Some participants stated that combining a number of apparently simple processes can result in a very complex system and that frequent ongoing monitoring is required to get an accurate picture of quality in the service, which is not always possible due to capacity issues. Data collection was generally acknowledged to be time-consuming, particularly where duplication of data entry is unavoidable. All data need to be recorded electronically, but some are still collected initially by hand on paper. Although there was a focus in most sites of reducing this activity as soon as possible, it was also acknowledged that it would probably not be possible to remove paper notes completely:
We have to have notes in the patient’s home . . . it’s not just us that are involved with those patients;
we’ve got adult social care; we’ve got GPs. We’ve got a lot of family that would like to be more
involved in the care . . . so our home notes are integral to good, personalised care. But at the same time we need to put things [on computer].
The increasing emphasis on documenting information for quality purposes was perceived as having been accompanied by a decrease in the time available to spend with patients, so that nurses felt that their workload was being driven by indicator reporting requirements:
Dogwoodheath CNFG5:It’s totally taken over. Patients don’t come anywhere near priority now,
they’re right down at the bottom. It’s all these targets, audits, data this that and the other.
Dogwoodheath CNFG6:But the hardware isn’t up to speed yet, that’s the problem.
Dogwoodheath CNFG5:And I think over the years, face to face contact with patients has gone down,
because you’re spending more of the afternoons on a computer.
From a patient point of view, although recognising the time taken to complete notes, the nursing records held in the home were a valuable resource and found to facilitate involvement in their own care, enabling them to monitor progress and also accurately to inform other visiting professionals of current nurse input: Yes. I mean, I think the nurses have a heck of a lot of paperwork to do. I mean, B is writing for ages
when she’s here but every single thing is focused on; everything is jotted down. The notes are left
here so she’s not writing down anything that we can’t know about. So we know what the blood
pressure was that day. We know the blood test results, and it’s wonderful . . . If the doctor rang and
wanted to know what his blood pressure was, I’d know instantly because it’s there in the notes.
Alderton West C1
One unintended consequence of increasing electronic data recording, which has the potential to reduce nurse time spent documenting quality information, is that patients could be potentially excluded from the benefits of having access to paper care records in the home. However, it appeared that the amount of documentation required can impact heavily on nurse workload, in particular the need for data to be recorded in a variety of formats:
Beechbury CNFG1:It’s all in the patient’s notes, documentation I think, some people have the [electronic] notebooks . . . And online as well, put it on the system.
Beechbury CNFG3:Yes . . . We still have paper notes and [IT package 1] . . . and some practices have [IT package 2] as well so we have to fax or e-mail consultations for them to get on to their systems. So it’s all, it’s quite difficult at times because some of them are triple entry.
There is a national drive to encourage patients to take some responsibility for their own care and prevention of further health problems. This has been interpreted in at least one site as requiring a signature from the patient to say they understand their responsibilities to avoid PUs occurring. However, in the context of financial penalties for not achieving quality outcomes it could suggest an element of defensive record keeping as such a record could constitute evidence that the nurses had done all in their power to prevent the PU and would be helpful, perhaps, in reporting back to the commissioners. Additionally, for safeguarding reasons, the nurses recorded in the notes the fact that all options regarding prevention and equipment had been discussed with the patient or carer. During a shadowing session, a staff nurse at a handover meeting reported a problem with a patient who had been discharged from hospital that day, provoking an immediate response from the team leader:
Another nurse brought up a newly discharged patient from hospital who has come onto caseload with
a black heel (PU)– ‘to be Datixed immediately’. PUs are a quality standard – ‘need to demonstrate it
did not start in our service’, ‘to be done ASAP’.
Datix (Datix Ltd, London, UK) is the electronic serious incident reporting proforma used in provider organisations. If a patient on the caseload was identified as having a grade 3 or 4 PU (classed as moderate/severe), a serious incident investigation would be triggered. These investigations include interviews with the staff involved and scrutiny of care records leading up to the date the PU was identified. Such investigations are badged as learning opportunities for staff but can be construed as punitive and take a long time to complete:
I think there’s a fear as well, isn’t there, that the finger’s going to be pointed. People do feel
scapegoated. I did. I felt terrible. I wasn’t even here when the woman developed it, I was off.
Beechbury CNFG3
During a shadowing session in Elmhampton, one clinical leader said that she thought she spent about 30% of her time on investigations prompted by the Datix system.
Collecting QI data appeared both to have an impact on, and be affected by, difficulties for the workforce arising from issues associated with the complexity of the caseload, adapting to new IT systems, high levels of sickness and staff shortages, as outlined in Chapter 4. Many of the participants mentioned the degree of support community nurses have required to enter quality data onto the computer systems:
A lot of this stuff depends on the inputters. And many of the inputters are the clinicians and the people at the front line. So they have to have access to good IT systems to input the data as well. And sometimes, you know, the systems are slow and clunky.
Alderton West PM2
Recording‘outcomes of care’ is a key community nursing performance QI. Nurses are required to record
the outcomes of their visits on a daily basis. As outlined previously, electronic care records often cannot be
updated when nurses are out on visits due to connectivity problems, so‘outcoming’ (the updating of visit
outcomes in order to enable ongoing planning for allocation of workload) must therefore be undertaken when nurses access the live records back at base. Several nurses spoke of working out of hours to meet the requirement:
You stay over your time. On your day off, you come in. Because you don’t want your name to be
called as someone who has not done their outcome.
Cedarham CNFG4
It was also noted to be difficult to collect data from some patients on the community caseload, as many of them are frail or lack capacity. In some instances there may also be language problems adding to the
challenges. Patient satisfaction surveys are either posted or taken into patients’ homes and left there for
completion. Nursing team leaders did not think it ethical for nurses to sit with patients while they complete a survey.
A suggestion was made that it might be better if such forms were administered by an independent body. This would have an additional advantage of circumventing another factor which may contribute to the
apparently low completion rates– that the nurses do not like to give the forms out – expressed by one
nurse in Elmhampton as feeling‘like touting for compliments’. At one nurse team leader meeting, it was
clear that some nurses did not think that they should be responsible for collecting these data from patients at all:
Manager 2 said that an envelope should be given out with the forms so that staff can collect them.
Team leader 7 said that it should not be the nurses’ responsibility to collect responses.