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Pushing paper

November 27, 2005 -- Today the Observer (U.K.) ran a leader (op-ed) and an article by health editor Jo Revill about concerns over how much time nurses now spend on paperwork. The leader, "Let nurses nurse: Their bedside manners save lives," argues that the government must find ways to reduce nurses' administrative work and get them back to the bedside. Revill's article, "Paperwork mountain keeps nurses from care," reports on a new study that is expected to confirm that some nurses spend as much as 40% of their time on "non-clinical" administrative work. Certainly, at a time of shortage it would seem that nurses should not be saddled with paperwork that does not require their special skills and judgment. And both pieces rightly suggest that the time nurses spend at the bedside affects patient outcomes. But one key theme seems to be that nurses improve outcomes because they "talk" to patients. That is literally true, but without much explanation, many readers will not get that it's because nurses are skilled professionals, not just handholders with "bedside manners." And nurses make many key clinical judgments at the bedside that are not based on talking. The pieces also seem to reflect the assumption that paperwork cannot be part of nursing, as if nurses are just there to be with patients, rather than think and write as real professionals do. But would anyone suggest that nothing physicians do away from the bedside is medicine? Lastly, neither piece mentions the role of the nursing shortage and associated short-staffing in the apparent lack of nurses at the bedside.

The leader begins with patient complaints that nurses now spend too much time "filling in forms" and not enough "at the bedside talking to them." It links this to recent changes in nursing practice, including nurses' "increasing professionalism" and "desire to take on roles traditionally carried out by doctors," which "means that many hands-on tasks are now left to healthcare assistants." This suggests that to some extent nurses are absent from the bedside because they're finding more important things to do, an idea that many nurses who have struggled for years with the denursification imposed on them by budget cuts and the shortage itself might find offensive. The leader says that another reason for the apparent decrease in time nurses spend at the bedside is administrative work: "Filling in forms and documentation, ensuring that every intervention is recorded (in order to avoid future legal action), and carrying out audits of hospital activity take up an enormous amount of time." But "studies show that talking to patients before and after surgery has a major, positive effect on outcome. If a nurse can spot a problem early, it can be treated before it becomes a complication." The piece urges ministers to act quickly, "otherwise patients will go on feeling neglected and their outcomes after surgery will be worse."

Revill's piece focuses on the pending study, which will apparently suggest that nurses "are being overloaded with paperwork and administrative tasks, with as much as 40 per cent of their working week diverted from patient care." Patients are reportedly complaining that nurses spend more time at their computers than at the bedside. The study, commissioned by the Department of Health, involves asking staff at three Birmingham trusts to keep logs of their daily activities. Revill reports that the study is aimed at finding how many hours are "wasted filing, answering the phone and preparing documents rather than on bedside care." In particular, the piece notes that nurses must now record all health "events," that most notes are still handwritten, and that filing is a priority largely because of litigation concerns. Preliminary results apparently indicate that stroke rehabilitation nurses working "in the community" spend 5-10 hours per week on "non-patient work." One of these nurses is quoted complaining that "[e]verything has to be written down" because of litigation concerns.

Royal College of Nursing general secretary Beverley Malone has reportedly warned that paperwork is taking too much time, and that more clerks are needed so that nurses can get back to "talking to patients and their relatives." Malone says the increases in clerical tasks and documentation are taking "an incredible amount" of nurses' time, and keeping them from "things that need to be done, whether it's tackling patient safety or infection control or talking to patients." Malone is also quoted as saying that nurses get tied up in administrative tasks, but "if you're there to hold someone's hand and talk to the patient about the surgery they are facing, we know that they are going to get better clinical results."

The point about the role of nurses in patient outcomes is an excellent one, and we wish the pieces had more specifics on how that occurs, beyond the oddly persistent focus on "talking" to surgical patients. Of course talking to patients can be a critical part of the nursing assessment, and nurses do catch many problems that way. It's also the primary avenue nurses use to educate patients about their health conditions and how to manage them at home. But when readers without much knowledge of nursing see the heavy focus on talking, along with statements about holding hands and bedside manners, they are likely to think that nurses provide generalized emotional support that any nice person could do, and when they do so, patients may mention potential care issues--thus the difference in outcomes. This does not convey the tactful but persistent probing of patient conditions and concerns that skilled nurses do, nor the extensive clinical knowledge nurses need to know when patient statements indicate a potential problem. Nor does it tell people about the hundreds of key clinical judgments nurses make through other observations at the bedside.

Much of the piece also seems to suggest that all nursing paperwork is pointless except as a shield to litigation. But it's not hard to imagine how there might be some health care benefit to keeping records of patient conditions and treatments. How can else can there be any meaningful oversight of what health professionals are doing? How else can one health professional know what another did yesterday, last week or last year? How else can a great deal of important research occur--for instance, isn't the Birmingham study itself being conducted by having nurses create "paperwork?" An unnamed Department of Health spokesperson seems to take a more measured approach. He admits that nurses should not have to spend time on "unnecessary administrative tasks," but notes that some such tasks "related to patient care" are necessary, and that the Birmingham study is about "differentiating between non-essential and essential paperwork."

It seems to us that the issue is not just whether the paperwork needs to be done, but whether a skilled nurse is required to do it. If not, then as Malone suggests, it would seem better to have a clerk do the work. But the apparent assumption that all nursing is non-written work that occurs at the bedside seems to reflect a view that nursing is mainly about physical and emotional support. This suggests that nursing does not involve critical judgments, observations, or recommendations--the kind of things that serious professionals often write down for the benefit of colleagues and those they serve. It would seem important not to suggest that nursing and written work are somehow antithetical.

We thank Ms. Revill and the Guardian for addressing these important issues.

See the leader: "Let nurses nurse: Their bedside manners save lives," and Jo Revill's article, "Paperwork mountain keeps nurses from care," both from the November 27, 2005 edition of The Observer.

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