The Situation:

Our population will continue to grow and get older,and our citizens will require skilled, dedicated professionals to meet their health needs. Nurses are the backbone of health and social care and have a key role in promoting health and keeping people well as well as supporting them during times of illness.

Whilst the fundamentals will be the same – delivering care with kindness and compassion - the role of nurses is rapidly expanding. Nurses are leading teams and working in many different settings, using a wide range of technologies to support patients in their care. They are running their own clinics, prescribing drugs and taking on the work of managers.

Nurses need time to be able to do their jobs effectively, time to care how they would like. They are dealing with increasing complexity, both in their patients’/clients’ needs and in the system in which they are working. Remaining present and focused on delivering patient-centred care when there are so many competing demands on the nurse’s time is a major challenge.

Well-written and factually accurate medical records are a fundamental part of delivering quality healthcare. Mounting documentation volumes reflect the increasing volume of patients, complexity of medicine, burden of regulation and more inter working with multidisciplinary teams and other health and social care organisations. 

Implication:

Documentation takes up a large proportion of nurses’ clinical time and producing detailed documentation in line with the Nursing and Midwifery Council’s guidance is challenging. The volume of clinical documentation has grown over time as a result of:

• Nurses taking on many of the roles that used to be undertaken exclusively by doctors; these require specific documentation
• Complicated conditions and therapies requiring the support of multi-disciplinary teams across complex care pathways need to be documented and communicated
• Worries about litigation require nurses to record why they took particular actions rather than just describing them
• The ability to keep people alive despite major life-threatening conditions means many long, complicated medical histories and complex needs – all of which need to be documented and communicated to the multidisciplinary teams
• The change in medical and nursing culture, whereby patients/parents/carers are now seen as partners in care, involves more communication than used to be required in a paternalistic medical environment

Purpose of Tweet Chat

This @WeNurses tweet chat aims to explore the challenge of clinical documentation for nurses and how technology in general and more specifically speech recognition technology could be used to overcome these challenges by asking some of the questions below.

For this discussion we will be joined by Anne Cooper, Chief Nurse, NHS Digital

• What are the biggest challenges you face with respect to the workload and management of patient clinical documentation? eg  Volume, Turnaround time , Backlogs, Quality (completeness and accuracy) of documentation, Managing the documentation workflow within your speciality and between others in your team or other specialities and other  healthcare professionals, Patient  and carer communication, Other
• What things do you think could be done to improve the patient clinical documentation/ paperwork challenge? eg Better technology, More People Resources, More Time, Training of nurses and other healthcare professionals, Training of support and administration teams, Re-engineer the processes, Other
• How do you think technology impacts positively or negatively on the clinical documentation challenge?
• What, if any, are the barriers to introduction of technology in general in your day to day nursing? Eg, Knowledge of new technologies that can support you, Time to introduce/implement new technology, people resources to introduce/implement new technology, IT knowledge and experience. Training, Support for new technology investments from management, healthcare leaders, Funding, Data security and privacy, other
• What personal experience do you have in the use of Speech Recognition? Eg. No experience, Smartphone, In-Car,Consumer devices such as TV, wearables etc., Professional use ie in the working environment, Other
• What could we learn about the use of consumer speech recognition in healthcare?
• Do you use speech recognition technology in your day to day nursing?
• If yes, what impact you think speech recognition technology has had upon patient documentation challenges in your day to day work?

About our guest hosts

Nuance Healthcare Solutions enhance the production and management of clinical documentation by simplifying how nurses interact with technology. Nuance speech recognition solutions turn voice into text three to four times faster than typing, recognise clinical language and enable voice navigation of clinical systems including the patient electronic health records anywhere, anytime on any device. Now nurses can focus on capturing the patient story and get back to caring for their patients.

Benefits of Nuance Healthcare Solutions:

• Reduce the administrative burden of clinical documentation improving nurse productivity by 10-15% per day.  That’s at least another 30 -60 minutes per day freed up or more time with your patients. (Based upon a University of Dusseldorf JMI study, Alder Hey Speech toText report Nursing Times report )
• Reduce paper-flow, backlog of letters, referrals and discharge notes and reduce document turnaround time.
• Puts the patient back at the centre-of-care, improving communication and transparency with patients and their experience and feeling of well-being
• Document the care record of the consultation with the patient in real-time improving accuracy, data gathering, decision making and patient safety