Liz Charalambous reminds us how important assessments are - as long as staff don’t forget to use they clinical judgement as well.
I admitted a frail older patient to the ward last week and began the daunting task of completing all the paperwork. This is vital to establish a baseline so we can treat and discharge people as quickly as possible. However, while documenting the information, I wondered how much of it was useful and whether anyone actually reads it.
Take, for example, assessment tools. Will my clinical judgement be accepted if I assess a patient to be at risk of malnutrition, or do I have to present a Malnutrition Universal Screening Tool score?
Twenty years ago, I developed a clunky yet workable method of assessing malnutrition risk to help treat and prevent malnutrition in older people (Charalambous, 1993). I encountered resistance and was told by many that we didn’t need such paperwork, that it would generate more work and nurses knew intuitively if patients were at risk of malnutrition. Nevertheless, I persevered and the tool has since been developed by BAPEN into the MUST. This mandatory screening method of assessing patients at risk of malnutrition should be used on admission and throughout the patient’s hospital stay.
Today, it appears nurses praise assessment tools with a religious fervour. But has their clinical judgement been replaced by blunt tools? If an assessment is not due, will nurses always think to reassess if they suspect a problem?
The Scottish Intercollegiate Guidelines Network guidance on managing suspected bacterial urinary tract infection now recommends that nurses do not dipstick urine from patients who are catheterised, as the results are meaningless without taking account of the clinical symptoms.
However, we would fail audits if this particular box wasn’t ticked, with possible financial consequences for our employers.
Dipsticking urine is routine on admission and part of the assessment process - why? We complain we are busy, finish late, miss breaks - but what of the content of our work? Do we allow ourselves, as a profession, time to consider what we are doing and why? And what of the patient in all this? Is it ethical to be completing possibly unnecessary tasks instead of listening to patients and families?
A document does not stand to account in a coroner’s court - we do. We need to come out from behind the illusory shield of paperwork and stand accountable as confident practitioners, self-assured in our clinical knowledge and judgement, choosing to use validated tools as necessary.
However, this will require management support. We need time to reflect, to participate in clinical supervision and look at processes to decide whether they require change. Change is complex. It comes from within but relies on external forces. We need to guard against organisational constraints. We must take control and question, reflect and encourage others to do so, particularly students and new staff.
If we don’t, my fear is that the road we have travelled in our profession will sadly lead back to the very place we started.
Liz Charalambous is staff nurse at Queen’s Medical Centre, Nottingham.
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