Project Summary

New ways of keeping nursing records with the potential to save nurses' time and improve the quality of nursing care in Scotland.

Innovation of nursing record keeping processes and systems is needed to improve patient safety and care. Almost all of the NHS Scotland regions use paper-based nursing records, which causes problems such as loss of information, poor quality recording of care and lack of access to existing patient information. It also creates a large administrative overhead. This is against the well-understood backdrop of chronic underfunding and understaffing within the NHS.

An Experience Lab was held following several interviews with senior nursing staff to scope the current issues and existing improvement work around nursing. The Lab helped us move towards a group consensus on what innovative technologies may be suitable to help nursing staff and how to make progress. This report details the work and findings of the Experience Lab team.

The primary finding of the Experience Lab is a desire and need to move to electronic health records (EHRs). It is important that this should go hand-in-hand with work to increase the amount of professional judgement that nurses can use within care (as opposed to too many forms and task-based working). Ongoing work to make nursing records more person-centred should continue, with the obvious example being a move to a multidisciplinary record centred on the patient as a whole.

A particular problem for nursing staff is that they work with their hands and so record keeping is often delayed until after the time of care. This delay can be significant and can compromise the integrity of the records system. This is the case whether using paper or electronic record systems. We found no suitable existing solution for enabling time-of-care record keeping.

Finally, the methods of progress within NHS Scotland’s regions are as important as the desired changes. “One shot” procurement should be replaced as far as possible by pre-procurement working with industry, and ideally with long-term working relationships.