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Wendy Carter Kooken, PhD, RN Joan E. Haase, PhD, RN, FAAN

A Big Word for Something We Do All the Time Oncology Nurses Lived Experience of Vigilance

K E Y

W O R D S

Background: Oncology nurses are responsible to be vigilant for patients to keep

Colaizzi

them safe from harm. Yet, nurse vigilance and its role in preventing error are not well

Oncology nursing

understood. Increased knowledge of how oncology nurses practice vigilance may lead

Patient safety

to interventions that enhance nurses’ abilities to be vigilant, decrease error rates, and

Qualitative research

protect patients from harm. Objective: This article describes oncology nurses’ lived

Vigilance

experiences of vigilance while practicing in an acute care hospital setting. Methods: The study design was an adaptation of Colaizzi’s empirical phenomenology. Data were obtained from a purposive sample of oncology registered nurses (n = 7) who were identified as being vigilant by patients and family members, following their own interviews about their experiences of vigilance. Results: Four theme categories indicated the following: (1) nurses use vigilance to keep patients safe; (2) vigilance is incorporated into expert practice over time; (3) barriers impede nurses’ abilities to be effectively vigilant; and (4) nurses expect patients and families to participate in vigilance partnerships with them because it enhances the nurses’ abilities to be vigilant. Conclusion: Nurse vigilance is a complex phenomenon that is not well understood but is used by nurses in daily practice to protect patients from harm. Implications for Practice: Ways in which nurses can enhance vigilance are identified, as well as barriers to vigilance, which if addressed may promote patient safety and well-being. A theory of vigilance and a measure of it could provide objective feedback, which will enhance nurses’ abilities to be effectively vigilant.

Author Affiliations: School of Nursing, IllinoisWesleyan University, Bloomington (Dr Kooken); School of Nursing, Indiana University, Indianapolis (Dr Haase). This research was funded through the National Institutes of Nursing Research, individual NRSA, and a T 32 training grant (NR 07066). The authors have no conflicts of interest to disclose.

Oncology Nurses Lived Experience of Vigilance

Correspondence: Wendy Carter Kooken, PhD, RN, Illinois Wesleyan University, PO Box 2900 STV 214, Bloomington, IL 61702 ([email protected]). Accepted for publication October 2, 2013. DOI: 10.1097/NCC.0000000000000113

Cancer NursingTM, Vol. 37, No. 6, 2014

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I

n healthcare, vigilance is the degree to which a knowledgeable watchfulness occurs between persons in response to a threat.1 Vigilance has been widely recommended across many disciplines as a way to improve outcomes, but relatively little research has been done to understand how vigilance is experienced, enacted, or influenced in healthcare or to identify its role in error prevention. Since their landmark report on healthcare errors in 2000, the Institute of Medicine has called for expanded research to identify ways to decrease errors; however, there has been little progress in identifying appreciable ways to reduce error.2 In a review of published abstracts, we found literally thousands of authors recommending healthcare provider vigilance as critical to the early recognition of patient deterioration and as a means of keeping patients safe; however, the abstracts did not include discussions of what healthcare providers, especially nurses, do that constitutes being vigilant. In general, protecting patients from harm is difficult, because hospitals are highly complex work environments. The complexity of care provided by nurses is reflected in their myriad responsibilities, including collaboration among many healthcare providers from multiple disciplines, supervision of multiple unlicensed assistive personnel, attention to patients’ families, and simultaneous provision of safe care to multiple, vulnerable patients. In the context of cancer nursing, vigilance is especially important because the complexity of care increases when patients undergo chemotherapy and radiation treatments for cancer due to the many potential treatment adverse effects. Nurses must be vigilant for immune-compromised states, fluid and electrolyte imbalance, alterations of the central nervous system, and a cadre of adverse psychological responses.3Y5 Despite the high potential for serious errors happening while nurses provide care to acutely ill cancer patients, little is known about how oncology nurses enact vigilant care on a day-to-day basis. Vigilance is only 1 component of error prevention. While we now understand that some types of errors cannot be averted because of the complexity of healthcare environments, identifying attributes and antecedents may allow us to reduce barriers to nurses’ vigilance and create environments for health that may foster vigilance. Research on vigilance has the potential to reduce the likelihood of medical errors and promote patient safety by (1) better understanding how nursing vigilance is integrated within nursing care and (2) identifying specific ways nurses enact vigilance. In many cases, breakdowns in safety-related standards of care contribute to medical errors or near misses.6Y8 In a study comparing errors rates across several developed countries, the United States had the highest error rate; one-third of US patients experienced some type of medical error.9 Medical errors are expensive, costing $19.5 billion annually and averaging $13 000 per error10 and are compounded by extended days of inpatient care and increased need for care after discharge.11 The high complexity inherent in cancer care increases the risk of breakdown in safety-related standards of care. With the goal of greater understanding of vigilance in the context of cancer nursing, the purpose of this article was to describe the lived experiences of vigilance of oncology nurses practicing in an acute care hospital setting. Findings reported here are part of a larger study that aimed to provide a holistic underE16 n Cancer NursingTM, Vol. 37, No. 6, 2014

standing and comparing vigilance experiences across 3 samples: patients with cancer, family members, and oncology nurses.

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Background

Historical Perspectives of Vigilance Empirical research about vigilance first emerged in the defense industry to find ways to better train radar operators to detect the radar signals of approaching enemies. These first empirical studies of vigilance consisted of experiments to determine how variables affected maintaining a state of vigilance.12 The variables examined in relation to vigilance included rest, interruptions, incentives, knowledge, medications, environmental temperature, and signal intervals. According to Mackworth,12 vigilance performance was a state of being and a matter of stimulus-response conditioning.13 From such studies, detractors and contributors to vigilance performance were identified. Detractors from vigilance included (1) long tasks leading to fatigue, (2) boredom, (3) high numbers of false alarms, (4) an isolated work environment, (5) lack of evaluation of performance efficiency, (6) difficult tasks, and (7) maintaining responses to alarms over a long period.13 Contributors to vigilance included anything oppositional to the detractor list, such as short tasks and variation in the environment to stave off boredom.

Perspectives of Vigilance in Nursing Two perspectives of vigilance are found in the nursing literature. One perspective reflects the historical views of vigilance as a stimulus-response that is affected by the same detractors identified in historical studies (eg, boredom, fatigue, etc). Studies based on the historical view operationalized vigilance as the ability to stay awake and alert; they operationalized the lack of vigilance as being sleepy or falling asleep.14 In particular, medical and anesthesia residents were often the focus of studies that hypothesized vigilance was impaired by fatigue.15 Many investigations examined links between lack of vigilance, errors, and fatigue-inducing practices such as reported difficulty staying awake, working long shifts, and being on call. In nursing, research results do not consistently support correlations between vigilance, defined as sleepiness, and risk for nurses making errors.14 The inability to establish a consistent and significant correlation between nurse vigilance and errors might be explained by considering that nurse vigilance is likely to consist of additional and more complex behaviors or qualities other than just being alert or awake. An alternate conceptualization of nurse vigilance is found primarily in qualitative research studies in which vigilance emerged as an important component of nursing care for several specialty nursing practices, including critical care,16 nursing anesthesia,17 newborn nursery,18 long-term care,19 and psychiatric nursing.20 The commonalities among these research findings include situations in which patients are vulnerable, unstable, and exposed to threats; the objective of nurse vigilance in each article was to protect patients from threats. Although vigilance was identified

Kooken and Haase

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as a concept of importance to patient safety, how nurses enacted vigilance to achieve this goal was not substantively discussed. As the phenomena of primary interest, research examining vigilance is limited. Only 1 theory of nurse vigilance, developed using a grounded theory approach, was identified.21 The theory, titled Professional Nursing Vigilance, suggests the outcome of nurse vigilance is to minimize unintended patient outcomes; authors recommended that nursing surveillance (a substitute term for vigilance) be adopted as a NANDA diagnosis (North American Nursing Diagnosis Association). Unfortunately, this grounded theory can be applied only within a very narrow context, because the theory was based on only 1 study of how women (n = 9) were vigilant for the onset of their migraine headaches22; no subsequent testing of the theory was found. In summary, the literature describes nurse vigilance as either watchfulness or being alert and awake.16,17,19,20,23 A commonly agreed-upon definition of nurse vigilance is needed as a basis from which to measure behaviors associated with vigilance and assess outcomes in relation to nurse vigilance. Primary outcomes of vigilance identified in the literature include protection from threats and patient safety.14,16Y20,23 Lack of, or inadequate, nurse vigilance is associated with healthcare error.6 The literature does not include (1) a common definition of nurse vigilance, (2) ways in which vigilance can be operationalized by nurses, (3) variables that enhance or detract from nurse vigilance, or (4) considerations of specific outcomes of nurse vigilance.

during this hospitalization. Prior to beginning any recruitment, all nurses on the unit were informed about the study by their nurse manager and told how they could confidentially opt out of participation. All nurses agreed to be approached about study participation, if and when they were identified by a patient or family member. After being identified, the researcher approached the nurse to obtain written consent to participate. Because patients or family members identified the nurses as vigilant, from this point forward in this article the term nurses will be used to mean vigilant nurses.

Data Collection Once consent to participate was obtained, nurses chose the time and private setting (the hospital, their home, or the school of nursing) for the interviews. Each nurse was interviewed separately. The audiotaped interviews lasted between 26 and 50 minutes (mean, 38.8 minutes). To elicit rich descriptions of experiences of vigilance, within 6 days prior to the interview, nurse participants were given 2 broad, data-generating questions (Table 1). To ensure the focus of the participant’s description was on the experience and not on technical knowledge of the term used to represent vigilance, clarification of the word vigilance was provided by also describing vigilance as ‘‘being watchful.’’22

Data Analysis n

Design and Methods

This study was guided by an adaptation of Colaizzi’s empirical phenomenology method.24 Phenomenology is a preferred methodology when little is known about specific phenomenon experienced in life or when the phenomenon appears elusive or unclear. In phenomenology, commonalities in the lived experiences of people in similar life situations are described.25 While human experiences may be examined in a number of ways, empirical phenomenologists adhere to underlying philosophies about consciousness, intentionality, bracketing, and phenomenological reduction to arrive at a description of the essential structure of the phenomenon.26

The audiotaped interviews were professionally transcribed verbatim and checked for accuracy. Ongoing analysis of data obtained was accomplished through a process first described by Haase24 that was an adaptation of Colaizzi’s26 method. Analysis steps included (1) gaining familiarity with the interview content, identifying significant statements, restating them in more general language, and deriving formulated meanings (Table 2); (2) identifying themes within each participant’s data; and (3) merging the themes from across participant data into theme clusters and larger theme categories. Redundancy was achieved with the 7 interviews; that is, by the analysis of the seventh interview, no new theme categories emerged. After the outline of combined

Table 1 & Nurse Participant Interview Questions

Setting and Sample Recruitment The Indiana University Simon Cancer Center Scientific Review Committee and the Indiana University Institutional Review Board gave permissions for the study. The study setting was an oncology unit of the hospital associated with the cancer center. The patients on the unit were primarily being treated for newly diagnosed or relapsed acute myelogenous leukemia. Nurse participants were identified by the patients or family members who participated in the larger study. Patients and family members were interviewed first about their experiences of vigilance so they had demonstrated a familiarity with experiences of being vigilant. After patients or family members completed interviews about their experiences of vigilance, they were asked to identify a nurse who had been most vigilant for them

Oncology Nurses Lived Experience of Vigilance

(1) Please describe to me your experiences of vigilance that is sometimes called ‘‘being watchful’’ for your patients during their hospitalization and treatments for cancer. You may have another word that also fits this experience. Please describe all you can remember about how you stayed vigilant or ‘‘watchful’’ for your patientVall your thoughts, feelings, and actions. You might begin by telling a story about a specific time when you needed to be vigilant or ‘‘watchful’’ for your patient. (2) Please describe to me your experience of seeing family members or patients being watchful. Please describe all you can remember about how it was for families or patients to be watchfulVall your thoughts, feelings, and actions about how they were watchful. Again, you might begin by telling a story about a specific time family members or patients were vigilant or ‘‘watchful.’’

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Table 2 & Example of Colaizzi’s Method of Analysis Significant Statement 2.58C UmI I mean things do change daily up here, especially for the population of the leukemia patients.

Restatement

Formulated Meaning

Theme Category

Things do change daily up here, especially for the population of the leukemia patients.

2.58C Leukemia is a disease that is difficult to treat and stabilize. Nurse feels as if watching out needs to happen all the time because of the changes that occur daily with patients.

Recognizing threats

participants’ themes, theme clusters, and theme categories was created, the theme outline was used to distill the findings into an essential structure of the phenomenon of vigilance.

Rigor To ensure study findings were valid, several strategies for maintaining trustworthiness and credibility were used including a rigorous adherence to the adapted Colaizzi’s method of analysis. In empirical phenomenology, the researcher must bracket or set aside biases and presuppositions.27 Bracketing is a safeguard by which researchers attempt to stay true to participants’ meanings of experiences, rather than imposing the researchers’ experiences onto those of the participants. Formulated meanings were reviewed by the second author, an experienced researcher who has expertise in phenomenology; in addition, for further validation of formulated meanings, participants’ deidentified data were discussed with a team of doctoral and postdoctoral students taking an empirical phenomenology course. Finally, an audit trail was maintained to ensure each step of analysis could be traced back to the original transcripts.

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Findings

The purposive sample included registered nurses (n = 7) who worked on the unit. The nurse participants ranged in age from 28 to 52 years (mean, 38.2 [SD, 8.38]); 6 were female; all identified their race/ethnicity as white, non-Hispanic. Participants’ marital status included 3 who were single, 3 married, and 1 divorced; their level of education included 2 with a degree of bachelor of science in nursing, 4 with associate degrees in nursing, and 1 with a nursing diploma. Participants’ years practicing as a nurse ranged from 2.5 to 32 (mean, 12.7 [SD, 9.9]); years practicing in oncology ranged from 1.5 to 19 years (mean, 6.35 [SD, 6.47]). Four theme categories were derived from the analysis. In the following description of findings, participant quotes illustrate the theme categories, and pseudonyms are used in place of participant names. Table 3 provides an overview of the theme categories and theme clusters and a brief explanation of each theme category.

Theme Category 1: ‘‘Trying to Avoid Problems’’: Using Vigilance to Respond to Potential Threats and Keep Patients Safe Nurses spend much of their time assessing potential threats to patient well-being. They are aware that protecting patients from E18 n Cancer NursingTM, Vol. 37, No. 6, 2014

harm and promoting patient safety require that threats be swiftly identified and addressed. Nurses adapt their level of vigilance according to the seriousness of the threat. Two theme clusters describe how nurses perceive threats and actions taken to promote patient safety. THEME CLUSTER 1.1: ‘‘SOONER YOU GET SOMETHING DONE [TAKE ACTION]; THE BETTER OFF PATIENTS WILL BE’’: RECOGNIZING THREATS

Nurses perceive that enacting vigilance requires an essential first stepVrecognizing data on patients’ conditions as potential threats or harbingers of actual harm for patients. When nurses cannot access and/or process data to recognize the existence of a threat, they cannot be vigilant. Nurses take their roles as guardians seriously and are vigilant for things that are not obvious to most people. It’s just wanting to try and pick up on any little problems that could turn into a [big] problemI and trying to avoid that. [Jill] Nurses spend a lot of time sorting through data to recognize potential threats and prevent harm: This doesn’t seem right. Isometimes it’sI a process of sifting through things because sometimes it might not be anything. [Jill] Once nurses have identified a potential threat, they try their best to deal with it before it leads to harm: If somebody’s [patient’s] hemoglobin is 6 or 7, and their platelet count is 2 or 3, maybe they [doctors] will get those orders written eventually throughout the day, but in those cases, the sooner you get something done about it, the better off they’re gonna beI [Jill] THEME CLUSTER 1.2: ‘‘IT HEIGHTENS YOUR VIGILANCE’’: ADAPTING TO THE LEVEL OF THREAT

Vigilance is perceived as not only necessary for patient safety; it is also a quality care indicator. Specifically, patients who have vigilant nurses have lower risks and less negative outcomes. The outcome of recognizing and responding to threats as early as possible is that patients are kept safe from potential harm. In order to maximize their ability to be effectively vigilant and prevent harm, nurses adapt their level of vigilance according to the seriousness of the threat to the patient: Ianytime you’re [nurses are] giving anything that [patients] might have a reactionIyou’re going to be, of course, a little more watchful. [Ellen]

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Over time and with gains in knowledge and experience, nurses incorporate vigilance into expert care. Common nursing skills such as communication, patient education, and establishing a nursing routine are used to focus nurses’ vigilance toward threats and responses to them. As nurses gain expertise, nurses incorporate vigilance into expert practice. They become unaware of the ways in which they practice vigilance and are largely unaware that patients and families notice nurse vigilance.

2.1. ‘‘We do it all the time and don’t think about it’’: nurses are not always aware of being vigilant 2.2. ‘‘We all pretty much make it a practice, first thing in the morning, check for your labsI’’: common nursing skills 2.3. ‘‘It’s just old hat for me’’: experienced and knowledgeable nurses 3.1. ‘‘Ten things you want me to do right now’’: competing demands for nurse vigilance 3.2. ‘‘We don’t have the staff for one-on-one nursing’’: many complexities hinder nurse vigilance

4.1. ‘‘We’re in this together’’: cultivating nurse-patient relationships 4.2. ‘‘You might see something I won’t’’: sharing vigilance 4. ‘‘The more people to double check, the better the care’’: partners in vigilance

3. ‘‘We have our hands full’’: complex barriers to vigilance

Complexities inherent in patient care and the environment impede effective vigilance. Nurses mentioned many specific barriers to being vigilant including interruptions in their routines; demands for immediate attention from patient families; disorganized, rushed coworkers, healthcare providers, patients, and families who lack knowledge; patients who are uninvolved in their own care; and situations in which strong negative emotions are expressed. In particular, nurses felt unable to be effectively vigilant when critically ill patients were left on a general oncology floor. Nurses perform purposeful actions to enhance their abilities to be effectively vigilant. Nurses carry out actions to develop partnerships with patients and families. Nurses connect with them on personal levels, engender trust, and instill and maintain hope.

Nurses use vigilance to provide safe care for patients. Nurses look for threats to patients and take actions to reduce or ameliorate threats. Nurses adjust their level of vigilance according to how harmful the threat might be. 1.1. ‘‘Sooner you get something done [take action]; the better off patients will be’’: recognizing threats 1.2. ‘‘It heightens your vigilance’’: adapting to the level of threat

1. ‘‘Trying to avoid problems’’: using vigilance to respond to potential threats and keep patients safe 2. ‘‘It’s a matter of routine’’: vigilance is incorporated into expert practice

Key Components/Descriptors of Essential Structure based on Theme Categories/Clusters Theme Clusters Theme Category

Table 3 & Theme Categories, Theme Clusters, and Description

Oncology Nurses Lived Experience of Vigilance

Iif someone’s more critical, it heightens your vigilance. [Jean]

Theme Category 2: ‘‘It’s a Matter of Routine’’: Vigilance Is Incorporated Into Expert Practice Nurses’ vigilance is refined with experience, over time. As nurses gain knowledge and experience, vigilance becomes part of their routine practice. Nurses focus and refine vigilance through fundamental nursing skills, first learned in school, such as communication and establishing clinical routines. Vigilance becomes so ingrained into nurses’ expert practice that they are not always aware they are being or acting in a vigilant manner. Three theme clusters describe vigilance as part of expert practice. THEME CLUSTER 2.1: ‘‘WE DO IT ALL THE TIME AND DON’T THINK ABOUT IT’’: NURSES ARE NOT ALWAYS AWARE OF BEING VIGILANT

Vigilance becomes ingrained over time. It is something nurses do automatically, so they are not aware of being vigilant, and consequently, vigilance is difficult for them to describe. I think that to me vigilance is a really big word for something that we just do all the time and don’t even think about it. [Jill] In addition, nurses are not usually aware that patients or family notice that they are being vigilant: I didn’t realize how much I made him feel more secureIuntil his family came up and hugged me, and thanked me. And I was like ‘‘for what?’’ [Sophia] THEME CLUSTER 2.2: ‘‘WE ALL PRETTY MUCH MAKE IT A PRACTICE, FIRST THING IN THE MORNING, CHECK FOR YOUR LABSI’’: COMMON NURSING SKILLS

Despite being unaware of enacting vigilance, nurses’ narratives revealed several fundamental nursing skills that provide the basis for vigilance, including communication skills, noticing what is subtle, being present, being responsive and looking for responses, and thinking/acting like a nurse, (ie, critical thinking and being prepared and organized). In addition, vigilance was experienced through the fundamental nursing roles: educator, advocate, and caregiver. For example, to enhance vigilance, nurses use every conversation as an opportunity to gather information from patients and families: Patients make a really innocent kind of statement, and you pick up on itI and start questioningI come to find out moreIyes, that could be a potential for complication. [Jill] Nurses perceive vigilant nurses as orderly and having routines; such organization seems to enhance the ability to be vigilant. Nurses indicate that every time they enter a patient room, their presence and their actions are purposeful, such as continually assessing patients’ responses to interventions: Ievery time you go in, you’re not just doing ins and outs [fluid intake and output], monitoring on a 12-hour Cancer NursingTM, Vol. 37, No. 6, 2014

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timelineI every time you go in the room, you’re measuring, you’re monitoring. [Marilyn] Nurses perform critical thinking in order to make crucial connections that protect patients. As part of thinking and acting like a nurse, nurses learn to hold information about patients in their minds; sometimes over a period of hours or days, even on days off work: You might not be able to pinpoint it right away eitherI until you go on in the day just a little, and thenI sometimes you can put things together and say ‘‘oh, I think it’s this.’’ [Jill] THEME CLUSTER 2.3: ‘‘IT’S JUST OLD HAT FOR ME’’: EXPERIENCED AND KNOWLEDGEABLE NURSES

Nurses perceive that their ability to be vigilant is enhanced as they gain knowledge and experience over time: Ithose of us [nurses] that have been here longer will just look [at the doctor and say] ‘‘I don’t have time to mess around, I need these orders, so please write them.’’ [Jill] Nurses in this study were aware that new nurses, whether new graduates or new to the specialty, did not always have the knowledge and experience needed to be effectively vigilant. One nurse recounted a story about a new nurse who requested help in getting suction equipment. The new nurse then asked the experienced nurse to come and look at the suction because it did not seem to be working: So I walked in there, and I’m like, ‘‘Oh, my gosh!’’; he needs way more than this. I mean the patient was in [such bad] pulmonary edema. I have never seen a patient [with] this much pulmonary edema. [Joe] Because nurses will not always be available (to patients and family), they are also vigilant in extending their knowledge to the patient and family (eg, planning for discharge). Nurses believe patients must learn to make critical connections so they can be vigilant for themselves. Nurses educate patients and family so they can become aware of behaviors that minimize threats: Iif you give them a reason for a symptom, or what they’re going through, then they’ll put the picture together. [Marilyn] Oncology nurses help patients reduce threats, beginning with the very basics in patient education: Iif they’ve never been neutropenic beforeI they’ve never had low countsI we discuss with them what they’re not allowed to useI certain toothbrushesI can’t shave with a regular razorI it’s all part of the education at the beginning. [Joe]

Theme Category 3: ‘‘We Have Our Hands Full’’: Complex Barriers to Vigilance Nurses indicated their awareness of the complexities involved with caring for multiple patients and families in complex enviE20 n Cancer NursingTM, Vol. 37, No. 6, 2014

ronments. They know their patients’ conditions and treatments contribute to conditions that threaten patient safety. In addition, nurses are aware of barriers to being effectively vigilant. Two theme clusters provide a description of circumstances that complicate nurses’ abilities to be effectively vigilant. THEME CLUSTER 3.1: ‘‘TEN THINGS YOU WANT ME TO DO RIGHT NOW’’: COMPETING DEMANDS FOR NURSE VIGILANCE

Oncology nurses feel compelled to remain vigilant for any changes in patients’ conditions. If nurses suspect patients are declining in any kind of way, they have to respond and complete multiple tasks, seemingly all at once: [Nurses] have to be vigilant with every patient ‘cause things can turn around so quickly with [oncology] patientsI one day they could be doing fine. The next hour, they could be having a fever, and you have to get their blood cultures, and everything has to go really quickly. Get blood cultures. Send urine. Get their chest x-rays, or antibiotics all in an hour. [Ellen] Amid nurses’ need to adapt to fluid work conditions and coordinate care among many healthcare providers to meet the needs of multiple patients, families also need and seek nurses’ attention: Isometimes the patient’s family makes it like we [nurses] are supposed to just drop everything and come running to their family member, when we have our hands full as it is. [Joe] Nurses continually struggle with and seek ways to balance and prioritize their vigilance for patients among the many competing demands. THEME CLUSTER 3.2: ‘‘WE DON’T HAVE THE STAFF FOR ONE-ON-ONE NURSING’’: MANY COMPLEXITIES HINDER NURSE VIGILANCE

Nurses relayed many things they commonly experience that add to the complexity of care and complicate their ability to be vigilant. These complexities include caring for critically ill patients on a general floor; healthcare providers, patients, and family who lack knowledge; uninvolved patients; disorganized, rushed nurse coworkers; interruptions in the normal routine; and strong, negative emotions. A frequently mentioned situation that hinders nurses’ abilities to be vigilant is when critically ill cancer patients on their unit are not transferred to intensive care. At such times, nurses must free up time to attend to the critical patient. This is often accomplished by the nurse focusing the majority of their attention on the critical patient, in which case other patients to whom the nurse is assigned receive less attention: There was one instance where this patientI looked like he was going to code on his way in the doorI. Family left, and doctors didn’t discuss code status with this patientI. He became unresponsive, gurgling, respirations like 60I. He was an older guy and doctor’s ‘‘we’re not taking him to ICU [intensive care unit].’’ They wanted

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us to do one-on-one nursing [care], which we don’t have the staffing for.’’ [Joe] Another nurse said: ‘‘Ithat’s not my area [critical care]I I don’t like it when they go bad. I’m just not like a code person.’’ [Marilyn] When a nurse shifts to one-on-one care, responsibility for the rest of the nurse’s patients falls on the other nurses during the shift. The other nurses have to adjust their planned patient care routines in order to provide vigilant care to not only their assigned patients, but also to the additional patients shifted from the nurse who needed to provide one-on-one care. Adjusting routines of care was perceived by nurses as detrimental to vigilance. Nurses describe specific routines that keep their attention focused in an orderly fashion; however, nurses become anxious and sometimes angry when this routine is interrupted. Although many things interrupt routines, nurses most often mentioned family members, who did not seem to understand nurses’ work and felt they could frequently interrupt the nurse: Sometimes you [nurses] have [family] where they go over the top and you literally have to actually make them leave because you can’t getI job done because they are disrupting the flow of things.’’ [Jane] As the number of family members increases, the complexity of nurses’ work increases: We had like a whole waiting room of people [family members] campingVlike livingVin our waiting room. Kind of overwhelming when you have that much family, and they take over the room. One [family member] doesn’t know what has been doneI and sometimes you have to repeat a lot that you said [already to other family members]. [Ellen] When there are tensions, situations can be emotionally charged. Nurses indicated that when families or patients become extremely angry, or sometimes abusive, the nurse avoids them: Ithe angry people. Mean. They are the ones you’re glad that their time is done. That’s when you’re just like okay they’re gonna have to do [for themselves]I If they need me, call. [Marilyn] Nurses relayed how important it was to be vigilant every time they went in patients’ rooms, but when patients or families exhibit strong, negative emotions, the nurses avoid going into their rooms.

Theme Cluster 4: ‘‘The More People to Double Check, The Better the Care’’: Partners in Vigilance Nurses cannot be individually and solely responsible for being vigilant. Nurses presented that it is imperative that patients, family members, and other nurses must help in being watchful. From descriptions, it appears that nurses work diligently to

Oncology Nurses Lived Experience of Vigilance

develop vigilance partnerships with as many persons involved with patients as possible. Nurses purposely carry out specific actions that they believe will give them an advantage in being effectively vigilant. Two theme clusters describe their actions in developing partnerships with patients and relying on other nurses as partners in care. THEME CLUSTER 4.1: ‘‘WE’RE IN THIS TOGETHER’’: CULTIVATING NURSE-PATIENT RELATIONSHIPS

To improve their abilities to be vigilant, nurses use 3 specific relationship strategies: (1) connecting with patients and families on a personal level, (2) developing trust, and (3) maintaining hope. Opportunities to gain personal knowledge of patients offer nurses a unique vigilance advantage compared with other healthcare providers: I don’t mean to say we know more than the doctors, ‘cause we don’t, but we know more about the patients than they do on a personal level. [Jane] Nurses indicate that when they get to know patients, their ability to be vigilant is enhanced: Iyou can sign up as first primary; meaning that when you’re here, you have first dibs on taking care of the patientsI it’s good for you because you get to know the patient betterI whichI is helpful because that’s when you pick up on things quicker. [Jill] To further enhance vigilance, nurses work hard to establish trust with the patients. Nurses recognize that trust is based, in part, on how patients perceive what nurses think of them: I want them to feel likeI she [the nurse] wants to know everything about me, and it’s okayIshe’s not going to make me feel like an idiot. [Sophia] In addition, nurses seem aware that building trust takes time and investment: You would ask him a question and he would be real short. ‘‘Yes. No.’’ And I had to sit in there with him for 10 hours, and for some reason we clicked, and he trusted me. From that point on, he opened up to nursesI when he trusted me, he would tellI us things versus keeping it to himself. [Marilyn] Lastly, an important aspect of nurse vigilance was maintaining hope. Nurses seemed to notice the patients who exhibited signs of well-being were hopeful and had positive attitudes: It [positive attitude] makes a big differenceI when you see someone who can be so depressed, so withdrawn, and flat in the face [compared] to someone who’s laughing: they’re eating more, they’re enjoying people coming in thereI. [Sophia] THEME CLUSTER 4.2: ‘‘YOU MIGHT SEE SOMETHING I WON’T’’: SHARING VIGILANCE

Nurses perceive that they are more effectively vigilant when vigilance is shared among patients, families, and other healthcare Cancer NursingTM, Vol. 37, No. 6, 2014

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providers. Nurses who understand what patients can contribute to vigilance partnerships encourage vigilant behaviors in patients. For example, nurses encourage patients to notice and speak up. One nurse tells patients: Iyou might see something I won’tI you’re going to be the first person who’s going to know before I do, and I hope you feel open enough to always tell me. [Sophia] Nurses also indicate that family members provide valuable information: I’ve learned through experience to always listen to what they [family] say, because if you don’t, you might miss something. [Jill] Being partners in vigilance is so important to nurses that when patients do not participate in being watchful for themselves, the nurses become frustrated. For example, when patients do not share what they know about their medications or illness, nurses cannot be effectively vigilant because the nurse is missing information: Ithere’s been some that it was sadI they didn’t know what antibiotics they took, andI one that came in with the rash. We didn’t know if it was vancomycin. She didn’t know what she took. [Sophia] Finally, nurses describe how important it is that other nurses are not just vigilant for their own patients, but enact vigilance as a group, especially when one nurse’s attention must be shifted away from patients. When nurses have to ‘‘leave the floor,’’ often to take a patient to diagnostic tests, their other assigned patients are watched over by other nurses: I’m going to have to leave the floor with this patientI could be down there for 20 minutesI where I’m not even on the floor to be with my patients. You [other nurses on the unit] have to have help. [Joe]

Essential Structure Phenomenological reduction, which is the use of bracketing and adherence to Husserlian methods, should lead researchers to identify the essential structure of the phenomenon under study. The goal of describing the essential structure is to describe, in a context and as clearly as possible, the phenomenon and its relationships.28 Vigilance was described in this study by oncology nurses, who were identified by patients or their family members as vigilant. These oncology nurses worked with patients who were most often hospitalized for a month in an acute care setting. Within this context, the essential structure of vigilance is described as follows. Nurses use vigilance to provide safe care for patients. Nurses are especially vigilant for anything that may be a threat to patient well-being. Once a threat is identified, nurses will work diligently to manage or ameliorate the threat. They understand that preventing patient harm hinges on threat management. Nurses adapt their levels of vigilance in relationship to the seriousness of E22 n Cancer NursingTM, Vol. 37, No. 6, 2014

the threat to the patient; the higher the threat, the more vigilant nurses become. Over time and with gains in knowledge and experience, nurses incorporate vigilance into expert care. Common nursing skills such as communication, patient education, and establishing a nursing routine are used to focus nurses’ vigilance toward threats and responses to them. Nurses develop assertiveness over time to help them manage threats, letting go of passivity or fear in getting patients what they need. As nurses gain expertise, nurses incorporate vigilance into expert practice. They become unaware of the ways in which they practice vigilance and are largely unaware that patients and families notice nurse vigilance. Because they ‘‘do it all the time,’’ vigilance is not an effort that requires a conscious thought process; it just is. Contrary to the use of vigilance in expert practice, nurses believe that vigilance is not ingrained into inexperienced or new nurses’ practice. Complexities inherent in patient care and the environment impede effective vigilance. Multitasking, especially under pressure and in emergent situations, makes vigilance more difficult to practice effectively. Nurses mentioned many specific barriers to being vigilant including interruptions in their routines; demands for immediate attention from patient families, disorganized, rushed coworkers, healthcare providers, patients, and families who lack knowledge; patients who are uninvolved in their own care; and situations in which strong negative emotions are expressed. In particular, nurses felt unable to be effectively vigilant when critically ill patients were left on a general oncology floor. Such situations demand one to one care, requiring nurses to shift their entire attention to one patient, who they often do not feel capable of caring for (because they are not ICU nurses). In addition, when one nurse shifts his/her entire attention to 1 patient, the other nurses on the floor have to pick up more patients, which increases the denominator over which their vigilance is divided. Nurses perform purposeful actions to enhance their abilities to be effectively vigilant. They expect patients, families, and other healthcare providers to participate as partners in vigilance. So, nurses carry out actions to develop partnerships with patients and families. Nurses connect with them on personal levels, engender trust, and instill and maintain hope. As for nurses helping each other watch over patients, families, and the environment, this is a concept that seems expected and understood.

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Discussion

In this research study, oncology nurses’ vigilance was perceived as a complex phenomenon. Unlike historical literature, or some nursing research, that presents vigilance in relation to fatigue, nurses in this study never mentioned fatigue. Current study results are similar to findings in reviewed nursing research studies: vigilance is complex, arises in response to threats, and ultimately is used to protect patients.4,16Y20,23 However, in these reviewed studies, the research was not about vigilance, but vigilance was a concept that arose as one variable among many in whatever topic the research was about.

Kooken and Haase

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The current research study provides some new information on ways nurses manage threats. Nurses try to recognize threats or potential threats as early as possible in order to avoid bigger problems later. Nurses manage their level of vigilance and adapt it in response to the nature of the threat. The more harmful the threat, the more vigilant nurses are. Nurses are at the sharp end of errors,29 meaning they are often the last to try and prevent harm or errors from occurring. Nursing vigilance may play a role in error prevention, but research and instrumentation for correlating vigilance and error are lacking. Over time, vigilance is incorporated into expert practice, much like Benner30 describes intuition in expert nurses. Nurses sometimes lack awareness that they are being vigilant, which may be similar to Haase’s24 findings on courage in patients, wherein it becomes a selfassigned attribute, incorporated into who the person is. Nurses’ years of training and experience are used to gather information and look for and respond to threats. The skills learned in nursing school and honed by experience lead to vigilance, which is unique to nursing. There is little in the literature to indicate that nursing educators have considered fundamental nursing skills and the role they may play in patient safety.31 Nursing education is constructed as a unique experience that educates nurses to enter practice as generalists. Specialized training ensues in work experiences after graduation. Yet, nurses in this study described fundamental skills used to assess patients and make decisions about threats and safety. More current research identified the value of nurses’ foundational education in being able to assess situations, but also indicated a need for expanded learning.32 Much has been written about critical thinking, clinical reasoning, and clinical judgment in nursing, and principles within these theories may be useful to promote more meaningful connections between threats to patients and nursing responses early in nurses’ careers. In complex systems, which are ever-changing and unpredictable, nursing vigilance is crucial because it is adaptable. We are just beginning to understand and substantiate the complexity involved in nurses’ work and nursing within complex environments.31,32 Although vigilance can be adapted to individual circumstances, there are also limitations to nursing vigilance. Strong negative emotions contributed to complexity in nurses’ work environments. Complex environments and serious illnesses create stressors that may bring out strong negative emotions in patients, families, and nurses, which, in turn, interfere with nurse vigilance. The literature indicates that the presence of negative emotions is linked to patient safety.33,34 The Joint Commission was so concerned about strong, negative emotions, violence, and their impact on patient safety that they published Sentinel Events on the topic, which states that hospitals must address these issues.35 There is a limit to the amount of things for which nurses can be vigilant. Nurse minimal staffing laws were created to limit the number of patients to which nurses were assigned. But, in this research study, it was not the number of patients that nurses were assigned that created barriers to vigilance but rather patients who were critically ill and needed one-to-one care on a general nursing floor. Although nurses requested critically ill patients be transferred to ICU, physicians often refused, which created a ‘‘worst-case scenario’’ for nurse vigilance. Nurses’ con-

Oncology Nurses Lived Experience of Vigilance

cerns regarding transfer of critically ill patients to ICU are supported in the literature. When compared with patients transferred more immediately, lack of expediency in transferring patients to ICU contributes to higher mortality rates.36 Oncology nurses and ICU nurses serve very different functions; oncology nurses expertly manage symptoms, oncologic emergencies, and immunosuppression, whereas ICU nurses are experts on physiologic stabilization.37 Oncology-ICU collaborations in care have contributed to successful patient outcomes. Lastly, nurses perform purposeful actions such as connecting with the patients, engendering trust, and instilling hope, to create vigilance partnerships among themselves and as patients. The closest concept to shared vigilance found in the literature is reciprocity, which was most often noted as a means of sharing responsibility for certain elements in relationships.38,39 Trust is a cornerstone in persons being able to reciprocate in relationships, and reciprocal relationships have elements of constancy and purposefulness.40 When reciprocity exists, the relationship is viewed as positive and is accompanied by the outcome, ‘‘sense of well-being.’’

Implications The current research study supports findings from other studies in nursing research that vigilance is a complex phenomenon, carried out by nurses to protect patients from harm. Nurses can use the specific skills identified by expert, vigilant nurses in this study to enhance their abilities to be vigilant. Finding ways to instill hope in patients, getting to know patients and their families on a more personal level, and finding ways to help patients and families trust them all contribute to nurses being able to be more effective in their vigilance. Nurses can be more explicit about patients and families being vigilant and sharing what they notice with their nurses. Nurses also need to be aware of what impedes their vigilance. If nurses know that strong negative emotions interfere with vigilance, then they can develop ways to allay such emotions. Taking breaks and having someone to talk with may allow enough time to lessen emotions that are overwhelming and distracting. Nurse administrators can review policies about other complexities in nurses’ work that distracts them from vigilance. Agreements to move critically ill patients to intensive care environments not only give better outcomes for patients, but also relieve the nurses of dividing their vigilance too thin. More research is needed to understand relationships between nursing vigilance and error prevention, beginning in schools of nursing and encompassing the clinical environment. The development of a comprehensive theory of vigilance may be useful in improving nurses’ abilities to be vigilant. Such a theory could be useful in defining the complex components of vigilance and translating them into practice. An instrument designed to capture nurse vigilance would help quantify relationships between nurse vigilance and errors, patient satisfaction, and patient outcomes. With a theory and instrument to measure vigilance, nurses in clinical practice could receive objective information that may enable them to enhance ways in which they are vigilant and improve patient safety outcomes. Cancer NursingTM, Vol. 37, No. 6, 2014

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A big word for something we do all the time: oncology nurses lived experience of vigilance.

Oncology nurses are responsible to be vigilant for patients to keep them safe from harm. Yet, nurse vigilance and its role in preventing error are not...
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