by Sue B. Davidson, Ph.D., R.N., C.N.S.; Assistant Executive Director Nursing Practice, Education & Research
At an increased rate, processes and methods, technology, and roles in health care are coming under scrutiny for their capacity to deliver positive outcomes – be they economic, patient status related or related to quality of care. This focus – shared in the entire health care system – has led to new analyses of "what is” and "what should be” in the care the patients and families receive. Many – if not all – of Oregon’s acute care facilities are launching efforts to improve quality and ensure safety. This article explores nursing’s involvement in improving quality and ensuring safety from the perspective of the direct care nurse. As early as 1967, nursing authors have specifically written about the pathway to quality nursing care. What did they have to say?
One of the first publications in this genre is entitled Nursing and Ritualistic Practice, by Virginia Walker (1967). Walker conducted mini-studies of five common activities of nurses who delivered direct patient care. The practices were vital signs (TPR), charting, shift reports, special reports (currently called unusual occurrence reports) and interruptions and reassignment of nursing activities. The findings:
Routine taking of TPR was found to be unreliable and to some extent, dysfunctional because it was frequently inaccurate;
Charting: Nurses’ notes were scant, unused, and omitted significant information;
Shift reports: Incoming staff need current information about patients, people sharing responsibility for patients need to talk to each other, and reports could be made more interesting and valuable; and
Interruptions: It was found that before having a head nurse, patient contacts per hour for direct care staff were n = 16; after the arrival of a head nurse, they rose to n = 23.
Walker concludes that rituals which are performed but have little value, may be ways to reduce nurses’ anxiety when what they do seems to have little or no recognized value to the patient or the organization.
Another nursing author, Zane Robinson Wolf (1988) has written about other rituals in nursing such as post-mortem care, medication administration, medical aseptic practices and change of shift report. This work is based on the author’s doctoral dissertation which used an ethnographic methodology. This was a study of nursing rituals that involved nurses, patients, and other hospital workers when working on a medical unit of a large urban hospital. Participant observation techniques were used. She saw nurses "…doing good, avoiding harm, passing on their knowledge about nursing and patient care chiefly by word of mouth and by demonstration.” Wolf’s findings identify the hidden value of many nursing acts which, while appearing to be a "ritual” really are significant routines of care because they avoid error, identify and remove sources of error and demonstrate ethical conduct of nurses, e.g., doing good, avoiding harm.
In summary, these nursing authors – besides pinpointing what may be unnecessary – also show us what must be considered to identify practices that contain value and should be retained.
This year, nurses engaged in the Releasing Time to Care Project (RT2C) conducted a process analysis of personal hygiene practices as practiced on a medical surgical unit in our state. The various components that were looked at were mouth care, assisted washing, and bed bathing. But what is new and different about this approach is that it is done through use of "lean” tools and techniques by a group of nurses and other staff on a particular unit. Here are some of the steps taken by the group:
- Prepare: Choose a team, talk with patients and staff and take photos or videos (if appropriate);
- Assess: Review all the collected data, monitor what staff do and how long (in minutes) it takes, build a process map;
- Diagnose: Review the description of good patient hygiene practices;
- Plan: Brainstorm and identify changes in the process, prioritize what you wish to change;
- Treat: Test the patient hygiene processes in the new way;
- Evaluate: Gather and understand staff and patient feedback.
Using this process, nurses learned in this project that the current method of patient hygiene took 51.6 minutes of time, and of that time, a lot of it was spent hunting and gathering supplies to complete the personal hygiene. They also learned that some steps that were important such as brushing teeth were omitted and some members of the team did not understand the importance of this step. When the new process was tested and piloted, it took 45 minutes.
What this tells me is that these new tools and methods are capable of identifying ways to refine what we do as nurses, yet meet standards and best practices of nursing work. Some have feared that "lean” and methods related to identification of quality and safety are barely concealed efforts being used to get rid of nurses. However, the significance of these practices are that they confirm and reinforce the meaningful and needed practices of nursing, moving them from rituals and approaches that may not be meaningful to those which achieve outcomes and safety. Secondly, core processes of nursing – some of which may have appeared to be ritualistic in the past – are rituals with meaning and should be sustained.
National Health Service Institute for Innovation and Improvement (2008). Releasing Time to Care: The Productive Ward – Patient Hygiene. Coventry House, University of Warwick Campus, Coventry, CV4 7AL.
Walker, V. H. (1967). Nursing and Ritualistic Practice. New York: The Macmillan Company.
Wolf, Z. R. (1988). Nurses’ Work, The Sacred and The Profane. Philadelphia: University of Pennsylvania Press.