Arming The Peasants

The New Nurse had a hard time of it at the meeting on November 4th. Discussion of the new chair inevitably led to discussion of its use. I had already primed the OT with my concern that Rosemarie was being left in the chair for extended periods and if moved from the chair it was to the bed and she was likely to stay there for the rest of the day. I asked her to bring this up in the meeting and lay down some guidelines, which she duly did.

It was quite simple really. She should not really be in the chair - any chair - for more than three or four hours. At the end of that time, or earlier if she shows signs of being uncomfortable, she needs to be moved. It doesn't have to be to the bed (although it should be if she looks tired) it can be her other, outside wheelchair. A change is as good as a rest. Even briefly moving her to the bed to check and change her pad and then hoisting her back to the same chair after a few minutes rest can relieve her discomfort. Indeed, there will be times when she has not been in the chair long but looks uncomfortable and all that is needed is for her to be repositioned either by lifting or hoisting. 

That's not too difficult is it?

Apparently it is. I have had interactions with New Nurse (and others) before on this topic, and hit the same wall. Everything must be documented. Initiative is to be discouraged because monitoring it requires too much management time (and by implication at least some staff cannot be trusted to make the correct decisions).

I suppose it could be created as a decision path and programmatically it would look something like this:

if Rosemarie is in the chair
      if she has been in the chair for four hours or more
            if she looks tired
                  move her to bed for an hour
            else
                  move her to a different chair
            end if
      else
            if she looks uncomfortable
                  try adjusting her posture
                  if she still looks uncomfortable
                        try another chair or put her to bed
                  end if
            else
                  leave her where she is
            end if
      end if
else
      if Rosemarie looks sufficiently rested
            hoist her into a chair
      else
            leave her in bed
      end if
end if

It could also be created as a flow chart. The point is, any attempt to document the process makes it seem more complicated than it actually is. I trust most of the staff to make the right decision in a perfect world, but therein lies the problem. In a world of limited staff resources rigid procedures are a way of ensuring a certain standard of care. Initiative can all too easily result in making a decision that is in the best interests of the staff rather than the best interests of the resident. 

New Nurse struggled in the meeting and afterwards to come up with simple procedures but it has proven very difficult. The OT suggested that a record needed to be kept of movements between chair and bed and also tilting when in the chair and moving position when in the bed. Miraculously the day after the meeting a form appeared in her file to record this, and so far it seems to have been used correctly.

This is a good sign. I have plotted the data on a spreadsheet and it shows the random pattern which could be consistent with decisions being made based on need, but also shows graphically when she has been in the chair too long. It will be used in our next review.

The title of this post is not intended as an insult to the care staff but a quote from an amusing and thought-provoking book Writing on the Wall: The Campaign for Commonsense Business by Geoff Burch, which I heartily recommend. One of his points is that if done intelligently devolving decision making to front line staff and encouraging initiative brings far more benefits than risks.