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I received the invitation to talk about my recent research project with pleasure mixed with trepidation. Pleasure at being able to share some of the interesting things that we found, and trepidation at the size of the task. A research project depends on the help and interest of so many people, not just those whose job is to research. The ward sisters and all the nurses in the wards involved, the members of the research steering group, willing volunteers from both the school of nursing and the central nursing office, who often gave up some of their off-duty to observe and all the staff who then gave careful consideration to the results and agreed to try out the ideas and forms. I hope I can do justice to all that work today.

Research demands careful attention to detail as it may yield clues about the nature of what is being investigated. It also has to be recorded in detail so that an investigation can be repeated as exactly as possible to allow comparisons to be made. I cannot give you all the details in the brief time available and indeed, many of them would only be of interest to those who wished to replicate the research.

It is often useful to define words used in projects. I'd like to share with you one definition of research that I find useful.

'Research is to see what everyone else has seen
and to think what no-one else has thought'.

Let us focus on what we saw and how we came to see it.

Jenny Hunt's research clearly showed that we had problems in communicating nursing instructions within the ward team. These included stereo-typed phrases which were imprecise, a reliance on verbal instruction and reporting back and inadequate or incomplete written records of instruction and care given.

Some of the ward sisters complained that the learners could not be trusted to carry out instructions properly. They had found Jenny Hunt's work on developing the nursing admission sheet helpful and the sheets were introduced throughout the general divisions by Maureen Scholes and Veronica Chapman. By the time I arrived back at The London in February 1980 most wards at Mile End and Whitechapel were using the sheets to assess the needs of each patient.

The nursing care plan, which had been tested by Caroline Redd (now Mrs James) in Currie Ward, had not been adopted. The ward sisters wanted less writing and a system which gave an 'at a glance' view of the nursing care required by each patient. And they wanted the solution as quickly as possible, preferably yesterday!

I spent a few weeks working in the wards, picking up the threads again, all the time talking, and listening to what the nurses felt they needed. A group of sisters with one nursing officer and one tutor met to discuss the sort of documentation they required.

Through the generosity of the Special Trustees, a research assistant post was funded for one year. Susie Hewins joined me in April, she had been involved in the computer project evaluation and was familiar with the wards at 'The London'. The short time available concentrated our minds wonderfully! In research terms, one year was very short for all we wanted to do. So I settled for what I would call a blunder-buss technique. I used a variety of research methods to pepper my larger area in the hope of hitting on enough pieces of information to be able to suggest an answer with a moderate degree of confidence. Blunder-buss might also aptly describe some of the things that happened. We watched what happened in the wards, took samples of written records, carried out an experiment by introducing care plans and asked the staff questions with a written questionnaire.

Arrows are used to indicate that an action is to be continued unchanged on the next day. The results of the nursing action are recorded in the progress notes.

The way in which care plans were to be used during their trial was felt to be important.

Sue Pembrey reported that individualised care for each patient was made possible by the ward sister who undertook the following.

a) Daily round of the patients

b) The patients allocated to a specific nurse

c) Accountability of the nurse for the care given

d) A prospective work prescription.

With these criteria in mind we asked the ward sisters in the two wards to be involved in the experiment to carry out the following, when the care plans were introduced:-

i) To assess the patient's needs through the night nurse's report and during the first drug round of the shift.

ii) To allocate each nurse to a specific group of patients, these geographical groupings had patients of differing dependences.

iii) To exact accountability through a verbal report of the patient at the afternoon report and a written entry in the progress notes.

iv) To prepare a care plan for the following day.

The sister was also asked to stop the use of personal notebooks or scrap paper by the learners. Both sisters agreed to these requests.

The first set of observations that we made was to provide the 'before' picture. Care planning would then be introduced and after a period of use the observations were to be repeated for the 'after' picture. On each ward we observed for five days, Monday to Friday for the 08.00 handover report until 17.00 hours in the first week, and then from 12.00 to 21.00 hours the second. Each day's observation was broken down into two hour periods with a half-hour break between them. Susie Hewins and I took turns in starting half an hour early to note down in full any written instructions about the four chosen nursing care activities. We then listened to the report noting any changes in the instructions or verbal instructions. These we termed initial instructions. Each observer watched the care given to a specific group of patients.

The three single rooms and the first bay of four beds was usually allocated to our volunteers. The next two bays provided the second group and the twelve-bed ward or 'big-end' the third group. These groups matched the patient allocation once care planning was introduced. This made the 'after' set of observations easier to follow.

The four activities we chose for observation were revealed only to the ward sister and to the observers. They were selected because they could be seen without following the nurse behind the curtains. The four were:

1. Oral fluids under the control of the nurse, for example the surgical patient being given small regular volumes of fluid or the confused old lady to have hourly drinks.

2. Mouthcare.

3. Turning.

4. Blood pressures.

Each activity was broken down into steps and coded for speed of recording. So that the nurses did not realise that we were interested in blood pressures we checked all the charts at the end of each patient's bed at the start of each two-hour period. An entry we had not observed because it was written down when we were on a break was given a tick and later counted as being completed on time.

The nursing notes were used where possible to provide the sequence of each procedure for coding.

In the 'before' span of observation the nurses in the medical ward had written instructions in the side column of the progress notes and in the nursing reminders section of the nursing admission sheet. In the surgical ward work cards were filled out in pencil each day. The format for each instruction was noted and we even included a code letter for the nurses' aprons. Additional instructions were recorded together with the time, who gave them and to which nurse. The forms used to collect all this data were designed so the patient's name could be cut off after coding. As you may imagine we collected a great deal of data and that amounted to a lot of paper. All this was locked away after the first set of observations so we could not be influenced by an analysis of the 'before' activities.

And how did the nurses react to being observed? This was important as the presence of the observers could influence what the nurses did in our presence. The GNC ward assessments provide examples of what may hap p en! The recordings that we made on the first day were not included in the analysis. The non-verbal gestures with which human beings communicate became less frequent as the day progressed. The raised eyebrows or eyebrow flash, smiles, comments, all became so infrequent that we started to feel non-people. A very uncomfortable feeling but one we saw as useful as it indicated we were becoming part of the furniture. At one point, Susie came very close to being sat on by a doctor!

Some of our volunteers found it very hard not to comment when they saw students not undertaking procedures exactly as taught! Being a fly on the wall opened quite a few eyes to the hard facts that what is demonstrated in the classroom does not always go on in the ward. In research terms, the use of volunteers with only limited training weakens the value of the data collected, but in terms of getting the need for change accepted it was most helpful.

Another source of error could creep in during the teaching sessions when we introduced the care plans. Susie and I tried to cover the same information in our sessions and to do it in the same way. The same example care plans were used. Miss Collins kindly purchased and loaned us a portable overhead projector which could be used in the ward office or day room so we used the same transparencies.