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Evidence or instinct?

  • Comments (4)

Should you wake patients at 2am to measure vital signs? We posed this question last week in Behind the Rituals and the debate is still going on in Twitterland.

Why did we ask? A few of you thought this was a stupid question. @firstilast gave me the biggest laugh of the week “No, let’s not carry out clinically indicated observations. That way patients get to sleep… for a very long time”.

Good point, but for others the issue is less clear cut.

If a decision has been made to carry out 4-hourly obs then surely nurses are obliged to do them?

As a student nurse I remember making a list of patients who should have their obs done in the middle of the night. Clinical judgement was used and usually involved patients who had just had surgery or were critically ill. Everyone else was left to sleep – which begs the question why 4-hourly obs were needed in the first place.

@AshDuffyHayes suggested the positives of waking patients outweigh the negatives, but others voiced concerns about loss of sleep. @JuliePacker highlighted the effect of disturbed sleep in ITU and this was reinforced by @AgencyNurse who said “it’s all about clinical judgement and should be individual to the patient. Routine obs [can] wait until the pt wakes”.

Many nurses commented on the expertise of the nurse making the decision, using terms such as instinct, clinical judgement, intuition and knowing your patient. Perhaps this is where the answer to the question lies.

Rigorous adherence to 4-hourly observations is probably a good idea for the novice nurse who is still learning and developing skills. In the hands of the expert nurse informed decisions can be taken to prioritise sleep over recording observations. As David Jones noted in his expert comment, nurses should be able to carry out an “end-of-bed” observation without waking a sleeping patient… but they should also trust their instinct and if they feel the patient is deteriorating the question they should ask themselves should be whether four-hourly observation is enough”.

Nurses have to balance competing priorities when caring for patients and the patient’s best interest has to be at the heart of this process. As @ShannonsideTrng says “It depends on the competence of the nurse to judge, therein lies the art and science of nursing!”

  • Comments (4)

Readers' comments (4)

  • Anonymous

    I think it fully depends on the condition of the patient, yes in some cases no in others, you cant class every situation and patient in the same way you need to remember everyone is different and even and will react differently to things, i dont think you can say yes or no without the background of each individual patient.

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  • sharon rose

    Evidence or instinct both i think is the two ingredients for nursing care, whether in the acute setting or comminity. I have often frightened myself in what i consider to be my sixth sense or instinct within a patient assessment. I wondered if i have special powers or whether i have the advantage of interaction on all levels with people a generic population over many years in the NHS. I have the fortunate ability to communicate with any person i come face to face with whether it be with my smile, my eye contact or by the ability to touch a stranger and project empathy and support through all these mechanisms of commuunication. Therefore i think i may have a skill and knowedge of interpretation of a patients, body language without speech, i can hear what they re saying without them speaking to me just the wy they look at me. their facal expression. i am tuned in to the aura around the patient and can sense theri fear. Yes trust your instincts your are usually right then when you know what you may be dealing with then its time to beleive in the evidence based treatment or the evidence based investigations process and adhere to this evidence and so from instinct to evidence both so important.
    My instinct was to comment on this subject

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  • The answer to this age old question is rooted in the debate about whether you think nursing is an art or science. It is further influenced by the disciplinary culture of the unit or ward and senior staff.

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  • Anonymous

    I agree a qualified and experienced nurse can use clinical judgement but it is normally HCA's doing routine obs.

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