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Practice comment

“Focus on the values of nursing to boost care – not checklists”

Nurses must ensure that ward rounds do not become tick-box exercises

Task-focused nursing is making a comeback. Tick-box lists of tasks are designed to ensure patients’ needs are met in a systematic way. Some schemes, such as intentional rounding, even tell nurses or healthcare assistants to finish up with: “Is there anything else I can do for you – I have the time?”

In a speech earlier this month, the prime minister said formal nursing rounds are needed because of acknowledged shortcomings in nursing care, especially in that of older people. Rounds and checklists may be a safety net but will they provide compassionate care – or be a paper exercise?

In 2011, the Care Quality Commission’s report, Dignity and nutrition Inspection Programme: National Overview, blamed the failure of management on poor care, stating: “People were spoken over, and not spoken to; people were left without [a] call bell… or not given assistance to do the basics of life – to eat, drink, or go to the toilet.” It also indicated a lack of compassion. “‘Care’ seems to be broken down into tasks to be completed – focusing on the unit of work, rather than the person,” it found. 

Ironically, one aspect of the changes to nursing in the 1970s, aimed at increasing professional status, was to move away from task-orientated nursing and hierarchical leadership. In the 1980s, when Project 2000 proposals were published, Nursing Timescontributed its own critique, condemning the traditional model of nursing by caricaturing it. A series of satirical letters supposedly written by the old-fashioned “Sister Plume” parodied her punctilious attitude. In one she commented: “I have long considered that we do our young girls a disservice by insisting on all the psychology and technology (this is far better left to the medical men) instead of concentrating more on ‘bottoms and bowels’” (Russell, 1988). Paradoxically, bottoms and bowels, pressure ulcer prevention and toileting are now on the intentional rounding checklist.

Changes to nursing, and the diminishing of the sister’s role, reflect deeper cultural shifts in society. Hierarchy and authority are seen as negative constraints undermining individual freedom. Governments and the Royal College of Nursing have recognised the problems around care and attributed this to a need to strengthen leadership, but reports show that despite their efforts, serious shortcomings persist and cannot just be blamed on shortages.

Sister Plume would have been shocked it has come to this. Maybe she was luckier than today’s sister – she had control over her nurses and ward. Back then, commitment to patients was expected to override all other considerations. Nurses existed for patients’ needs, however menial, and their job was to ensure this. They embodied a system that patients trusted and esteemed.

Prime minister, it is the values of Sister Plume’s system and not mechanical rounds and checklists that will improve care.

Dr Ann Bradshaw is a senior lecturer in adult nursing at Oxford Brookes University

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Readers' comments (24)

  • Couldn't agree more...tick boxes often lead to laziness and leads to focusing on achieving targets rather than providing care in the first place! I've had managers that are so focused on paperwork that they don't seem to be aware that patients are sitting there asking for help!

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  • Let's find Sister Plume and set her loose on the Prime Minister to start with!

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  • PLEASE NOTE SECOND PARAGRAPH AND LAST SENTENCE IN PARTICULAR!

    Here is a review of the book. The description can be found on the Amazon.uk site - link below


    Inspiration for nurses, 11 July 2002
    By
    Simon Russell (Milford, Surrey United Kingdom) - See all my reviews
    This review is from: Sister Plume's Notes on Nursing: Letters to the "Nursing Times" (Paperback)
    There is more common sense, wit and practical insight in this little book than I have found in any other popular nursing text. The cognoscenti may know that Florence Nightingale also wrote her own "Notes on Nursing", but it's not a patch on this.
    Plume is perhaps at her best when offering robust advice on the daily routines of nursing practice, but she is not afraid to tackle the larger philosophical and political issues of the day, as seen from a nursing perspective."




    "I believe Notes on Nursing should be required reading for all young people, whether or not they are interested in nursing as a career. I'm sure it could gather many converts to a profession that faces a continuing crisis in recruitment. It is a tragedy for the UK, if not the world, that this seminal volume is not more widely available. In the words of Angela Plume herself, "The welfare of our patients is at stake!"

    http://www.amazon.co.uk/Sister-Plumes-Notes-Nursing-Letters/dp/033346656X/ref=cm_pdp_rev_itm_title_1

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  • michael stone

    A woman sent a comment to Radio 4 a month or so ago, about niot nursing but Health and Safety. It was this:

    'When I started work as an inspector, we were all very experienced and carried out our inspections based on our experience and expertise. Then a Labour goverment came in, and wanted sets of tick-box rules which any idiot could follow'.

    Which is the point: you can either have objectives and allow expertly trained staff to get on with it, and to personally defend any errors they make, or you can try and design a tick-box system of rules, which much less expert people can simply follow.

    The tick-box system is always simplified to exclude really unusual situations, so it tends to fail disastrously when expertise and freedom of action would work better: but expertise requires training and experience, which are 'expensive', so these tick-box lists still exist.

    But the 'experts using judgement' and 'non-experts following tick-box rules' do not mix very well, as experts get frustrated when they know a tick-box set of rules isn't sensible, while allowing non-experts to use their own judgement is dangerous. Very tricky indeed, to resolve the problem !

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  • very difficult when there is no question on the list specific to a particular situation and in which solutions can only be sought by applying a set of algorithms. what are you supposed to do then?

    has anyone tried to get advice from a medical call centre who bombard you with a long list of questions related to a similar part of the anatomy where your symptoms occur but which may be totally irrelevant and the training of the 'clinically qualified' operators does not appear to permit them to extend their thinking outside any box possibly because of the severe time and financial constraints they work under.

    such centres have been set up gate keep access to medical practitioners, including GPs, to save costs and pharmacists in chemist shops are also going to offer this service! this is now what is happening in Europe and if you are unlucky and have to keep trying to get through or your phone call is deviated to a call-centre in India any attempt to communicate in a common language may be highly problematic and especially if you are feeling unwell and rather feeble!

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  • Little One

    "Rounds and checklists may be a safety net but will they provide compassionate care – or be a paper exercise?"

    At the Hospital where I have just completed a placement, it was alreay just a paper exercise which was completed so that the ward could pass the audit. Many patients did not need help drinking or going to the toilet and yet were supposed to be asked every single hour whether or not they needed help, which they didn't. It took away valueable time, which we could ill afford, asking inane questions to patients who would never need the help, when we could have actually focussed the time on patients who did need repositioning and helping to the bathroom. Nurses know their patients, why not give us the time to focus on the patients who really need the help rather than a blanket cover of intentional hourly rounding for all.

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  • Little One | 16-Jan-2012 11:58 am

    aren't these questions also a little invasive and perhaps offensive to some patients who are independent. it may also make the staff look rather silly in their eyes.

    I agree with your comments.

    It seems like a return to the old style ritualistic care which we have fought to get rid of, and care which is not well thought out and planned.
    This goes to show that the PM has to say something and act upon it for the benefits of the complaining public without fully understanding what he is talking about or the full implications of his suggestions. it would be better if he could listen more to the experts in their own field and concentrate more on what he may be better at.

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  • michael stone

    Anonymous | 15-Jan-2012 1:00 pm

    Quite !

    Of course, there are 2 different 'types' of check-list.

    If you write your own check-list as an aide memoir, just to be certain that you have not forgotten to do something (perhaps out of 'familiarity breeds contempt', which can creep in to behaviour), then you understand why the items on it are present.

    But if someone is simply following a check list 'imposed from above', it is not necessarily true that the person ticking off the items, really understands the point !

    2 quite different 'uses' of a list, there !

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  • michael stone

    Little One | 16-Jan-2012 11:58 am

    As you say, check list behaviour often infringes common sense. But the problem is, as I mentioned earlier, essentially 'are staff to be trusted and assumed to be competent, or must 'set rules of behaviour' be imposed to guard against the possibility that some staff are not sufficiently competent ?'.

    The answer to this one, isn't easy - but objecting to really pointless tick-boxes, does seem very sensible to me.

    This issue of tick-boxes, is very awkward to work out.

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  • tinkerbell


    Yes let's tick some more boxes, privatising our NHS, asking us to work longer for less, getting rid of agenda for change, freezing our pay and less recruitment. We are the whipping boys being grinded to our knees and they're telling us that they know more about what we should be doing than we as nurses know who are actually doing it. What is happening to the nursing profession at the moment is an injustice. We will end up like America and other countries that put money before humanity. Where you can only receive decent healthcare if you are rich. Intentional rounding/ticking boxes is very low on my list of priorities right now, we do it anyway without having to tick the box. We are in a fight right now & up to our necks in it and we are on the ropes. Everything else is academic if we no longer have a profession that can do its job properly to start with. We are being hung out to dry, give us the tools and we'll do the job, take those tools away and we are extinct. The tools are us!
    Everything else to my mind at the moment is academic until we get the future of our nursing profession sorted.The debate has gone beyond intellectual and is now a fight for our survival and that of our patients care.

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  • tinkerbell | 17-Jan-2012 0:03 am

    very well expressed Tinkerbell, as always but what you say is basic common sense. why does nobody else but us see that? our we the only ones with such special qualities to see this?

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  • the good news is that we could soon have tick box questionnaires on admission to eliminate the need for taking a case history or establishing a diagnosis. algorithms could then determine which diagnostic tests will be needed and this will very much reduce the need for staff : patient contact.

    there is no limits to the uses of the tick box / algorithm system. it just requires a little imagination for further innovations!

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  • tinkerbell

    Anonymous | 17-Jan-2012 11:28 am

    of course, what fools we've been. Looks like a big order for some new clipboards needs to be processed. Don't even need to wait until admission, someone could just meet the people at the front door, tick a few boxes to see if they even reach the criteria to move forwards onto the reception area before any assessment even needs to be done. We have been so unimaginative in our thinking. This needs some serious thought and 'blue sky' thinking. If nobody gets as far as a diagnosis we'll be quids in:)

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  • I remember ward and theatre sisters as being a huge source of knowledge. WIth daily ward reports we all knew what was happening with and to the patients. We read the notes, asked the patients questions on their health and needs. We acted on our own initiatives ....... no tick boxes needed. We where supported and encouraged by the sisters , even when mistakes where made. I do hope this does not sound too ante diluvian . It worked as a care model, our patients where well looked after, clean , fed , given the appropriate drugs and they went home and said thank you. Its the kind of care I would like when I am in hospital . Lets look backwards to go forward.

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  • tinkerbell | 17-Jan-2012 11:55 am

    From Anonymous | 17-Jan-2012 11:28 am alias Mu

    only snag here is who is going to meet the patients at the door and whether there would be enough staff to fill in the tick boxes!

    further visit from Cameron required to determine this!

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  • tinkerbell

    apparently we are being replaced by a holographic nurse (article on nursing times).

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  • tinkerbell | 17-Jan-2012 9:21 pm


    my comments on Holographic Nurse

    Anonymous | 17-Jan-2012 11:24 am and 11.28

    isn't it totally hilarious! I am falling around laughing, I don't think. I already left my remarks on that site as above!

    we could have big screens up on the wards showing holographic nurses and cut down considerably on our work (sorry I keep forgetting I am retired!) - lol Mu the mere cat

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  • Anonymous | 17-Jan-2012 10:22 pm

    tinkerbell | 17-Jan-2012 9:21 pm

    just added another as well!

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  • Little One

    Anonymous | 16-Jan-2012 12:12 pm

    "aren't these questions also a little invasive and perhaps offensive to some patients who are independent. it may also make the staff look rather silly in their eyes."

    I think you are completely right. I was recently an inpatient myself at the Hospital I was working at, and found it quite intrusive to be asked every hour if I needed to go to the toilet (I'm 23, and mobile). I was not impressed because I was there because I was in status migrainus and really could have done with being left in a dark, quiet, room with some very strong painkillers. No consideration for me as a patient with these checks at all.

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  • Have to say my department has laready introduced a poor knee jerk reaction to the intentional rounding which in less than 2 weeks has become a tick box checklist. The trouble with it is a poorly thought out knee jerk reaction where the achievement of this set of rounds has now taken precedence over the complete and proper assesment and treatment of patients upon their presentation to the department.
    What worries me about this, is that my management do not trust me to complete my job intelligently and completely, and that I now have to annotate the same information in three to four places in order to achieve all directives. So much for reducing paperwork and caring for patients!

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