This month's cover shows a critical care nurse at the bedside of an obviously very ill patient, given the monitoring equipment, ventilator, and number of IV lines. On the surface, it doesn't appear as if the nurse is doing much. This is what family members might think if they enter the room. It also might be what crosses colleagues’ minds as they hurry by, perhaps wishing they too had time to “just stand there.”
But in that quiet stillness, many things may be happening. The nurse may be reading the monitors for heart rate and rhythm, mean arterial pressure, and oxygen saturation levels. A quick look would tell him the patient's urine output, and a quick touch would reveal whether the patient's skin is cool and clammy or dry and warm. He could also be looking for facial grimacing or biting on the endotracheal tube—clues that sedation might be inadequate. Or he could just be taking a quiet moment to reflect on all that has happened during his shift and what he will report to the next shift during handover.
Watchfulness is one of nurses’ most valuable skills and important responsibilities. Yes, medications must be administered and interventions implemented and managed, but our critical assessment and evaluation of a patient's responses might arguably be even more important. Indeed, patients are in our charge because they require our careful vigilance. But is this crucial nursing function becoming a thing of the past?
In AJN’s February editorial and follow-up blog post (https://wp.me/p7sy0l-6KR), I wrote about how experienced nurses seem to be fleeing bedside nursing positions in favor of other roles and attaining advanced degrees, leaving new, inexperienced nurses to staff acute and critical care units. We received a deluge of comments and letters on the topic. Most respondents agreed that nurses seemed to be leaving the bedside and blamed the difficult hospital work environment and the fact that nurses’ time is spent rushing from one patient and task to another, without, as one person wrote, “the time or resource to perform the job as it's intended to be [performed].” Another person noted, “Nurses are no longer able to provide comprehensive quality care because there's just no time for it.” And from another, “Nurses are swamped with numerous tasks, procedures, and protocols on top of unsafe [nurse-to-patient] ratios and are not supported by upper management. Their frustration builds as their voices aren't heard and leads to high turnover.”
While the disconnect between new nurses’ expectations of practice and the reality of hospital nursing isn't new, it seems to have taken on a new level of tension, as emphasis on quality improvement, implementing care bundles, managing new computerized systems, and data reporting has created an additional burden on nurses at the point of care. How can nurses be vigilant watchers if there's so little time to just be there, really looking at and evaluating their patients? Yet, most hospitals still fail to invest in staff as a means of ensuring quality and safety.
Data on how nursing makes a difference in patient outcomes have been gathered for nearly 200 years—from Florence Nightingale in the Crimean War to Linda Aiken in the present day. This hit home when I attended this year's annual meeting of the National Association of Clinical Nurse Specialists, where in session after session I heard about nurses improving care and lowering costs. I also recently heard a presentation by Regina Cunningham, a nurse and the chief executive officer of the Hospital of the University of Pennsylvania (see Profiles in this issue), in which she cited several projects led by nurses that improved outcomes, increased patient satisfaction, and lowered costs. And nurses’ ability to create innovative solutions to increase access to care and quality was also evident at the American Nurses Association's Quality and Innovation Conference in March.
It's frustrating that despite all the evidence, nursing is still struggling to prove its value. From observation to assessment to managing care—nurses possess the intimate knowledge of what works for each patient.
For Nurses Week, instead of giving nurses trinkets or ice cream, perhaps hospitals could highlight nursing's vital contributions to patients, families, and even boards of trustees by showcasing nurse-led improvements in quality and safety. Having experienced, knowledgeable nurses at the bedside is as critical as having a qualified anesthetist for surgery: good outcomes aren't possible without either.