Daily ward life

The context includes not only the individual patient who is being assessed, but also the daily ward life, which had an impact on navigation of an assessment on the ward. Two aspects were found in the data, including practical issues such as time limitations and availability of people, and requirements of the health care system.

4.5.2.1 Practicalities

The availability of professionals steered the navigation of an assessment:

‘It depends … how busy the ward is and where the nurses are. But if there is someone there I would try and ask them if there is any nursing concern to that patient, but as always, that doesn’t always happen.’ (Physician 15)

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‘As soon as you see the nurse you are like: “Oh quickly, I have got to tell you this before I forget”. ... Because if she is on break or she is not around or anything I just write on my handover so that I remember to tell her later on.’ (HCA 21)

These examples show how the availability of other professionals may influence the immediate action of sharing information and communicating amongst individual professionals. In the first example the participant seems to suggest that if the nurse is not there, communication does not happen, whereas in the second example the HCA talks about a delayed communication. In both occasions the navigation of assessment is influenced by the practical issue of staff availability.

Time and heavy workloads were also mentioned practicalities which influence the way professionals navigated the assessment process:

‘If the patient has been seen by ... speech and language therapist, and they have said that they shouldn’t be taking any fluid or diet, and they don’t actually ... tell me, well then there is a risk that I don’t actually look in the notes until lunch has passed.’ (Junior nurse 7)

‘We try to do it when we have got time that me and the nurse will sit down and ... make sure that we have got the same things written down .... But we don’t always get a chance to do that.’ (Physician 13)

The first example shows how the nurse needs an informal verbal message as the formal written documentation might not be read in time. The second example shows verbal communication is sometimes under pressure, which was also mentioned concerning the board round:

‘Some days it is quite a lot of people in there ... sometimes we can’t get everybody together because everybody is busy.’ (Senior Nurse 20)

Therefore, the resource of time seemed limited and this influenced how an assessment was undertaken. Time was highlighted as an important resource in order to conduct and navigate assessments:

‘It is having the time to sit with the patient to make sure we get everything, all the information, have that time to … be able to really know the patient.’ (Senior nurse 20)

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Examples of time constraints have been presented previously in section 4.3.2.4 in relation to prioritising and separating care processes into isolated tasks. As addressed in section 4.3.3, time limitation was linked to a high pressure on the beds:

‘The big priority is to get people out quickly.’ (Senior nurse 14)

This priority focuses on making sure the processes in hospital happen as quickly as possible, including the assessment process.

4.5.2.2 Practice guidelines

‘At the end of the day, this is the hospital guidelines, this is how you are supposed to [work].’ (HCA 1)

Another aspect of daily ward life found in the data, involves the care requirements according to the guidelines used by the NHS, also referred to by HCA 1 as ‘how we are supposed to work’. The following examples show how standardised practice guidelines influence assessment practice, especially in relation to the more formal and documentation related approach to assessment:

‘You need the normal standard stuff, like diet and nutrition that have to be in, and your skin assessments have to be in, and bowels have to be in.’ (HCA 1)

‘We have to see them every day. That is the hospital ... so they get seen every day by a medic. So I will see them as a daily review.’ (Physician 13)

Another example of standard practice is when two junior nurses explained that the risk assessments were updated weekly for every patient, also showing the NHS guidelines requirement regarding this:

‘It is assessed weekly at the weekends.’ (Junior nurse 22)

‘We write that in weekly though, their weights and whether they have lost or gained weight with us.’ (Junior nurse 30)

The existing assessment documentation in itself is based on guidelines. A large part of the documentation is predesigned paperwork, such as the risk assessment booklet, the admission booklet used by the nursing team, as well as predesigned documents for therapists. When looking at the nurses’ documentation regarding day-to-day issues, it was mentioned before that they were found having to use an eleven-point system:

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‘Nurses use a number system in their documentation where each number links to a certain aspect of nursing such as breathing and mobility.’ (DR Patient 1)

‘What we normally do on the ward, most of the nurses, if like on a morning shift we normally use all the numbers because normally you cover everything. However, if you are on a late shift I would skip out a few of them like hygiene.’ (Junior nurse 22)

In a similar way, risk assessments add up to scores, which lead to standardised and guideline-dictated care actions:

‘It is scored. If it is not 3 do this, if it is 4-6 do that. ... It has taken away some of that responsibility for decision making.’ (Senior nurse 27)

‘So, if the Waterlow is high we need to be ordering their matrasses. Same with the nutrition, if their nutrition score is high then we will refer them to dieticians.’ (Junior nurse 30)

Actions taken based on assessment in this practice is based on NHS guidelines before clinical judgement. These examples show how the guidelines used within a care organisation lead to a certain standardisation of care, influencing the navigating process of an assessment.

4.5.3 Summary

In this section the theme ‘Situating the process’ was presented. It showed how practical aspects influenced the navigating process of an assessment. These aspects included the individual patient needs and daily ward life, which was divided into practicalities such as availability of staff and time, and NHS guidelines which are followed by professionals when assessing older people.

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