At nurse’s discretion

I have been struggling with this recently. Or, at least, some of my team have found this a tricky instruction and have become concerned.

I’ll explain the context.

Most recently this arose in relation to the care of some of my patients on the ward.

You see, when a person passes through the doors of a hospital and becomes a patient, several things happen to them. Not only are their clothes exchanged for pyjamas, their shoes for non-slip totes, and their lifelong medicines locked away, they are also subject to a whole array of safety measures and assessments – checks to determine the presence or otherwise of pressure ulcers, weight, urine, stool consistency, oxygen levels, temperature. You name it and so long as it is within the remit of physiological scrutiny, we will check it.

Of these assessments, one of the most universal is monitoring of observations, or, ‘obs’ for short. This entails checking temperature, pulse, blood pressure, respiratory rate, and oxygen saturation twice a day.

Patients who are sick or unstable have the frequency of the obs increased and, with escalation, an individual can end-up on the intensive care unit where these parameters are continuously checked.

This is a great thing and a useful way for the system to ensure that no one is missed – for, variation from the norm, for example, a low blood pressure and fast heart rate can be a bad sign requiring urgent treatment.

Sometimes, despite worrying signs, doctors haven’t been called, or, when they attend, haven’t realised the severity of the situation and allowed deterioration, at times, death. (In the health and safety jargon, we call this ‘failure to escalate’)

Mostly within modern NHS hospitals staff and teams are very good at monitoring and adjusting measurements.

And I do not have a problem with this. It is a safety-net.

Yet, sometimes observations can be a bit too much. They can get in the way.

A couple of years ago we moved to measuring blood pressure using the old fashioned aneroid manometers – instead of the automatic ones you see on TV or might have at home. This requires a nurse or healthcare assistant to make physical contact with a patient, touch their skin, feel for a pulse and listen for the Korotkoff sounds. This has reduced the incidents where people on autopilot record HR 35 BP 60/30 and move on to the next patient without thinking.

Despite this, sometimes observations are unnecessary. After all, if an older person is deemed to be fit and ready for discharge and they are waiting for a bed to become available in a care home or for their home-care to start, and, they are fully recovered, do they require 12 hourly monitoring?

You could argue that there is always the chance that something will go wrong and it is best to err on the side of caution, yet, we know from experience that performing tests and investigations on people when there is nothing wrong can lead to false positives, anxiety and over-treatment.

I am not aware of any evidence suggesting harm related to routine observations, but that is conceivable.

Other patients, the group I found myself becoming involved with the discretion question are those on my ward who have either significant dementia or delirium.

At times, patients struggle with the intrusive nature of observations. A caring nurse inflating a tight balloon round your arm, when you don’t understand the context can cause distress. Usually in these situations we document that a patient has refused and move on. It is only very rarely worthwhile persevering with an anxious or stressed patient to obtain their blood pressure (sometimes necessary if it is acute illness that is causing the confusion or disorientation).

In the instances of an otherwise well patient (or a patient who is dying, in which case, monitoring blood pressure and temperature are unnecessarily invasive), who is confused and fearful of the interaction, I usually, following a discussing with family agree to suspend to obs.

And this is the problem.

I could say, stop the obs altogether, they are doing more harm than good – but what about a situation where one of my otherwise well patients develop an infection – I wouldn’t want to miss the opportunity to consider treatment (which could be refused or rejected by the patient, but that is also another matter).

The alternative is to do what the system advises and stick to routine with 12 hourly observations and ‘refused’ documented.

This doesn’t sit well with me and my preference is to request that nurses, not do routine observations unless they are specifically concerned i.e. at their discretion, after all, nurses are healthcare professionals, most of whom are able to determine if someone is well or sick.

Some of the nurses have struggled with this, feeling I am placing too much responsibility on their shoulders. My response is that I have complete faith in their shoulders.

It is interesting.

Doctors make clinical decisions all the time. Indeed, that is perhaps one of the purposes of a doctor or an advanced practitioner – to train to a level at which they can produce important decisions continuously, nine to five, day after day, moving-on from one tricky situation to the next.

Why is it that only doctors and advanced practitioners (by this I mean nurse, pharmacy or other practitioners) make these tricky decisions – it this not something that can be learned and shared? Understanding risk and clinical uncertainty amidst the variety of human disease and experience is within the grasp of most of us.

Not something to be taken lightly, but an area which far more people are likely to achieve if provided adequate training, support and supervision.

A fundamental of decision-making is the confidence to make that decision, without allowing it to eat you up afterwards.

After all, what is the worst that can happen – a nurse will check my patient’s blood pressure and they will either succeed or fail, depending on the will of the patient and the prevailing circumstances.

I don’t want anyone to feel awkward and the conversation I had with the team has led me to the realisation that if there are concerns relating to this it is not enough for me to tell people to pull themselves together, but, perhaps more support from me in the process would enable this form of advanced, person-centred care to become more standardised across the hospital.

I welcome any thoughts on this.

Rod

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