Nursing and Curation of Meaning in Patient Records

Recently, I have been writing about sensitivity to complexity as a leadership quality for nursing (see here). So far, I’ve highlighted the awareness of relationships and the ability to understand different perspectives and interpretations of information. In my previous post, I referred to the crisis of interpretation—the so-called hermeneutic crisis—I experienced as a nursing student and later as a new nurse.  How do such crises arise?  What do they mean in terms of meaning making in nursing communities?

There is no doubt that nurses occupy a unique position in healthcare. We live at the intersection of processes and communication between patients and their support networks and individuals whose work activities impact patient care, both nurses and non-nurses. In the acute care setting, there are periods during which we conduct “business as usual.” At these times, there may be few, if any, changes in physicians’ orders, and the shift-to-shift status of a given patient may seem stable.

Patient status can indeed be relatively stable for extended periods, but then there are nursing shifts when patient status changes, sometimes dramatically. Some physiologic crisis ensues, which requires action by healthcare professionals to resolve. However, the resolution may not take the form of a return to the pre-crisis state. Sometimes, patient condition deteriorates, even resulting in a change of level of care.  For example, I’ve previously spent hours with a patient, attempting to resolve a crisis related to respiratory distress, which culminated in an early morning transfer to my hospital’s intensive care unit.

It seems to me that not all physiologic crises are predictable, but doesn’t this go without saying?  After all, if they were predictable, would they not be avoidable?  Well, not necessarily.  That’s one of the most intriguing aspects of a complex system.  The signs of future states, of changes to come, may or may not be noticeable prior to the changes.  Even if they were noticeable, there is no guarantee one could capitalize on that knowledge to influence the changes.

The crisis of interpretation that takes place in acute changes of patient status is reflected in the permanent record of our activities.  In the midst of the flurry of rapid assessments, vital signs checks, phone calls, and STAT orders, is the tendency to act rather than record.  This is for good reason, of course, because the patient’s care must be foremost in the nurse’s mind.  On the other hand, it is conveyed information that becomes the basis of care decisions. Simply put, information must be known and conveyed to be acted upon.

I use the phrase “conveyed information” to note that there is a great deal of information brought to light in the course of patient care that is never incorporated into the permanent record.  There are some records that are important, even essential to patient care, that are nonetheless temporary.  Not all such records are derivative of permanent records, and many of them do not give rise to permanent records.  Obvious examples are various nursing unit-specific forms that are never scanned into patient medical records, nurses’ “brain sheets,” meal tickets that arrive on trays from the kitchen, and labels applied to disposable items used in the course of patient care.

These are only a few of the many possible sources of information that bear patient identifiers during use but are ultimately destined for the shredder rather than the scanner.  As cues for further care decisions, at least some of the information these records contain may be “invisible,” effectively omitted from the process of meaning making.

Accounting for this potential loss of meaning while contributing to the ongoing record of activities is a task that lies near the center of nursing practice.  At the point of decision, nurses “curate meaning” to a greater extent than any other healthcare professionals.  Nurses spend the greatest proportion of time with patients, and their fine-scale interactions with patients and their support networks arguably generate the bulk of real-time content within patient records.

Independent healthcare providers may contribute a larger volume of text in the form of narrative assessments and plans of care, and diagnostic and lab test results may form a backbone of data for clinical decisions.  However, these sources of information are derived from nursing activities and in turn influence nursing activities, so that there is no masking the fact that nursing is one of the most important sources of information that gives rise to meaning in healthcare.

The next time you encounter a crisis in nursing, let me encourage you to consider the implications of your contribution as a nurse to patient care, both immediately through patient interaction as well as long-term through the meanings you preserve for posterity.