Caring is a central element of nursing practice (Potter & Perry, 2001). Leininger (2001) and Watson (1994) developed nursing theories that espouse the primacy of caring in nursing. Benner, Tanner and Chesla (1996) also affirmed that caring is a primary function of the nurse in their study of expertise in nursing. The American Nurses Association (ANA) (2003) stated that an essential feature of professional nursing is the provision of a caring relationship that facilitates health and healing. Yet nursing, as one of a multitude of health care professions, does not have a monopoly on caring. Physicians, pharmacists, physical therapists, and occupational therapists all have references to caring in their literature (Fjortoft & Zgarrick, 2003; McLeod, 2003; Ries, 2003; Sachs & Labovitz, 1994; Stiller, 2000; Wright & Carrese, 2001; Wright-St. Clair, 2001). What, then, makes caring by the nurse different from care received from other health professionals? Valentine (1997) has suggested that caring is a multidimensional concept that consists of attributes of the nurse including professional knowledge, vigilance, and therapeutic communication. Knowledge and communication are required elements in the practice of all health professionals. We submit, therefore, that professional vigilance is the essence of caring in nursing, and, as such, defines the key role of nursing within the health care system.

Vigilance has been defined as "a state of watchful attention, of maximal physiological and psychological readiness to act and of having the ability to detect and react to danger" (Hirter & Van Nest, 1995, p. 96). Drawing upon and adding to the precision of this definition, professional nursing vigilance may be defined as a state of scientifically, intellectually, and experientially grounded:

• Attention to and identification of clinically significant observations/signals/cues;
• Calculation of risk inherent in nursing practice situations; and
• Readiness to act appropriately and efficiently to minimize risks and to respond to threats.

Professional nursing vigilance is based on nursing knowledge and is prerequisite for informed nursing action. Vigilance is the backdrop against which professional nursing activities are performed. It is the sustained attention, the perpetual scanning, that must always be present as nurses practice. Vigilance is not the action of taking the vital signs, dressing the wound, or starting the IV. It is the "watch-ful-ness" that is always a part of the nurse’s thinking process as activities such as these are completed. The purposes of this article are to provide support for the idea that vigilance constitutes the essence of nursing practice and to suggest an alteration in nursing terminology that will reflect the fundamental nature of vigilance in nursing.

Historical Support

Nightingale (1860/1969) recognized the importance of vigilance in nursing. In Notes on Nursing, she wrote:

The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are evidence of neglect—and of what kind of neglect. All this is what ought to make part, and an essential part, of the training of every nurse (p. 105).

Nurse scholars have repeatedly acknowledged that observation is a vital element in the practice of nursing. In their 1939 text, The Principles and Practice of Nursing, Harmer and Henderson devoted an entire chapter to the observation of the patient. They stated:

The habit of observation is one of the most (if not the most) essential qualities in nursing. ...The responsibility [to observe] is distinctly that of the nurse, for during the greater part of the time she is the only one present to care for the patient and thus to observe and report. Without close observation...a nurse can not carry out the first essentials in nursing—those measures not prescribed by the doctor but dictated by the underlying principles and methods of nursing itself (p. 219).

In another early text, McClain (1950) proposed, "in observing the nurse must know what she is looking for and, to a certain extent, what she is likely to find. Observation is based on knowledge, interest and attention" (p. 51).

The appreciation of this ability of nurses to recognize important cues in their patients continued into the era of the grand nursing theories in the 1970s. Carper (1978) identified the ability to perceive as part of the aesthetic pattern of knowing in nursing. She defined perception as the "active gathering together of details and scattered particulars into an experienced whole for the purpose of seeing what is there" (p. 17). King (1971) and Orem (1985), among others, affirmed the importance of perception as an important nursing ability.

Theoretical Support

Current professional and lay literature is replete with stories of errors in the health care system and with issues that revolve around patient safety. In 1999, the Institute of Medicine concluded that at least 44,000, and perhaps as many as 98,000, people die in hospitals each year as a result of preventable errors (p. 1). This report received an enormous amount of attention in both lay and professional nursing press. Clearly, the public and the profession are concerned with our ability to be vigilant caregivers.

Curtin (2003) presented an integrated analysis of nurse staffing and its effect on patient outcomes. She concluded that nursing staffing had a definite and measurable impact on patient outcomes, medical errors, length of stay, and patient mortality. Why does having an adequate number of nurses at the bedside result in these improved outcomes for patients? We submit that appropriate staffing allows nurses to maximize their practice of professional vigilance for their assigned patients. There are limits to the human ability to sustain vigilance. To prevent airline disasters, air traffic controllers are allowed to accept responsibility for a limited number of planes. Likewise, nurses can only be reasonably expected to "watch out" for a certain number of patients. The optimal practice of professional vigilance is critical to ensuring the safety of patients in health care settings. The question is: How is professional nursing vigilance practiced to maximize intended patient outcomes and minimize adverse outcomes?

Exploring the concept of vigilance in psychology can suggest an answer to this question. Loeb and Alluisi (1984) conceptualized vigilance within the theory of signal detection. According to this theory, vigilance is the search for signals. Signals are events that the individual determines to be indicators of something significant and always occur against a background of "noise." The challenge for the individual is to correctly determine if the signal is indeed significant or merely a manifestation of background noise. For instance, is that ringing sound really the telephone (a signal) or part of the background noise (television, radio, stereo) that is typical of the everyday hubbub in a home?

The mental processes that individuals use to differentiate signals from noise have been studied extensively in psychology and, to a lesser extent, in nursing. In a grounded theory study of women with migraine headaches, vigilance was conceptualized as "the art of watching out," predicated on a particularized knowledge of the condition in each respondent (Meyer, 2002). Vigilance resulted in a decision to take, or not to take, an action. Vigilance was not seen, felt, or heard by others. It was only through the action that resulted from "watching out" that others could infer that vigilance had occurred. The elements of vigilance derived in the migraine study have been adapted for relevance in nursing: attaching meaning to what is, anticipating what might be, calculating risks, readiness to act, and monitoring the results of interventions (Figure ).

Attaching meaning to what is. The first component of vigilance Meyer (2002) defined was attaching meaning to what is. Attaching meaning is a basic element of nursing practice. When a nurse walks into a patient’s room, he or she begins to scan the patient and the environment for signals. Questions immediately arise: "What is going on here?" "What does it mean?" "Is it significant?" Assessments follow the questions to determine the "what is." Nurses spend much of their time with patients gathering data: taking vital signs; auscultating heart and lung sounds; observing performance of activities of daily living; and ascertaining capabilities. Gathering and recording data is only one part of the nurse’s responsibility in patient assessment. To complete an assessment, the nurse must attach nursing meaning to what is heard, seen, and felt (Orem,2001). Attaching meaning to observations allows the nurse to make inferences about what observations require intervention and what observations are "within normal limits." Attaching meaning allows the nurse to differentiate signals from noise.

Nurses attach meaning to "what is" in the context of their knowledge, experience, and education. This is the pattern recognition phenomenon described by Benner (1984). To recognize patterns, nurses must not only have abstract knowledge about the phenomenon at hand, they must also have developed the intellectual capacity to contextualize and to adjust what is known to the particular case (Paul & Heaslip,1995). The expert nurse who detects a slight change in the breathing pattern of a patient, and knows that the change requires immediate intervention, is attaching meaning to what is. This is why educated, experienced, professional nurses are valuable at the bedside of the patient. Their ability to perceive signals and to determine the relevance of those signals cannot be matched by unlicensed personnel taught only to collect and record health data at prescibed intervals. Such personnel might be able to gather data accurately, but they do not have the educational preparation and scientific background needed to attach meaning to those data.

In brief, to recognize patterns is to attach meaning to the assessment of the "what is." The attachment of meaning leads to making nursing diagnostic statements (Figure). Stating the diagnosis is not professional vigilance; it is an informed action that results from that vigilance. It is only through that action, however, that others see that vigilance has occurred.

Anticipating "what might be." While assigning meaning to "what is" actually happening with a patient is an essential facet of nursing practice, the ability to anticipate and observe for "what might happen" is another critical component of professional vigilance. Consider the case of Mr. P., an 86-year-old patient with a history of atrial fibrillation who was being maintained on warfarin sodium at home. Mr. P. is immediately post-operative following an emergency hip pinning. His nurse decides to take vital signs more frequently than ordered, repeatedly checks his dressing and assesses his mental status with every encounter. Mr. P.’s nurse is attaching meaning to "what is" but is also asking, "What might happen here?" "How will I know?" This nurse knows that Mr. P. is at significant risk for hemorrhage and is watching out for what might happen; for what might be called the "need for rescue."

The term "failure to rescue" has recently received attention in the nursing literature (Clarke & Aiken, 2003). Failure to rescue is defined as a clinician’s inability to save a hospitalized patient’s life in the event of a complication (a condition not present on admission, such as hemorrhaging in the case of Mr. P.) (Clarke & Aiken, p. 43). To "rescue" a patient appropriately, the nurse must be able to anticipate when complications are likely to occur and rapidly recognize cues that indicate that problems are beginning. Surveillance, involving frequent assessments, is required, as is the ability to analyze information and react to the implications of that analysis in a timely manner. Reacting to information and intervening appropriately are the result of professional nursing vigilance and will often include both independent nursing action and mobilization of other members of the health care team.

Calculating the risk. Understanding the risk inherent in any course of action is another aspect of vigilance (Figure). Rarely in nursing practice is an intervention totally risk free. The frail, emaciated patient for whom the nurse elevates the head of the bed to facilitate breathing has an increased risk of developing a pressure ulcer on his coccyx due to shearing and friction. Lowering the head of his bed may reduce his pressure ulcer risk, but will increase the work of breathing. Administering opioids for pain to bedridden patients may increase the risk of pneumonia by depressing respirations, but may reduce the risk of pneumonia by enhancing mobility and permitting nursing-prescribed deep breathing and coughing. Allowing the woman with Alzheimer’s disease to wander in a restricted area may increase her risk of injury, but decrease her agitation. Helping the adolescent with diabetes configure his meal plan to incorporate a fast food meal eaten with friends may have some short-term risk, but may result in better overall diet adherence. Nurses become adept at seeing and calculating the risk inherent in these and other courses of action, and juggling that risk to maximize intended, and minimize unintended, patient outcomes. This ability to weigh and minimize risk is a characteristic of professional vigilance.

Staying ready to act. Readiness to act is another key component of the nurse’s ability to "watch out" (Figure). Every Kelly clamp taped to the bed of the patient with a chest tube and every suction machine on standby at the bedside of a patient being fed for the first time following a stroke are testaments to a nurse’s vigilance. Public health nurses who go out into the community with their well-stocked "nursing bags" are staying ready to act, as are nurses who can be counted on to have tape or scissors or an alcohol wipe in their lab coat pockets. This readiness is about more than mere convenience. It is born of a knowledge base that allows the nurse to know what things might be required in what situations, and to make sure that intervention can be accomplished quickly when necessary.

Monitoring results/outcomes. The final component of vigilance Meyer (2002) uncovered was monitoring results. This is fundamental to nursing practice. Nurses project and monitor the achievement of outcomes on an ongoing basis. Because nurses are often the only health care professionals at the bedside of hospitalized patients for 24 hours a day, they are charged with monitoring the results of not only their own interventions, but of the interventions of others. The physician will ask about the patient’s response to furosemide administered last evening and the physical therapist will ask about whether or not there has been any improvement in the patient’s ability to transfer from bed to chair. By monitoring the effectiveness of actions, and making judgments about what interventions work, or don’t work, in specific situations, nurses continually adjust patient care and build the multifaceted knowledge base that Benner (1984) described as a characteristic of expertise in nursing.

Figure. Professional Nursing Vigilance

Vigilance and Nursing Terminology

Vigilance is the mental work of nursing; it is a prerequisite to informed nursing action. Because this mental work is the essence of nursing and one of the nurse’s primary functions in the health care system, it should be described and included in our nursing terminology. Samuel Johnson, an influential English lexicographer of the 18th century, said, "Language is the dress of thought" (1905/1967,p. 58). The advancement of the profession of nursing requires that we name those things we spend so much time and effort thinking about. Beginning nursing students often hear, "If you didn’t chart it, you didn’t do it." This maxim may be hyperbolic, but it indicates that the failure to communicate the nurse’s work renders it invisible to others. As nursing documentation becomes increasingly computerized, it will become vital to enter terms that represent the mental work of nursing to convey nursing’s contribution to patient care, aggregate and analyze nursing data, and facilitate payment for nursing activity. It has been relatively easy for nurses to document what they do. Nurses routinely chart the medications they have given, the treatments they have done or the teaching they have initiated. Unfortunately, it has not always been as easy for nurses to attach a label to what they think and to communicate the judgments that result from the mental work of professional vigilance.

Diagnosis of phenomena is an essential step in the application of theory to explain a condition and to determine actions to be taken for treatment. In the 1980 Social Policy Statement on nursing, the ANA stated that the phenomena for which nurses were responsible were brought into focus by naming or diagnosing them (ANA, 2003, p.42). The 2003 Social Policy Statement identified the use of judgment and critical thinking in the application of scientific knowledge to the process of diagnosis as one of the essential features of professional nursing (ANA, p.5). In 41 of the 50 states and the District of Columbia, the nurse’s responsibility to diagnose is delineated in the nurse practice act (Lavin, Avant, Warren, Craft-Rosenberg, & Braden, 2003). Nursing diagnoses reflect the clinical judgments made by professional nurses.

North American Nursing Diagnosis Association (NANDA) International (2003) defined a nursing diagnosis as a clinical judgment about individual, family and community responses to actual or potential health problems or life processes (p. 263). Vigilance is the basic skill that nurses need to make these judgments. NANDA International stated that a nursing diagnosis must be one for which the nurse can select nursing interventions and be held accountable for the outcome. This type of nursing diagnosis is familiar to most nurses. Labels such as "ineffective airway clearance," "activity intolerance," "self-care deficit," and "risk for falls" are NANDA-approved diagnoses and are used in many standardized documentation systems. These labels could be considered central nursing diagnoses because they reflect independent nursing practice.

Nurses have long known that not all phenomena for which they are concerned are well represented by current nursing diagnosis terminology (Carpenito, 2000). Nurses who observe the patient with brittle diabetes for hypoglycemia or hyperglycemia, the newly post-operative hip pinning patient for hemorrhage, or the post-operative thyroidectomy patient for hypocalcemia are certainly practicing the vigilance that is the essence of nursing. However, current diagnostic language does not include appropriate terms to represent the identification of these risks, even though this type of vigilance is fundamental to nursing. We propose that a second type of nursing diagnoses is needed, one which is called surveillance diagnoses.

A surveillance diagnosis, like a central diagnosis, is a clinical judgment about individual, family, and community responses to actual or potential health problems or life processes. For surveillance diagnoses, the nurse is accountable for professional vigilance and the recognition (or diagnosis) of the problem, but is not solely accountable for the interventions or outcomes. Rather than selecting interventions independently, the nurse participates, interprofessionally, in the ongoing management of the problem. Surveillance diagnoses are risk diagnoses, for example: risk for hypoglycemia; risk for hemorrhage; risk for increased intracranial pressure; risk for hypokalemia; and risk for deep vein thrombosis.

A search of the nursing literature demonstrated that diagnoses of this type are of interest and concern to nurses. We conducted a search of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from 1982 through 2005 via the Ovid database on March 23, 2005. We entered the term hypoglycemia and limited the retrieval to nursing journals; 466 articles were found. When we limited the search to diagnosis, prevention and control, risk factors, and symptoms of hypoglycemia, 183 articles were retrieved --- more than one-third of the total. Clearly, recognizing and controlling risk for conditions such as hypoglycemia is an integral part of nursing practice. A classification of surveillance diagnoses will enable nurses to name this important work and claim it as a nursing responsibility.

Often, central and surveillance diagnoses exist in tandem. For example, an older adult patient with poor eyesight who is receiving medication for hypertension has a surveillance diagnosis of "risk for orthostasis." For this diagnosis, the nurse would be monitoring changes in lying, sitting, and standing blood pressures and consulting with the primary care provider and pharmacist about altering the medication regimen if the problem becomes severe. This patient also has a central diagnosis of "risk for falls related to orthostasis and poor eyesight." As with the surveillance diagnosis, this diagnosis calls for clinical nursing judgment, but it also calls for independent nursing action to treat with teaching, safety measures, and more frequent observation. Even though these are both risk diagnoses, there is an important difference. The nurse shares responsibility for the management or prevention of the orthostasis, but is independently accountable for preventing falls in this patient.

Conclusion

Vigilance is the essence of caring in nursing and nursing terminology should adequately reflect this fundamental aspect of our work. Florence Nightingale’s soldier patients acknowledged her vigilant presence by referring to her as "the lady with the lamp" when she walked among the cots at Scutari. Today, nurses are similarly engaged in watching out for their patients to promote their recovery and ensure their safety. Vigilance in nursing requires both caring and expertise (Cullens, 1999). We must be able to name this vigilance, describe it, and communicate it, or risk having this unique aspect of our work be invisible to others. Nursing terminology, as the external manifestation of professional thinking or the "dress of our thoughts," must be revised to encompass all the mental work that nurses do, not just those aspects that reflect independent nursing practice. Both central and surveillance diagnoses have a place in nursing language.

Nurse caring is actualized through vigilance. As Nightingale (1860/1969) said, "For it may be safely said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion" (p. 112). It is time to make sure that our nursing terminology represents both our caring and the primacy of our professional vigilance.

Authors

Geralyn Meyer, PhD, RN
E-mail: meyerga@slu.edu

Geralyn Meyer, PhD, RN is an Assistant Professor at Saint Louis University School of Nursing. Dr. Meyer is the coordinator of the Accelerated Option of the Baccalaureate Program in Nursing at Saint Louis University. As an educator, she has long been interested in the clinical decision making process of nurses, particularly new graduates. She is an elected member of the Diagnostic Review Committee of NANDA International and has a continuing interest in the development and refinement of standardized nursing terminology.

Mary Ann Lavin, ScD, RN, FAAN
E-mail: lavinma@slu.edu

Mary Ann Lavin, ScD, RN, APRN, BC, FAAN, is an Associate Professor at St. Louis University School of Nursing. In 1973, Kristine Gebbie and she called the First National Conference on the Classification of Nursing Diagnosis. Dr. Lavin is a member of NANDA and served as its President from 2002-2004. She coordinates the Network for Language in Nursing Knowledge Systems (nlinks.org) and heads the team that developed its evidence based nursing filter databases (go to nlinks.org and click on Research Center). Recognizing that physiology is a science basic to nursing, Dr.Lavin is a strong proponent of physiologically-rooted nursing diagnoses.