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Do risk scores undermine a nurse's intuition?

  • Comments (5)

Recently, I’ve been thinking about risk scores, and whether they work or not.

An example comes to mind of a trust where high risk scores are called PAR (patient at risk) scores. Basically the higher the number, the worse the patient’s condition is. You would give a higher score for high or low respirations, pulse, and systolic blood pressure and so on. 

On this particular occasion the patient was in severe pain.

The patient had had quite extensive surgery and there was a fear that they were suffering from some severe complications. The nurse administered morphine but this had little to no effect on alleviating the patient’s pain.

While the trust has its own measuring system for pain for which the patient was obviously scoring quite high, the actual PAR was quite low and this is where the difficulty arose.

The nurse contacted the outreach team who are a highly skilled team of nurses based in the critical care unit to come and assess the patient. Following that assessment the outreach nurse agreed that the patient needed to be reviewed quickly.

House officers were called, senior house officers were bleeped and the team tried desperately to contact the registrar. A recurring theme came up that because the patient wasn’t scoring high on the risk score, and as such it was difficult for the nurses on the ward to convey the severity of the patient’s condition.

Eventually, a registrar came and assess the patient and agreed with the nurse that the patient did need some intervention.

The patient was taken to theatre where a full investigation could begin. If I’m honest, I’m not sure what the moral of the story should be but it does make me wonder whether the current approach is really working?

As students we are hopefully being taught to develop our intuition and it is certainly something that will develop over time.

My only concern is that with all of these systems, pathways and scales we could be distilling nursing intuition into a numerical scale.

What do you think? Do you think risk scores undermine a nurse’s intuition?

  • Comments (5)

Readers' comments (5)

  • Jo Thomas

    I feel that this is an area where good and effective verbal communication skills are needed. Obviously scoring systems have their value and their place in our practice, but intuition should never be underestimated or disregarded by other medical staff, especially doctors. Nurses are the ones who live by the bedside and observe those in their care from minute to minute. And if a nurses judgement is that a patient needs to be assessed by a doctor then it should happen.

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  • Adam Roxby

    Hello Joanna

    Thanks for your comment. I think you are right but I fear that there are still some out there who disregard the 'gut feeling' of the staff who spend the majority of time with the patents. Having a risk score does standardise things but a healthy balance is needed. Thanks once again.

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  • Little One

    How apt, we have just had a lecture on this today discussing this topic, delivered by a member of our Outreach Team. We use a similar system here, called EWS - Early Warning Score System which does not take pain or oxygen saturations into account of the scoring. The Outreach Nurse delivering our lecture assured us that there are currently plans to review and implement an Early Warning System, similar to ones in use now, but standardised across Britain and taking pain and saturations into consideration.

    We also talked about the newly implemented RSVP system which enables easier communication between doctors and nurses, so that the patient can be reviewed in a timely manner in accordance to their needs, as a recent study in 2007 identified that communication between Nurses and Doctors can be poor and that it can negatively influence the patient. The RSVP technique used in conjunction with EWS scoring can be quite effective because even if the patient is not scoring highly, you can communicate the needs of the patient effectively and succinctly and discuss the plan that you would like implementing.

    Nurses are not the only members of staff who perform observations, HCAs regularly take and record observations too and on the EWS System at our Trust there is a clear pathway to follow if any observation is outside of normal parameters, meaning that the correct member of staff is always alerted. Nurses can then use evidence based practice, intuition and knowledge to determine whether or not the patient's observations need to be increased, whether a medical review is required, or whether the patient will be ok without any further intervention.

    I don't think that scoring systems undermine intuition, because on places like haematology/oncology you may have a patient who scores very highly but does not need an urgent review because that is 'normal' for the patient as they are so unwell, on the flip side I will always remember talking to a very fit patient whos resting heart rate was 45, which meant that he automatically would need a review from an FY1 because of his scoring, but it was not required as he was fit and healthy.

    When admitted recently as a patient myself, I was awoken at 2am to have my observations taken and scored very highly due to the fact that I was cold because my window had been left open and my HR, RR and BP were low because I had been resting, and I naturally have a low BP. Needless to say I was not impressed to then be kept awake for the next 2 and a half hours with my observations taken every 15-30 minutes and to be reviewed by a registrar because I was 'critically ill', it did not make my condition any better!

    In my case, had my Nurse used her common sense and intuition, she would have given me a couple of extra blankets (not gone and gotten a Bair Hugger) and rechecked my observations just once or twice again overnight as she could clearly see that I was asymptomatic regarding my vital signs and it was not having an adverse affect on my health. I know she was required, following the Scoring, to discuss my condition with the registrar, but the conversation could have been a simple one, rather than a very worried doctor arriving on the ward to find a young woman, wide awake, and who apart from being annoyed and in pain, was absolutely fine.

    Scoring systems should be used as a guide to show a patient's progress, monitor them for deterioration and to show trends such as a constantly low BP or a high respiration rate so that appropriate action can be decided by the Nurse in charge of the patient, or a doctor, and changes to their care can be made as and when it is required.

    Phew, sorry this is so long!

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  • I don't think I can say it any better than little one above (and I totally agree about the SATs not being in the EWS. But I will say this. No it doesn't undermine our intuition, it enhances it.

    You have to remember that risk scores are a TOOL, nothing more, nothing less. We use it to back up our intuition, document a patients progress, etc, but our skill, knowledge, training and intuition will always be needed to interpret these scores and act on them correctly.

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  • Adam Roxby

    Hello again.

    Just wanted to thank you for your comments, there really insightful.

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