How to Quantify a Nurse’s ‘Gut Feelings’

At the start of my shift, at 7 a.m., my patient, newly admitted a few days before for a blood cancer, was talking and acting normally. By the end of my shift, 12 hours later, she had grown confused and her speech was garbled. A CT scan revealed bleeding in her brain. She was sent to intensive care and died the next day.

This was years ago, but the case still haunts me. I believe that moving faster on her treatment might have prevented her sharp decline. But the medical team didn’t share my sense of urgency, and no obvious red flags signaled a coming emergency. Without a worrisome clinical value or test result to point to, my concern alone wasn’t persuasive.

Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.

In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble.

These reactions and observations typically aren’t given the clinical weight of test results and lab values. Similarly, a large part of every nursing shift is spent on the computer documenting how patients are doing, but the content of these notes is more often than not ignored, particularly by physicians.

It doesn’t have to be this way, and it may not be for much longer. The change began in 2003, when an 87-year-old woman named Florence Rothman was hospitalized for a heart-valve replacement. She was in good health and initially did well, but experienced a slow, unnoticed deterioration in the hospital. She eventually received treatment for her symptoms, but no one investigated the cause. However, she improved and was sent home.

Four days later Ms. Rothman was seen by a home health nurse during an episode of severe breathlessness. When it happened again the same day, her family called 911, but it was too late: Her heart stopped in the emergency room, crushed by fluid surrounding it.

Ms. Rothman’s sons — Michael, an engineer, and Steven, a data scientist — wondered if their mother’s death could have been avoided, had there been a better way to track her signs of distress. Doctors later determined that she had developed a condition called cardiac tamponade, and it probably started during that first deterioration in the hospital. If her overall condition had been thoroughly examined at that point, the tamponade likely could have been detected and treated.

Together the Rothman brothers came up with the Rothman Index, a commercial product that uses data from standard electronic health records — including lab values, vital signs, cardiac rhythms and key aspects of nursing assessments — to monitor hospital patients. It tracks their status as a graph that falls into a blue, yellow or red zone, based on whether they are at low, medium or high risk of an acute event. Michael Rothman said cartoons about hospitals that show a chart with a zigzag line appended to the foot of each patients’ bed reflect the visual power of the Rothman Index.


The goal is to identify those patients who might look stable but are in fact fragile; applied correctly, it allows medical teams to intervene well before a crisis hits. This saves lives, and money. I have seen the Rothman Index in action at the Yale New Haven Health System, where special SWAT team nurses use it to coordinate care for the sickest patients.

The Rothman Index empirically validates nurses’ gut feelings by showing that nursing assessments — what nurses see and document when they “lay eyeballs” on patients — offer crucial information about patient stability. It validates what nurses have known all along: that well-honed clinical instincts matter.

Part of why I still feel haunted by my patient who suddenly took a turn for the worse and then died is because of that nagging sense I had, early on, that something was wrong. Her disease put her at risk for spontaneous bleeding, but at the start of her third day in the hospital a treatment plan still wasn’t in place. My gut told me we were moving too slowly, and I was able to push here and there. But there was nothing I could articulate as a sign of impending calamity.

I don’t have access to that patient’s records, so I can’t go back and chart her Rothman Index. But I can promise myself that in the future, I will take any sense of urgency very seriously, document my concern and speak up. There’s now solid evidence that when a nurse says she’s got a bad feeling about a patient, the entire care team needs to listen.

Theresa Brown, a hospice nurse, is the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.”


Training recommendations issued for practice nurses performing foot assessments

Calls have been made for diabetic foot assessment training to be mandatory for practice nurses after a snapshot survey in the West Midlands revealed “inadequacies”.

Diabetic foot assessments (DFAs) are increasingly being provided by practice nurses but the study across Sandwell and West Birmingham Hospitals NHS Trust revealed nurses received little training in how to do these assessments both before or after registration.

Specialist diabetes podiatrist Trupti Lakha and Dr Brian Lee, a consultant in diabetes, both from the trust, carried out the project and shared the results and issued a series of recommendations in an article published by the Nursing Times.

They said: “Diabetic foot care used to be managed by podiatrists but, in recent years, practice nurses have started undertaking diabetic foot assessments as part of diabetes care plans.”

In 2015, National Institute for Health and Care Excellence recommended that DFAs were conducted by skilled and trained health professionals in a bid to reduce the risk of diabetes-related foot complications. The survey of 46 practice nurses aimed to assess whether the practice nurses receive adequate training on diabetes and its foot-related complications.

According to the results, 76 per cent of the respondents perform DFAs as part of their job. None of the nurses had been trained in performing DFAs at undergraduate level, while 91.3 per cent had received “a little” knowledge about foot-related complications in pre-registration training and 8.7 per cent had been taught nothing.

When it came to post-graduate training, 82.6 per cent had received some in their employment, but 82.6 per cent did not feel confident how, and why, they were performing the tests involved in DFAs.

Following the findings, the authors issued a series of recommendations:

  • In the pre-registration nursing curriculum, DFA is incorporated into the existing diabetes module or a separate DFA module is created. This would equip newly qualified nurses with the knowledge, skills and confidence to meet NICE (2015) and Skills for Health (2016) recommendations, and subsequently build on their skills through CPD.
  • A diabetic foot module is developed to address the need for more specific diabetes education in foot health at undergraduate and at employment level.
  • The creation of a mandatory online training module on DFAs with graded competency levels for all practice nurses as part of their CPD.
  • Every person responsible for diabetic foot health should receive training from a suitably qualified clinician every year and have a professional assessment of their competency.

The authors said: “This survey highlights inadequate DFA training provided to student nurses and registered practice nurses. We believe that DFAs should be part of both the pre-registration nursing curriculum and of CPD for practice nurses.”

Trinidad and Tobago: No foreign nurses until Ministry hires locals

President of the TT Registered Nurses Association Idi Stewart says the association will not tolerate Government hiring Cuban nurses when 300 nurses were sitting at home awaiting employment.

Stewart said the regional health authorities would continue to be short of registered nurses as the compensation package for nurses was extremely poor.

He said nurses were being recruited by foreign nursing agencies for better packages which was the reason why the Health Ministry could not stop the exodus. Stuart said these agencies were asking for at least two years’ experience so the seasoned, experienced nurses were leaving, with only junior nurses remaining.

Stewart said shortage of experienced nurses led to significant patient morbidity and mortality rate because patients were not getting quality health care.

Rheumatology nurses require better coordination with ophthalmologists

When filling prescriptions for hydroxychloroquine for rheumatoid arthritis, systemic lupus erythematosus or juvenile idiopathic arthritis, rheumatology nurses should coordinate with their patients’ ophthalmologists and be direct about the information they need regarding possible eye-related adverse effects, according to presenters at the Rheumatology Nurses Society Annual Conference.

“Ophthalmology, especially in the past 2 years, has called on rheumatology to say we are giving too much hydroxychloroquine,” Denise Smith-Hauser, NP-C, of the Cleveland Clinic, told attendees. “So, typically we would say, if you weigh less than 100 lb, you get one pill per day, and if you are more than 100 lb, you get two pills per day. There is a formula to calculate the dose, and that’s what ophthalmology does. The concern is that ophthalmologists need to do the visual field exam — it needs to say that there is no [hydroxychloroquine] toxicity.”


One way to strongly encourage patients to see an ophthalmologist for an eye exam, according to Smith-Hauser, is to fill their prescription for only 3 months — to provide enough time for the patient to seek out and receive the exam — and then not at all until the eye exam is completed.

“Once the patient does get the eye exam, I fill the prescription for a year,” she added. “I’m not mean, but with these medications, I will only fill it for 3 months, because if you fill it for a year before receiving the tests you need, you will never see that patient again. You will never have blood tests again, when they should be getting this test regularly.”


Vickie L. Sayles, BSN, CRNI, RN-BC, of the Cleveland Clinic Foundation, also added during the discussion that rheumatology nurses should be clear with their patients’ ophthalmologists that they require regular visual field tests, typically once per year.

“You also should educate the patient on what they need from their physician or ophthalmologist — it is a great opportunity to educate them,” Sayles said. “You need to ask the patient, ‘Did they make you chase the light around? That is what you need for the field test.’ A lot of the time, the patient does not know what to ask, but by being direct with both the ophthalmologist and the patient, we can improve that.” – by Jason Laday

Sayles SL. Current treatment guidelines and therapies. Presented at: Rheumatology Nurses Society Annual Conference; Aug. 8-11, 2018; Fort Worth, Texas.

Disclosure: Smith-Hauser reports speaking fees from AbbVie, Amgen, Novartis and BMS, as well as consulting fees from AbbVie, Amgen and Novartis. Sayles reports speaking fees from Kevzara and Sanofi Genzyme.

The heartwarming moment nurses teach young cancer patient the Kiki dance

This is the heartwarming moment nurses put a huge smile on a young cancer patient’s face by teaching her a brand new dance.

Louise Goulden is currently undergoing treatment for leukaemia at the Royal Manchester Children’s Hospital.

8 year old Louise Goulden
Louise Goulden is undergoing chemotherapy. Credit: MEN Media

The eight-year-old was diagnosed with the disease two years ago, and spent four-and-a-half months on Ward 84 before going into remission.

But around seven weeks ago, Louise, who lives in Royton, relapsed and ended up back in hospital.

Last week, during her second round of five-day chemotherapy, the youngster was surprised in her room by a group of nurses who asked her if she wanted to learn the ‘Kiki’ dance:

The routine – which is to rapper Drake’s hit single, In My Feelings – was captured on video by her parents and shared on social media.

It has already had hundreds of shares and thousands of views.

Louise’s mum Janice Thompson praised the staff at RMCH for going above and beyond for her daughter every single day.

kiki dance
The Kiki dance has swept social media. Credit: MEN Media

Louise loves singing and dancing and was so happy when she got to do it

The people working at RMCH are truly amazing. The compassion and dedication of the staff just inspires me, they take it to a whole new level.

– Janice Thompson, mother

Louise’s mum added that the hospital staff make her daughter smile “every day”.

Her family hope she will be able to go home for several weeks before undergoing a bone marrow transplant in September.


Indira Gandhi National Open University (IGNOU) Begins Training of Nurses, Ayurveda practitioners

Bridge programme to begin in five districts today

The Indira Gandhi National Open University (IGNOU) has introduced a bridge programme in ‘community health and nursing’, in collaboration with the Union Ministry of Health and Family Welfare.

The programme is aimed at improving knowledge, skills and competencies of working nurses, RNRM and Ayurveda practitioners to enable them to serve as mid-level providers (MLPS) for strengthening the primary healthcare services across the country.

This six-month programme is offered to the working Nurses and the RNRMs who are sponsored by the State governments with the support of Ministry of Health and Family Welfare. The regional centre of IGNOU in Visakhapatnam has set up five study centres for this programme in the five north coastal districts in its jurisdiction.

The Directorate of Public Health and Family Welfare and State government have already selected the candidates who have been allotted to their respective study centres. The classes will begin from Friday.

The students shall be provided intensive practical training by posting them at district hospitals, community health centres, PHCs, sub-centres and urban PHCs for 50 days, covering different departments.

Study centres

The study centres include Government College of Nursing in Srikakulam, District Hospital in Vizianagaram, Government College of Nursing in Visakhapatnam, Government College of Nursing at Kakinada and District Hospital at Eluru.

On completion of the bridge programme, the participants will be appointed as mid-level providers by the State government at PHCs.


Why Hospital Architects Need to talk to Nurses

Many of us pay close attention to how our taxes are spent, and how well governments invest in infrastructure projects such as roads, schools and hospitals. Value for money is key. Yet horror stories of waste, lateness and poor quality are common.

To develop and finance public services and infrastructure, governments around the world (but especially in Europe) have become increasingly keen on private sector involvement. These cross-sector collaborations can help provide value for money for taxpayers – but they are also at risk of wasting it.

In health care, collaborations between public and private partners have a direct impact on society. This is why it is important for health care professionals like doctors and nurses to talk directly to the designers and builders of a new hospital. It ensures that these projects not only deliver economic value for the private companies building the hospital – but also social value for the doctors, nurses and patients who will use the hospital for decades to come.

For instance, in one recently built British hospital, medical staff were able to bring valuable insight to the design process. A visit by some of the hospital’s senior nurses to a children’s hospital in the US led to the replication of a lighting design on the ceiling of a children’s ward so that it mimicked a starry night sky. As one of the nurses explained to me afterwards:

It might sound like a small change, but it provides a much more homely surrounding than the normal NHS lighting. This is important for our young patients [providing a] less scary, hospital experience which positively impacts on the healing process. […] It creates a much nicer environment in which our little patients can recover.

In another hospital, input from senior nurses helped to establish a ward design that most suited their professional needs – right down to the placement of plumbing. This saved large amounts of money that might have been spent on undoing unnecessary building work had the nurses not been consulted.

As one project manager of the construction company told me: “Thanks to [the senior nurses’] input and telling us how they intend to use wards, we changed the ward layout, such as the position of sinks. This may seem to be a minor issue, but may have a huge impact when caring for a patient.”

To see how social value can be best achieved through cross-sector collaborations we looked into the key building blocks that go beyond a mere focus on contracts.

An organisations’ prior experience of cross sector collaboration and a supportive climate is vital in creating social value. It also helps to have had some exposure to previous projects (good and bad). But a major ingredient is the individual employees in both public and private sector organisations.

We need a starry sky ceiling right there. Shutterstock

Building mutual knowledge and aligning goals between doctors, nurses and design and construction professionals is key, as public and private sector employees often have different objectives for projects (making a profit vs healing patients). A shared understanding can come through listening to and appreciating the other parties’ professional language and the expertise that language expresses.

Joint expertise

Beyond an understanding of the other parties’ expertise, practical matters of shared goals and jointly developed timelines are necessary. Coordinating efforts between the two sectors needs to take priority at the outset – rather than emphasising project speed and completion.

To encourage these positive outcomes, the key people need to meet frequently to exchange information, address problems and discuss plans. Without this kind of coordination and collaboration, it will be impossible to make the most of both sides’ specialist knowledge.

So when it comes to hospitals and clinics, the private company needs to actively seek the involvement of doctors and nurses in the design and construction phases. Similarly, doctors and nurses should not be threatened by private companies, but instead seek to become actively engaged. This will help drive creative design innovations such as the “night sky” ceiling in the children’s ward.

It takes time and resources, but this kind of collaboration and coordination between public and private sectors provides an opportunity to increase value – both economic and social. And that’s something that not only benefits construction companies and health care professionals – but patients and taxpayers, too.


At last Zambia General Nursing and Midwifery Council Releases June/July 2018 Examination Results

The General Nursing Council of Zambia has released the June/July 2018 Examination result according to a post released today by the board on her facebook page

As alluded to yesterday, the General Nursing Council of Zambia (GNCZ) released examination results for June/July 2018 GNCZ Qualifying and licensure examinations today. Therefore, interested parties are advised to check for results with their respective nursing and midwifery training colleges and universities, and congratulations to all successful candidates.

In the same vein, registration of newly qualified nursing and midwifery practitioners will commence on thursday 16th August 2018. Kindly check for the comprehensive GNCZ registration schedule and requirements with your respective nursing and midwifery colleges and universities tomorrow afternoon.

Once again Congratulations.

Issued by

Thom D. Yung’ana







Congratulations to the successful Nurses


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