I would argue that nurses work with a never-ending litany of contextually imagined yellow and red flags of possible future , potentially likely and actual and immediate threats to patient safety on a minute-byminute basis . They manage this through “ cognitive stacking ” – continually re-prioritizing their mental list of tasks and worries as their shifts progress .” hygiene practices and therefore infection rates . ( See : https :// qualitysafety . bmj . com / content / 31 / 4 / 322 and https :// www . sciencedirect . com / science / article / pii / S0195670123000725 ) Clinicians are accustomed to working in very messy settings where the group norms determine the practices , as well as making their own clinical decisions – that ’ s what they are paid to do , as registered health professionals . This is why some data and monitoring , as well as healthy working relationships , are crucial to be able to assess and interpret practices in an ongoing manner . Again , the magnet hospital approach supports this transparency and openness to practice development and change . ( See : https :// www . nursingworld . org / organizationalprograms / magnet / magnet-model / and https :// www . ncbi . nlm . nih . gov / pmc / articles / PMC4431919 /)
HHM This is also a key observation from your paper : “ Activities are prioritized in relation to the perceived impact of non-performance ” — are nurses taking it upon themselves to reject evidence-based practice because they think there is negligible impact on patients ? Isn ’ t this a potential undoing of any patient safety-first nursing care ?
KB : I think that is an extreme interpretation , regarding “ rejecting evidence-based practice .” The point of evidence-based practice is for the clinician to make interpretations of the evidence , and apply them in relation to the current situation , and their knowledge of the patient . I often tell my students to imagine they have one hand on the patient , one hand on their pile of textbooks and journals , and they themselves are the body in the middle with the eyes and ears to interpret the situation and try to make the best possible decision . I would argue that nurses work with a never-ending litany of contextually imagined yellow and red flags of possible future , potentially likely and actual and immediate threats to patient safety on a minute-by-minute basis . They manage this through “ cognitive stacking ” – continually re-prioritizing their mental list of tasks and worries as their shifts progress ( See : https :// journals . lww . com / jonajournal / Abstract / 2005 / 07000 / Understanding _ the _ Cognitive _ Work _ of _ Nursing _ in _ the . 4 . aspx ). It is exhausting , exacting and delicate work . They use their knowledge of their patients , biology , pathophysiology , pharmacology , hospital systems , hospital policies , hospital personalities and time and other resources to make these decisions on a minute-by-minute basis . An activity that will alleviate an immediate and actual threat to safety ( and , of course , patient comfort ) may need to take priority to a possible threat with a lower likelihood of risk outcome . It is a never-ending and constantly adapting risk matrix that the nurse conducts without much support . It has been argued that nurses would benefit from “ clinical supervision ”
– the approach that psychologists use to reflect on the complexities of their role in working patients and use a mentor to help reflect on decision making and allow space for growth and adaptation . This is being taken up in a number of jurisdictions . This reflective practice would offer an opportunity to review practices and policies with a peer . Arguably this used to often happen in handovers , however handovers are now often done by tape recorder or at the bedside and / or with the computer , potentially limiting the reflecting learning space that they provided . In the style of magazine questionnaires , I have compiled some examples of the kinds of impossible decisions nurses deal with on a minute-by-minute basis :
● You have 10 minutes left in your shift . Do you : a . Check whether Mary ’ s pain relief has worked or if she needs another 5mg of endone . b . Check the emergency trolley and make sure all equipment is present and sterile if appropriate in case of a life-threatening code next shift . c . Go home early . You ’ ve already done two hours unpaid overtime this week .
● You are interrupted mid-task . Do you : a . Continue your task of educating Mr . Aliia regarding his colostomy bag , including infection control practices and emotional support for coming to terms with his new body b . Stop your current task , and attend to Mavis the patient in the next room who you have been told is nauseous and about to vomit c . Depends on whether you like Mr . Aliia or Mavis better
● You are set up to do a catheter insertion on Maria . You realize you may have touched the tip of the sterile catheter with your sterile glove but you ’ re not sure . Do you : a . Stop the procedure , and set it all up again , because the risk of infection is present and you would like to save Maria from that risk b . Continue the procedure , because you ’ re not certain you did touch it so the risk is small , and also because Maria is confused with delirium and also doesn ’ t speak English as a first language , so you think you would do more harm by lengthening the procedure , and also because relieving her distended bladder with the catheter may ease her delirium , which is a higher and more immediate risk than the risk of infection c . Call out to see if another nurse can help you make the decision
Reference :
Bail K , et al . Missed infection control care and healthcare-associated infections : A qualitative study . Collegian . Vol . 28 , Issue 4 . Pages 393-399 . August 2021 . www . healthcarehygienemagazine . com • august 2023
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