantly on our observations of a persons behaviour, speech, interactions etc. We tend to write a lot down I think to create a broad picture, as we are often not able to rely on a straightforward medical diagnosis and treatment plan.
I don’t want to imply that Adult Nurses are not holistic, as I realise that other factors also greatly influence physical health and treatment/ care and that these are illustrative within documentation, but I think the difference is possibly in level of emphasis.
However, that said, I think we do over document and that this is historic and cultural and often influenced by other factors such as accountability, regulation, litigation, commissioning …. rather than solely about a persons care.
I think we need to simplify how much repetition and duplication there is and we need to be much smarter about how we use emerging technologies and also in how technology can support practice and facilitate more time for direct patient contact. I think there is also a challenge in how we use technology in a way that facilitates more access and involvement by the person who we are writing about, particularly as much of what we write is subjective and may not be a view shared by the person we write about. It’s complex, as there will always be differences in views here and there will always be other issues to consider such as third party information. However, I firmly believe in ‘ Nothing about me without me’ and think we have further to travel with this.
Finally, I really like your suggestions about Adult Nurses and Mental Health Nurses spending time in each others areas in order to reflect further on this. I wonder if the connections forming through #HSCLeeds could help facilitate this locally. 😊
Our deployment of Electronic Records was facilitated by strong clinical leadership and an emphasis on staff engagement.Deployment is the start of the process in order to sustain and embed the changes in practice this approach needs to continue in the face of financial and other considerations, record keeping is the bedrock of practice and should be recognised as such.
Thanks Anne great blog
Another great piece Anne. You have been busy haven’t you! Please keep on doing what you do, as per my comment on your other blog, it’s affirming that those of us already with you on this journey do live in the real world.
Thanks Mandy. You make a tremendous difference both locally and in the wider community and help me stay sane :0) informatics is one of the most challenging places I have ever worked and I am grateful for your support! I hope that is mutual too :0)
Anne
You have touched on a subject very dear to my heart, nursing (and other health professionals) interaction with the patient and recording of information electronically.
Yes Natural Language Processing seems to be the way forward for nurses and patients too and I think Consultants may also benefit from such systems converting a “daily diary” to monitor the patients care.
The biggest problem, apart from needing the processing power for the software to “Convert English” to “Binary” is your interaction. We still see an interaction with the patient, then having to interact with the screen either at the bedside with a tablet or having to go back to the nurses station to enter on a keyboard.
What has really got to come soon is a move away from the 2 step information gathering to the 3 way simultaneous interaction of Patient, Nurse and computer. Yes recording information whilst you interact with the patient.
Currently technology is being developed on the market that could achieve this but it will take a brave NHS or individual professionals to push the boundaries.
For instance, Google Glass and other IT eye ware are appearing with built in microphones which will record and convert your conversations with patients, convert this to text and then display the information in the small screen for verification.
If a patients Early Warning Score suddenly goes up, you could get a warning even if you are interacting with another patient.
Other interactions could be the meds round, automatically recording medications from the bar code to the patient. Right Med on time every time.
Sounds far fetched?
I think you need to look at your working time. How much of your day is sitting in front of a patient against how much of your day is spent in front of a screen or writing/reading.
With the NHS at such a financial crisis point it might be the only way to make your lives possible in the future.
As always I look forward to more of your blogs Annie.
Thank you for your comments Anthony and i agree with you- we have a long way to go but one of the points am trying to make s that professionals, working with patients, need to own this. Not be done to. And that means courage and stepping up 🙂
AHPs and many other professions in health and social care have the same problems. There is a flicker of hope emerging from the Professional Record Standards Body launched to help. http://www.theprsb.org.uk/
Hi Liz
Thank you for commenting and the link. For a while I was a member of the PRSG but it is dominated by doctors and nurses (and AHPs) struggle to get the voice they deserve in this forum. I’m also not sure that a group organised in this way can go fast enough but I wish them luck!
Anne