Soapbox

Your say about nursing issues

Helen Calabretto
School of Nursing, University of South Australia, SA

PP: 040 - 041

Article Text

A call for subjectivity in nursing documentation

While moving towards greater clarity and professional confidence in describing our nursing activities, it is time to be critical of influences that restrain us.

Nursing literature exposes a growing recognition of, and articulation about, nursing practice. Nurses have always known what it is that they do in providing care for patients, and in fact they have traditionally been adept at describing and articulating such. This has occurred predominantly in circles in which they felt safe, and through the spoken word. A cultural cringe about nursing has and, one may suggest, still exists. Much of nursing's work is hidden and made ordinary (Parker 1991, Taylor 1991, Wolf Robinson 1988). The taboo of body work and domain of women's work contribute to this isolation of nurses' work from wider social and professional acceptance (Lawler 1991).

Much nursing literature, including guidelines and institutional policies dictate that the written records of patient care by nurses be objective. The resulting style of nursing documentation conceals nurses as active agents in the delivery of patient care and construction of nursing knowledge. How is it that we accept and participate in this blatant censorship of the actuality of our work? Why is it that despite numerous experiences and studies about our verbal handover, and the illustrated shortcomings (time-intensive, value-laden), the majority of nurses still defend the vital role of handover (even if taped) in the delivery of ongoing nursing care. The value of oral culture and oral knowing are contemporary explanations for this practice.

The structure of the nursing process requires that nurses compartmentalize their 'holistic' activities for the purposes of documentation. Nursing diagnosis has not assisted this process. Jargon and distortion of language, particularly rejection of known terminology because it has its roots in medicine, has not helped our cause in communicating nursing activities. The individual context of patient care is usually lost in this pre-printed standardized plan.

Nurses have only recently been availed of an education that required or allowed them to demonstrate literary competency. But nursing decisions are still hidden in a scientific discourse that sanitizes their meaning and worth. The principal polemic of this discussion is that the rules by which nurses have participated in the documentation of nursing care, have not been conducive to communicating the reality of what it is that we do. Anecdotally, nursing documentation is dismissed as 'fairy tales' that bear little resemblance to our practice.

With respect to the ethical, legal and administrative requirements of nursing documentation, I challenge nurses to acknowledge and understand how these valid social requirements can be met without forsaking the communication and development of our professional knowledge. If subjectivity is an acknowledgment of the thinking subject (patient and nurse) and just the nature of the object (body parts and functions), I invite nurses to own and be proud of their clinical decisions and judgements, and to express them confidently within the permanent and powerful medium of the patient case notes.

Marie Heartfieldi RN BNsg FRCNA

Nursing assessment: More than merely 'doing the obs'

In recent years there has been increasing acknowledgement of the importance of thorough nursing assessment, in all nursing contexts. Despite this it would seem that in acute care clinical practice the emphasis still remains on 'doing the obs', rather than truly assessing the patient/client. The measuring and recording of 'TPR and BP' remains the primary focus, if not the sole activity in the assessment of the acute care patient. A frequently overheard question from the oncoming shift on a post-surgical ward is 'what obs are my patients on?'

I can vividly recall the look of consternation on the face of nurses who would commonly ask me the very same question when I was the CNC of a post-surgical high dependency unit. My reply, perhaps somewhat facetiously, was that all of the patients in the HDU were on continuous observation-that was why they were admitted to the unit in the first place! It was interesting to note how readily nurses become socialized into conceptualizing nursing assessment as being a matter of TPR and BP performed at varying time intervals. One classic example is the night nurse who sneaks into the patient's room to 'do the obs' by dim torch light. The task of measurement complete, the nurse charts the findings and feels her/his assessment complete- without even having looked at the patient! Unfortunately, the 'observation charts' in common usage have tended to reinforce this narrow conceptualization of assessment.

I often quote a well respected nursing colleague of mine, who has unfortunately now left the profession to become a medico, who used to say that 'the most important information about a patient can be gathered by standing at the side of the bed and looking and listening.' However, in order for this to be true the data gatherer, i.e. the nurse, must have the knowledge and understanding of what she/he is looking/listening for and I would argue that this is where the problem lies! The importance of a sound (and relevant) scientific knowledge base to underpin skilled nursing assessment must not be forgotten in undergraduate nursing curricula, nor indeed continuing education programs for all acute care nurses.

Judith Wilcox RN, RM, ICCert, DipAppSci(Nsg), BSc(Adel)
Acute Care Nursing, Consultant/Clinician, Adelaide

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