4 Practice Breakdown: Attentiveness/Surveillance

Karla Bitz

Vicki Goettsche

Patricia Benner

The nursing shortage has created multiple changes within the nursing profession leading to diminished nurse-patient contact and less attention to the needs of patients. Fewer nursing caregivers are available today to provide nursing care to a more acutely ill patient population and lower nurse-to-patient staffing ratios have been shown to decrease patient safety ( ; ).

The goal of system designers is to minimize the attentiveness required of human beings with the caveats that even the best-designed systems require intelligent human alertness and attentiveness to deviations in the performance and design flaws of these systems. In complex, open-ended, underdetermined systems such as health care, attentiveness and critical thinking cannot be engineered out of the system ( ). In fact, the loss of transparency that accompanies increased automation and technology calls for even more attentive monitoring and thoughtfulness on the part of professionals ( ).

Health care systems must be designed to foster attentiveness to the most important critical aspects in the clinical situation while “disenburdening” the human problem solvers and knowledge workers. As noted by the Institute of Medicine (IOM) report “Keeping Patients Safe: Transforming the Work Environment of Nurses” ( ):

· A primary activity performed by nursing staff in all hospitals, long-term care facilities, and ambulatory settings is ongoing patient surveillance (sometimes referred to as patient “assessment,” “evaluation,” or “monitoring”)—an important mechanism for the detection of errors and the prevention of adverse events. If a patient’s status begins to decline, the decline will be detectable though the nurse’s observation of changes in the patient’s physical or cognitive status. Performance of this patient monitoring requires great attention, knowledge, and responsiveness on the part of the nurse ( ).

A major threat to attentiveness and surveillance for all health care workers is sleep deprivation and fatigue. Shift work is required in hospitals, long-term care, rehabilitation, and psychiatric facilities—that is, in any institution where around-the-clock care is required. report that hospitals usually have 8-hour and 12-hour shifts, with slightly more than one third of all nurses working on shifts other than day shifts. This report was completed in 1988, and since that time patient acuity in hospitals has required increased staffing on evening and night shifts. With staff shortages, the problem of fatigue and sleep deprivation can become compounded by nurses working extra shifts. Four disasters, the Exxon Valdez, Bhopal, Chernobyl, and Three Mile Island have been associated with sleep deprivation and fatigue, as have driving and airline accidents ( ; Rosekind et al., 2004; ). The quality of sleep deteriorates with disturbed sleep-wake patterns, and chronic disturbances in sleep cycles often cause cumulative sleep deprivation ( ; ; ). Quiet shifts on long-term care units may create negative patterns of “dozing” and inattentiveness due to fatigue.

Vigilance on the part of nurses is required in order to anticipate and respond to predictable complications, to monitor changes in the patient’s condition, and to handle unpredictable emergency conditions that may arise. A commercial and competitive environment in health care increases emphasis on efficiency without equal emphasis on effectiveness, which further increases the demands for nurses’ focus and attention while creating climates that make attentiveness to particular patient needs more difficult. Efficiency, if it disrupts attentiveness, is not efficient because it is ineffective. Performing more and more interventions at a faster pace impedes life-saving attentiveness.

To cope with the high demands of work overload, nurses use risky shortcuts because they have too many competing demands for their attention and lack the system supports that they need to provide safe, reliable care. Efficiency, shortcuts, and productivity may be the major organizational source of rewards and recognition while the consequences of inattentiveness may go unrecognized. Attentiveness and surveillance to the patient’s well-being and changing condition provide an essential first-line defense against undetected changes in the patient’s condition and hazards in the administration of therapies as well as environmental hazards in the hospital. The good outcomes of adequate levels of nurse attentiveness typically go unmeasured, and we are left with indirect measures of the absence of adequate attentiveness to the patient’s needs. It is easy to identify a problem with inattentiveness when the patient goes unchecked or unmonitored for long periods of time. It is more difficult to identify problems with rushed assessments and interventions.

Nurses who observe their colleagues cutting corners in ways that might endanger patient safety are expected to speak directly to the nurse or report their concerns to management or administration ( ). However, when staff perceives that punitive or even nonconstructive communication will result, there will be less incentive to report such incidents since punitive reprimands rather than constructive problem-solving may only make the problem worse. describes a culture of patient safety that focuses on improving system issues. Poor system design and short staffing interfere with attentiveness. A culture of safety is achieved by building one that encourages mutual disclosure and immediate corrective action without the anxiety of blame and shame. A sense of collective responsibility and continuing improvement and a just social climate are central to improving the quality and effectiveness of nursing attentiveness to patients’ changing conditions and needs.

Recommendation 6-2 of the IOM report ( ) discusses the direct-care nursing efforts and the nursing leadership that are necessary in order to reduce errors. Those direct-care efforts include attentiveness and observant surveillance of a patient’s health status. Lack of recognition or detection of patient care needs jeopardizes all patients but is especially dangerous for patients who are very young, heavily medicated, somnolent, unconscious, or cognitively impaired. describes the practice breakdown category of attentiveness and surveillance. If the nurse has not observed the patient, then he/she cannot determine whether changes have occurred and/or make knowledgeable decisions about the patient.

STAFFING ISSUES AND ATTENTIVENESS

The nursing shortage has had a significant impact on nurses’ ability to provide safe patient care. Working short-staffed or understaffed, requiring mandatory overtime, and working long hours and possibly two jobs are just a few of the results of the nursing shortage. Numerous studies and summaries of the impact of nurse staffing on patient outcomes have documented the seriousness and far-reaching nature of problems associated with the nursing shortage. In a recent study conducted by about nurse staffing levels and quality of care issues in hospitals, they reported that a higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day were directly associated with better care for hospitalized patients.

TABLE 4.1 Case Analysis Category of Breakdown: Attentiveness/TERCAP® Surveillance Items

Cause of Breakdown

Examples

Absence of patient contact or monitoring

Patient not observed for an unsafe period of time

Staff performance not observed for an unsafe period of time

found that nurses in hospitals with the highest patient-to-nurse ratios are more than twice as likely to experience job-related burnout and almost twice as likely to be dissatisfied with their jobs compared to nurses in the hospitals with the lowest patient-to-nurse ratios. Aiken and colleagues also noted that inadequate staffing is one of the factors that adversely affects the quality of health care and negatively impacts patient care and safety ( ). The relationship of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contribute significantly to surveillance, early detection, and timely interventions that save lives ( ).

Inadequate staffing also fosters practice breakdown and compromises the safety of the patients, nurses, and other staff. Nurses who are working short-staffed may not have the time to perform their responsibilities in a careful manner and may not be able to identify the subtle but life-threatening changes in a patient’s condition. Nurses are present around the clock to detect complications in patients and initiate prompt interventions to minimize negative outcomes ( ). determined that patients in hospitals with a higher proportion of nurses educated at the baccalaureate level or higher had patients that actually experienced lower mortality and failure-to-rescue rates than hospitals with fewer baccalaureate and advanced-practice nurses. In this particular study, failure to rescue was defined as “death within thirty days among patients who experienced complications” ( ).

SYSTEMS AND ATTENTIVENESS

In addition to the availability of nurses, the organizational structures and issues related to system processes within the health care environment also affect the attentiveness or inattentiveness of nurses. For example, environmental issues of increased noise levels, poor lighting, or equipment failures within the work setting can impede attentiveness and alter the competencies of interventions by nurses ( ).

· When people are hospitalized, in a nursing home, having a baby, or learning to manage a chronic condition in their own homes—at some of their most vulnerable moments—nurses are the health care providers they are most likely to encounter; spend the greatest amount of time with and … depend on for their recovery” ( ).

Hospitalized patients require close monitoring and rapid adjustment of therapies. Acutely ill patients are physiologically unstable and require patient, response-based interventions and monitoring for untoward effects of both the ongoing therapies and disease states.

Nurses, the primary caregivers, are present with patients more than any other health care professional. Patients place their trust for the safety of their lives in a nurse’s hands when they are the sickest and the most vulnerable. Nurses are expected to be attentive to patients’ changing conditions and to act in the best interests of their patients. Patient safety depends on nurses paying attention to patients’ clinical conditions and responses to therapies, as well as potential hazards or errors in treatment ( ).

TECHNOLOGY AND ATTENTIVENESS

The significance of the nurse’s role in monitoring technical interventions has also increased as modern medicine has increased the level of technology. Patient safety requires that nurses understand and monitor for complications such as proliferating new surgeries, interventional radiology, electrophysiologic interventions, and highly technical care for premature infants. Nurses take on an increasingly vital role in detecting and ensuring early intervention in the progression of their patients’ illnesses and responses to treatment.

The numbers of technical health care interventions per patient have increased in hospitals, in skilled nursing facilities, and in the home. Patients receive an array of pharmaceutical products with potential for drug interactions. Many pharmaceutical interventions must be titrated according to the patient’s physiologic responses to the drug(s). Nurses monitor patients’ responses to the intravenous therapies whose therapeutic range of dosage may lie close to toxic levels. Hospitalized patients are typically managed by more than one team of health care specialists, and the interventions of one team may conflict with the interventions and plans of another team. This potential for conflicting therapies requires that nurses carefully scrutinize plans of care by different medical consultants to ensure that they are compatible and consistent with the general medical consensus on every patient’s diagnosis, plan of treatment, and nursing care.

As noted, nurses are present 24 hours a day with patients, and consequently play a crucial role in evaluating patients’ responses to therapies and assessing changes in their patients’ clinical conditions. This role requires that nurses be sufficiently engaged with their patients and remain attentive to possible significant physical and emotional changes, as well as to the social circumstances surrounding patients’ illnesses and recovery. Nurses speak of their need to know their patients’ concerns and clinical situations ( ). All of this monitoring requires astute diagnostic skills and clinical judgment on the part of the nurse (see ). However, this judgment cannot come into play if the nurse does not have the time to properly monitor patients’ therapies and assess patients’ responses to those therapies. Attentiveness over time is required to identify subtle changes in a patient’s condition.

Effective patient care requires that nurses advocate for their patients’ best interests. Although nurses have an interprofessional alignment with physicians’ goals for treatment and plans of care, nurses have a moral obligation to be aligned first and foremost with their patients’ concerns and well-being. For example, if a patient needs urgent medical attention at an inconvenient hour for the physician, the patient’s needs must come first.

OVERLAPPING NURSING CONCERNS IN GOOD NURSING PRACTICE

The nurse’s attentiveness, skills of engagement with patients and their families, and patient advocacy go hand in hand. These caring practices are at the heart of good nursing practice. The nurse who does not or cannot meet with the patient/family because of patient care delivery design and/or assignment cannot come to understand the patient’s concerns, clinical condition, and treatment plan. Consequently these nurses will not be able to notice significant changes in the patient’s condition and will not learn what the patient’s goals are with regard to treatment and care. The nurse-patient relationship establishes certain conditions that make it possible for patients to disclose their concerns, fears, and discomforts. If the nurse is too rushed or too task oriented to notice what the patient/family is experiencing, then the level of disclosure on the part of the patient/family will be constrained. Likewise, the nurse’s attunement and engagement with the patient allows the nurse to notice subtle changes in the patient’s condition.

As noted earlier, a socially organized practice such as nursing has notions of good internal to the practice ( ). For example, attentiveness, not neglect, and recognition practices, not depersonalization, are notions of good internal to the practice of nursing. A nurse educated to be an excellent nurse can recognize, in most instances, good and poor nursing care, even though it would be impossible to formally list all of the precise behaviors and comportment of excellent nursing care.

LIMITS OF FORMALISM

In philosophy, the inability to make explicit or formal all elements of a social practice identifies the limits of formalism ( ; ). For example, in nursing identifying learning objectives leads to the recognition that each objective is linked to many contexts and behaviors and that it is impossible to make explicit all of the background knowledge and contexts associated with the complex learning objectives in nursing. Likewise, the practical knowledge embedded in the traditions of science cannot be made completely formal and explicit ( ; ; ). Every complex social practice has a foreground of focused attention and a background of comportment, practical skills, and understanding of the social practice. Science and technology have extensive traditions of formalizing the reasoning and knowledge associated with scientific experiments. Consequently it can appear to the naïve scientific practitioner that thinking within a particular scientific discipline is restricted to what can be formalized. This creates a risk to patient safety because a safe health care system depends on the attentive, knowledgeable work of professionals who must observe and detect signs of risk and/or danger and changes in patients’ clinical situations. For example, in patient safety work the goal is to limit the attentiveness required by practitioners so that the patient’s safety is not entirely dependent on constant practitioner attentiveness. This is only useful to the extent that it is possible and effective. Whatever can be made more reliable through automation and information system reminders can indeed improve patient safety. However, it must be continually recognized that health care practices are underdetermined, open ended, and complex, thus limiting the effectiveness of the usual strategies of automation and routinization. For example, automated intravenous fluid pumps can provide more accurate rates of delivery of fluids and medications. These machines are equipped with valuable alarm systems, but these systems must be set according to particular patient parameters and danger points. The constant attentiveness of the nurse to the intravenous pump is minimized by effective alarm systems, but defective alarms or parameters set inappropriately may tempt the practitioner to ignore the alarm or render it less sensitive to changes in the flow rate. The human factor must be taken into account and technological devices co-designed to fit the needs for adequate, but not excessive, attentiveness on the part of the nurse.

The attentive nurse and other health care providers remain the patient’s front line of defense. The nurse is at the sharp end of practice and is often the last chance for patient care error to be averted ( ; ; ). Systems engineering must be cognizant of the goals of good practice, the requirements for effective surveillance, and the use of technology by nurses and other knowledge workers. Knowledge work and knowledge workers (a term used by sociologists) refer to any worker who requires a formal education for their work, who works in a field that requires ongoing knowledge development in their practice, usually a professional.

In practice disciplines such as nursing and medicine, the ethos of the practice shapes and is shaped by relevant science. The development of knowledge occurs in science and in experiential learning that comes directly from engaging in practice. Practice is a way of knowing in its own right, in this nontechnological understanding of what constitutes a practice and practice responsibilities ( ; ; ).

ATTENTIVENESS AND SURVEILLANCE

Attentiveness and surveillance of patients constitute moral acts as well as skillful judgment about what needs to be monitored for a patient’s condition. The skills of attentiveness and noticing patient problems are developed both in nursing school and over time in nursing practice. However, when the institutional conditions for surveillance and attentiveness are impeded because of inadequate staffing or excessive “paperwork,” then professional levels of attentiveness and surveillance of patients are likely to break down. Nurses who find themselves in situations of unsafe levels of staffing or excessive paperwork must have institutional avenues to demand correction of the staffing or paperwork in order to protect the patient.

LACK OF ATTENTIVENESS

Lack of attentiveness can also occur when a practitioner does not know what needs to be known or observed, or when the nurse does not observe and remain attuned to what is happening with patients and staff because of poor staffing, unsafe patient care assignments, lack of nursing knowledge, or other reasons ( ). Inattentiveness to the point of patient neglect or abandonment is more than simply not paying attention and is as much a part of unprofessional conduct as fraudulent documentation or covering up a medication error.

Disruption of the nurse’s attentiveness to patients is a barrier to quality nursing care and may prohibit the achievement of standards of nursing practice. Consequently lack of attentiveness, monitoring, and surveillance of patients may be grounds for reporting lack of attentiveness or surveillance to the state board of nursing for disciplinary action by the board. Occasionally nurses violate standards of good practice by leaving the patient care unit without notifying their colleagues and arranging adequate coverage for their patients; a just culture ( ) calls for strict adherence to this minimal standard of professional responsibility. However, lack of surveillance is often due to miscommunication and conflict within a health care team or constant interruptions. Some hospitals have begun to use interventions to avoid interruptions of nurses during periods when they are administering medications. Nurses wear an apron signaling that they are carefully administering medications and should not be interrupted if at all possible. Of course, it takes cooperation and consensus among the health care team to change habits of interruption and make this work. A board of nursing looks carefully at the environmental, social, and personal causes of inattentiveness. Lack of nurse attentiveness is often associated with poor workload design or management. However, where patient surveillance is possible, it may be hindered by a lack of sufficient quality of engagement and interest in patient care on the part of the nurse.

In and of itself, a single incident of inattentiveness may not be a reportable offense to a board of nursing and may not even violate the laws regulating the practice of nursing. However, a detected pattern of inattentiveness may reveal that a nurse is practicing below the standard of professional practice or that some systems issues exist within the facility that impede or prevent the nurse’s attentiveness to the patient’s needs. A health care institution that does not plan for enough staff nurses to adequately monitor and pay attention to the patient’s changing clinical condition or to patient responses to therapy, places patients and the nurses responsible for these patients at grave risk. Adequate monitoring of patients was identified as a greater problem in long-term care facilities, which are often understaffed, in our pilot work using the TERCAP® instrument.

The causes of deleterious consequences stemming from lack of attention and surveillance are difficult to identify. In the most obvious cases, if a patient has not been monitored or even seen by a nurse for more than 2 hours, the first undetected problem usually results from a lack of surveillance and monitoring rather than errors of clinical judgment. One cannot make good clinical judgments in the absence of attentiveness and monitoring of the patient.

The nurse, the team, the system, or a combination of the three may be complicit in lack of attentiveness and monitoring of patients. Ultimately, it is the responsibility of the nursing profession and institutions of health care to require the institutional possibility of monitoring patients’ physiologic states, responses to therapies, and patient/family concerns.

When inattentiveness or a lapse of attention to subtle changes regarding a patient’s condition occurs within the health care setting, an assessment and evaluation is needed to determine the reason for the occurrence. Consideration should be given to nursing issues related to a nurse being fatigued, being too busy, feeling overwhelmed, experiencing personal problems, or lacking necessary knowledge, skills, or abilities. The IOM report ( ) stated that the effects of fatigue include a lapse of attention to detail and can compromise one’s problem-solving abilities. These factors along with poor staffing and workload design generate a culture that produces devastating effects on the possibility for attentive patient care.

identifies the responsibilities and duties for nurses. Provision 4 of the ANA Code states, “The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care” (p. ). Adhering to this particular provision of the ANA Code of Ethics requires critical thinking skills and making appropriate clinical judgments. Sound clinical judgment results from information produced through the design of safe and efficacious monitoring and surveillance of patients.

CHALLENGES

The challenge of providing public protection and safety with the provision of high-quality, cost-effective, and readily available and accessible nursing care is central to the mission of the nursing profession and the health care institutions that employ nurses. Every licensed nurse is required to adhere to his/her licensing board’s scope of practice and is held accountable to his/her particular state board of nursing’s nurse practice act. Likewise, nurses must be accountable for their nursing performance and actions in accordance with the minimal established standards of nursing practice. When the institutional conditions such as staffing and patient assignment make it impossible to live up to the Nursing Code of Ethics, the nurse is accountable for reporting such conditions.

LEGAL AND ETHICAL CHALLENGES

Nurses have a legal and ethical obligation to assess, plan, implement, and evaluate the care patients need. A nurse who does not access a patient or who is inattentive to the patient will be unable to implement the appropriate plan of care and therapeutic interventions necessary for that patient. The challenging and fast-paced world of health care has created additional needs for nurses within the health care setting. Nurses cannot individually overcome workplace demands and structures that disrupt attentiveness. Nurses need time to listen to their patients and to their staff. They are the eyes and ears for the patient. Patient safety depends on strategies and processes that are the result of collaborative efforts from the individual, the team, and the system that allows the nurse to pay attention to the subtle symptoms of a patient’s condition, as well as to respond appropriately and in a timely manner.

Being observant of patients’ needs can be as simple as checking the patency of a patient’s IV or as complicated as detecting critical signs and symptoms of a patient’s worsening condition. Lack of attentiveness indicates a lack of monitoring of therapies and patient responses on the part of the nurse and can result in serious injuries for the patient, even death ( ; ). As noted earlier, nursing errors can occur as a result of several factors. These include a lack of attentiveness due to increased workload, short staffing, failure to detect substandard care, lack of effective monitoring for an unsafe period of time, and failure to recognize an error.

Age-related factors, the mental status of a patient, cultural bearings, language deficits, and cognitive or functional abilities require even more attentiveness on the part of the nurse. Therefore nurses must have the moral agency, the professional responsibility, and the ethical duty to be attentive to their patients. Faulty supervision and the lack of appropriate staffing may be the underlying causes of an undetected critical patient condition when the nurse is overwhelmed with other patients or non-nursing duties. Given those factors, it is important to be responsible and declare one’s unwillingness to work in that environment and setting but continue to do work on the particular shift where the need for nursing care is urgent and there are no additional nurses available. During a patient crisis, the system must be flexible and responsive enough to provide backup care for the nurse’s other patients. Nurses must be able to see the overall situation, not just the one in front of them. Efforts to create a culture of safety in the health care environment include the ability to detect high-risk situations and the capacity to respond before an error or adverse event occurs.

RECOMMENDATIONS TO INCREASE ATTENTIVENESS/SURVEILLANCE

On the basis of the above description of the role of nursing attentiveness, surveillance, and monitoring, health care teams and health care systems are advised to:

· 1Provide education and communication regarding early identification and assessment of critical elements in each patient’s monitoring and surveillance plan.

· 2Encourage ongoing communication efforts, i.e., conduct hourly check-ins with team members, and report critical changes in patients’ vital signs and physiologic states to the charge nurse and those at supervisory levels.

· 3Prioritize the work as a team, helping those individuals who may have difficulty prioritizing needs in patients and in patient conditions with which they are unfamiliar or inexperienced.

· 4Ensure the delegation of …