The measures that can be taken to reduce the incidence of errors in nursing practice and the potential for learning from errors will now be discussed briefly. These will then be further expanded in the concluding chapter.
6.5.1 Supervision and support.
The issue of lack of supervision and support for trained staff, which were perceived as important sources of errors, must be addressed. Supervision of trained nurses has always been weak link in the management of patient care in the health service. Until very recently, it has been generally accepted that once a nurse receives her/his registration, she/he becomes immediately responsible and accountable for her/his action, and is expected to make important decisions in patient's care often without recourse to more experienced colleagues.
6.5.2 Updating of knowledge and skills.
A second measure that needs urgent consideration is how best to update nurses' knowledge and skills. Findings from this study point to a deficiency in this areas. There is a need for a stronger linkage between supervision and professional updating where needs of individual nurses can be better ascertained. This issue will be further investigated in chapter 9.
6.5.3 Addressing the causes of errors.
The majority of nurses in this study perceived external factors (e.g. stressful atmosphere, high work load, lack of support) to be important contributory causes to their error. Causal attributions are known to influence behavioural reaction to a negative event. It is therefore important to understand more fully what causal
Chapter 6: Types o f nursing errors and their perceived causes
attributions nurses use to explain causes of errors and other deficiencies in care before implementing measures to manage errors and inadequacies in care. Mitchell and Wood (1980) also argue that managers should focus less on the "outcome" (i.e. the error) and more on the causes and circumstances leading to the error.
The chapter has reported the types of errors that occur during the process of giving care to patients and the perceived causes of these errors as well as responses of nurses to them were investigated. The causes of errors were found to be multi-factorial. The results also highlighted the factors that predict changes in practice in the aftermath of an error.
The next chapter will examine the assessment of patients admitted with chest pain, more particularly to develop a questionnaire to audit the assessment of patients with chest pain. The aim is to identify potential factors in the nurses' method of work which may predispose to active failures (errors) in the assessment and care of patients with chest pain.
CHAPTER SEVEN: THE DEVELOPMENT OF AN AUDIT
QUESTIONNAIRE TO INVESTIGATE THE FREQUENCY OF
OMISSIONS IN THE ASSESSMENT OF PATIENTS WITH CHEST PAIN.
7.1 Introduction.
The previous chapter provided some evidence that errors in nursing care may occur at any of the four stages of the nursing process, errors of assessment/ planning and intervention being particularly quite common. Assessment is a crucial aspect of the nursing process involving a search for relevant and precise information about the patient's clinical condition with a view to arriving at a diagnosis, i.e. identification of the problem(s). Pagana and Pagana (1990) argue that nurses use specific assessment data to make nursing diagnoses as well as identifying collaborative problems. They define nursing diagnoses as problems that nurses can deal with through independent nursing interventions whereas collaborative problems are potential complications arising from the disease or treatments that can be prevented or resolved through collaboration with the physician. Thus, nurses not only have a responsibility to identify "nursing" problems but also signs of complications or potential complications which would need to be reported to the physician. An inadequate assessment of a patient may result in a poor care plan, and may also affect the quality and safety of nursing care.
Cardiac chest pain is a common reason for admission to hospital. The chest pain may be a symptom of cardiac ischaemia (angina) or actual blockage of the coronary artery (myocardial infarction). On admission, it is not always possible to differentiate whether the chest pain is caused by angina or myocardial infarction. It is also possible that a patient may be admitted with angina and then develop myocardial infarction. Thus, all instances of acute chest pain should be considered as serious and life threatening. Since complications in the form of dangerous arrhythmias and shock are more common during the first 48 hours
Chapter 7; Audit o f the assessment records: The development o f a questionnaire
following the initial cardiac chest pain, it is crucially important that patients are thoroughly assessed on admission and that the assessment needs to be repeated frequently as the patient's condition may change rapidly. Thus, cardiac chest pain is a good illustrative condition to depict the way nursing process should be used in the care of a patient, and the consequences of not following all the stages of the nursing process in a systematic way. For instance, failure to identify or to report/record critical changes in the condition of a patient with chest pain would mean that actions required to resolve these problems may not be taken or be delayed, hence putting the patient at risk or giving substandard care to the patient.
7.1.1 Core criteria for assessment of patients with chest pain.
When assessing patients with chest pain, nurses evaluate the patients' presenting complaint and current physiological manifestation of the condition to enable them to decide what to do (Jacavone & Dostal, 1992; Corcoran-Perry & Graves, 1990). Crow et al (1995) also argue that assessment forms the basis of decision making; knowledge and expertise are crucial in this process (Webster & Thompson, 1992). In order to assess patients effectively, the nurse needs to have specific and relevant knowledge to "zero on the most relevant symptoms" (Jacavone & Dostal, 1992). This is referred to as domain-specific knowledge, i.e. cognitive strategies required to gather and organise information (Norman et al, 1987). For example, cardiovascular nurses collect general information about the patient's condition "to get a general picture of the patient to plan the provision of care" (Corcorran-Perry & Graves, 1990). Jowett and Thompson (1995) argue that much of the nurses work with chest pain involves a high degree of medical and technical expertise, incorporating the collection and recording of clinical data and taking prompt and appropriate action. Implicit in the holistic or "gestalt" approach nurses use in the assessment of patients is the ability to recognise relevant from irrelevant cues (Baumann & Bourbonnais (1984). Assessment of patients with chest pain also needs to be repeated frequently, and Zander (1988)
has suggested that the use of a critical pathway for patients with chest pain may enable this to be carried out at different stages during the patients' stay in hospital.
Panzer et al (1991) state that the probability of significant coronary disease can be predicted on the basis of the person's age, sex and characteristic of pain. In angina, the chest pain is typically substemal. It is brought on activity and relieved by rest. The patient's age, the timing and duration of the chest pain, radiation of the chest pain, associated sweating, and history of coronary heart disease are significantly related to myocardial infarction (Goldman et al, 1982). When assessing a patient with suspected coronary heart disease, the history of the present complaint, previous medical history, current medication, general appearance, characteristic of pulse rate, BP, oedema, dyspnoea, cyanosis, ECO changes and type of pain must all be recorded (Lumley & Bouloux, 1994; Drake et al, 1997). It has also been argued that nurses can use their clinical knowledge and skills to identify those patients who have suffered a myocardial infarction, thus enabling them to receive immediate thrombolysis (Albarran & Kapeluch, 1994). In an audit of thrombolysis in the elderly patients, Hendra and Marshall (1992) found that nursing staff usefully influenced treatment, by their thorough assessment of patients with chest pain and accurate interpretation of ECO changes, identifying those patients to the doctor who had a myocardial infarction and enabling thrombolysis treatment to be started in the immediate stage following a myocardial infarction when it is expected to, be most effective.
In the first 24 hours following admissions, most potential high risk problems such as recurrent chest pain, left ventricular failure, cardiogenic shock and severe arrhythmias may be identified, which may require adjustment to the care and mobilisation plan (Jowett & Thompson, 1995). This requires accurate and continuous assessment. Raised anxiety levels are also common in coronary
Chapter 7: Audit o f the assessment records: The development o f a questionnaire
patients, particularly at the initial stage of the chest pain and admission, and this would need to be assessed so that intervention could be specifically tailored at the patient's needs (Jowett & Thompson, 1995).
The effects of lifestyle and habits on the aetiology of coronary artery disease and on rehabilitation following its diagnosis are well recognised. Thus, demographic variables, patient's knowledge about his condition, lifestyles and habits and other known risk factors such as smoking, dietary fats, obesity, stress, alcohol abuse and hypertension would need to be assessed (Jowett & Thompson, 1995; Drake et al, 1997). These assessment strategies are quite complex and not all nurses may be equipped with the necessary skills and knowledge to carry out an effective assessment of a patient.
7.1.2 Aims of the study. The study has two broad aims:
1) To develop an audit questionnaire to evaluate the quality of assessment of patients with chest pain.
2) To identify the type and fi*equency of omissions in the assessment record of patients with chest pain.
7.1.3 Operational definition.
In this study, chest pain is used as a diagnostic umbrella for angina and myocardial infarction and not just the cardiac pain.