The nurses made reference universally to the importance of the patient ‘response’
in their assessment, which provides an indication of the level of consciousness and any neurological impairment affecting the expression and understanding of language. Nurses recognised that altered levels of consciousness or new onset confusion were worrying signs.
“I came on duty to an unresponsive patient. I was really worried...”
(Nurse B, 20 months).
Similarly, the presence of confusion, distress or agitation in the patient were features commonly associated with an urgent problem and generally recognised by the nurse as relating to an underlying physical process affecting the behaviour or cognitive function of the patient. Goldhill et al. (1999) identified conscious level as an important indicator of physiological instability and this is reflected by Endacott et al. (2007), who state that assessment of the patient conscious level was the first cue used by staff to identify deterioration. Despite this, Endacott et al.
(2007) found that supporting documentation of an assessment was rarely completed. Furthermore, they do not verify exactly how this assessment of conscious level was determined by the staff in the study.
The AMU nurse participants confirmed that they assessed the patients for the presence or absence of confusion, agitation or distress in order to make a judgement about the patient’s wellbeing, demonstrated by the following data:
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Nurse F states that agitation is always a worrying sign (New onset) or confusion. She knows this can be a sign of infection.
Maybe a chest or urine infection. (Field notes).
‘His obs are fine but he’s really confused. He keeps trying to get out of bed and is quite agitated. I’m worried he’ll fall again. He’s going for a CT in a bit.’
Researcher: ‘Why is the confusion so important?’
‘Well it shows there’s something irritating his brain- infection or a bleed maybe.’
(Participant interview in context, Nurse A, 15 months).
I asked Nurse B if she was worried about the patient. She said
‘No’ because the half hourly obs help her to see any change. Also, she looks for a change in the patient’s appearance or behaviour, signs of deterioration.
(Participant interview in context, Nurse B, 20 months).
In the data extracts above, the nurse participants identify that evidence of agitation or confusion in the patient would concern them. The nurses were vigilant to a change in behaviour which might suggest deterioration in the patient’s clinical condition, and also to the presence of existing confusion or agitation which might point to a condition affecting the neurological status of the patient. Assessment of patient response was generally made in conjunction with the visual assessment of the patient. Using the fundamental nursing skill of communication, the nurse would ask the patient some simple questions to assess their level of alertness and appropriateness of the response. Again, this simple and efficient assessment provided significant amounts of valuable information to the nurse within a few seconds. The value of communication is often overlooked because it forms part of the daily routine, but is of critical importance in the health care setting and is fundamental to the effective assessment of the patient (McEwen & Harris, 2010).
A single word communicated to the nurse by the patient can provide significant
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information in terms of the patient assessment: mood, emotion, appropriateness and physical difficulty affecting vocalisation. Whilst this form of assessment may be performed by the nurse subconsciously (McEwen & Harris, 2010) it involves the intuitive interpretation of cues (Benner 1984; Fairley & Closs, 2006).
From the verbal assessment, the nurse was able to consider if the patient was making no response, a partial response, or if the patient was struggling to respond, to form the words or to make sense; maybe the verbal expression was inappropriate to the question or showed signs of delirium where the patient was shouting out and agitated; all of which would be worrying signs. Other information which might be obtained from this simple exchange of words was whether the patient sounded strong or weak, was breathless, upset or happy. The nurses used verbal communication to assess patients frequently. Examples of this from the data are:
Nurse B states that she came on duty to an unresponsive patient- was very worried re possible brain injury. Over the day, the patient has gradually improved. Eyes are open and the patient is communicating. Nurse B feels reassured.
(Field notes)
‘At the start of the shift, I check every patient and speak to them.
See how they answer.’
(Participant interview in context, Nurse C, 20 months)
The nurses made reference universally to the importance of the patient ‘response’
in their assessment, which is an indicator not only of the level of consciousness, but also provided the nurse with wide ranging information through a short, simple
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yet effective form of assessment. Nurses recognised that altered states of consciousness or new onset confusion in the patient were worrying signs and verified that they assessed and observed patients for any evidence of this. The nurses talked about what they assessed patients for:
‘EWS trend, high pulse, low BP, low urine output, confusion...’
(Nurse A, 15 months. Participant interview in context)
‘Conscious level. I think if that’s going down, its a bad sign...’
(Nurse C, 20 months. Participant interview in context).
‘Agitation is always a worrying sign, or confusion...’
(Nurse F, 14 months. Participant interview in context)
The nurses also referred to situations where they were concerned about a patient demonstrating evidence of altered level of consciousness, or were reassured at the absence of these signs:
‘Ive noticed that patient is drowsy...Im worried about her.’
(Nurse E, 14 months. Participant interview in context)
‘Yes- he looks fine. He’’s alert and comfortable. No worries.’
(Nurse B, 20 months. Participant interview in context)
Nurse C attends the patient who is distressed and pulling at the mask. Writhing in the bed. He isn’t responding to Nurse C’s requests. Nurse C bleeps the doctor. (Field notes)
Researcher: ‘What are you worried about?’
‘He doesn’t look well, and he’s confused- worse than before. He’s retaining I think- he’s getting panicky.’
(Participant interview in context, Nurse C, 20 months)
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Wheatley (2006) contended that some nursing staff possess the skills and experience to assess patients during the normal course of nurse-patient interaction and suggested that this was a skill acquired with experience. During his ethnographic type study, he found that nurses were not taught to assess the overall patient condition in their basic training, only the measurement of vital signs.
Wheatley (2006) suggested that the ability to synthesise the information obtained through observation, questioning and prior information about the patient was a skill acquired with experience. However, it is not clear what constitutes
‘experience.’ Effective communication is considered fundamental to nursing practice and the provision of high-quality patient care. Recognised as a key benchmark area in the Essence of Care strategy (DH, 2010), communication is critical to patient safety (McEwen & Harris, 2010) and as a core clinical skill for nurses, should be formally taught as an independent module.
In addition to the cues already identified, the nurses used their visual and verbal assessments to observe for other evidence of a clinical problem in the patient. In particular, the signs that would give rise to concern were ‘breathlessness’ and
‘pain.’ These were considered important signs and symptoms in the patient which required urgent attention and generally prompted the nurse to request a review from a doctor, mirroring the process of recognition used by nurses in Cioffi’s study (Cioffi, 2000a; Cioffi, 2000b), when deciding to call the medical emergency team.
The nurses considered pain and breathlessness to be important indicators of a problem in the patient, which supports the findings of both Minick & Harvey (2003) and Donohue & Endacott (2010). This is demonstrated by the following excerpts:
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Nurse D has explained that one of her patients has just had a fall.
She has bleeped the junior doctor to attend.
Nurse D is assisting the patient back to bed. Nurse D talks to the patient all the time, asking how they feel now. Do they have pain anywhere? Questions used to make assessment of the patient- uses specific reference to pain. (Field notes)
Researcher: ‘Are you concerned?’
‘No- she’s fine. She’s alert and responding normally. She’s not in any pain, but I’ll keep an eye on her- make sure she stays alert, in case she banged her head. But I can’t see any obvious lumps or bumps.’ (Participant interview in context, Nurse D, 12 months)
Researcher: ‘What will you observe for in this lady?’
‘Any pain, shortness of breath, change in colour, or if she gets sweaty or feels sick.’
(Participant interview in context, Nurse F, 14 months)
Breathlessness in a patient was considered by the nurses to be a worrying sign, although none of the nurses demonstrated any skills in the performance of respiratory examination. Following its review of critical care services, the Department of Health guidelines (DH, 2000) recommended that all nurses should possess critical care skills. Respiratory assessment is considered essential to the care and management of patients with critical illness (Higginson & Jones, 2009) and has been identified as a key skill for AMU nurses (Carroll, 2004; Lees &
Hughes, 2009). Nurses were frequently observed managing the care of patients with critical illness despite their lack of formal preparation, which is explored further in section 5.4. Where the nurse identified a specific concern or suspected an underlying problem, decisions were made as to the appropriate ongoing monitoring for the individual concerned, which is explored further in section 5.1.3.
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