The <scp>4S</scp> approach: a potential framework for supporting critical care nurses' patient assessment and interprofessional communication

Patient assessment and effective communication are two practices that are implicit in the conduct of good nursing care (Timmins, 2011). However, the act of communicating within health care institutions is frequently problematic with recent studies identifying the presence of communication failures within both verbal and written data sources amongst nursing cohorts (Rabol et al., 2012; Bagnasco et al., 2013; Costa 2014). This is particularly pertinent within critical care settings where the consequences of poor communication can negatively influence patient safety and be potentially life-threatening (Grant and Jenkins, 2014; Reader et al., 2014). At the same time, tools have emerged in the last decade, internationally, to facilitate and improve in-hospital communication, particularly in conjunction with early warning detection scoring systems (Lambert et al., 2014). These have proved useful in reducing communication errors and enhancing a timely response to patient deterioration (Lambert et al., 2014). Significant improvements in communication and responses to deterioration have emerged as a result of using frameworks such as the Situation, Background, Analysis Response (SBAR) (Ludikhuize et al., 2011; McCrory et al., 2012; Bagnasco et al., 2013; Tume et al., 2013). Expansions of this method such as Identification, Situation, Background, Analysis, Response (ISBAR) have also proven useful in minimizing communication errors at handover among medical staff (Thompson et al., 2011) and have been adopted in many countries as best practice and in some cases, within clinical guideline documentation (National Clinical Effectiveness Committee, 2013). Clearly, structured reliable communication tools such as these are helpful, and predefined communication categories and mechanisms have a part to play in reducing error and improving patient safety. That said, there remains a paucity of tools that assist nurses in understanding the complexities of individual patient cases. What this means is that while detailed case history and physiological information gathering and responses to this is consistently improving, these tools contribute little to our holistic understanding of patient situations. Inherent within each patient presentation is breadth of information (in contrast to specific information) such as social and/or psychological factors that often remain unattended despite their potential to influence case management. Quite simply treating the medical condition and symptoms within critical care settings is (quite naturally) prioritized over developing a more detailed understanding of the patients' (Edwards 2001 and Moharahi et al. 2010) own comprehension of their illness and their life story that brought them to this point. While modern approaches suggest a holistic approach and espouse patient-centred care, realistically, and particularly in light of an increasing amount of required documentation associated with assessment, nurses now have less time for engaging with patients' narratives. For this reason, even though the ISBAR tool has recently been recognized by some as suitable for use as a tool to facilitate good patient handover in the Republic of Ireland (ROI) (National Clinical Effectiveness Committee, 2015), we suggest that this tool is not broad enough to incorporate other factors (for example, the patients' narrative) that are essential to good holistic assessment. This is also the case in relation to other well-recognized and useful assessment approaches tools such as Airway, Breathing, Circulation, Disability, Exposure (ABCDE). Whilst these are internationally recognized and clearly useful for assessment and to communicate the patients' condition to other health care staff, we suggest there is scope and necessity for further development of these frameworks to incorporate a broader perspective. Within the context of assessment, it is essential that nurses develop clinical reasoning as an essential element of good nursing practice (Benner et al., 2010). Clinical reasoning is used to 'assimilate information, analyze data, and make decisions regarding patient care' (Simmons et al., 2003, p. 701). Promoting clinical reasoning within educational settings using simulation techniques and virtual patients is common practice (Forsberg et al., 2014); however, there is a lack of guidance regarding specific frameworks that would assist students to develop their clinical reasoning skills. Available tools such as SBAR, ISBAR and ABCDE, although well-known, appear to disappoint students in practice. The tools provide details of physiological parameters, but they do not necessarily help students to grasp the complexity of clinical situations or to diagnose. In simulation situations, teaching patient assessment also has limitations in terms of informing clinical reasoning skills as it is based primarily upon patient cases that are symptom-based rather than including a broader narrative of patient and family experiences (Forsberg et al., 2014). In our view, there is a need for an overarching assessment framework that would guide both nursing students and staff in undertaking an assessment that includes the patients' own story and narrative. This type of assessment framework would not only be useful for understanding patient situations more fully and informing diagnosis and treatment, it may also be useful for communicating this information to others. A modified acronym, ‘ASSESS’, prompts the students to recall that there are four of these [s] to consider (as there are four instances of the letter s in the word assess). To explain the potential usefulness of this approach, each aspect of the 4S approach is now explained. It is important to remember that the 4S is suggested as an overarching framework that would incorporate multiple elements of assessment, including relevant assessment tools, and is meant as a holistic lens with which to view patients and their families and, importantly, to hear their voice. Situation relates to the immediate assessment of the clinical context and clinical environment in order to determine whether or not the situation should to be deemed an emergency or not. A particular critical care context would be incorporated within this aspect of the tool through the incorporation of relevant additional assessments (such as the ABCDE assessment) to determine the severity of the patient's clinical condition and whether immediate action by the nurse is required. Situation also provides for assessment of the broader context of patient and family safety by determining whether or not there are sufficient resources including staffing numbers and competence, facilities and appropriate family support. The second ‘S’ relates to the assessment and interpretation of the accompanying Story. This consists of three elements. First, Story relates to appreciation of the (medical and social) history of the presenting patient. Particularly with critical care patients, understanding the past medical history and comorbidities is an essential element of nursing assessment. Social history, for example, may influence diagnosis, treatment and discharge planning, so this is important. Secondly, a lesser-known aspect of Story assessment relates to asking about and interpreting the patient's [or family's] own story. This permits the nurse to interpret what they are saying (or not saying) about their experience. Of course, the ability of a patient do this in critical care situation varies, so there is also reliance on a family member or friend to provide this information. Similarly [or in addition], an intimate picture of the person and their story may be built from the assessment data and patient notes. It is important to be mindful of the many clinical decisions that are made in health care on the basis of a told story. However, too little attention may be given to the skill of interpreting such stories (Corbally and Grant, 2016). A patient may, for example, not fully disclose harm, self-harm or addictions. In critical care, the patient story may be minimized or receive less attention because of the severity of the patient condition and the necessity for immediacy and fast response. Therefore, the power of a patient and/or family member story and its potential impact on the critical care setting is not to be underestimated (Christensen and Prost, 2014). A sub-element of this particular parameter is the nurse knowing and being aware of their own Story and how this has the potential to influence care. Not unlike personal knowing espoused in Carper's seminal work (1979), a nurse's own narrative positioning can affect the way they care for patients. For example, if a nurse recently experienced a death, caring for a similar patient with a similar condition shortly after such bereavement may present a challenge (Corbally and Grant, 2016). Similarly, a nurse's personal religious beliefs and experiences may influence their perspectives and responses to the patient and/or family's spiritual requests and/or practices (Tiew and Grury, 2012). Ergo, an appreciation of the possible influences of stories on the clinical encounter is a useful adjunct to nursing care. Symptoms (the third ‘S’) relate to sensations and feelings expressed by patients and families. Describing their symptoms in their own words using terminology, metaphors and expressions that are at variance with medical terminology is common for example. Some patients do not have the verbal language to explain/describe symptoms and may use manual gestures or different words to explain, for example, their chest pain (Albarran, 2002). As such, any approach to measurement needs to be mindful of the 'words used by patients to articulate the nature of their symptoms', and as such, exploring a patients ‘story’ needs to become a central feature of assessment in critical care. Clinical signs and/or symptoms are often the primary reasons for prompting nurses to initiate and escalate interventions (in conjunction with the multidisciplinary team) with a view to bringing such symptoms under control. Systematic symptom assessment can be structured and guided by tools such as the Onset, Provocation/palliation, Quality, Severity, Time (OPQRST) pain assessment, Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment (OLDCART) symptom assessment and numerical pain rating scales (Hogan-Quigley et al., 2012). Thus, the category of Symptoms might incorporate multiple assessment techniques and tools as relevant. Obviously, the scope of this 4S framework is vast, and it is open to interpretation and adaptation in local settings. Subcategories to guide the nurse student through each ‘S’ would be required, including guidance from key assessment tools to use within each category. Determining the sub-elements for inclusion requires further research, development and testing, including practice development at local level. Interpreting symptoms is a key clinical reasoning skill required of critical care nurses; therefore, Signs is the final ‘S’ in this proposed framework for practice. Signs are of great significance and relate to cues that the nurse can notice and interpret using mostly visual but also olfactory and sensory information (Forsberg et al., 2014). This nursing skill relates to understanding the significance of particular visual cues such as grimacing, pallor, asymmetry, and swelling in supplement data from vital sign monitoring systems and ABCDE assessment (Forsberg et al., 2014). Sensitivity to contrasts and contradictions within each of the 4 ‘S’ areas is encouraged. For example, if a patient states they are not in pain yet grimace upon movement and are tachycardic, these areas alert the nurses to examine why this contrast might exist. Similarly, the effects of sedation within the critical care setting may mask the detection of particular signs, and staff should be mindful of this. Experienced critical care nurses may find this proposed framework over-simplistic. However, less-experienced practitioners may find this practical framework useful to articulate elements of nursing activity that are often subtle or difficult to relay. Nursing (critical care nursing in particular) is complex. As we have illustrated, mistakes can be made in communication with vital pieces of non-medical information omitted in preference for more medicalized information (Costa, 2014). Therefore, the 4S framework ‘ASSESS’ may be useful for nurses to undertake a more comprehensive assessment. We suggest that it has potential use in all areas where a holistic approach to patient care is advocated.

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