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Making Sure: Registered Nurses Watching Over Their Patients

Lee A. Schmidt, RN, PhD Loyola University Chicago

Partial funding through the James A. MacLamore Award in Business and Social Sciences, University of Miami

The Watching Over Concept

Identified as a direct care activity in Delphi study of direct and indirect nursing care activities by RNs; Watching Over = Checking on Patient Wolf & Smith, 1997

Watchful oversight, surveillance of a source or object of worry or concern

Schmidt, 1997

Watching Over from the Patient's Perspective:

Knowing the nursing staff is in close proximity; feeling safe because the nursing staff is watching over them and checking on them

Schmidt, 2003

Empirical Indicators of Patients' Perceptions of Being Watched Over:

Someone from the nursing staff was around all the time A member of the nursing staff would stop by unexpectedly to check on me I felt safe knowing the nursing staff was watching out for me The nursing staff watched me closely

Schmidt, 2004

Related Concepts: Surveillance and Vigilance

Surveillance:

From the French, surveiller: to watch over, supervise

Public Health:

Observing, recording, and collecting facts, analyzing them, considering reasonable courses of action Systematic collection of data Orderly consolidation Evaluation of data and prompt dissemination to those who need to know and can take action

Thacker, 2000

Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making (NIC) Surveillance Interventions: Measuring Collecting Detecting Determining Interpreting Analyzing Treating Prioritizing

Titler, 1992

Vigilance:

The essence of caring nursing; defines unique nature of caring in nursing; mental work of nursing; prerequisite to informed nursing action State of attention to and identification of clinically significant observations and cues; calculation of risk inherent in nursing practice situations; readiness to act appropriately and efficiently to minimize risk and respond to threats Accomplished through sustained attention and perceptual scanning

Meyer & Lavin, 2005

Intense watchfulness and evolving holistic knowledge for pattern recognition and decision making for a turning point in any environment Involves: Timely identification of change Knowing the patient for pattern recognition Clinical decision making

Geib, 2003

Research Question:

What is the process used by Registered Nurses as they watch over their hospitalized patients on a workshift?

Method:

Classical Grounded Theory (Glaser & Strauss, 1967; Glaser, 2001)

Data Collection and Analysis:

Semi-structured interviews Theoretical sampling Constant comparison Theoretical memoing

Sample Characteristics:

15 Registered Nurses 1-27 years experience as RN Medical-Surgical, ICU, Telemetry, Endoscopy, Pediatrics units

Results

Making Sure

(core category)

Taking responsibility for the care of patients; being certain about the patient's care and nursing actions taken; being in control of the patient care situation Requires a focus on the patient as a priority and an adequate level of confidence and comfort with nursing care abilities

Knowing What's Going On

Getting the big picture of the patient; knowing the whole person rather than the individual parts; knowing everything possible about the patient and finding out what happened to them; understanding their unique perspective; integrating the care from all specialties into the whole of the hospital experience

"Knowing from day one when that patient first steps in, but you know what medicines that patient came on, what history that patient has, medical history, and as far as what type of support systems, so we'll know what we have to work with."

Being Close

Proximity to the patient as well as a connectedness to the patient; allows the nurse to see the patient by going into the room and being at the bedside frequently; being close also involves a purposeful presence with the patient

"I try to be close by where my patients are. That's why sometimes I even fight, I want my patients on the same side [of the nursing unit], not on a different side." "We are there for the whole, mind, body, and soul."

Watching

Close observation of the patient directly, rather than through a reliance on machines, technology, or laboratory data; involves checking on the patient and seeing how the patient is doing through careful monitoring and making comparison evaluations across the frequent checks and observations of the patient

"So I guess for me, that's a big part of it. Monitoring their vital signs and monitoring the patient." "It's important to round and check on your patients."

Not Taking Anything For Granted

Attention to detail and remaining alert and attentive; involves picking up the subtleties and subtle changes in the patient; sensing in those situations where something doesn't seem right; knowing something is about to happen or change with the patient; catching things early before a patient deteriorates or a negative event occurs

"You can sense a difference, whether it be a difference in their respirations, or just how they look overall." "We contacted the physician and the [nurse] practitioner walked by and I said, "I don't know what's going on but something is wrong and my gut feeling is that this baby is going to die and it's going to be soon. We need to look at his heart.""

Protecting

The outcome of the watching over process from the perspective of the nurse; negative events that could threaten patient safety are guarded against to the extent possible; patients are protected from harm

"I really felt I was there to protect them." "I act to protect these people from harm."

Making Sure (core category)

Knowing What's Going On

+

Set In which conditions the nurse for is Being Close Watching

Not Taking Anything for Granted

Is how the nurse is

Protecting

New information integrated into existing data; the big picture of the patient becomes more detailed

Action(s) taken as needed

Inferences Drawn by Patients

Trust

Patients trust their nurse's abilities and are confident of the care being received from the nurse; patients develop an overall comfort level with the nurse and their hospital experience

Feeling Secure

Patients develop a sense of safety and security at this very vulnerable point in their lives; they sense the nurse is looking after their best interests

"The patient or that family has trust in my abilities as a nurse." "They felt they could trust somebody there and that person actually helped them getting better."

"You give this patient a sense of security that you are there and you are watching out for them."

Implications, Conclusions, and Next Steps

The Making Sure theory may provide some explanation of why RNs are consistently ranked high as a trusted profession

Feeling secure may represent a nursing outcome, and thus be a more direct indicator of quality nursing care, rather than the adverse nurse sensitive events (e. g., decubitus ulcer, pneumonia, failure to rescue)

Nursing work environment conditions must be optimized to allow the watching over process to be accomplished effectively

Further study is needed to develop measures to test the theory

Information

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