The Nurses’ Room: A Hidden Hub of Care and Paperwork
In a previous post, I discussed how the LTCF (long-term care facility) and each of its floors is tethered to the institutional routines (medication work, serving meals, as well as staff and physician schedules) and spaces or everyday infrastructure of the institution.
This post zooms in on one of the most important yet unseen spaces in long-term care: the nurses’ room. It is here that the clinical and administrative work of care comes together, where medications are tracked, forms are signed, and crucial decisions about residents’ health are recorded. My broader goal is to understand how (problematic) polypharmacy unfolds, and the nurses’ room offers a window into the everyday institutional dynamics that make it possible.
Why does this matter? Because polypharmacy in long-term care (and elsewhere) is not just a medical issue—it is also an organizational one. Decisions about medications are made within a system of documentation, delegation, and professional hierarchies that influence what gets prescribed, renewed, or discontinued. To understand how residents come to be on multiple medications—and why deprescribing and other attempts to stem the flow of medications is so difficult—we need to examine where and how these decisions happen. To start, I take you inside the nurses’ room, a small but central space where medication management, staff coordination, and institutional routines intersect to sustain the rhythms of polypharmacy:
During one of my fieldwork visits to the Long-Term Care Facility (LTCF), I take the elevator to one of the residential floors. Given the architectural similarities, it is sometimes hard to remember which floor I am on. I exit the elevator and knock on the nurses’ room for one of my planned observations of Doctor Day, where the physician attends to the needs of the residents on the floor. There is a restricted access key-pad on the nurses’ room and I do not have the code and so one of the CCA’s (continuing care assistant) opens the door for me. Entering the nurses’ room, I notice there is a table, some chairs, and on the built-in desk on the outer edge of the room there is some computer equipment, binders, pieces of paper, and pens. There are several rows of heavy-duty maroon coloured resident binders or charts, the Doctor Book[1], and preprinted required forms such as the CGA (comprehensive geriatric assessment form) or the Bi-Annual which is a 6 month standard medication renewal form. Looking around the room I notice on the wall a taped legal sized piece of paper with 25 categories of “Standardized Filing Order.”
Categories include assessment, communication, consent and release forms, infection control, medication related forms[2], monthly forms, education/orientation, scheduling forms, outbreak binder, Doctor Book, and audits. One of the nurses shows me on the computer that there is a directory containing 302 files/forms of organizationally specific policies around areas such as nursing interventions, medication management and administration, staffing and scheduling, and Care by Design policies.
During this one day or morning or afternoon or evening a week, the assigned physician visits the floor. The work of Doctor Day is layered amongst the rhythms of everyday floor life. Daily activities go on as usual. The nurse, LPN and CCAs are juggling the varieties of care work on the floor: doing medpass (administering medications), changing wound dressings, administrative work, personal care work, and the like. Other staff are doing custodial work or prepping and serving food. Residents are also active participants. They are maintaining themselves by eating, sleeping, waiting, readying themselves for personal care work, swallowing drugs, and offering their arm for injections or drawing blood.
The power of documentation in the nurses’ room is everywhere as the highly accountable work is commonly structured by engaging with forms and text and pens (Smith 2001). The forms tend to be filled out or accomplished through a text-action-text sequence (Campbell and Rankin 2017). These objects shape the time, place and rhythm of the working day and its unfolding tasks. The CCA has a checklist, completes items on it, and rechecks it. The LPN reviews the pouches, 24 hour checks, and then administers the medications. For every drug dispensed she puts a checkmark on the MAR (medication Administration Record) as a sign of accountability.
Accountability is enacted in initials, signatures, and check marks. These are separated by scopes of practice: what you can and can’t do and what you are responsible for; scopes of practice are not, however, rigid. People and objects are always dependent on each other for bits and pieces of information and skills. For example, the chart and the MAR are relatively stable objects, though the MAR is moved around on the floor with great intensity during med pass, and it bridges time and space and can be consulted by staff when in eyeshot.
During the morning or afternoon of Doctor Day different tasks will be accomplished. The floor and the nurses’ room is run by the daily staff. The work that the physician will do produces a ripple of work downstream on the floor and within the organization, to the resident, LPN, RN and the pharmacy. The visit will also help move along some of the floor concerns, such as attending to time-sensitive forms, like bi-annuals, or dealing with specific resident and nurse concerns. Depending on the floor, the needs and capacity of the residents, and the practice preferences of the physicians, and the style of working relationships, the LPN/RN will be involved more or less during Doctor Day. Answering questions from the doctor will be one of many tasks today.
As usual, the RN/LPN shift starts at 7 am and she has been busying herself with responsibilities, ensuring the CCAs are up to date on the latest resident concerns and making sure to get things in order for Doctor Day. She knows that the visit by the physician is time-limited, and she is smoothing the way.
In the nurses’ room, there is a lot of scribbling by the CCAs, as they cross off their daily tasks. There is also a variety of talk. Staff are exchanging information of all types, personal anecdotes about the weekend (a concert attendance, a sports activity) and fragments of information about residents, sometimes clinical, sometimes more personal such as noticing a nice haircut on Gerry, a resident on the floor. Various staff members come in and out of the nurses’ room using the restricted access key-pad, and residents know they are generally not allowed in this room.
In the coming posts, I’ll take a closer look at how the billable Bi-Annual Medication Review Forms are completed—how they do structure decisions, reinforce institutional routines, and ultimately shape the medication regimens of LTC residents.
[1] The Dr Book (also known as communication book) has the following nine forms according to “Standardized filing order sheet”: Care by Design on call SBAR, exception status sheet - see MD binder, Nova Scotia Provincial Pharmacare Programs first request for cholinesterase, Nova Scotia Provincial Pharmacare Programs request for renewal of a cholinesterase, nursing concerns, physician follow up, reorder.
[2] Medication related forms have the following 28 forms: listings of medication storage, MAR sheet (Lawtons), medication administration information, medication coverage agreement, medication discontinued form for pharmacy (yellow), medication new order form for pharmacy (pink), medication reconciliation form, medication reorder form for pharmacy (green), monitoring of new or dosage change in antidepressants, monitoring of new or dosage change in anxiolytics, monitoring of new or dosage change in anxipsychotics [sic], monitoring of new or dosage change in cognitive enhancers, monitoring of new or dosage change in cognitive enhancers, monitoring of new or dosage change in mood stabilizers, narcotic count record, order set for prophylaxis treatment of influenza like illness 2014-15, resident request for product, supplement, and/or other, alternative/ complementary, RN/LPN master signature form for medication administration, routine bowel directive for constipation, routine medical directive, self admin of medication agreement app B, self admin of medication, clinical assess & prescriber, authorization app A, stable dose warfarin, subcutaneous injections rotation form, transform medication application sheet, treatment record, warfarin and INR record.