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 Needleman et al. (2002) 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.

Aiken et al. (2002) 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 (Aiken et al., 2003). 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 (Aiken et al., 2002).

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 (Clarke & Aiken, 2003). Aiken et al. (2003) 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” (Aiken et al., 2003, p. 4).

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 (Ulrich et al., 2004).

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 (Benner et al., 2002).

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 (Tanner et al., 1993). All of this monitoring requires astute diagnostic skills and clinical judgment on the part of the nurse (see Chapter 5). 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 (MacIntyre, 1984). 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 (Dreyfus, 1992, pp. 35-51; Dreyfus & Dreyfus, 1986). 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 (Dunne, 1997; Kuhn, 1977; Lave & Wenger, 1991). 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 (Benner, Hooper-Kyriakidis, & Stannard, 1999; Benner, Tanner, & Chesla, 1996; Page, 2004). 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 (Benner, Hooper-Kyriakidis, & Stannard, 1999; Dunne, 1997; Taylor, 1993).