Chapter 14: Observations
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Clinical governance
Nurses are accountable and responsible for providing optimum care for their patients (NMC [144]). The Nursing and Midwifery Council's The Code provides a framework of professional accountability for nurses and nursing associates (NMC [144]). It is essential that nursing staff objectively examine the information gathered from assessments and observations, including the patient's baseline as well as any information previously recorded (NICE [142]).
For nurses’ own professional accountability and in order to achieve safe, effective and proficient care of patients, it is essential that nurses are able to discuss (using physiological rationale) the potential cause of any changes in the patient's observations (Farenden et al. [63], Jackson [86]). Professional accountability demands more than just recording observations; it requires knowledge of underlying pathophysiology, the ability to interpret results, an understanding of clinical relevance and the ability to take appropriate action (Adam et al. [2], NICE [142]).
Observations should only be taken by staff who have undergone the appropriate training and assessment to ensure their competence in the use of the relevant equipment, the accurate recording and documentation of the observations, and the ability to interpret and act on results (MHRA [118], NICE [142]).
