I decided this week to go over some recent interviews with nurses and open-ended responses on surveys to see what they had to see about being accountable. Nurses generally perceive that their work is made account-able on the basis of their documentation. A common phrase in nursing is “If it wasn’t documented, it didn’t happen!” Legally, nurses are liable for malpractice if they fail to chart essential information thoroughly and accurately (Frank-Stromborg & Christensen, 2001). The CNA (a major insurer of the health care industry) issued a report of claims paid for nursing malpractice. As you can see, claims have increased significantly in cost over the last two decades.
Nurses face personal liability for not being account-able but their failure to supply evidence of appropriate care also increases the risk of health care organizations in which nurses practice. Therefore, managing risk has become a major initiative in health care. Most organizations have formal risk management programs and specific staff and departments responsible for reducing risk for the organization.
The functions of the risk management program include:
- Protecting the financial, human and other tangible assets of the organization
- Supporting quality assessment and improvement program elements across the corporation
- Preventing and minimizing the risk of liability against the corporation
- Implementing programs that fulfill regulatory and legal requirements
- Investigating and assisting in claim resolution to minimize financial exposure
- Providing risk management consultation across the corporation
- Forecasting future losses based upon past and current loss trends and analyses
- Recommending alternative risk management strategies to prevent, reduce or finance future losses
When asked about documentation, a nurse working in aged care described her dual responsibility:
“…. you’ve got this responsibility, this two-pronged responsibility towards the [institution] and towards resident care”
On the surface, it would seem that the more documentation, the more accountable the nurse, and the better the patient care. However, there is likely a tipping point beyond which documentation for accountability has negative effects. As one nurse explained,
“… we go in and help bring up the optimum care plans when someone’s admitted, there’s a whole heap of information, like I said, there’s quite a few pages, I don’t know how much, it’s quite thick that you have to go through and fill out because they all have to, well prior to coming in, they’re ACAT assessed and then, there’s the Braden Scale, there’s a whole list of information that we do a mini-mental on them. Lots of personal information, trying to deliver the activities that they like and all those things as well as their care plan, what their needs are. I’m not sure whether you’re familiar with the aged, the optimum care plans at all, but for example if a new person was to come in, and he might have dementia with Lewy Body Dementia you fill out all the paperwork, he has to have a ladder and faecal and urinary incontinence chart that checks every hour on the hour for 3 days. Then you do an overall assessment on them and then a care plan accounting for that, then there’s another one, a pain management chart that’s usually where they’re assessed for pain over a 3 to 4 day period and whether those needs are met. And then the care plan is made according to that, then there’s a restful sleep pattern, and that’s usually delivered over 3 days, that’s checking them every hour as well, and then there’s a behavioural assessment that you do as well, and that’s usually over a 3 day period. And then you do a, a care plan according to what those needs are for that resident and it’s just some of the example. So there’s a fair bit of input into put into packages together and they’re quite time consuming, but however that’s not to say that they’re not important, but I just think that, perhaps it could be a bit more simplified.”
Another nurse explained on our Missed Care survey, “What constitutes necessary data? Increasingly management ask for more and more data, some of it UN necessary and some of it down right old fashioned eg patient rounding”
Yet another nurse pointed out that when a new carer is assigned a patient they must read through reams of paper to get a sense of the patient’s needs. She stated simplifying the documentation would increase effectiveness and “…not take [the nurse] away from [her] true job, which is looking after these people.”
Indeed, the amount of time spent on documentation (38%) has eclipsed the amount of time nurses spend in direct care (7% as mentioned in an earlier blog post).
I headed up this blog with a cartoon showing an exhausted nurse who stayed over to finish her charting. This is all too true to be amusing. As one nurse assured the interviewer, “…the documentation of whatever I’ve done to that shift is also an important aspect of it, so I won’t go home until I’ve completed that documentation properly, and concisely, and done my SLS’s or whatever’s required before I go home.”
Frank-Stromborg, M., Christensen, A., & Do, D. (2001). Nurse documentation: not done or worse, done the wrong way — part II. Oncology Nursing Forum, 28(5), 841-846.