This report received an enormous amount of attention in both lay and professional nursing press. Clearly, the public and the profession are concerned with our ability to be vigilant caregivers. Curtin presented an integrated analysis of nurse staffing and its effect on patient outcomes.
She concluded that nursing staffing had a definite and measurable impact on patient outcomes, medical errors, length of stay, and patient mortality. Why does having an adequate number of nurses at the bedside result in these improved outcomes for patients? We submit that appropriate staffing allows nurses to maximize their practice of professional vigilance for their assigned patients.
There are limits to the human ability to sustain vigilance. To prevent airline disasters, air traffic controllers are allowed to accept responsibility for a limited number of planes. Likewise, nurses can only be reasonably expected to "watch out" for a certain number of patients. The optimal practice of professional vigilance is critical to ensuring the safety of patients in health care settings. The question is: How is professional nursing vigilance practiced to maximize intended patient outcomes and minimize adverse outcomes?
Exploring the concept of vigilance in psychology can suggest an answer to this question. Loeb and Alluisi conceptualized vigilance within the theory of signal detection. According to this theory, vigilance is the search for signals. Signals are events that the individual determines to be indicators of something significant and always occur against a background of "noise.
For instance, is that ringing sound really the telephone a signal or part of the background noise television, radio, stereo that is typical of the everyday hubbub in a home?
The mental processes that individuals use to differentiate signals from noise have been studied extensively in psychology and, to a lesser extent, in nursing. In a grounded theory study of women with migraine headaches, vigilance was conceptualized as "the art of watching out," predicated on a particularized knowledge of the condition in each respondent Meyer, Vigilance resulted in a decision to take, or not to take, an action.
Vigilance was not seen, felt, or heard by others. It was only through the action that resulted from "watching out" that others could infer that vigilance had occurred. The elements of vigilance derived in the migraine study have been adapted for relevance in nursing: attaching meaning to what is, anticipating what might be, calculating risks, readiness to act, and monitoring the results of interventions Figure.
Attaching meaning to what is. The first component of vigilance Meyer defined was attaching meaning to what is. Attaching meaning is a basic element of nursing practice. Questions immediately arise: "What is going on here? To complete an assessment, the nurse must attach nursing meaning to what is heard, seen, and felt Orem, Attaching meaning to observations allows the nurse to make inferences about what observations require intervention and what observations are "within normal limits. Nurses attach meaning to "what is" in the context of their knowledge, experience, and education.
This is the pattern recognition phenomenon described by Benner The expert nurse who detects a slight change in the breathing pattern of a patient, and knows that the change requires immediate intervention, is attaching meaning to what is. This is why educated, experienced, professional nurses are valuable at the bedside of the patient. Their ability to perceive signals and to determine the relevance of those signals cannot be matched by unlicensed personnel taught only to collect and record health data at prescibed intervals.
Such personnel might be able to gather data accurately, but they do not have the educational preparation and scientific background needed to attach meaning to those data.
In brief, to recognize patterns is to attach meaning to the assessment of the "what is. Stating the diagnosis is not professional vigilance; it is an informed action that results from that vigilance. It is only through that action, however, that others see that vigilance has occurred. Anticipating "what might be. Consider the case of Mr. His nurse decides to take vital signs more frequently than ordered, repeatedly checks his dressing and assesses his mental status with every encounter.
To "rescue" a patient appropriately, the nurse must be able to anticipate when complications are likely to occur and rapidly recognize cues that indicate that problems are beginning. Surveillance, involving frequent assessments, is required, as is the ability to analyze information and react to the implications of that analysis in a timely manner.
Reacting to information and intervening appropriately are the result of professional nursing vigilance and will often include both independent nursing action and mobilization of other members of the health care team. Calculating the risk. Understanding the risk inherent in any course of action is another aspect of vigilance Figure. Rarely in nursing practice is an intervention totally risk free. The frail, emaciated patient for whom the nurse elevates the head of the bed to facilitate breathing has an increased risk of developing a pressure ulcer on his coccyx due to shearing and friction.
Lowering the head of his bed may reduce his pressure ulcer risk, but will increase the work of breathing. Administering opioids for pain to bedridden patients may increase the risk of pneumonia by depressing respirations, but may reduce the risk of pneumonia by enhancing mobility and permitting nursing-prescribed deep breathing and coughing.
Helping the adolescent with diabetes configure his meal plan to incorporate a fast food meal eaten with friends may have some short-term risk, but may result in better overall diet adherence. Nurses become adept at seeing and calculating the risk inherent in these and other courses of action, and juggling that risk to maximize intended, and minimize unintended, patient outcomes.
This ability to weigh and minimize risk is a characteristic of professional vigilance. Staying ready to act. Public health nurses who go out into the community with their well-stocked "nursing bags" are staying ready to act, as are nurses who can be counted on to have tape or scissors or an alcohol wipe in their lab coat pockets.
This readiness is about more than mere convenience. It is born of a knowledge base that allows the nurse to know what things might be required in what situations, and to make sure that intervention can be accomplished quickly when necessary. The final component of vigilance Meyer uncovered was monitoring results. This is fundamental to nursing practice. Nurses project and monitor the achievement of outcomes on an ongoing basis. Because nurses are often the only health care professionals at the bedside of hospitalized patients for 24 hours a day, they are charged with monitoring the results of not only their own interventions, but of the interventions of others.
Vigilance is the mental work of nursing; it is a prerequisite to informed nursing action. The advancement of the profession of nursing requires that we name those things we spend so much time and effort thinking about. It has been relatively easy for nurses to document what they do. Nurses routinely chart the medications they have given, the treatments they have done or the teaching they have initiated. Unfortunately, it has not always been as easy for nurses to attach a label to what they think and to communicate the judgments that result from the mental work of professional vigilance.
Diagnosis of phenomena is an essential step in the application of theory to explain a condition and to determine actions to be taken for treatment.
In the Social Policy Statement on nursing, the ANA stated that the phenomena for which nurses were responsible were brought into focus by naming or diagnosing them ANA, , p. The Social Policy Statement identified the use of judgment and critical thinking in the application of scientific knowledge to the process of diagnosis as one of the essential features of professional nursing ANA, p.
Nursing diagnoses reflect the clinical judgments made by professional nurses. North American Nursing Diagnosis Association NANDA International defined a nursing diagnosis as a clinical judgment about individual, family and community responses to actual or potential health problems or life processes p.
Vigilance is the basic skill that nurses need to make these judgments. NANDA International stated that a nursing diagnosis must be one for which the nurse can select nursing interventions and be held accountable for the outcome. This type of nursing diagnosis is familiar to most nurses. Labels such as "ineffective airway clearance," "activity intolerance," "self-care deficit," and "risk for falls" are NANDA-approved diagnoses and are used in many standardized documentation systems.
These labels could be considered central nursing diagnoses because they reflect independent nursing practice. Nurses have long known that not all phenomena for which they are concerned are well represented by current nursing diagnosis terminology Carpenito, Nurses who observe the patient with brittle diabetes for hypoglycemia or hyperglycemia, the newly post-operative hip pinning patient for hemorrhage, or the post-operative thyroidectomy patient for hypocalcemia are certainly practicing the vigilance that is the essence of nursing.
However, current diagnostic language does not include appropriate terms to represent the identification of these risks, even though this type of vigilance is fundamental to nursing. We propose that a second type of nursing diagnoses is needed, one which is called surveillance diagnoses. A surveillance diagnosis, like a central diagnosis, is a clinical judgment about individual, family, and community responses to actual or potential health problems or life processes.
For surveillance diagnoses, the nurse is accountable for professional vigilance and the recognition or diagnosis of the problem, but is not solely accountable for the interventions or outcomes. Rather than selecting interventions independently, the nurse participates, interprofessionally, in the ongoing management of the problem.
Surveillance diagnoses are risk diagnoses, for example: risk for hypoglycemia; risk for hemorrhage; risk for increased intracranial pressure; risk for hypokalemia; and risk for deep vein thrombosis.
A search of the nursing literature demonstrated that diagnoses of this type are of interest and concern to nurses. We entered the term hypoglycemia and limited the retrieval to nursing journals; articles were found. When we limited the search to diagnosis, prevention and control, risk factors, and symptoms of hypoglycemia, articles were retrieved more than one-third of the total. Every day try and write down one terrible thing. His name like a figure jumping out of an aerodynamic object.
My history is comprised of the inappropriate. I look into the mirror and see disturbed human qualities,. Winter breathed out all language. My father appeared and began taking my hair one follicle at a time. He worked his way to the neural tissue threw himself down in a tantrum.
I listen attentively to the wind and cannot compute this. I sell my letter to the sentimentalists leaving behind a trail of fuck you crumbs the largest of birds cannot tear. Visualize a knock-knock joke with yourself in a white noise somewhere on the Upper West Side a box of Kleenex in your hand.
I say his name and I can see him. He fills another glass and pukes,. He stands in infinite points on the distance assuring with his ancient terrible glee that I am going to go out and get a drink with him. I used to put a miniature rosebush in the ground each year to counteract my squalor. The definition of madness is a certain enthusiasm, then there has to be another person there to not share in it—who is oppressed by it who can only stare into it.
Tell it to the bluebird rustling over my head. Tell it to a satellite orbiting in its delusion of being a moon. Used with permission of the author. Today I flew over the Midwest filling out a questionnaire on the emotional life of the brain and personal capacity for resilience against despair. I was making a sculpture of my limbic systems in a huge conceptual neurosis. Under the simulated middleclass environment of the fuselage the snow was falling.
I seek forever the right way to know this. That there are bridges not built in me. That there are areas that do not light up— You are at a party having a conversation with an interesting stranger. You are in a restaurant and the service is bad. You have experienced profound grief— how do you react to this? Down on the ground your family writhes. Down on the ground you are surrounded at Starbucks with a terrible glow. Although we want residents to enjoy the games and to celebrate safely — there continues to be the global COVID pandemic.
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