Poor observation skills are risking patients' lives

13 October 2009 | By Clare Lomas, Dave West

Patients’ lives are being put at risk because of poor practice in basic patient observations, Nursing Times can reveal.

A snapshot survey completed by 830 visitors to nursingtimes.net suggests many nurses are failing to monitor vital signs.

Almost one in four of the respondents said they could recall at least one situation in the last month where staff failed to notice a patient’s condition was worsening, adversely affecting the patient.

The finding was described as “almost catastrophic” by the RCN’s adviser in acute and emergency care Alan Dobson. “All ward sisters and matrons need to really look at this and see if this situation applies to them. This could’ve been happening for a long time, but if we don’t act now the situation will get much worse,” he added.

One respondent said they could recall “at least 20” incidents where failure to effectively monitor vital signs contributed to a deterioration in a patient’s condition.

The use of early warning scores - where a patient’s vital signs are measured and then turned into a score to reflect the stability of their condition – could have helped to prevent these situations occurring.

But according to those who responded to the Nursing Times survey, one in five nurses said these systems were “rarely” or “never” used on their wards. And only 27 per cent said they always follow an agreed procedure when signs indicate a patient is deteriorating.

Mr Dobson said early warning score systems should be accepted practice in acute settings. “These systems provide a pathway of care and alert staff to changes in a patient’s condition. If they are not using EWS, they should be using something better,” he said.

Nursing Times’ survey revealed that many nurses feel the increased use of technology - for automated blood pressure recording - meant nurses were becoming too reliant on it.

Forty-two per cent said nurses would be less capable of identifying signs of deterioration in a patient’s condition without the equipment.

Despite 85 per cent of respondents saying that observation technology was used in their workplace, almost 40 per cent said that staff using this technology had received no training.

Just under half of the respondents to the survey said they are “not confident” or only “fairly confident” that staff who routinely carry out observations are able to identify significant changes that could indicate a patient’s condition is taking a turn for the worse.

Additionally, 47 per cent of those who replied to the survey said they had little confidence that those doing observations knew how to respond if signs indicated a patient’s condition was deteriorating.

“It is easy to take a blood pressure or temperature, but it is about putting this information together and coming to a judgement about a patient’s condition. This takes a high level of skill,” he said. “Relying on staff who are not adequately trained to spot sick patients could be putting patients at risk.”

The observations that are needed can depend on the patient and the setting, but even pulse, temperature, blood pressure and respirations are not being measured 100 per cent of the time.

Patient observation and the deteriorating patient is one of the central elements of a National Patient Safety Agency drive to increase engagement with nurses. A patient observation indicator is being developed, likely to set minimum standards for documentation, frequency of observation and use of an early warning score.

NPSA chief executive Martin Fletcher said patient deterioration was “high on the patient safety agenda”.

He told Nursing Times: “Simple measures can save lives, we see this consistently in the world of patient safety. We need to focus on making sure these measures are implemented and embedded into practice.”

Responding to Nursing Times’ survey a spokesman for the Department of Health said patient safety is the “highest priority” for the DH and the NHS. “Nurses must monitor their patients effectively and must make intelligent judgements about the frequency and type of observations to undertake so they can intervene early when a patient’s condition changes.”

Nurses’ observation skills are likely to come under further scrutiny over the next 12 months. When the “failure to rescue” outcome measure is introduced as part of nursing metrics, observations will be one of the first areas to be looked at.

The Prime Minster’s Commission on Nursing and Midwifery is also looking at the essentials of nursing care, including observation skills.

Readers' comments (41)

Martin Gray | 13-Oct-2009 11:13 am
I find this article horrifying! Nurses should not need to rely on 'technology' to see if a patients' condition is deteriorating, nor should they be unable to take manual BPs and temperatures through 'lack of training'. Is this what having a degree only profession is coming to?

To me it supports my belief that our profession has been led down a path to try and equate with the medical profession rather than ensure the basics are not only taught correctly, they are also practiced on a daily basis, any changes noted and interpreted so that any risk of patient deterioration is reduced. This is particularly important for things like BP, respiration rate, and temperature fluctuations as they are the initial indicators of a patient becoming more unwell.

I do not accept that nurses and HCAs do not have the time to take these readings, or that they lack the intelligence to be able to interpret them. If, however, we continue to rely on technology in the form of digital/infra red thermometers and automatic sphygnomanometers (which most GPs don't use at our surgery anyway)then this problem will, as has been stated, only get worse. As for scoring systems, why are such things necessary? If readings are going up, or down, dependent on the conditon then common sence surely rules the decision making process rather than having to 'score' such things. Where readings change for the worse this would indicate the need for more frequent observation taking until there is improvement.

My advice is that the schools of nursing, in whichever establishment and in whatever form, ensure that students DO get the training they need. What happens if there are no batteries or there is a sustained power cut? Are they going to do nothing?
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Anonymous | 14-Oct-2009 6:57 am
I agree with the above writers comments but the development of skills associated with monitoring of vital signs needs to be extended into the practice areas as well as taught in the classroom. We only teach our students skills associated with the monitoring of vital signs using non automated devices. There isn't a dynamap device anywhere! However students frequently feedback that they are not encouraged to practice these skills within placement areas as the equipment is simply often unavailable!This leads many of the students to consistently question the relevance of being taught to use non automated devices in the classroom ! I believe that we are able to justify our approach by highlighting all the evidence we know exists in relation to the reliability of some technology and by pointing students in the direction of NPSA safety alerts etc. The only places that seem to still use the types of devices that I used when a student nurse are GP surgeries and it has to be said the feedback we receive from may practice nurses is that it is refreshing to have a student who knows how to do a manual blood pressure recording!
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Paul Slade | 14-Oct-2009 7:22 am
I work in the middle east and have this problem with my team all the time. I thought it would be better at home !!
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Anonymous | 14-Oct-2009 8:04 am
This is why Patient Safety First campaign was launched.
Staff either are not being taught to recognise this even with early warning scores or staff just do not know.
I would like to see the training and staffing of the 1980s back please.
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Anonymous | 14-Oct-2009 8:23 am
I am a newly qualified nurse working in an acute medical ward. We do not use dynamaps, do regular obs and the MEWS early warning system is key in monitoring a patient's condition. Is there any other comprehensive way, aside from regular observations, which would give an overall indication of the patients condition. I find the MEWS system an invaluable tool in recognising, and knowing when to act upon, a patients deteriorating condition.
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Anonymous | 14-Oct-2009 8:38 am
I have to support the view that students ARE taught manual blood pressure techniques. Time after time students that I have taught this skill report back to me that there were unable to practise this skill when on placement. I fail to see why this is other than the over reliance on technology as indicated in this article.
It is not only the responsibility of HEI's to deliver nurse education - the courses are split 50/50 between universities and the practice environment.
This has nothing to do with the degree vs diploma debate.
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Anonymous | 14-Oct-2009 9:10 am
You are all concentrating on the wrong topic.

There is absolutely nothing wrong in using technology if it is available, after all you have all used it to respond to this article.
Are you advocating a return to analogue measuring devices, including mercury thermometers? The error on an analogue device is usually approximately 1/2 the smallest marked division; for example on a thermometer this could be as much as 1/2 a degree. For a digital device the error is 1/2 of the value of the Least Significant Bit in the Analogue to Digital converter, for a temperature this could be as little as 1/100 of a degree.

It isn't the method of getting the numbers that matters it's what is done with them once you have them.

Observations are not just BP, MAP, temp, resps etc, but include looking at the patient themselves. Also the relative importance of the measured parameters to each other and their indication of a deteriorating patient; not all parameters indicate deterioration at the same time. This is why using an Early Warning System is essential.
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Anonymous | 14-Oct-2009 9:11 am
Further to my last posting, I am a DipHE in nursing, but I am also a BA (Hons) in Science and Technology, having worked as a systems engineer before nursing.
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Anonymous | 14-Oct-2009 9:42 am
So what happens if there is a poer cut, the battery goes or a patient is critically ill and the BP machines just give up and read error?

There is plenty of evidence to suggest that taking manual BP is a more accurate and reliable method.

I agree though the main issue here is what happens to the information when you have it - a lack of understanding will result in a lack of action.
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patrick evans | 14-Oct-2009 9:58 am
If we go back to what Benner was saying about beginner nurses we should not be surprised about their lack of ability to fit all the pieces together. Until staff spend years looking at what Benner called the meaningful recurring patterns they just don't see what it all means. Are MEWS and variations now replacing this level of experience?
Context is alo important. I wonder how far a deteriorating patient stands out against a ward full of ill people.
In any case this issue is not just about observations it is about the whole context and management of nursing and other care in the NHS. Thank goodness there are fora for exploring these issues
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Anonymous | 14-Oct-2009 10:22 am
The mews early warning system is used within the trust where i work and we are constantly reminded that this is not to be used independtly and visual observations of your patient is also vital. This process is taught and developed throughtout training both in theory and practice, so even the most junior of nurses should have a basic insight to picking up on an acutely ill patient.
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carley vaudrey | 14-Oct-2009 10:54 am
I am a 2nd year student nurse and we are only taught how to use sphigometers in university, but when we are out in practice we are not encouraged to or given the chance to use anything other than a dynamap. This is mainly because there is a shortage of them on the wards. Perhaps the trusts should make sure there is adeqaute equipment available in order for the staff to use appropiately before us student nurses lose our basic skills.
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Anonymous | 14-Oct-2009 11:20 am
Well said the nurse who was a systems engineer, but there is another fundamental point which only one person has touched on - observing the person. I have worked for over 25 years in intensive care with a whole range of technology but still the first thing one should do when taking over the care of a patient or attending to them is to observe the person. It need take only moments but is a crucial part of the totality of the observational picture. Modern healthcare is impossible without technology (it all has some error - both user related, device related and gold standard related) but observing the person is no less important than it always was. What someone looks like and feels like to touch, and says they feel like if they are able to communicate, tells one a great deal and helps to verify what the technology is telling one.
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Anonymous | 14-Oct-2009 11:48 am
Whatever happened to holistic care? One of the first practical sessions we ever had was patient observation. It seems to me that observations are being taken and recorded, but nothing is being done about any changes that occur. It makes little difference which devices are being used but has everything to do with how the information is interpreted and used. Taking a patient's blood pressure should be an opportunity to observe all kinds of other facts about that patient and use that information to establish stability (or otherwise), of that patient's condition.
A good nurse looks at her patient overall; not just as a set of measurements
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Martin Gray | 14-Oct-2009 12:44 pm
I agree with the actual observation of a patient being one of our most essential skills, but I would also point out that sometimes physical changes in a patient are the result of symptoms that have gone undetected. The visible changes are the latter signs which warn us of that deterioration, and may well have been avoided if correct monitoring had been in place.

Another sad fact that is appearing in numerous posts is that hospitals do not have anything other than machines such as Dynamaps. I am not against technology, indeed it is now essential in medical science, however that should not mean there is not a supply of manual equipment available should the need arise. Technology has allowed us to move away from the use of mercury thermometers and sphygs; there is nothing wrong with using modern manual devices, which do not contain dangerous chemicals, and which may now be manufactured from plastics. Yes there is error in all methods; provided that degree of error is known then it allows adjustment - take the difference between oral, rectal, and axillary temperature as an example which has been used for years.

Perhaps my own view of nurse education has become very jaded over the past 30 odd years; academics is an important part of being a nurse and always has been. However the modern methodology does have faults and nursing has changed a great deal but I'm not convinced all for the good.
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Anonymous | 14-Oct-2009 2:43 pm
As students, we were taught both methods of taking BP and I agree that on placement, there was very little opportunity to use a sphyg. Obs are a vital part of evaluating a patient and if taken correctly, raise flags about a patient's condition. However, just as vital is knowing your patient and using the holistic approach we were taught. I would always err on the side of caution and inform the medical staff if I had any concerns whatsoever. It is hugely important that they are aware of any potential problems. If they consider me a pain in the backside for doing this then, too bad! The patient is the reason we are all there and their welfare and safety should be everyone's ultimate goal,
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tim stokes CAMHS | 14-Oct-2009 2:46 pm
i think the issue extends well beyond the use of technology into the training our students recieve. i am seeing similar problems in mental health environments where newly qualified staff have a remarkable grasp of theory but with little practic to underpin their knowledge base.

this means intellegent degree level staff with high expectations and taught they are in leadership roles infact have not got some of the basic skills that would allow them to teach/model to junior and untrained staff and actively promote good patient care.

what is more dispiriting is due to their ignorance of this they are often blissfully unaware of what they are doing leading to a loss of confidence in qualified staff and poor patient care. this is a fault that needs to be addressed by our educators and policy drivers, not nursing staff, as it is they who are damaging our profession in this way

how can you assess a patients needs if you are not interacting with your patient?, how do you manage a ward you only see through the nursing station window? how do you understand how a ward functions if you have not dealt with all of it....and yes that includes making beds, tidying linen cupboards, cleaning up bodily fluids, it is all our job to ensure that patients get the best care!
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Anonymous | 14-Oct-2009 2:57 pm
Well said, Tim Stokes!! I am a relatively newly qualified nurse with a degree and part of my job is to do everything. I would never ask an auxiliary to do what I was not prepared to do myself.

I am a bank nurse and have found it very common on the wards I work on that nurses "don't do personal care". The only way to treat your patients is to be there among them and do everything for them they cannot do for themselves. While the "too posh to wash" attitude is prevalent on wards, the treatment patients receive will be sadly lacking.
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Rebecca O'sullivan | 14-Oct-2009 3:44 pm
I am a first year Student Nurse on a Degree programme and i disagee with some comments made. within my first two weeks we had lectures and small group sessions on EWS, also we only practiced manual BP, along with other fundamental nursing procedures for vital signs. one of our skills to master on our frst placement is manual BP, pulse and Temp. the university offers drop in services (which lecturers do on their lunch hours) for students to practice there skills and become profficient. it is not a matter of mode of entry into nursing which is the discussion, rather the fundamental nursing skills. students want to learn these skills, but on many placements there is an over reliance ont he uses of technical equipment and nto time for students to practice, this is soething that needs to be chnged for the benefit and safety of patients.
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David Kennedy | 14-Oct-2009 4:24 pm
Anonymous | 14-Oct-2009 10:22 am

You've identified (again) a serious topic.

I think the comment by Anonymous at 10:22 am sums up the best advice:

"The MEWS early warning system is used within the trust where i work and we are constantly reminded that this is not to be used independently and visual observations of your patient is also vital."

That captures the necessary combination to prevent undetected deterioration:
- vigilant nurses who make the observations, plus
- the use the MEWS score to evaluate the significance of these observations for the patient's progress.

David Kennedy
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