Art of noticing and recognising symptoms of distress

Question 1

what is marking?

Answer 1

Intentional noticing
Involves a higher level of energy and commitment compared to casual attention (Mason, 2002)
Ordinary noticing is when you recall stuff when prompted
Marking is when we notice and deem things signif enough to mention

Question 2

what was Tanner’s clinical model (2013)?

Answer 2

The first stage of the clinical judgement model.
Noticing leads to action.
Ref to clinical practise of the Macleod sisters.
Ideal: notice signi features, understanding meaning of features in situation and act in the interest of the patient.
Process is not linear.
Order:
NOTICING=> INTERPRETATION => RESPOND TO INTERP => REVIEW OUTCOME

Question 3

When we should notice as a nurse:

Answer 3

holding/guarding body parts to indicate pain, bruising behind ears/bleeding from ears to indicate head injury, sunburn, ulcers (wet sloughy tissue), rashes and electric burns

Question 4

Senses in relation to practise

Answer 4

• Senses: sight, smell, touch, hear
• Hear: hearing a heartbeat, the Korotkoff sounds of the manual BP, bowel sounds, cries/screams, equipment
• See: see respirations
• Smell: smell ketones on breath, urine sample, infected wound, stool sample
• Touch: touching skin to feel if its cold/clammy, feel pulse, temperature
• But also: changes in tone of voice indicating fear/anxiety, visible wincing indicating pain or smell body odour suggesting self-neglect.

Question 5

what can we notice?

• nurse’s values affect practise
• importance of context

Answer 5

• Machale and Fenton (2010)

• Reviewed factors affecting attitudes to self-harm and found that a significant number of professionals believe that those self-harm are able to control their behaviour.
• Paired with a lack of personal confidence in caring for those 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 cam blind the nurse to real distress and suffering.
• This could have a fatal consequence considering that those who repeatedly self-harm are at a high risk of suicide ( Owens et al, 2002, Haw ton et al.,2003) with a 30 fold increase than the general population (Cooper et al., 2005).

• Context is very important!
-E.g. 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 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- you may decide that what you have noticed is a man trying to have a conversation on a mobile phone.

Question 6

Summarise the Rosenham 1973 experiment and its relation to noticing symptoms

Answer 6

• Basically where 8 people admitted themselves to a psychiatric hospital fabricating symptoms.
• Once admitted, they began to act normally however staff still “noticed” symptoms of psychiatric illness. It was the context of the psychiatric care that informed the noticing of the staff

Question 7

what can lead to failure to noticing?

Answer 7

• If we’re looking for something in particular then we might fail to notice things in plain view!
-Diagnosis can stop us from noticing other important changes.
-E.g. diagnosis of personality disorder may prevent us from noticing very real attempts for suicide. This links to stigma and disability. By believing we know the needs of certain disadvantaged groups we fail to notice the needs of the person within that group.
•

Question 8

what are the negative implications of failing to notice?

Answer 8

-Consider a malfunction on the alarm of a syringe driver. If a 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 patients condition, however the concerns raised by Browne and Cook illustrate how noticing cannot be solely “handed over “ to machines.

Question 9

Outline debate of whether nurses rely too much on technology:

Answer 9

• By exploring levels of trust nurses place in technology, Browne and Cook (2011) identify how inappropriate levels of trust in equipment used in ICU can lead to:
-poor monitoring of equipment
-equipment failures going unnoticed
• There is no real evidence that technology (e.g MUST, AVPU, GCS, NEWS2, Braden etc) is much more effective than clinical judgement.

• 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.