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Addressing the challenge of nursing documentation

By Helen Balsdon, interim chief nursing information officer, NHS England



A common misconception I often hear about nursing and midwifery documentation is that it’s an IT issue – if we go out and buy the right systems, the challenges we face in documenting practice will be resolved.

The truth is that digital is the how, not the why, and to be able to harness the power of technology, we first need to be clear what we document.

Addressing the foundations is essential to end the culture of creating endless reams of documentation to evidence the care we deliver.

In my role in the national Chief Nursing Information Officers (CNIO) team, I’ve witnessed pockets of fantastic initiatives to address the challenge of overwhelming amounts of documentation head on.

We have seen several paper picnics run by nurse leaders across England. Paper picnics seek to make visible the volume of nursing documentation that exists across an organisation by placing it on the floor to help visualisation.

It’s a pretty sombre image seeing paperwork stretched way out across rooms, and if you look closely, you will see the duplication and old versions that never got taken out of use.

This is why we took a national approach, seeking the views of nurses and midwives across England to create the guidance Towards a unified vision of nursing and midwifery documentation.

The guidance sets out the principles of good documentation practice through standardised and succinct approaches and is relevant to organisations and teams, whether recording on paper or through an electronic patient record.

The good thing about Towards a unified vision of nursing and midwifery documentation, is that it was not designed as a one-size-fits all solution, but recognises the local requirements, whether it’s the geographical differences, structures, or if your organisation is not the most digitally mature, the principles are still applicable to inform your conversations.

For these recommendations to be realised, we need proactive leadership from the nursing and midwifery community to put the guidance into practice. Chief Nurses have a role to play to provide direction, to inspire, support and enable the workforce in realising this vision.

Digital nurses, subject matter experts and those using the documentation need to work together to understand different perspectives and work together to lead changes to improve processes that meet their needs and use the technology they have available to them, to make the right thing the easy thing to do.

The burden of documentation has been such an issue for a long time that you might be questioning why change it now?

As many organisations are moving paper-based systems into digital record keeping, the true scale of documentation nurses and midwives complete has been exposed.

I’ve been overwhelmed by the appetite from colleagues ready to tackle this and build a better way of working that releases time to care and supports improved decision making.

There is so much more to follow as we continue the work to manage documentation in the digital world.

Looking forwards, we are seeking to implement a common language to document care that means we can share data in a way that helps us be smarter and faster together and look at how advanced technology, such as voice recognition, might support our work.

This will take time and require patience, but through the collective power of nursing and midwifery we can collaborate with colleagues to instigate these changes – I encourage you to lead, be part of the conversation, help inform what is needed and be the change.

This is just the start of the journey.

Learn more on the standardisation of documentation in nursing and midwifery at Digital Health’s Rewired 2024 on 12-13 of March.

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