The art of noticing: essential to nursing practice Fiona Watson and Annessa Rebair
Abstract
Noticing is integral to the everyday practice of nurses; it is the precursor for clinical reasoning, informing judgement and the basis of care. By noticing the nurse can pre-empt possible risks or support subtle changes towards recovery. Noticing can be the activity that stimulates action before words are exchanged, pre-empting need. In this article, the art of noticing is explored in relation to nursing practice and how the failure to notice can have serious consequences for those in care. Key words: Patient assessment ■ Clinical judgment ■ Failure to notice ■ Patient-centred care ■ Compassionate care
of attentiveness shown by nursing staff, and as a result patients failed to receive basic nursing care in relation to hygiene, safety and continence needs.The Health Service Ombudsman Report (2011) also found a failure in the nursing staff ’s ability to look beyond the clinical condition of the patient and recognise or respond to emotional and social needs of the patient and his or her family. Consequently for some, their experiences of being a patient have differed markedly from the values and principles embedded within professional nursing practice. Lack of attentiveness led to failures to notice, which resulted in care that lacked compassion, sensitivity or professionalism, and caused unnecessary suffering (Health Service Ombudsman, 2011; Francis, 2013).
Professional noticing
Fiona Watson is Senior Lecturer Mental Health and Annessa Rebair is Senior Lecturer Mental Health, Faculty of Health and Life Sciences Department of Public Health and Wellbeing, Northumbria University. Accepted for publication: March 2014
514
Despite the importance of noticing, and the consequences of failure to do so, there is little contemporary literature exploring the issue. Tanner (2006) identifies noticing as the first stage of her Clinical Judgement Model, and defines it as: ‘A perceptual grasp of the situation at hand’ (Tanner, 2006: 208). For Tanner, noticing leads to interpretation of the situation, responding to that interpretation, and reviewing the outcome of the response. Where the nurse is unable to immediately make sense of what has been noticed a hypothetico-deductive reasoning process may take place where hypotheses are rejected until a reasonable interpretation, based on available information, is reached. Where the nurse has immediate recognition of what has been noticed, interpretation and response may be more intuitive. Within this model, noticing is a prerequisite for nursing action. In examining the clinical practice of ward sisters, MacLeod (1994) also recognised the importance of noticing in relation to expert nursing practice. The nurse notices significant features of the situation, understands the meaning of what has been noticed, and acts in the interests of the patient. However, for MacLeod this is not a linear process, although noticing, understanding and acting are ‘inextricably intertwined’ (MacLeod, 1994: 365). MacLeod found that in relating to their patients, the quality of this process contributed to the ward sisters’ ability to deliver goal-directed patient-centred care. Again, noticing is identified as key part of the process of nursing activity. Noticing can be seen as a more complex activity than first realised. Mason (2002) differentiates between ‘ordinary noticing’ and ‘marking’ and recommends that we must become disciplined in our noticing if we are to improve
© 2014 MA Healthcare Ltd
N
oticing may be seen to be a natural act, something we do throughout the course of our day.We notice the weather, the price of petrol, the noise of a lawn mower through an open window. Noticing involves all five of the senses and we are constantly exposed to a vast number of stimuli. It would of course be impossible for us to notice all the stimuli that surround us. Although we may feel sensitive to what is going on around us, there will be much more that we have failed to be aware of, that we do not give attention to. What does capture our attention, therefore, is selective, this is what we notice. Often what we notice is that which has most relevance to us. We will notice the weather if we are planning a picnic, we will notice the time if we have an appointment to keep. Our noticing informs our actions: if it looks like rain we may well revise our picnic plans. Failure to notice the clouds gathering could result in wet sandwiches, for what we fail to notice cannot influence our behaviour. This failure to notice has serious consequences in terms of nursing practice, and has been identified as a significant contributory factor in poor standards of nursing care. The Francis Report (2013) highlighted a number of failings at the Mid-Staffordshire NHS Foundation Trust including a largely business-oriented approach, low staffing levels and a tolerance of poor standards. These failings contributed towards an organisational culture in which there was a lack
British Journal of Nursing, 2014, Vol 23, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
professional issues professional practice. ‘Ordinary noticing’ refers to that which we can recall when prompted by someone or something and lasts for only a short time in accessible memory such as being asked if we noticed where the house keys were placed or if the light was switched off. ‘Marking’ refers to that which has more significance, and not only do we notice it, we initiate mention of it. Remarking on our noticing to others demonstrates the importance of what we noticed and makes it available for further evaluation. As Mason highlights: ‘…marking is a heightened form of noticing. Intentional marking involves a higher level of energy, of commitment, because it requires more than casual attention.’ (Mason, 2002: 33) This heightened form of noticing is essential for nursing practice if we are to assess, monitor and evaluate patient responses, inform our clinical decisions and ensure nursing care is person centred and individualised. As multi-sensate beings we notice with all of the senses. If we consider the area of vital signs, we notice the rise and fall of the chest to count respirations, we listen to notice a heartbeat, and use touch to notice a pulse. All of these require careful attention. However, salient features that indicate a change in condition may be more subtle than this. Intentional marking is required to notice the slight change in voice tone that indicates anxiety, the pressure of someone holding a hand tightly indicating a need for comfort, or the smell of body odour suggesting possible problems with self-care. Equally important are the subtle changes that indicate personal growth, hope, and a readiness to move forward. MacLeod (1994) identified how individualised these changes might be, for example when patients articulate more interest in outside events than they have previously done or demonstrate a readiness to wear false teeth. When such subtleties are noticed, nurses are able to act in a way that facilitates independent action by the patient and movement towards recovery.
© 2014 MA Healthcare Ltd
Failure to notice—the importance of noticing There are serious consequences of failure to notice in nursing. Failures to notice a drug error, the need to turn a non-ambulant patient, or increase in pain are examples where patient care will be compromised. Where patients are unable to communicate their needs, the ability to notice change becomes increasingly important. Consider the person with severe learning disability: because of cognitive impairment he or she may be unable to verbalise pain, but it is likely that subtle changes in behaviour will indicate a problem. Changes such as loss of appetite or restlessness may point to something requiring nursing action. It is only through noticing these subtle changes that appropriate care can be given. Similarly, as Cawson (2002) identifies, it is unlikely that the neglected child will seek help directly from a health professional. Nurses must therefore notice the indirect signs of neglect, or issues within the family that may adversely affect the child. Yet as Taylor et al (2012) identify, recognition of neglect remains inconsistent. If detection rates are to improve, professional noticing must be enhanced, emulating the difference between ordinary noticing and marking.
British Journal of Nursing, 2014, Vol 23, No 10
Dossey (2008: 225) suggests that ‘not noticing is a virus that is loose in modern culture’ and argues that it is our relationship with technology that has led to this demise. There is no need to notice the roads travelled as GPS will enable you to reach your destination; there is no need to go outside to check the weather as a computer screen can update you in seconds. This reliance on technology may also inhibit noticing in nursing. By exploring the levels of trust that nurses place in technology, Browne and Cook (2011) identify how inappropriate levels of trust in equipment used in the intensive care unit can lead to poor monitoring of that equipment and equipment failure may go unnoticed. Failure to notice a malfunction can then have potentially serious implications for the patient. Consider a malfunction on the alarm of a syringe driver. If the nurse is relying on the alarm to indicate a problem, failure of the machine to deliver the correct dose may go unnoticed. Of course, it can be argued that advances in technology have allowed nurses to notice much more in relation to the patient’s condition. However, the concerns raised by Browne and Cook illustrate how noticing cannot be solely ‘handed over’ to machines. Similar matters can be raised with regard to the use of clinical rating scales. Concerns regarding usefulness, sensitivity, reliability and validity of assessment tools are well documented and there is contradictory evidence on their effectiveness over clinical judgment (Richardson et al, 2007; Anthony et al, 2008). Furthermore, as such tools require nurses to assess the patient against a set range of predetermined criteria, there is a danger that only these patient behaviours will be given attention. Individual subtle, yet noteworthy, indicators may go unnoticed if not part of the listed criteria for assessment. As rating scales are now a significant feature of nursing practice, an additional question of ‘what else did you notice?’ within the criteria would be advantageous in order to accommodate a meaningful assessment.
What can be noticed? Both Tanner (2006) and MacLeod (1994) identify that the process of clinical judgment, beginning with noticing, is seen in the practice of experienced nurses. Noticing is only possible when the nurse is able to draw on his or her knowledge of patterns of recovery gained from past experience, from textbooks and formal learning, and knowledge of the particular patient’s patterns of responses. This collective knowledge then provides an expectation for this patient, and allows the nurse to notice when this is not met. Consider the patient recovering from an appendectomy. The experienced nurse will be able to draw on knowledge of other patients undergoing this surgery, common post-operative patient experiences and the usual recovery rates. When compared with the particular patient’s response, the nurse can notice if the expectations for recovery are being met. As Tanner (2006) identifies, the less experienced nurse may not have this previous knowledge or experience to provide a frame of reference. Consequently important changes in condition may go unnoticed and opportunities to act could be missed. Rating scales may arguably limit what can be noticed, but the personal position from which the nurse acts can
515
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Noticing
can be a nursing activity that is taken for granted, yet has been shown to be a complex multi-dimensional aspect of nursing practice
n Where
patients are unable to communicate their needs, the ability to notice change becomes increasingly important
n Increasing
reliance on technology has raised concerns noticing cannot be solely ‘handed over’ to machines.
n Values
and beliefs held by the nurse and brought to the clinical situation can significantly influence what is noticed, and frame the nursing response
n Improved
practice and improved outcomes for patients can only come about by improved noticing
516
patient responding to auditory hallucinations—the context of the mental health ward helps name what is being noticed. However, consider this scenario in a busy shopping centre: there you may decide that what you have noticed is a man trying to have a conversation on a mobile phone. Witkin (2000: 102) has identified how noticing is ‘subject to the sway of social processes’ in that what can be noticed is influenced by societal values, cultural norms, and sociopolitical forces. This can also be said of noticing within the context of nursing.
Improving our noticing, implications for nursing practice Noticing can be a ‘taken for granted’ nursing activity, yet has been shown to be complex multidimensional aspect of nursing practice. The importance of context should be acknowledged and nurses must be aware of what they personally bring to a clinical situation in relation to values, attitudes and experience. Noticing is essential for nursing interventions to take place, therefore, it must be a purposeful, directed activity. Improved practice and improved outcomes for patients can only come about by improved noticing. Public confidence has been rocked by events such as those at Winterbourne View and Mid Staffordshire, and nursing practice is under scrutiny (Ford, 2012). Evidence suggests a significant number of patients experience missed nursing care because of a lack of attentiveness to patient needs, poor resources and poor communication (Barker et al, 2002; Kalisch et al, 2009; McHale and Fenton, 2010). It is therefore vital that nurses make the opportunities to notice their patients, improve their sensitivity to noticing and use the opportunities provided by noticing to deliver timely interventions. Inexperienced nurses need the support of those more experienced to name what they notice and understand the relevance. Support systems such as preceptorship and clinical supervision must be embedded into the practice of clinical areas to provide this. Tanner’s (2006) Clinical Judgement Model can also provide educators with a framework to provide guidance and feedback to students in developing sensitivity to noticing that leads to appropriate actions. Kapuscinski (2004) tells of the Greek traveller and historian Herodotus, who lived 2500 years ago. Herodotus travelled to the far corners of the earth and on his travels he was a careful observer, sensitive to details that at the time seemed minor or inconsequential, for Herodotus recognised that these may be the most essential indicators of something significant. Most importantly, Herodotus recognised that to notice what was most essential, he had to be ‘on the spot’ and this involved great travel across the then known world. Out of this travel and ability to be on the spot, Herodotus was able to recount information related to his experiences, providing rich detail. Nurses can learn from the efforts of Herodotus in relation to observation and inquiry. The slight change in behaviour or the seemingly trivial comment should be noticed and evaluated. For this to happen nurses must also travel—leave their ward offices, nursing stations and computers and be ‘on the spot’ with patients. Only then BJN will they be able to notice.
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also impact on his or her ability to notice. What the nurse brings to a situation, his or her personal values and beliefs, can have considerable influence. In a literature review of factors affecting attitudes to self-harm, McHale and Fenton (2010) highlight that a significant proportion of professionals believe that those who self-harm are able to control their behaviour. This, along with a lack of personal confidence in caring for people who self-harm, negatively impacted on the care given. Believing patients to be ‘attention-seeking’ ‘selfish’ or ‘manipulative’ will impact on what will be noticed and can blind the nurse to real distress and suffering. Failure to notice such distress can have potentially fatal consequences considering that those who repeatedly self-harm are at high risk of suicide (Owens et al, 2002; Hawton et al, 2003) with a study by Cooper et al (2005) estimating a 30-fold increase compared with the general population. Twycross (2010) provides further evidence of the impact of personal values in a literature review examining the administration of pain relief to children in hospital. Twycross found nurses’ inaccurate and outdated beliefs about pain and pain management to be one contributory factor in poor pain management. Some nurses held the assumption that pain should be expected therefore the individual child’s expression of pain went unnoticed. The review also demonstrated that nurses concentrated on the technical aspects of care, believing comforting to be a role for parents. Consequently indicators of distress and need for comfort went unnoticed. The studies by McHale and Fenton (2010) and Twycross (2010) demonstrate that the values and beliefs held by the nurse and brought to the clinical situation can significantly influence what is noticed, and frame the nursing response. Nurses must therefore make significant efforts to recognise and address personal beliefs that may limit their noticing, and adopt a lifelong-learning approach to nursing practice in order to maintain their ability to notice. The context within which noticing takes place will also have an effect on how noticing is interpreted. Without context, what is noticed can have multiple meanings. Take for example the context of an acute care mental health ward. When a man is noticed standing alone talking to the wall, it may be interpreted that what is being noticed is a
British Journal of Nursing, 2014, Vol 23, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
professional issues Conflict of interest: none Anthony D, Parboteeah S, Saleh M, Papanikolaou P (2008) Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 17:646-53 doi: 10.1111/j.1365-2702.2007.02029.x. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL (2002) Medication errors observed in 36 health care facilities. Arch Intern Med 162:1897-903 Browne M, Cook P (2011) Inappropriate trust in technology: implications for critical care nurses. Nurs Crit Care 16(2):92-8 doi: 10.1111/j.14785153.2010.00407.x. Cawson P (2002) Child Maltreatment in the Family: The Experience of a National Sample of Young People. NSPCC, London Cooper J, Kapur N, Webb R et al (2005) Suicide after deliberate self-harm; a 4 year cohort study. Am J Psychiatry 162: 297-303 Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Robert Francis QC. Final Report. http://tinyurl.com/anb9zme (accessed 6 May 2014) Dossey L (2008) Noticing. Explore (NY) 4: 225-7 doi: 10.1016/j. explore.2008.04.006 Ford S (2012) Nurses to face public scrutiny. Nurs Times 108(10): 2-3 Hawton K, Zahl D, Weatherall R (2003) Suicide following deliberate self harm. Long-term follow-up of patients who presented at a general hospital. Br J Psychiatry 182: 537-42 Health Service Ombudsman (2011) Care and compassion? Report of the
Health Service Ombudsman on ten investigations into NHS care of older people. http://tinyurl.com/q5aqhex (accessed 6 May 2014) Kalisch BJ, Landstrom MS, Williams RA (2009) Missed nursing care: Errors of omission. Nurs Outlook 57(1): 3-9 doi: 10.1016/j.outlook.2008.05.007 Kapuscinski R (2004) Herodotus and the Art of Noticing. New Perspectives Quarterly 21(1): 50-3 MacLeod M (1994) ‘It’s the little things that count’: the hidden complexity of everyday clinical nursing practice. J Clin Nurs 3: 361-8 McHale J, Fenton A (2010) Self-harm: what’s the problem? A literature review of factors affecting attitudes towards self-harm. J Psychiatr Ment Health Nurs 17: 732–40 doi: 10.1111/j.1365-2850.2010.01600.x. Mason J (2002) Researching Your Own Practice: The Discipline of Noticing. Routledge, London Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 181: 193-9 Richardson A, Crow W, Coghill E, Turnock C (2007) A comparison of sleep assessment tools by nurses and patients in critical care. J Clin Nurs 16: 1660-8 Tanner CA (2006) Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 45(6):204-11 Taylor J, Daniel B, Scott J (2012) Noticing and helping the neglected child: towards an international research agenda. Child & Family Social Work 17: 416-26 doi: 10.1111/j.1365-2206.2011.00795.x. Epub 2011. Twycross A (2010) Managing pain in children: where to from here? J Clin Nurs 19: 2090-9 doi: 10.1111/j.1365-2702.2010.03271.x. Witkin SL (2000) Noticing. Soc Work 45:101-4
Quick reference accident and emergency radiology guide About this book By Chris Harvey, Steve Allen and Declan O’Regan
The purpose of this book is to show how a systematic analysis of accident and emerg ency radiographs allows the correct diagnosis derived while minimising errors. Pocket sized book presents ato besystematic analysis of This book is aimed at accident and emerg ency doctors, surgical, accident and emergency radiographs tomedic assist inlogydiagnosis. al and radio specialist registrars and medical stude nts. This lavishly illustrated pocket sized book facilitates instant consultation when faced with an X-ray. At the start of each chapt er there is a description of the relevant anatomy It contains: followed by a quick and easy yet detail ed systematic approach to all types of X-rays likely to be encountered in the accident and emerg ency department. The book is illustrated with easy to follow line diagrams as well as fully • Descriptions ofativerelevant anatomy annotated illustr examples and is divide d into concise chapters covering a partic ular region or problem. In addition to provid ing a systematic approach to the interp retation of the X-ray, tables provide instant access to lists and there • A quick, detailed systematic approach to all are useful tips and hints in avoideasy ing mistakes.yet There is also a list of key points at the end of each chapter. types of X-rays
About the authors
• Illustrations Chris Harvey with easy to follow diagrams BSc(Hons) MBBS MRCP FRCR is Consu
ltant Radiologist, Hammersmith Hospi
tal, London UK
• TablesDecla with access to lists n O’Reginstant an
Accident and Emergency Radiology
Interpretation of plain films
BSc MBBS MRCP FRCR PhD is Senior Lectu
rer, Hammersmith Hospital, Londo
n UK • UsefulStevehints Allen and tips to avoiding mistakes BSc(Hons) MBBS MRCS FRCR is Consu
ltant Radiologist, Royal Marsden Hospi
• Key points at the end of each chapter
tal, London UK
ISBN-13: 978-1-85642-315-1; 210mm x 140mm paperback; 170 page; publication 2009; RRP £19.99
© 2014 MA Healthcare Ltd
ISBN 978-1-85642-315-1
Order your copies by visiting
www.quaybooks.co.uk www.quaybooks.co.uk or call our Hotline +44(0)1722 716 935 9
781856 423151
Chris Harvey Steve Allen Declan O’Regan
A&E RADIOLOGY.indd 2-3
British Journal of Nursing, 2014, Vol 23, No 10
30/3/09 14:31:17
517
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Abstract
Noticing is integral to the everyday practice of nurses; it is the precursor for clinical reasoning, informing judgement and the basis of care. By noticing the nurse can pre-empt possible risks or support subtle changes towards recovery. Noticing can be the activity that stimulates action before words are exchanged, pre-empting need. In this article, the art of noticing is explored in relation to nursing practice and how the failure to notice can have serious consequences for those in care. Key words: Patient assessment ■ Clinical judgment ■ Failure to notice ■ Patient-centred care ■ Compassionate care
of attentiveness shown by nursing staff, and as a result patients failed to receive basic nursing care in relation to hygiene, safety and continence needs.The Health Service Ombudsman Report (2011) also found a failure in the nursing staff ’s ability to look beyond the clinical condition of the patient and recognise or respond to emotional and social needs of the patient and his or her family. Consequently for some, their experiences of being a patient have differed markedly from the values and principles embedded within professional nursing practice. Lack of attentiveness led to failures to notice, which resulted in care that lacked compassion, sensitivity or professionalism, and caused unnecessary suffering (Health Service Ombudsman, 2011; Francis, 2013).
Professional noticing
Fiona Watson is Senior Lecturer Mental Health and Annessa Rebair is Senior Lecturer Mental Health, Faculty of Health and Life Sciences Department of Public Health and Wellbeing, Northumbria University. Accepted for publication: March 2014
514
Despite the importance of noticing, and the consequences of failure to do so, there is little contemporary literature exploring the issue. Tanner (2006) identifies noticing as the first stage of her Clinical Judgement Model, and defines it as: ‘A perceptual grasp of the situation at hand’ (Tanner, 2006: 208). For Tanner, noticing leads to interpretation of the situation, responding to that interpretation, and reviewing the outcome of the response. Where the nurse is unable to immediately make sense of what has been noticed a hypothetico-deductive reasoning process may take place where hypotheses are rejected until a reasonable interpretation, based on available information, is reached. Where the nurse has immediate recognition of what has been noticed, interpretation and response may be more intuitive. Within this model, noticing is a prerequisite for nursing action. In examining the clinical practice of ward sisters, MacLeod (1994) also recognised the importance of noticing in relation to expert nursing practice. The nurse notices significant features of the situation, understands the meaning of what has been noticed, and acts in the interests of the patient. However, for MacLeod this is not a linear process, although noticing, understanding and acting are ‘inextricably intertwined’ (MacLeod, 1994: 365). MacLeod found that in relating to their patients, the quality of this process contributed to the ward sisters’ ability to deliver goal-directed patient-centred care. Again, noticing is identified as key part of the process of nursing activity. Noticing can be seen as a more complex activity than first realised. Mason (2002) differentiates between ‘ordinary noticing’ and ‘marking’ and recommends that we must become disciplined in our noticing if we are to improve
© 2014 MA Healthcare Ltd
N
oticing may be seen to be a natural act, something we do throughout the course of our day.We notice the weather, the price of petrol, the noise of a lawn mower through an open window. Noticing involves all five of the senses and we are constantly exposed to a vast number of stimuli. It would of course be impossible for us to notice all the stimuli that surround us. Although we may feel sensitive to what is going on around us, there will be much more that we have failed to be aware of, that we do not give attention to. What does capture our attention, therefore, is selective, this is what we notice. Often what we notice is that which has most relevance to us. We will notice the weather if we are planning a picnic, we will notice the time if we have an appointment to keep. Our noticing informs our actions: if it looks like rain we may well revise our picnic plans. Failure to notice the clouds gathering could result in wet sandwiches, for what we fail to notice cannot influence our behaviour. This failure to notice has serious consequences in terms of nursing practice, and has been identified as a significant contributory factor in poor standards of nursing care. The Francis Report (2013) highlighted a number of failings at the Mid-Staffordshire NHS Foundation Trust including a largely business-oriented approach, low staffing levels and a tolerance of poor standards. These failings contributed towards an organisational culture in which there was a lack
British Journal of Nursing, 2014, Vol 23, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
professional issues professional practice. ‘Ordinary noticing’ refers to that which we can recall when prompted by someone or something and lasts for only a short time in accessible memory such as being asked if we noticed where the house keys were placed or if the light was switched off. ‘Marking’ refers to that which has more significance, and not only do we notice it, we initiate mention of it. Remarking on our noticing to others demonstrates the importance of what we noticed and makes it available for further evaluation. As Mason highlights: ‘…marking is a heightened form of noticing. Intentional marking involves a higher level of energy, of commitment, because it requires more than casual attention.’ (Mason, 2002: 33) This heightened form of noticing is essential for nursing practice if we are to assess, monitor and evaluate patient responses, inform our clinical decisions and ensure nursing care is person centred and individualised. As multi-sensate beings we notice with all of the senses. If we consider the area of vital signs, we notice the rise and fall of the chest to count respirations, we listen to notice a heartbeat, and use touch to notice a pulse. All of these require careful attention. However, salient features that indicate a change in condition may be more subtle than this. Intentional marking is required to notice the slight change in voice tone that indicates anxiety, the pressure of someone holding a hand tightly indicating a need for comfort, or the smell of body odour suggesting possible problems with self-care. Equally important are the subtle changes that indicate personal growth, hope, and a readiness to move forward. MacLeod (1994) identified how individualised these changes might be, for example when patients articulate more interest in outside events than they have previously done or demonstrate a readiness to wear false teeth. When such subtleties are noticed, nurses are able to act in a way that facilitates independent action by the patient and movement towards recovery.
© 2014 MA Healthcare Ltd
Failure to notice—the importance of noticing There are serious consequences of failure to notice in nursing. Failures to notice a drug error, the need to turn a non-ambulant patient, or increase in pain are examples where patient care will be compromised. Where patients are unable to communicate their needs, the ability to notice change becomes increasingly important. Consider the person with severe learning disability: because of cognitive impairment he or she may be unable to verbalise pain, but it is likely that subtle changes in behaviour will indicate a problem. Changes such as loss of appetite or restlessness may point to something requiring nursing action. It is only through noticing these subtle changes that appropriate care can be given. Similarly, as Cawson (2002) identifies, it is unlikely that the neglected child will seek help directly from a health professional. Nurses must therefore notice the indirect signs of neglect, or issues within the family that may adversely affect the child. Yet as Taylor et al (2012) identify, recognition of neglect remains inconsistent. If detection rates are to improve, professional noticing must be enhanced, emulating the difference between ordinary noticing and marking.
British Journal of Nursing, 2014, Vol 23, No 10
Dossey (2008: 225) suggests that ‘not noticing is a virus that is loose in modern culture’ and argues that it is our relationship with technology that has led to this demise. There is no need to notice the roads travelled as GPS will enable you to reach your destination; there is no need to go outside to check the weather as a computer screen can update you in seconds. This reliance on technology may also inhibit noticing in nursing. By exploring the levels of trust that nurses place in technology, Browne and Cook (2011) identify how inappropriate levels of trust in equipment used in the intensive care unit can lead to poor monitoring of that equipment and equipment failure may go unnoticed. Failure to notice a malfunction can then have potentially serious implications for the patient. Consider a malfunction on the alarm of a syringe driver. If the nurse is relying on the alarm to indicate a problem, failure of the machine to deliver the correct dose may go unnoticed. Of course, it can be argued that advances in technology have allowed nurses to notice much more in relation to the patient’s condition. However, the concerns raised by Browne and Cook illustrate how noticing cannot be solely ‘handed over’ to machines. Similar matters can be raised with regard to the use of clinical rating scales. Concerns regarding usefulness, sensitivity, reliability and validity of assessment tools are well documented and there is contradictory evidence on their effectiveness over clinical judgment (Richardson et al, 2007; Anthony et al, 2008). Furthermore, as such tools require nurses to assess the patient against a set range of predetermined criteria, there is a danger that only these patient behaviours will be given attention. Individual subtle, yet noteworthy, indicators may go unnoticed if not part of the listed criteria for assessment. As rating scales are now a significant feature of nursing practice, an additional question of ‘what else did you notice?’ within the criteria would be advantageous in order to accommodate a meaningful assessment.
What can be noticed? Both Tanner (2006) and MacLeod (1994) identify that the process of clinical judgment, beginning with noticing, is seen in the practice of experienced nurses. Noticing is only possible when the nurse is able to draw on his or her knowledge of patterns of recovery gained from past experience, from textbooks and formal learning, and knowledge of the particular patient’s patterns of responses. This collective knowledge then provides an expectation for this patient, and allows the nurse to notice when this is not met. Consider the patient recovering from an appendectomy. The experienced nurse will be able to draw on knowledge of other patients undergoing this surgery, common post-operative patient experiences and the usual recovery rates. When compared with the particular patient’s response, the nurse can notice if the expectations for recovery are being met. As Tanner (2006) identifies, the less experienced nurse may not have this previous knowledge or experience to provide a frame of reference. Consequently important changes in condition may go unnoticed and opportunities to act could be missed. Rating scales may arguably limit what can be noticed, but the personal position from which the nurse acts can
515
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Noticing
can be a nursing activity that is taken for granted, yet has been shown to be a complex multi-dimensional aspect of nursing practice
n Where
patients are unable to communicate their needs, the ability to notice change becomes increasingly important
n Increasing
reliance on technology has raised concerns noticing cannot be solely ‘handed over’ to machines.
n Values
and beliefs held by the nurse and brought to the clinical situation can significantly influence what is noticed, and frame the nursing response
n Improved
practice and improved outcomes for patients can only come about by improved noticing
516
patient responding to auditory hallucinations—the context of the mental health ward helps name what is being noticed. However, consider this scenario in a busy shopping centre: there you may decide that what you have noticed is a man trying to have a conversation on a mobile phone. Witkin (2000: 102) has identified how noticing is ‘subject to the sway of social processes’ in that what can be noticed is influenced by societal values, cultural norms, and sociopolitical forces. This can also be said of noticing within the context of nursing.
Improving our noticing, implications for nursing practice Noticing can be a ‘taken for granted’ nursing activity, yet has been shown to be complex multidimensional aspect of nursing practice. The importance of context should be acknowledged and nurses must be aware of what they personally bring to a clinical situation in relation to values, attitudes and experience. Noticing is essential for nursing interventions to take place, therefore, it must be a purposeful, directed activity. Improved practice and improved outcomes for patients can only come about by improved noticing. Public confidence has been rocked by events such as those at Winterbourne View and Mid Staffordshire, and nursing practice is under scrutiny (Ford, 2012). Evidence suggests a significant number of patients experience missed nursing care because of a lack of attentiveness to patient needs, poor resources and poor communication (Barker et al, 2002; Kalisch et al, 2009; McHale and Fenton, 2010). It is therefore vital that nurses make the opportunities to notice their patients, improve their sensitivity to noticing and use the opportunities provided by noticing to deliver timely interventions. Inexperienced nurses need the support of those more experienced to name what they notice and understand the relevance. Support systems such as preceptorship and clinical supervision must be embedded into the practice of clinical areas to provide this. Tanner’s (2006) Clinical Judgement Model can also provide educators with a framework to provide guidance and feedback to students in developing sensitivity to noticing that leads to appropriate actions. Kapuscinski (2004) tells of the Greek traveller and historian Herodotus, who lived 2500 years ago. Herodotus travelled to the far corners of the earth and on his travels he was a careful observer, sensitive to details that at the time seemed minor or inconsequential, for Herodotus recognised that these may be the most essential indicators of something significant. Most importantly, Herodotus recognised that to notice what was most essential, he had to be ‘on the spot’ and this involved great travel across the then known world. Out of this travel and ability to be on the spot, Herodotus was able to recount information related to his experiences, providing rich detail. Nurses can learn from the efforts of Herodotus in relation to observation and inquiry. The slight change in behaviour or the seemingly trivial comment should be noticed and evaluated. For this to happen nurses must also travel—leave their ward offices, nursing stations and computers and be ‘on the spot’ with patients. Only then BJN will they be able to notice.
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also impact on his or her ability to notice. What the nurse brings to a situation, his or her personal values and beliefs, can have considerable influence. In a literature review of factors affecting attitudes to self-harm, McHale and Fenton (2010) highlight that a significant proportion of professionals believe that those who self-harm are able to control their behaviour. This, along with a lack of personal confidence in caring for people who self-harm, negatively impacted on the care given. Believing patients to be ‘attention-seeking’ ‘selfish’ or ‘manipulative’ will impact on what will be noticed and can blind the nurse to real distress and suffering. Failure to notice such distress can have potentially fatal consequences considering that those who repeatedly self-harm are at high risk of suicide (Owens et al, 2002; Hawton et al, 2003) with a study by Cooper et al (2005) estimating a 30-fold increase compared with the general population. Twycross (2010) provides further evidence of the impact of personal values in a literature review examining the administration of pain relief to children in hospital. Twycross found nurses’ inaccurate and outdated beliefs about pain and pain management to be one contributory factor in poor pain management. Some nurses held the assumption that pain should be expected therefore the individual child’s expression of pain went unnoticed. The review also demonstrated that nurses concentrated on the technical aspects of care, believing comforting to be a role for parents. Consequently indicators of distress and need for comfort went unnoticed. The studies by McHale and Fenton (2010) and Twycross (2010) demonstrate that the values and beliefs held by the nurse and brought to the clinical situation can significantly influence what is noticed, and frame the nursing response. Nurses must therefore make significant efforts to recognise and address personal beliefs that may limit their noticing, and adopt a lifelong-learning approach to nursing practice in order to maintain their ability to notice. The context within which noticing takes place will also have an effect on how noticing is interpreted. Without context, what is noticed can have multiple meanings. Take for example the context of an acute care mental health ward. When a man is noticed standing alone talking to the wall, it may be interpreted that what is being noticed is a
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professional issues Conflict of interest: none Anthony D, Parboteeah S, Saleh M, Papanikolaou P (2008) Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 17:646-53 doi: 10.1111/j.1365-2702.2007.02029.x. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL (2002) Medication errors observed in 36 health care facilities. Arch Intern Med 162:1897-903 Browne M, Cook P (2011) Inappropriate trust in technology: implications for critical care nurses. Nurs Crit Care 16(2):92-8 doi: 10.1111/j.14785153.2010.00407.x. Cawson P (2002) Child Maltreatment in the Family: The Experience of a National Sample of Young People. NSPCC, London Cooper J, Kapur N, Webb R et al (2005) Suicide after deliberate self-harm; a 4 year cohort study. Am J Psychiatry 162: 297-303 Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Robert Francis QC. Final Report. http://tinyurl.com/anb9zme (accessed 6 May 2014) Dossey L (2008) Noticing. Explore (NY) 4: 225-7 doi: 10.1016/j. explore.2008.04.006 Ford S (2012) Nurses to face public scrutiny. Nurs Times 108(10): 2-3 Hawton K, Zahl D, Weatherall R (2003) Suicide following deliberate self harm. Long-term follow-up of patients who presented at a general hospital. Br J Psychiatry 182: 537-42 Health Service Ombudsman (2011) Care and compassion? Report of the
Health Service Ombudsman on ten investigations into NHS care of older people. http://tinyurl.com/q5aqhex (accessed 6 May 2014) Kalisch BJ, Landstrom MS, Williams RA (2009) Missed nursing care: Errors of omission. Nurs Outlook 57(1): 3-9 doi: 10.1016/j.outlook.2008.05.007 Kapuscinski R (2004) Herodotus and the Art of Noticing. New Perspectives Quarterly 21(1): 50-3 MacLeod M (1994) ‘It’s the little things that count’: the hidden complexity of everyday clinical nursing practice. J Clin Nurs 3: 361-8 McHale J, Fenton A (2010) Self-harm: what’s the problem? A literature review of factors affecting attitudes towards self-harm. J Psychiatr Ment Health Nurs 17: 732–40 doi: 10.1111/j.1365-2850.2010.01600.x. Mason J (2002) Researching Your Own Practice: The Discipline of Noticing. Routledge, London Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 181: 193-9 Richardson A, Crow W, Coghill E, Turnock C (2007) A comparison of sleep assessment tools by nurses and patients in critical care. J Clin Nurs 16: 1660-8 Tanner CA (2006) Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 45(6):204-11 Taylor J, Daniel B, Scott J (2012) Noticing and helping the neglected child: towards an international research agenda. Child & Family Social Work 17: 416-26 doi: 10.1111/j.1365-2206.2011.00795.x. Epub 2011. Twycross A (2010) Managing pain in children: where to from here? J Clin Nurs 19: 2090-9 doi: 10.1111/j.1365-2702.2010.03271.x. Witkin SL (2000) Noticing. Soc Work 45:101-4
Quick reference accident and emergency radiology guide About this book By Chris Harvey, Steve Allen and Declan O’Regan
The purpose of this book is to show how a systematic analysis of accident and emerg ency radiographs allows the correct diagnosis derived while minimising errors. Pocket sized book presents ato besystematic analysis of This book is aimed at accident and emerg ency doctors, surgical, accident and emergency radiographs tomedic assist inlogydiagnosis. al and radio specialist registrars and medical stude nts. This lavishly illustrated pocket sized book facilitates instant consultation when faced with an X-ray. At the start of each chapt er there is a description of the relevant anatomy It contains: followed by a quick and easy yet detail ed systematic approach to all types of X-rays likely to be encountered in the accident and emerg ency department. The book is illustrated with easy to follow line diagrams as well as fully • Descriptions ofativerelevant anatomy annotated illustr examples and is divide d into concise chapters covering a partic ular region or problem. In addition to provid ing a systematic approach to the interp retation of the X-ray, tables provide instant access to lists and there • A quick, detailed systematic approach to all are useful tips and hints in avoideasy ing mistakes.yet There is also a list of key points at the end of each chapter. types of X-rays
About the authors
• Illustrations Chris Harvey with easy to follow diagrams BSc(Hons) MBBS MRCP FRCR is Consu
ltant Radiologist, Hammersmith Hospi
tal, London UK
• TablesDecla with access to lists n O’Reginstant an
Accident and Emergency Radiology
Interpretation of plain films
BSc MBBS MRCP FRCR PhD is Senior Lectu
rer, Hammersmith Hospital, Londo
n UK • UsefulStevehints Allen and tips to avoiding mistakes BSc(Hons) MBBS MRCS FRCR is Consu
ltant Radiologist, Royal Marsden Hospi
• Key points at the end of each chapter
tal, London UK
ISBN-13: 978-1-85642-315-1; 210mm x 140mm paperback; 170 page; publication 2009; RRP £19.99
© 2014 MA Healthcare Ltd
ISBN 978-1-85642-315-1
Order your copies by visiting
www.quaybooks.co.uk www.quaybooks.co.uk or call our Hotline +44(0)1722 716 935 9
781856 423151
Chris Harvey Steve Allen Declan O’Regan
A&E RADIOLOGY.indd 2-3
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