Patients and their families expect nurses to deliver high-quality care. Maintaining these high standards is vital; however, this involves overcoming many challenges. Standards can be undermined by conflicting messages and interactions, as well as failures of communication, both with patients and between health professionals. Likewise, mistakes in data collection, documentation or interpretation, especially if influenced by professional bias, can lead to misdiagnosis and inappropriate interventions.
History taking and physical examination are increasingly being undertaken by senior clinical nursing staff, especially in nurse-led clinics and community-based care. Therefore, it is increasingly important that nurses are able to be systematic in their assessment and evaluations of interventions, as well as sensitive to patient wellbeing. Assessment is the crucial first stage of care delivery, forming the basis of diagnosis, planning, implementation, and evaluation. Nurses need to think critically about all the data they collect, whether subjective or objective. For the patient, assessment should not be a passive process, but should instead be dynamic, with active patient participation in explaining and clarifying the clinician’s findings. If a clinician relies entirely on their own findings without consulting the patient for their input, professional bias, whether unconscious or sometimes conscious, can lead to diagnostic overshadowing, in which a comorbidity can go undiagnosed. In patients with complex needs, this can lead to suboptimal care and even early preventable death.
This presentation aims to help nurses be aware of potential bias, employ theories of critical reasoning and take a systematic and patient-centered approach to assessment.