Rasmussen, PhilippaWiechula, Rick (Richard)Mcliesh, Paul Christopher2025-05-232025-05-232025https://hdl.handle.net/2440/144705Background: Assessment of patient needs are core to the delivery of effective nursing care and serves as a platform to identify individual patient risk and then plan and implement relevant care. The way nurses conduct and document patient assessment is guided by policies designed to ensure consistency and completeness of assessment. The complexity of those assessment requirements has intensified over time, to a point where conducting and documenting patient assessment has become an inefficient use of nurses’ time. Expert nurses have developed an ability to make rapid and accurate decisions about patient needs based on previous clinical experience that allows them to quickly identify and prioritise key elements of patient needs. There is a risk that the complexity and inflexible structure of contemporary patient assessment requirements constrain that practice and result in unintended consequences. This research was conducted across two phases to establish if expert nurses identified a disjuncture between patient assessment requirements and their practice. And if so, determine institutional factors that have led to this disjuncture and identify the effect on that practice. Methodology and Methods: Institutional Ethnography was used to investigate institutional factors that determine the design and implementation of patient assessment requirements. The research sought to identify existing social and ruling relations that determined the way expert nurses were required to conduct and document patient assessments. Phase1 was designed to establish if a ‘Problematic’ existed - a disjuncture between expert nurses’ experience of practice and the assessment requirements, by interviewing 12 expert nurses working in a large acute care hospital. Phase 2 included direct observation of expert nurses conducting patient assessment activities in the clinical setting, mapping of relevant texts (policies, procedures etc), review of institutional structures and identification of how assessment requirements were established, refined and communicated to staff. Further interviews were conducted with key nurses to assist in establishing context of the processes identified above and gain insight into the historical development of the requirements. Results The experts described their frustrations with various elements of the assessment requirements, particularly the complex and inefficient use of their time that detracts from their ability to deliver care. A disconnect between assessment requirements, determined centrally, and those who deliver care locally was established. While these requirements are managed and determined centrally, a lack of coordination that considers the local consequences is missing. The number and range of assessment tools that must be completed in any patient assessment have grown in complexity, resulting in unintended consequences that may actually contribute to the risks they are designed to prevent. Additional assessment tools are added to the requirements, to address concerns regarding emerging risks, but the impact and effectiveness of those changes has not been considered, managed nor measured. The time it takes nurses to complete the assessment tools was perceived as negatively affecting nurse’s capacity to deliver care. The experts also identified concerns about how the purpose of assessment has been reframed towards a task based process, using a screening methodology rather than genuine assessment. Nurses are concerned that clinical judgement is being lost in contemporary healthcare practice. Conclusions: The findings in this research are supported by an emerging body of evidence that identifies concerns about unintended, adverse effects of existing documentation requirements. Researchers and commentators are challenging assumptions associated with contemporary documentation practices by suggesting that they have become so burdensome that they are interfering with clinicians’ ability to deliver efficient and safe care. The expert nurses in this study described a sense of frustration with the existing requirements but struggled to identify changes that would improve this disjuncture. This is reflective of creeping normalisation where nurses have gradually accepted the assessment requirements over time to a point where they may not fully recognise the negative effects beyond a sense of frustration. The disjuncture was established as a complex and nuanced issue that has transpired slowly over time, making it difficult to recognise the unintended consequences but also identifying solutions. It was identified in this research, and supported in the literature, that the effectiveness of nursing care delivery is being measured by documentation compliance as a de facto measure. This is motivated by a flawed assumption, especially where a large number of risk assessments are required, that completion of risk assessment tools will lead naturally to risk reduction. This research establishes that effective patient assessment may be achieved through using a combination of structured assessment tools designed in an efficient manner to minimise data duplication combined with clinical judgement or reasoning. Recognising the problem and how it occurs offers those affected, the opportunity to understand and measure those unintended consequences and equip themselves with evidence to challenge existing requirements. A basis is established that can be used to frame and justify future research that focuses on measuring the impact of existing requirements and advocating for change. Findings in this research are reflected by a growing body of research and publications that have identified the unintended consequences of current assessment requirements, the effect of complex and inefficient documentation requirements on nurses’ time and efficiency and the need to consider critical thinking in patient assessment.enClinical Assessment ToolsDocumentationSafetyPatient AssessmentRisk AssessmentInstitutional ethnographyThesis