The consequences of using advanced assessment skills in medical and surgical nursing: keeping patients safe
Zambas, Shelaine Iris
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My aim in this study was to explore the consequences of advanced assessment skill use by nurses through their stories of using the skills with patients on medical and surgical wards. Appropriate, accurate and timely patient assessment by nurses is the cornerstone of maintaining patient safety and wellbeing in hospitals. In order to ensure nursing assessment meets patient needs, a wide range of physical assessment skills, including auscultation, palpation and percussion, have been included in nurses’ educational preparation. The inclusion of these skills is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations, however, very little is known about how, or if, use of these skills improves patient outcomes. Linking specific actions to outcomes in the health care setting is challenging. Patient outcomes are varied and influenced by a myriad of factors, and always involve a wider team than any one nurse. It is difficult to control for a single action or set of actions of a particular nurse. Furthermore, practice is seldom about any ‘one’ action, for one thing leads to another, all within a complex interplay of influencing factors. Health care practitioners are, however, able to tell stories of patients they cared for, what they did and how they believe their individual actions influenced care, treatment decisions and ultimately patient outcomes. The hermeneutic tradition of Gadamer and the pragmatic tradition of Dewey provide the philosophical underpinnings for the study. Both philosophers emphasize action as a way of interpreting experience. A pragmatic hermeneutic study allows for recognition of the experience of consequences of an individual’s actions by interpreting stories of practice. This methodological approach allowed the complex interplay of influences to be revealed in the unfolding story. Experienced medical and surgical nurses who are considered expert at assessment were asked to tell stories of practice in which they believed their assessment made a difference to the outcome for a patient. Twelve interviews were conducted with 5 nurses from paediatric and adult medical and surgical wards in a large urban city in New Zealand. Multiple interviews were used to obtain a variety of stories, and to capture the insights gained from reflection on practice. The stories were analyzed to identify the consequences as reflected in and through the nurses’ actions and perceived outcomes for patients. The stories of actual practice reveal that consequences are strongly integrated with the character and disposition of the nurse and together lead to tangible consequences for patients. The use of advanced assessment skills sets up ‘habits’ within the nurse which direct what she looks for, what she sees, and how she responds. Advanced assessment skills enable the nurse to not only recognize problems, but also to identify what needs to be done, do what she has the authority to do, or work to ensure those who do have authority respond appropriately. Advanced assessment habit is a predisposition to certain ways of thinking and acting which keeps patients safe.