AJN, American Journal of Nursing:
Rose, Louise PhD, RN; Clarke, Sean P. PhD, RN, FAAN
Louise Rose is the Lawrence S. Bloomberg limited term professor of critical care nursing, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada. Sean P. Clarke is the Royal Bank of Canada chair in cardiovascular nursing research, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and University Health Network, Toronto, Ontario, Canada.
Contact author: Louise Rose, firstname.lastname@example.org.
No longer a nursing priority?
Vital sign monitoring is a fundamental component of nursing care. We're taught in nursing school that a patient's pulse, respirations, blood pressure, and body temperature are essential in identifying clinical deterioration and that these parameters must be measured consistently and recorded accurately.
These ought to be the most reliable data in a patient's chart—but they're not. Abundant research indicates that vital signs aren't consistently assessed, recorded, or interpreted. These lapses interfere with appropriate and timely interventions for deteriorating patients. All too often physiologic abnormalities that develop up to 24 hours prior to death are either undocumented or unrecognized, as evidenced by a well-publicized case in which a patient died from hemorrhagic shock after major abdominal surgery, either because blood pressure wasn't monitored or changes in vital signs weren't interpreted properly.
Vital sign monitoring is a repetitive, time-consuming task. The average nurse measures and documents thousands of normal vital signs during the course of her or his career. Have nurses come to see this task as tedious and unprofitable, despite its potential to identify significant adverse consequences? Or are nurses neglecting vital sign monitoring because they're trying to balance their workloads with the need for greater documentation?
In some settings, nonnursing personnel are responsible for this task, in others, automated devices do it. Whether or not they're actually taking the measurements, nurses are always responsible for overseeing vital sign monitoring and interpreting the data. They must be alert to trends and abnormal values.
Our profession has yet to adequately study and address nurses' failure to reliably measure, record, and interpret vital signs. Possible reasons for this include excessive workloads, failure to recognize the importance of vital signs (particularly respiratory monitoring), and unclear delineation of accountability for decision making. Nursing practice leaders and researchers—preferably working collaboratively—must learn more about why so many nurses fail to monitor these parameters effectively and propose evidence-based solutions.
Figure. Louise Rose ...Image Tools
Education programs that teach nurses to recognize and manage acute patient deterioration may help—to the extent that they strongly emphasize the need for extra vigilance in vital sign monitoring. But a lack of knowledge isn't the main problem. Our years of observing clinical practice and studying the literature lead us to believe the problem is in the application of these monitoring skills. Nurses are under heavy time constraints and overloaded with information about many assessment parameters. Perhaps we need to reduce and focus the physical assessment and examination skills taught to undergraduate students. We should also devote attention to individually targeting and tailoring the measurement of vital signs and better equipping nurses to interpret the information vital signs provide, which can be achieved through continuing professional education.
Nurses bring a wide skill and knowledge base to the service of the public, but there's no excuse for neglecting the most fundamental tools at our disposal. The longer we wait to acknowledge, discuss, and research this situation, the greater the risk of a serious reengineering of our work, which could shift the responsibility of vital sign assessment away from nurses—a move that's unlikely to benefit patients or our profession.
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