Praise the Automaton?

[jayebug]

I guess, since it's nurses week, I've been reflecting on my career choice, and regardless of whether or not anyone wants to be subjected to any of my revelations, I thought it was necessary to share them.

Lately, I've been thinking about what it means to be a nurse. In nursing school, I had an instructor who stated that nursing, as a career choice, is "a calling rather than a profession." I think her words stuck with me because it really defined how I view nursing practice. To me, a nurse is an educated professional who incorporates their continuously acquired knowledge and skill into the action of providing care and guidance to each specific patient in order to assure a more desirable health outcome. Wordy, I know, but let's just say that it's difficult to touch on every facet of nursing in one sentence, so I'm trying to describe here, what I view are the most important aspects. These are : education, patient instruction, implementation of a finely tuned skill set, and overall planning and collaboration. I purposefully did not include the execution of tasks or documentation of events here so much because I honestly don't believe that these are MOST important parts of nursing practice. And I never will.

Of course, this always seems to cause an uproar amongst my colleagues. I think mostly because they're missing my point. I won't say that task completion or documentation isn't important. It is. But I find that, in the course of any given shift, nurses are so inundated with tasks and documentation that, really, in an attempt to deliver excellent patient care, one must really prioritize their actions.

I'll give you an example. I recently had a patient who was admitted to my unit around midnight on a night shift with a diagnosis of pnuemonia and pancreatits. If you think about all those nursing diagnosis you learned in school, then I'm sure you understand that inadequate oxygen exchange, pain control, and fluid and electrolyte imbalance (secondary to vomiting) were the priorities when developing a care plan for this particular patient. So, I got report from the ambulance crew, and, after I insured the patient was well oxygenated via nasal cannula, I brought the bedside computer (or WOW) into the patient's room and completed the admission. I drew and sent his labs, reviewed the doctor's orders, checking specifically for pain medications and antibiotics, prepared for him to be sent for various scans and tests, and, after verifying his name and date of birth via ID band administered the appropriate medications. The patient had come to the unit via the health system owned ambulance company from a subsidiary hospital. The ID band that he had on was from that hospital, unfortunately, in all the hustle and bustle of his admission, I forgot to apply a new ID band. OK, not good. I admit my mistake. The ID band he had on looked identical to the ones that were specific to the hospital where I was working, because it was the same health system, but it didn't have the correct institution written on it. Upon discovering this, the day shift nurse alerted, I think, every possible disciplinary figure she could think of and, subsequently I had to answer to my nurse manager who described this as "a very serious issue". The upside, however, to my meeting with the nurse manager was that she emphasized the importance of bedside hand off in order to review anything that has been missed by the previous shift.

I firmly believe in bedside report, although, many times I get a lot of resistance because I think that the other nurse feels as though I'm looking for things to bring to the attention of management, but honestly, I'm thinking of the patient and providing a smooth continuum of care. I can tell you that in the course of my 11 yr career, I have only "written up" two people and that was when patient safety had been seriously threatened or compromised. This goes back to my statement of what I think the most important aspects of nursing practice are in that I cannot prioritize the disciplinary action of another nurse over delivering patient care unless their actions are serious enough to merit this and/or are further unresolved by simply speaking to that person.

The importance of appropriately prioritizing patient care related tasks and documentation is something that I feel is missing in the nursing profession. I use the above example as an illustration of this. My point being that with the recent*increase in litigation that has been occuring over the years, it seems that nurses are forced to view every minute detail of our interaction with patients as being especially relevant to their overall care. In all of the what was going on in the specific scenario I just described, I can really see how I missed the ID band because it was really at the bottom of my list of prioritized tasks that I'm certain would have been completed in entirety should I have had the time. I know. It's the age old "24 hr job" thought. Am I negating it's importance? No. I'm just saying it wasn't AS important as some of the other tasks that I actually did complete during my provision of care to this particular patient.

I'm also concerned by, what I have seen in many facilities and would describe as, an emphasis on overdocumentation. The truth is, many facilities are keenly aware of the legal ramifications of providing an inadquate timeline of services rendered to the patient. The initial introduction of the nursing flowsheet was one way of establishing a "blow by blow" record of patient care services, status of a patient's condition, and reaction to treatment. However, it seems that a lot of nurses fail to view it as such, placing their emphasis on the written narrative instead. This quote is from a recent article I was reading from the American Hospital Association that stated:

"One strong advantage is that flow sheet design can incorporate clearly defined expectations for the type of patients cared for on each unit and in each care setting. A standardization of forms process within each facility allows caregivers to provide consistency in patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by nursing interventions. Charting by exception can reduce the amount of time spent on documentation.Charting by exception has the potential to be a great asset to electronic medical records documentation. The use of quickly scored checklists that document routine matters complement at-the-bedside computerized data entry. By shifting the emphasis from descriptive, discursive narrative paragraphs for every routine and expected event, CBE uses minimal narrative notes for only unexpected or highly significant events. CBE may be the cutting edge of medical documentation (Stansfield, K., Yetman, L., & Renwick, C., 2009). "

In short, I'm not a note writer. I never will be. I guess my question, here, is if we are being provided with technology that allows for us to spend more time at the bedside, then why are we not using it appropriately? I also completely agree with decreasing the nurse to patient ratio, but I disagree with the idea of spending the extra time that this allows for by excessively documenting on those 4-5 patients. The article I quoted before also stated:

"If it wasn't Charted, it wasn't Done"*is inaccurate and misleading,according to Dan Small of the legal firm Holland & Knight and Launa Rutherford of the firm Grower, Ketcham, Rutherford, Bronsor, Eide & Telan.Good documentation is important, they continue, but documentation is not care. "Nothing in the law requires health professionals to document everything they do or say. That would be impossible."*Charting should be "a way of trying to record things that give a fuller picture of the care", along with specific key elements essential for documentation."

I worked at a very prestigious facility recently where the manager of my unit boasted about adequate ratios and the recent introduction of a paperless EMR system, but I still found that the staff was placing priority on written notes even when nothing untoward had occured during their shift. They justified this by saying that "it only takes a few minutes to write a note", but, as I stated before, why are we allowing for this to become just as crucial as caring for the patient at the bedside? I was under the impression that one of the reasons EMRs are becoming so popular in facilities was, not only, to standardize documentation but to make it less time consuming to meet the required standards for describing what happens to a patient during any given shift. I think that viewing the EMR as means to increase the volume of progress notes in a patients' chart is sadly erroneous and it keeps nurses away from their patients.

In conclusion, I just wanted to share some of my thoughts and concerns about our practice during nurses' week. I agree that my views may be seen as non traditional, but I believe nursing is a professional occupation that should be open to evidence based actions. I tend to disagree with a non reflective, "just stick the pill in the cup" modality that still seems to be so popular, even amongst new nurses. I really think it's okay to not be an automaton!