sent approximately 54 percent of all U.S. health care workers (e.g., physicians, nurses, dentists, allied health professionals, technicians and technologists, and other health care assistants) (Bureau of Labor Statistics, undated). Registered nurses (RNs) alone constitute approximately 23 percent of the entire health care workforce. These 2.2 million RNs, along with 683,800 licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) and 2.3 million nursing aides, orderlies, attendants, and personal and home care aides, provide health care to individuals in virtually all locations in which health care is delivered—hospitals; long-term care facilities; ambulatory care settings, such as clinics or physicians’ offices; and other settings, including the private homes of individuals, schools, and employee workplaces. In most of these settings, the nurse or NA is the health care provider who has the greatest amount of direct contact with patients. In U.S. hospitals, approximately one of every four hospital employees is a licensed nurse (AHA, 2002). In nursing homes, the majority of patient care is provided by NAs, under the supervision of a licensed nurse. Efforts to detect and remedy error-producing defects in health care systems will be severely constrained without the assistance of the eyes, ears, cognitive powers, and interventions of over half the health care workforce.
A primary activity performed by nursing staff in all hospitals, long-term care facilities, and ambulatory settings is ongoing patient surveillance (sometimes referred to as patient “assessment,” “evaluation,” or “monitoring”)—an important mechanism for the detection of errors and the prevention of adverse events. If a patient’s status begins to decline, the decline will be detectable though the nurse’s observation of changes in the patient’s physical or cognitive status. Performance of this patient monitoring requires great attention, knowledge, and responsiveness on the part of the nurse.
Patient assessment is the basis for all licensed nursing care (ANA, 1998). Indeed, ongoing patient assessment and evaluation are the two guideposts of licensed nursing care between which hands-on nursing treatments, patient education, and care planning are delivered. In acute care hospitals, this bedside monitoring or surveillance of the condition of patients prior to, during, and following medical procedures such as surgery, initiation of new medications, or a course of medical therapy typically includes, for example, monitoring patients’ vital signs (temperature, heart rate and rhythm, breathing rate and character, blood pressure), airway, risk/presence of infection, fluid intake and output, electrolytes, and pain (Bulechek et al., 1994). In intensive care units, the monitoring is more frequent, invasive, and technologically complex, as illustrated in Box 1-1.