Active Observation

Marilee Muzatko, CVT, VTS (ECC), discusses the most important monitoring tool we have – our powers of observation.

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One of the ways to look at a profession is to identify key occupational skills that an individual needs to succeed in that profession. In an occupational skills study completed in 2009, four key skills were identified for successful practice of veterinary nursing care: observation, listening, locating information, and teamwork. The study, using survey data and analysis from experts in the field of veterinary nursing, concluded that the skill of observation was needed in 92% of the daily tasks performed by a veterinary technician- 92%! Obviously, this column is going to be about observation skills.

In the realm of occupational studies, the working definition of observation is “a skill a person uses when they pay attention to and remember work-related instructions, demonstrations, and procedures.” If we have reached the peak of practicing our observation skills within veterinary nursing care, those occupational experts go on to say:

  • We become adept at performing our detailed tasks quickly without instructions
  • We are able to follow cause-and-effect relationships and make valid judgments, comparisons, and plans for outcomes
  • We can visualize how a detail step fits into a overall procedure performed as a team
  • We can independently detect subtle changes in a situation that effect outcomes

Yep, as a skilled veterinary nursing staff, this is what you should be doing at least 92% of your time, and still get a pill in a fractious kitty without injury to the parties involved; no wonder we are sometimes tired at the end of our workday. Are you using your observation skills at that peak level?

Cognitive scientists, the people who study how we learn, tell us that the human mind is able to assimilate only three or four new pieces of information at a time, anything more than that simply evaporates from memory within moments. What they also know is that knowledge builds on itself; experts learn faster about a subject than novices. Let’s sum that up to say, the more you already know, the more new information you’ll retain. Those same scientists also tell us that a strong vocabulary is not only a reflection of the knowledge you already have but also a good indicator of how easily you will learn new information. This makes sense. It’s hard to understand a new concept when you don’t know what the words describing that concept mean.

So, your observation skills need to be supported by a sufficient knowledge base and vocabulary for effective use. Since you are a veterinary nursing professional, that knowledge base should include basic anatomy and physiology as well as a basic understanding of common disease processes and their common associated diagnostic and therapeutic procedures. It is also important to master the physical tools available in your practice (the pumps, the lab machines, the anesthesia machine) so that the tool becomes an ally, not a foe in providing patient care. Without this knowledge base your observation skills, and therefore your ability to be adept at patient care, weakens. You will not be as quick to look ahead and anticipate potentially adverse outcomes. Strive to use your medical vocabulary as frequently as possible when communicating with your veterinarian and co-workers about patients and procedures. Medical terms are specific and leave little room for miscommunication when used accurately. Hmm, maybe Purina is onto a good idea with their poop-scoring chart after all.

We also need to continuously evaluate our observation skills. A feedback loop sets us up for a more successful or repeatable outcome next time. One of the best veterinary technicians I ever worked with keeps a daily log, patient by patient, and uses that log to measure changes in her skills and knowledge levels. You might not want to keep a log, but at a minimum, review your work on a routine basis.

Let’s take a quick look at some examples of when observation skills come into use in our workday.

Patient intake: For returning routine patients, take a few moments to review the chart in your hands before going in to the exam room and visualize what you want to accomplish while in the room. The chart review will give you a context for this visit; the visualization will help you be prepared to complete your role effectively and anticipate the needs of other team members. Each practice establishes different protocols for history taking, but in general you want to glean and document from your observations the duration, severity, frequency, and triggers associated with the presenting compliant. There is always the temptation to focus solely on the presenting problem – the limp, the hotspot, or the laceration – to the exclusion of all else when taking a history; resist that temptation. Be concise, but also be thorough; you may find a second hotspot or wound or that the client is interested in a secondary service or product. You should become an expert at performing a complete, efficient technician physical exam. The nose to tail method works well for many, but feel free to develop your own pattern of assessment as long as you cover all the basic PE categories. The key is to do the same things in the same order every time. That forms a habit and you won’t forget to get the weight, the temperature, or any of the other observable baseline physical measurements the DVM will need. Why do a tech PE when you know the DVM is going to perform his/her own exam? I use my PE of healthy patients to sharpen my skills so I can spot problems in sick patients more quickly. And if I am the one that will be monitoring a patient under anesthesia later in the day to repair the laceration, I want to know as much as possible about him before induction. The information you gathered taking the history and the PE will allow you to prepare for the possibility of a procedure when the veterinarian has completed their exam. Depending on the workflow in your clinic, you might begin to layout the appropriate tools for the procedure. You are not making a diagnosis you are simply anticipating the needs of the veterinarian and where your involvement may be necessary. That anticipation makes the whole team more efficient and results in a more positive patient visit.

Monitoring anesthesia: It seems we all love our vital signs monitors, and rightly so as they augment our observations by telling us things that our eyes, ears, and hands can't detect. Properly interpreted monitoring devices can positively affect patient outcome especially when the staff member monitoring anesthesia is also the one performing additional tasks. And certainly advanced monitors provide quantitative information on harder to measure physiological changes for example, ventilation (ETCO2) or arrthymias (ECG). But do not let your fancy monitor lull you into a false sense of complacency about any anesthetic procedure! Notice above I used the words “can positively effect” not “will decrease anesthetic risk,” because the latter has not ever been proven. Equipment can malfunction or misread, so as important as a monitor is, the single most appropriate method for assessing the depth of anesthesia is an assessment of clinical signs by a skilled observer. Use those same observation skills you employed in the exam room or during triage, and get your senses focused on your patient (without violating the surgical field). By sight you can assess mucous membrane color, respiratory rate and pattern, and eye position. Use your sense of touch to palpate pulses and obtain capillary refill time, to check palpebral reflexes, to assess skin temperature, and to monitor jaw tone. And use the humble, hardworking esophageal stethoscope to listen to those heart and lung sounds. (What, you don’t use one?  Really? Try it; I think you will be glad you did). In our anesthetic procedures, we record vital sign measurements every five minutes not just as a rote record of the process, but as a tool to alert us to potential problems. Use your anesthetic record to think ahead of your monitor– two measurements going in an unexpected direction can be the start of a trend you’ll need to act upon. As our VTS(Anesthesia) Surgical Technician often reminds us all, “don’t let your surgeon be the one to tell you your patient is too light or too deep.”

Hospital care: It is not unusual for patients to be hospitalized for surgical recovery, fluid therapy or serial testing. In most cases, they are periodically monitored during that hospitalization. Our PE skills come into play again as we are the most frequent hands-on observer. In most clinics, you will likely be recording the measurements and observations you make throughout the treatment period. Even if you have performed the last two nursing checks yourself, look back at what has been previously recorded. Pay attention to abrupt changes or trends in recorded observations. Ask yourself what might be causing those changes. Can you, by taking an action appropriate for nursing staff, improve the patient’s condition? Sometimes the answer is yes, and a potty walk is all that is needed! Other times you need to go further. For example, you observe the patient’s respiratory rate and pattern have changed since the last nursing check. First of all, what are the possible causes of that change, what to you need to be ready for, and how fast do you need to be ready? Does the patient seem distressed by this change? Is this simply a nervous patient reacting to being handled? What’s the pulse ox reading? How long has it been since the last pain medications were administered? Does my patient respond to flow-by oxygen? Obviously this observation and questioning process should not cause any delay in the notification of the veterinarian nor in the delivery of necessary medical treatment. Your ultimate goal is to enhance the quality and level of patient care and you do that by observing subtle changes, gathering additional information when appropriate, and updating your veterinarian in a timely manner.

Not sure if you have some of these observation skills or knowledge base? Honestly assess yourself; you may really know more than you think. You just never looked at it this way. Observation skills are acquired through conscious effort during the day-to-day routines of our work, but you need be fully engaged to register what your senses reveal to you. Always take the time at the end of the day to review each patient interaction– what could you have done differently, what key physical finding did you miss/find for the first time, were all of the planned patient outcomes reached and why/why not? And if you find that you don’t yet have all the knowledge base or understanding that you need to move forward, it is time for some reading or CE, or find a mentor who will help you. Don’t be shy about growing your knowledge. Start small, choose a specific area to improve, and get your veterinarian onboard–  it is in his/her best interest.

For me, all this boils down to having learned to make the connections between what’s visible and what’s invisible in our patients and in my role as a veterinary technician acting appropriately on those connections. The more connections you make and the more appropriately you act, the stronger contribution you make to your veterinary care team and the greater the degree of trust and reliance placed upon you. We are talking about improving your professional worth and satisfaction in a job well done, but ultimately we are talking about improved patient care. And isn’t that why we all are here?

Ready? Get set. Observe!

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