How nurses ‘do’ data: record-keeping as part of everyday nursing work

With few existing studies of teachers’ data cultures, it makes sense to look toward studies of data-work within other professions – such as nursing. Indeed, some interesting parallels can be drawn between our own research interests and the empirical literature on how nurses engage with record-keeping and data during their everyday work.

Recording data is a key part of every nurse’s work – detailing what has occurred during their time on the ward so that other medical professionals can be fully informed and a continuity of care be ensured. This data can range from biographical information, relevant patient history, initial nursing assessments, nursing care plans, emerging areas of concern, what care the patient has received, their response to care, as well as other ‘events’ and ‘factors’ such visitors or scheduled consultations. One important focus of this work is the so-called ‘nursing record’ or ‘nursing kardex’ — a contemporaneous standardised record of each patient’s progress that nurses are required to add to on a regular basis.

Officially this record-keeping is expected to be as thorough, accurate and standardised as possible – while remaining mindful of the need to not breach patient confidentiality. In practice, however, this is an aspect of nursing practice that highlights a number of tensions between the professional expectations and practical execution of nurses’ data work.

Indeed, there is a long-standing literature detailing nurses’ ambivalence toward the requirement for record-keeping during their daily routines. For example, ethnographic research in the UK showed that nurses were reluctant to openly criticise the notion of record-keeping – valuing the nursing record as a symbol of their professionalism. However, as Davina Allen (1998) reported, the standardised ways that events were expected to be recorded was often a source of tension. In particular, nurses perceived the nursing record to be configured in ways that made implicit assumptions about the work that they were doing. Allen reported that nurses had little practical time to refer to previous records themselves in informing their own practice. This led to resentment that time was being spent maintaining records that were not being used during the ‘turbulent’ realities of a ward shift.

Instead, Allen noted how many nurses described their own decision-making while on the ward as intuitive. They also maintained a preference for verbally ‘handing-over’ to colleagues – thus being able to share narratives and stories about what had previously happened. Many nurses took a professional pride in ‘knowing’ their patients without needing to refer to record. In a broader sense, the requirements to record one’s practice was seen as managerial imposition that was also being used to standardise and monitor nurses’ own performance, as well as direct professional accountability and legal responsibility.

These professional resistances to standardised record-keeping and data collection have been reported in clinical settings around the world. For example, observations of actual ward practice in an Italian hospital suggested that only 40 percent of the assessments and interventions that nurses were conducting around a patient were then being entered on to the official nursing records. These rates of non-reporting increased during particularly busy sessions (De Marinis et al. 2010).

Of course, hospitals are experiencing shifts over to digitally-mediated practices in a similar manner to schools. However, there is a sense that tensions over record-keeping and data collection are perhaps being exacerbated by the transition to computerised patient records. There are, for example, continued concerns over mismatches between the design of electronic record systems and the realities of clinical work (Reuss et al. 2007, Kaipio 2011).

Thus an interesting strand of research continues to show nurses’ preference for keeping paper-based records – what Tobias Iverson terms “the peace of paper”.Indeed, in their study of a supposedly ‘digital’ Norwegian hospital, Iversen and colleagues (2015) showed how the use of paper-based records persisted in a number of unofficial ways. For example, paper-based records were felt to allow staff to include additional information through extensive hand-written annotations, and maintain a ritual where the paper records were ‘handed-over’ between different shifts – thus allowing a verbal conversation between different staff where stories and important points could be quickly conveyed.

Iversen also reports the continued use of small notes, memos and other ‘scraps’ – all preferred ways of recording details and information that staff were not fully sure of (see also Hardey et al. 2000). These scraps allowed staff to avoid entering this information in an official electronic form that they could be held responsible for. These scraps also allowed nurses and clinicians to continue long-standing modes of communication. For example, these written notes often took the form of abbreviations, symbols, and other means of encrypting the documents so they wouldn’t make sense outside of their immediate colleagues (what Jefferies et al. [2011] identify as vernacular ‘fragmentary language’ that have developed in local hospital cultures).

These studies all point to the affordances of these paper-based techniques in comparison to the official digital systems that they ‘worked around’. Indeed, other US-based research has noted the persistence of paper-records and Post-It notes as a means of not forgetting work-tasks, as well as some clinicians maintaining their own ‘shadow’ data-systems such as maintaining personal Excel spreadsheets where data can be more easily accessed and consulted (Saleem et al. 2011). Elsewhere, it has been noted that staff rely on information gauged from differences in handwriting and type of pen used (for example, such subtle cues allow them to discern when a particular consultant or external term has visited the patient).

In particular, Iverson notes how these practices all allowed for the quick accessibility and sharing of information – especially in wards where whiteboards and other forms of public notices could not be used due to matters of patient confidentiality. Crucially, Iverson et al.(2015) note that all these seemingly work-intensive and old-fashioned manual practices were valued as not “disturbing or complicating” the way that these professionals’ care work was performed.



Allen, D. (1998).  “Record‐keeping and routine nursing practice: the view from the wards.” Journal of Advanced Nursing 27(6):1223-1230.

De Marinis, M., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., and Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing19(11‐12):1544-1552.

Hardey, M., Payne, S. and Coleman, P. (2000). ‘Scraps’: hidden nursing information and its influence on the delivery of care. Journal of Advanced Nursing32(1), 208-214.

Iversen, T, Landmark, A. and Tjora, A. (2015)  ‘The peace of paper: patient lists as work tools’.  International Journal of Medical Informatics 84(1):69-75.

Jefferies, D., Johnson, M., and Nicholls, D. (2011). Nursing documentation: how meaning is obscured by fragmentary language. Nursing Outlook59(6), e6-e12.

Kaipio, J. (2011).  ‘Usability in healthcare: Overcoming the mismatch between information systems and clinical work’  PhD thesis, Aalto University

Reuss, E., Keller, R., Naef, R., Hunziker, S. and  Furler, L. (2007). Nurses’ working practices: what can we learn for designing computerised patient record systems?. In Symposium of the Austrian HCI and Usability Engineering Group (pp. 55-68). Berlin, Springer.

Saleem, J., Russ, A., Neddo, A., Blades, P., Doebbeling, B., and Foresman, B. (2011). Paper persistence, workarounds, and communication breakdowns in computerized consultation management. International Journal of Medical Informatics80(7):466-479.