Poor nursing care and record keeping: Is caring behavior of nurses always documented?

“Is caring behavior of nurses always documented?”

This question was posted in the Researchgate site, by Leadoro Labrague and it generated a few responses Which I think amounted to a ‘no’.

I tentatively add….  “and don’t bother”.
Managing risk in organisations, characterised by increasing managerialism, and the effects this has on practice and documentation was  mentioned in the responses, as was the difficulty of defining care, despite the list of these caring behaviours outlined :

 

attentive listening, comforting, honesty, patience, responsibility, providing information so the patient can make an informed decision, touch, sensitivity, respect, calling the patient by name” .

 

These behaviours, however can be and should be applied by many occupations and professions: teaching, social work, policing, medicine…hotel and customer services…you get the picture. Therefore caring behaviors are not the preserve of the nurse. However, we must be careful not to suggest that care is a defining essence of nursing. This would be erroneous both in theory and in practice as the long historical list of uncaring practices reveal: Stockwell 1972, Jeffrey 1979, Beech House Inquiry 1999, Francis 2013 and for our Australian friends: O’Niell 2013. I’m not suggesting that nursing is in essence uncaring, just that there are enough breaches to warrant further investigation into what nursing work entails and the context that binds it. Other occupations engage in caring behaviours, why should we expect nurses to be the only occupation to document them? Rather, lets critically examine the context of nursing practice and notions of idealized and unrealistic practice.

While I appreciate the differing regulatory and legal positions of say nursing, teaching and hotel customer services, are these contexts so different that nurses could be required to document care when in fact these should be the bedrock of practice for the host of occupations that routinely do not document them? Not only do they not document them, they would throw their hands up in horror at the bureaucratic load if asked to do so. Why should nurses document care and teachers not do so? I’m not convinced by the argument that if caring behaviors are not documented then they will either die out or be non existent (except of course in the legal sense of ‘if its not written it was not done). I would rather focus on developing and clarifying with students what a good/therapeutic relationship between nurse and client looks like and not worry too much about adding any other layer of documentation. Apart from the legal requirement to document certain interventions, do we have to describe how we carried them out as well?

Lets face the reality rather than rhetoric: Much, but not all, of nursing practice is technical, based on rational task orientated non autonomous direction by medics and managers.  Nurses themselves will undertake these tasks robotically and/or humanistically, regardless of documentary requirements. I suggests that adding documentation would increase the likelihood of non humanistic care (see for example the descriptions of care in Dixon Wood et al 2013, Hillman et al 2013, Tadd et al 2011). The context in which that practice is carried out will affect how nurses go about their daily practices with the humanistic nurse’s values being supported, or crushed, depending on managerial practice, interprofessional working, health care assistant ratios, patient dependency, illness and challenging behaviors, their education and continuing professional development……

As a would be patient who could be seriously ill, let me make a provocative statement: I would rather have a technically proficient nurse who makes the right clinical decision but perhaps is not quite as sensitive or touchy than a nurse who makes me feel great by engaging in the above list of caring behaviours, but fails to intervene quickly enough when I deteriorate through, for example, septic shock. I know this is a false dichotomy, in that I would like both technical and humanistic practice. But in many settings I want technically sound scientific care, and if that is the only thing on offer I’ll take that over ‘caring’ any day. I have heard so many times the lament about an academically failing student ‘but she is so good in practice, the patients love her”, while I think yes, but will she spot, and intervene on, sepsis quickly enough? That is the difference between the caring customer service in a hotel and nursing, the receptionist has little in the way of scientific techniques to apply and then the only thing they should be doing is facing a customer as a person not a ‘thing’.

Nurture and support the humanity students have, and in those who lack it, then engage in those activities to develop it, but documenting care practices may only satisfy out inner idealised notions of what nursing is when in fact the contextual issues are what actually define nursing.

 

Beech House Inquiry. Report of the internal inquiry relating to the mistreatment of patients residing at Beech House, St Pancras Hospital during the period  March 1993-April 1996.  Camden and Islingon Community Health Services Trust.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014

Francis, R. (2013) http://www.midstaffspublicinquiry.com/report.

Jeffrey, R, (1979) ‘Normal Rubbish’ Sociology of health and Illness (1) 1 http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.ep11006793/pdf

Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955

O Neill, L . (2013) Aged care workers cite abuse and neglect of nursing home patients http://www.abc.net.au/news/2013-08-13/aged-care-understaffed-as-nursing-home-patient-numbers-rise/4884056

Stockell, F. (1972) The unpopular patient http://www.rcn.org.uk/__data/assets/pdf_file/0005/235508/series_1_number_2.pdf

Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton

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