Under pressure: paperwork in the NHS

Physiotherapist Chris Tuckett sees nursing colleagues struggling on the clinical frontline every day. And he shares their pain on paperwork.


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Trusting medical staff can also empower them

I might not be a nurse, but I think my allied health professional background allows me to see what a travesty the nursing profession has become: it is now a desk job without even the luxury of a desk. I have spent the last eight years nestled in the safety of a musculoskeletal outpatient physiotherapy department in a very busy acute local hospital. There, you are protected and somewhat oblivious to the wider hospital activity.  
However, I felt it was time for a change and so when the opportunity to become the falls co-ordinator for my trust arose I embraced the change. And what a change it has been. First, moving from the relative safety of an outpatient department to a ward-based role is a culture shock. The chaos and level of activity on the wards is mind-boggling. 
You get a real sense of how the hospital is fighting to survive in a climate of cutbacks and funding crises while still trying desperately to offer safe and effective healthcare. All the while an ageing and increasingly unhealthy population continues to stream through the front door seemingly without any collective awareness of the need to try and improve their own health and wellbeing. 
Amid this frenetic activity are the nursing staff who battle bravely and forlornly against the incoming tide. To my eyes, they seem woefully under-staffed. This could be blamed on a number of factors: low salaries, low morale, job frustrations, a lack of willing recruits and a general media representation that paints nursing as a thankless task. This means the next generation don’t consider it as a potential profession. 

Mountains of paperwork and form filling

So, in the face of all of that, you would think a priority would be to ensure that the current nursing staff can go about their work as efficiently as possible. Sadly not: instead we tie them up in mountains of paperwork, risk assessments and form filling. If there is one thing that has shocked me more than anything then it is the sheer volume of paperwork we expect nurses to complete.
They have handover forms, endless risk assessments, care rounding charts, integrated patient records, flow charts, protocols, policies, root cause analyses, reports, staff reviews, observation charts and a million-and-one tick boxes to complete for every single patient sometimes on an hourly basis.
They have a mountain of paperwork that would make a bank manager blush, yet they do not even have the luxury of a proper desk. This all has to be completed at a nursing station or the foot of a patient’s bed while being disturbed by anyone and everyone.
Of course this paperwork is all deemed important and necessary to preserve ‘patient care’. But personally, I think that it is simply there to ensure that in the event something goes wrong then we can apportion blame and say ‘that is why X or Y occurred’.
Hospitals are terrified of complaints, to the point that they consider the retail model something to aspire to, and so enthusiastically invest time and money in surveys, ‘consumer’ feedback and patient engagement activities.
But they miss the point that healthcare and retail are fundamentally different arenas. In retail they charm you and respond to feedback because they want you to return to get more of your money: it is essentially a bribe. And, to be fair, most of us are experts in what constitutes a good retail experience. 

Mistakes happen but things go smoothly

In healthcare, however, it is completely different. First, we do not want patients to return. Hospitals are already under-funded and over-used so there is no value in wanting to make people return. Second, most of us are not experts in what makes a good healthcare experience.
We think we know but beyond the basics of cleanliness, speed, accuracy and politeness thousands of decisions are made that are completely beyond our knowledge base. We should entrust the doctors, nurses and support staff to deliver the healthcare that they are trained to deliver. 
But when mistakes happen – and they do, and always will happen – with this huge paper trail there is inevitably some piece of paperwork missing or incorrectly filled out. We can then point to it as evidence of why the mistake occurred, even if the paperwork really made no real difference at all.
I would guarantee that if we went through every single patient’s hospital stay, at any hospital, and analysed all their paperwork that there would always be something missing or done ‘incorrectly’. 
However, most of the time things go smoothly and so we never know. It is just in a minority of cases that something occurs and then the ‘mistakes’ are uncovered. In this culture of mass paperwork we have set up the nursing staff to fail.

Impossible to complete all paperwork for every patient

We have prepped them as the automatic fall guy when a mistake or complaint is raised, despite it being physically impossible to complete all the paperwork accurately and in a timely way for every patient. I think it’s unfair and creates a climate of fear and distrust but, more importantly, it gets in the way of delivering real patient care. 
If nurses are filling in forms all the time then they are not engaging with patients, but, sadly, filling out forms in the current NHS climate counts as patient care.
Filling out a falls risk assessment or a venous thromboembolism (VTE) form takes the place of actually discussing with the patient their individual risk factors. It provides a nice physical outcome that can be read and produced if the worst occurs and a patient does fall or develops a deep vein thrombosis (DVT).
Every week we audit a specific aspect of the paperwork, and every week we find large gaps in the audited paperwork.
However, instead of realising that perhaps the paperwork is not being completed for reasons other than poor time management we just expect the nursing staff to improve until we audit it again later. Unsurprisingly, things don’t change.
I would question the validity of paperwork that is mostly not done, especially when it would be physically impossible to complete it all anyway.
Even if it was all done it would be of little value to patient care. All it provides is a ‘reason’ when things go wrong. And currently the nurses are not completing all the paperwork for the simple reason they are already choosing to offer true patient care instead of completing it.

So what’s the answer?

I would suggest that trusting the medical staff and scrapping the risk assessments, comfort rounding charts and tick boxes would empower them.
It would free up their time and allow them to demonstrate their hard-gained medical knowledge rather than relying on pre-printed forms and checklists to provide the prescriptive knowledge.
Does it really need a risk assessment to tell a nurse that a patient should have slippers on rather than be barefoot to reduce their falls’ risk?
Does a doctor really need to be told on a form that they should consider compression stockings when a patient may be at risk of a DVT, or does a nurse really need to be informed that moving a patient regularly will reduce the risk of tissue viability issues? 
I think it is patronising and wasteful, and just covers the hospital against much-feared complaints and litigation while getting in the way of true patient care.

Nursing staff are the real heroes

There should, of course, be some documentation but a single set of integrated patient notes should be enough, and the professionals should all contribute to this shared piece of decision-making.
That way the patient journey would be linear, the collective thoughts and decision-making easier to see and, more importantly, patients would experience better care.
The nursing staff are the real heroes who perform the toughest job in the country against a backdrop of understaffing, financial cuts, low pay, long hours and a lack of trust from both their bosses and the public.
I salute them and feel very lucky to be an allied health professional instead.

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