Case Study

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 ( Aiken et al., 2003 ;  Cho et al., 2003 ).

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 ( Weick and Sutcliff, 2001 ). 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 ( Reason, 1990 ).

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” ( Page, 2004 ):

· 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 ( Page, 2004, p. 32 ).

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.  Coffey, Skipper, and Jung (1988)  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 ( Mitler et al., 1988 ; Rosekind et al., 2004;  Wylie et al., 1996 ). The quality of sleep deteriorates with disturbed sleep-wake patterns, and chronic disturbances in sleep cycles often cause cumulative sleep deprivation ( Smith-Coggins et al., 1994 ;  1997; 2006 ;  Smith-Coggins & Rosekind, 2004 ). 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 ( Maxfield et al., 2005 ). 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.  Mustard (2002)  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 ( Page, 2004 ) 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.  Table 4.1  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  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.

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

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 ).

· 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” ( Page, 2004, p. 2 ).

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 ).

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 ( Benner et al., 2002 ). 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 ( Marx, 2001 ) 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 ( Page, 2004 ) 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.

The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretative Statements (2001)  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.  16 ). 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 ( Benner, Hooper-Kyriakidis, & Stannard, 1999 ;  Benner et al., 2002 ). 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 nursing interventions and the supervision of this delegation function.

· 5Encourage cross-monitoring of work performance of health care team members.

· 6Encourage input and collaboration from unlicensed assistive persons, staff nurses, management, leadership, and others on the health care team.

· 7Engage the individual nurse, the team, and the system in identifying processes and strategies to create an attentive work environment.

· 8Create a system of adequate attentiveness of patients while the nurse is on lunch and coffee breaks, and when a nurse needs a short break for excessive fatigue and sleepiness.

· 9Design shift rotations with as much restorative time off as feasible.

· 10Consult with nurses and counsel them on sleep hygiene.

· 11Create an automated fast alert system such as a “computerized simple alert system “to supervisory personnel for increased acuity and or instability of the patient's condition on each nurse's patient care assignment. The supervisory response would be stipulated to reevaluate the adequacy of staffing and patient placement.

· 12Create Fast Response Teams to respond to emergency situations and ensure that those teams monitor the care of the rest of the patients on the unit during a crisis.

HISTORICAL CASE STUDY #1: When Attentiveness and Surveillance Break Down

HISTORY

Mr. Harry Stewart was a resident who lived in a cottage on the grounds of a residential care facility. He required total nursing care as he was not able to bathe or dress himself. A patient care incident occurred at the cottage where it was discovered that a nurse was found to be negligent when she left Mr. Stewart in a bathtub unattended, and he was later found unconscious and pronounced dead on arrival (DOA) at an area hospital.

THE NURSE'S STORY

Ms. Mary Manning, a licensed practical nurse, was working the evening shift at the facility and had 40 residents assigned to her. These residents lived in various cottages on the facility grounds. Practical Nurse Manning went into one particular cottage to administer the scheduled 8:00 PM medications to the residents. She did not see Mr. Stewart when she entered his room. She moved to the bathroom and observed Mr. Stewart soaking in the bathtub. Practical Nurse Manning spoke with Mr. Stewart; he was alert, responsive, and talkative. She gave him his prescribed medications and proceeded to the living quarters of the cottage and approached the developmental assistant, Mr. Mark Randolph, who was assigned to this particular cottage. Practical Nurse Manning asked why Mr. Stewart was bathing unattended. Developmental Assistant Randolph replied that the other developmental assistant was out of the building and it was very busy that evening. Practical Nurse Manning completed the medication administration in that cottage and then left the building.

After leaving the cottage, Practical Nurse Manning returned to the office where she started her paperwork. Approximately one hour later, at 9:00 PM, she received a telephone call from Mr. Randolph who reported that he had found Mr. Stewart unconscious in the bathtub and thought Mr. Stewart had had a seizure and that he was dead. Practical Nurse Manning and her supervisor responded to the call, and on arrival they were directed to Mr. Stewart's bedroom.

Practical Nurse Manning reported that Developmental Assistant Randolph had removed Mr. Stewart from the bathtub and placed him on his bed. He said he had initially placed Mr. Stewart on the floor and started to administer CPR. Staff's efforts to resuscitate Mr. Stewart were unsuccessful. Emergency Medical Service personnel arrived within a short time, and Mr. Stewart was taken to the local hospital where he was pronounced dead.

Practical Nurse Manning reported that she asked Developmental Assistant Randolph if Mr. Stewart was supposed to be in the bathtub unattended. The response was that Mr. Stewart could not take care of himself and needed assistance at all times. Developmental Assistant Randolph went on to say that it was extremely busy that evening, and there was only one developmental assistant in the cottage to care for the clients and there was no possible way to provide assistance to every resident in the cottage. Developmental Assistant Randolph expressed concerns about being understaffed in addition to having a heavy workload, making it necessary to leave residents unattended at times in order to get his work done.

INTERVIEWS WITH WITNESSES

Staff members were fully aware that Mr. Stewart was totally dependent on nursing care and was not to be left unattended. Practical Nurse Manning stated that when she observed Mr. Stewart was unattended in the bathtub, it was her responsibility to take corrective action; however, instead, she gave Mr. Stewart his medications and left him alone in the bathtub. The facility reported that the only policy in place regarding leaving residents unattended in the bathtub addressed patients who might harm themselves and thus were not to be left unattended.

Authorities conducted an internal investigation and found that Practical Nurse Manning and other staff members failed to provide reasonable and necessary services to Mr. Stewart. The internal investigation concluded that Practical Nurse Manning and Developmental Assistant Randolph, the person in charge of Mr. Stewart, violated the facility's policies regarding the matter. Both were terminated from the employment setting as a result of the investigation by the facility and for reasons of neglect and negligence.

CASE ANALYSIS

Individual and team issues were both identified in this tragic case and resulted in lack of attentiveness by the nursing staff. The developmental assistant had the responsibility to provide safe patient care to all patients, and this was accomplished by communicating through the proper chain of command the need for additional help. The nurse in charge had the responsibility to act when she became aware of the fact that there was unsafe care being delivered to the patient. In fact, the licensed practical nurse is indeed at fault for failing to monitor her staff's performance. In addition, a question is raised: Was she simply doing her job of routinely administering medications without observing or assessing any of the patients' conditions? It appears that critical thinking and sound clinical judgment were absent when she saw Mr. Stewart in the bathtub alone. The patient records indicated that the patient required total nursing care. This fact, in itself, is evidence enough that the patient never should have been left alone in the bathtub. In this instance, two staff members understood this constraint, observed the patient unattended in the bathtub, and failed to assist him. Nurses are charged with the responsibility of providing safe patient care to all patients. Along with that responsibility is the expectation that attentiveness and surveillance will occur in order to maintain safe patient care.

HISTORICAL CASE STUDY #2: Attentiveness and Surveillance

THE IMPORTANCE OF CROSS-MONITORING TEAM MEMBERS' PERFORMANCES

HISTORY

This case involved three shifts of nurses over a 24-hour period working in a long-term care (LTC) facility. The facility included three separate units with 40 beds per unit. A licensed practical nurse charge nurse was assigned to each unit. One registered nurse supervisor was responsible per shift for the oversight of all three units.

Ms. Kathy Chin had been admitted to the LTC facility in October with heart failure, bipolar disorder with depression, constipation, history of gastrointestinal bleed, glaucoma, and discomfort. She required total care and was not able to effectively express her needs to the LTC staff. In January she had a bowel impaction, and Fleet enemas were administered. She was discovered unresponsive in her room the next afternoon and was transported to the hospital. Blood work revealed that she had a urinary tract infection. She was administered antibiotics and discharged back to the LTC facility.

Six weeks later, Ms. Chin had another episode of constipation. The day shift Nurse Supervisor, Ms. Angela Guilarte, notified Ms. Chin's physician, Dr. Brian Fisher. Dr. Fisher ordered an x-ray of Ms. Chin's abdomen, and it revealed severe constipation with fecal impaction. Dr. Fisher ordered clear liquids only and “Fleet enemas until clear.” This was the same regime that was previously ordered and administered to Ms. Chin in January.

A licensed practical nurse, Ms. Margaret Reyes, took the order by telephone, notified day shift Nurse Supervisor Guilarte, documented the order in Ms. Chin's chart, as originally received from Dr. Fisher, and on the medication administration record [MAR] “enemas continuously until clear.” Practical Nurse Reyes, who received the order for “Fleet enemas until clear,” questioned the order and discussed it with Nurse Supervisor Guilarte. They determined that the enemas should be administered every 3 hours until the return was clear but did not clarify this with Dr. Fisher or pass this information on to the next shift.

The enemas were administered over a 12-hour period by three licensed practical nurses working various shifts. Again Ms. Chin was found unresponsive, and she was transferred to the hospital where she died 6 hours after admission.

THE NURSE'S STORY

I came to work early that evening and was told that the licensed practical charge nurse for one of the units had called in sick. I realized that I would have to cover the patients for the licensed practical nurse as well as provide supervision for the other two units. I received a short verbal report from Ms. Zellner, the evening shift registered nurse supervisor, who reported Ms. Chin's bowel impaction and the order to administer Fleet enemas until clear. I was told that Ms. Chin had been given three enemas prior to my shift.

It didn't occur to me that I should assess Ms. Chin and review her orders. I started administering the medications on the unit I was covering for the absent licensed practical nurse. About 3:00 AM, Ms. Mary Pellagros, a licensed practical nurse assigned to Ms. Chin, came to me and said she did not feel comfortable with the order for Fleet enemas until clear. Ms. Chin's blood pressure was 70/56, and eight enemas had been administered. She asked if the order should be changed. I told her to call Dr. Fisher. I also told Practical Nurse Pellagros to ask if we should start an IV for fluid replacement and draw stat labs to check her electrolytes. I did not assess Ms. Chin as I trusted Ms. Salamino to follow through.

Practical Nurse Pellagros later told me that Dr. Fisher repeated his order for “Fleet enemas until clear” and “reluctantly gave an order for an IV.” Dr. Fisher refused to order stat labs. I didn't ask Practical Nurse Pellagros if she had informed Dr. Fisher of the number of enemas that had been administered (eight). It took several hours for the IV fluid and pump to be delivered to the facility. I went to Ms. Chin's room and started the IV. I did not conduct an assessment, but Ms. Chin was responsive. At the end of the shift, I reported off to the Shift Supervisor Guilarte and told her about the new orders that were obtained during the night. I did not report the number of enemas given on the night shift (eight plus four), and I did not check to see if vital signs had been documented during the night shift.

It is my understanding that the day shift administered three more enemas to Ms. Chin after which, at 1:00 PM, she was found to be unresponsive. She was then transferred to the hospital. I trusted Practical Nurse Pellagros to provide the care Ms. Chin required. Nurse Pellagros called Dr. Fisher and carried out his orders. I didn't believe it was my responsibility to challenge a physician's order, and I didn't believe I should call my supervisor, the Director of Nursing, in the middle of the night.

INTERVIEWS WITH WITNESSES

All staff members who participated in or were present during the period of time the enemas were given were fully aware of Ms. Chin's history and the outcome she experienced with the first bowel impaction she had in January. None of the staff members were aware of the number of enemas that were administered during the second episode over the 12-hour time frame, after the order was received from the physician.

Dr. Fisher stated that Practical Nurse Pellagros called him during the night and questioned the order for enemas until clear but did not tell him how many enemas had actually been administered. He refused to clarify the order and believed the order was appropriate as he had given it. He said Practical Nurse Pellagros should have used her “common sense and not administered that many.” We recommend the use of the SBAR communication approach, which provides the standard framework for conveying key information. (The acronym stands for Situation—a brief statement of the problem; Background relevant for the situation at hand; Assessment—summary of what the clinician believes is the underlying cause and its severity; and Recommendation—what is needed to resolve the situation [ Pope, Rodzen, & Gross, 2008 ].)

CASE ANALYSIS

This case demonstrates the fatal outcome that emerged when nurses did not recognize the importance of continuous attentiveness and surveillance when providing what is perceived to be routine care. Bowel care in a long-term care facility is a part of most residents' care plans and is competently provided by licensed practical nurses, and sometimes by unlicensed assistive personnel.

The registered nurse supervisor did not recognize her responsibility to intervene when the licensed practical nurse came to her with questions about the physician's order and reported that the patient's blood pressure was low. The registered nurse did not fully assess the situation or the patient. She provided the licensed practical nurse with some suggestions, such as requesting an order from the physician for IV fluid replacement and a stat blood draw. She was aware that the patient's condition was declining but allowed the licensed practical nurse to continue to carry out an order that would endanger the patient. By not assessing the patient herself, she did not provide the input necessary to give the physician a clear picture of the patient's declining physical status and did not intervene when the physician continued to refuse to discuss further options for her care. The registered nurse did not contact her supervisor to obtain direction when she knew the physician's order was not appropriate. She did not check back with the licensed practical nurse and reassess the patient.

There were systems breakdowns as well as individual practice breakdowns that led to the patient's death. The LTC facility did not have a system in place to address short staffing when a licensed practical charge nurse was unavailable for work. This meant that the evening supervisor had to fill in for the absent licensed practical nurse and sacrificed the attention needed for supervisory functions during the shift. The environment provided by facility management did not encourage the registered nurse supervisor to contact the director of nursing with concerns regarding emerging issues during the night shift. The registered nurse supervisor did not understand her responsibility to assess the resident and provide adequate surveillance to ensure that the licensed practical nurse who was providing the direct care was meeting the patient's needs. The registered nurse did not initiate follow-up with the licensed practical nurse to ensure that the patient's status did not continue to decline. The registered nurse should have contacted the physician and challenged the order for “Fleet enemas until clear.”

In this case, lack of attentiveness and surveillance and faulty intervention on the part of the registered nurse supervisor prevented the patient from receiving the interventions required for her declining physical condition. The registered nurse supervisor contributed to the patient's death with the inappropriate administration of the physician's faulty order. This cascade of errors could have been prevented if the registered nurse supervisor, who was aware of the patient's history, had identified her responsibility to provide attentive surveillance of this emerging and preventable situation.

SUMMARY

Monitoring and thoughtfully observing and responding to changes in a patient's clinical condition or concerns is a bedrock nursing function and skill. Attentiveness without engagement with the patient falls short as these extreme cases illustrate. Sleepiness, fatigue, and disengagement are all personal factors that influence the attentiveness required for effective monitoring and surveillance of patients. Poor staffing, a culture of low expectations, and an inadequate staff mix of professional nurses and unlicensed assistants are institutional factors that disrupt attentiveness. Patients who are somnolent, cognitively impaired, or have a decreased level of consciousness are at great risk when nursing surveillance and monitoring are below standard. Patients who cannot effectively call for help or articulate their needs depend on the attentiveness of nurses to protect them from the many threats to their safety while they are hospitalized.