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.
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.