What nurses involved in a Medical Emergency Teams consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient. A nurse-oriented curriculum development project

Critical care nurses' role in rapid response teams: A qualitative systematic review

AIM

To analyse the qualitative evidence on the role of critical care nurses in rapid response teams.

DESIGN

Qualitative systematic review.

METHODS

This qualitative systematic review employed Bettany-Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach.

DATA SOURCES

A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases.

RESULTS

Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision-making.

CONCLUSION

Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision-making process concerning patient care.

IMPLICATIONS FOR THE PROFESSION

Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety.

IMPACT

Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review

AIM

Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking.

DESIGN

A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021).

DATA SOURCES

CINAHL, Medline, Embase, PyscInfo.

REVIEW METHODS

Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data.

RESULTS

Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool.

CONCLUSION

EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms.

IMPACT

This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a systematic review, and therefore, comprises no contribution from patients or the public.

A multi-facetted patient safety resource-A qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team

AIM

To explore hospital managers' perceptions of the Rapid Response Team.

DESIGN

An explorative qualitative study using semi-structured individual interviews.

METHODS

In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes.

FINDINGS

One theme, 'A resource with untapped potential, enhancing patient safety, high-quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub-categories.

CONCLUSION

The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes.

IMPLICATIONS

For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial.

IMPACT

This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re-organize managerial involvement in the function and development of the Rapid Response Team and System.

REPORTING METHOD

We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution".

Development and assessment of a curriculum model for virtual simulation in nursing: curriculum development and pilot-evaluation

BACKGROUND

To introduce virtual simulation as a strategy of nursing education and provide valid educational content, the best curriculum model of virtual simulation needs to be developed.

METHODS

Curriculum development process and pilot evaluation was used. The curriculum content and structure was developed by analyzing literature including previous studies and major nursing classification systems, and key words derived from focus group interviews of 14 nurses and 20 faculty members with expertise in simulation education. 35 nursing students participated in the evaluation of the developed virtual simulation curriculum.

RESULTS

The curriculum developed for virtual simulation in nursing education contained three domains of content areas: (1) enhancing clinical decision-making, (2) experiencing low-exposed situations, and (3) building professional resilience. In addition, seven subdomains of content areas and 35 representative topics in the virtual simulation curriculum were derived. Scenarios of nine representative topics were created, translated into 3D modeling and pilot-evaluated.

CONCLUSIONS

Considering that nursing education is encountering new demands and challenges from students and the changing society, the newly suggested curriculum for virtual nursing simulation can help nurse educators to plan better educational opportunities for students.

Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review

BACKGROUND

Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity.

OBJECTIVE

The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient.

METHODS

A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist.

RESULTS

Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity.

CONCLUSIONS

This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study

BACKGROUND

Intensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call.

OBJECTIVE

The study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team.

METHOD

A constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews.

FINDINGS

A substantive theory was developed that 'keeping patient's safe' is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety.

CONCLUSION

This study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.

A practical approach to establishing a critical care outreach service: An expert panel research design

BACKGROUND

For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting.

AIM

The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.

METHOD

An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed.

FINDINGS

There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation.

CONCLUSION

An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse

AIM AND OBJECTIVE

To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT).

BACKGROUND

For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction.

DESIGN

Qualitative focus group interviews.

METHODS

A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist.

RESULTS

One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'.

CONCLUSION

Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses.

RELEVANCE TO CLINICAL PRACTICE

Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study

BACKGROUND

Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context.

METHODS

Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n = 87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding.

RESULTS

Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily.

CONCLUSIONS

Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum

BACKGROUND

For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required.

AIM

The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system.

METHODS

An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes.

RESULTS

Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles.

CONCLUSIONS

A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

Identifying teamwork-related needs of the medical emergency team: Nurses' perspectives

BACKGROUND

The role of medical emergency team (MET) in managing deteriorating patients and enhancing patient safety is greatly affected by teamwork.

AIMS

To identify teamwork-related needs of the MET from MET nurses' perspectives. To assess the associations between MET nurses' perceptions of teamwork and their work experience and education.

STUDY DESIGN

A quantitative, descriptive correlational design.

METHODS

Registered intensive care unit (ICU) nurses (n = 50) who were members of the MET in an acute tertiary care hospital answered a modified version of the team assessment questionnaire in 2017. Data were analysed using descriptive statistics, the Kruskal-Wallis test, and the univariate analysis of variance method. The reporting of this study adheres to the strengthening the reporting of observational studies (STROBE) guidelines.

RESULTS

Participants showed least agreement with the items presenting leadership skills (mean = 2.6, SD = 0.68). Approximately 50% nurses disagreed that the MET had adequate resources, training, and skills. The majority of nurses (80%) felt that their responsibilities as a MET member interfered with taking care of their own ICU patients. Many nurses (64%) felt that they did not have a voice in MET's decision-making process. Approximately 50% nurses felt that they were not recognized for their individual contribution, and they were uncertain regarding MET's policies for dealing with conflicts. The amounts of MET nurses' work experience and education were associated with MET skills and function, respectively.

CONCLUSION

Key teamwork elements of the MET that need improvements include decision-making and conflict resolution skills, valuing team members, and team leadership. Practicing shared mental models, implementing the TeamSTEPPS curricula at hospitals for training ICU nurses, and simulation-based team-training programmes may be beneficial in improving teamwork of MET members.

RELEVANCE TO CLINICAL PRACTICE

This study revealed key teamwork elements of the MET that need improvements. Our findings may contribute to improve teamwork, thereby optimizing MET function, and enhancing patient outcomes.

A clinical competence approach to examine British and Finnish nurses' attitudes towards the rapid response system model: A study in two acute hospitals

BACKGROUND

Nurses' clinical competence involves an integration of knowledge, skills, attitudes, thinking ability, and values, which strongly affects how deteriorating patients are managed.

OBJECTIVES

The aim of the study was to examine nurses' attitudes as part of clinical competence towards the rapid response system in two acute hospitals with different rapid response system models.

METHODS

This is a comparative cross-sectional correlational study. A modified "Nurses' Attitudes Towards the Medical Emergency Team" tool was distributed among 388 medical and surgical registered nurses in one acute hospital in the UK and one in Finland. A total of 179 nurses responded. Statistical analyses, including exploratory factor analysis, Mann-Whitney U tests, Kruskal-Wallis tests, chi-square tests, and univariate and multivariate regression analyses, were used.

FINDINGS

Generally, nurses had positive attitudes towards rapid response systems. British and Finnish nurses' attitudes towards rapid response system activation were divided when asked about facing a stable (normal vital signs) but worrisome patient. Finnish nurses relied more on intuition and were more likely to activate the rapid response system. Approximately half of the nurses perceived the physician's influence as a barrier to rapid response system activation. The only sociodemographic factor that was associated with nurses activating the rapid response system more freely was work experience ≥10 years.

CONCLUSIONS

The findings are beneficial in raising awareness of nurses' attitudes and identifying attitudes that could act as facilitators or barriers in rapid response system activation. The study suggests that nurses' attitudes towards physician influence and intuition need to be improved through continuing development of clinical competence. When the system model included "worrisome" as one of the defined parameters for activation, nurses were more likely to activate the rapid response system. Future rapid response system models may need to have clear evidence-based instructions for nurses when they manage stable (normal vital signs) but worrisome patients and should acknowledge nurses' intuition and clinical judgement.

British and Finnish nurses' attitudes, practice, and knowledge on deteriorating patient in-service education: A study in two acute hospitals

AIM

The aim was to assess both nurses' attitudes about in-service education, and the impact had by attending in-service education on nurses' management and knowledge of deteriorating patients.

BACKGROUND

In-service education cannot reach its best potential outcomes without strong leadership. Nurse managers are in a position of adopting leadership styles and creating conditions for enhancing the in-service education outcomes.

DESIGN

We conducted a comparative cross-sectional study between British and Finnish nurses (N = 180; United Kingdom: n = 86; Finland: n = 94).

METHODS

A modified "Rapid Response Team Survey" was used in data collection. A sample of medical and surgical registered nurses were recruited from acute care hospitals. Self-reporting, self-reflection, and case-scenarios were used to assess nurses' attitudes, practice, and knowledge. Data were analyzed by Mann-Whitney-U and Chi-square tests.

RESULTS

Nurses' views on education programs were positive; however, low confidence, delays caused by hospital culture, and fear of criticism remained barriers to post education management of deteriorating patients. Nurses' self-reflection on their management of deteriorating patients indicates that 20-25% of deteriorating patients are missed.

CONCLUSION

Nurse managers should promote a no-blame culture, mitigate unnecessary hospital culture and routines, and facilitate in-service education focusing on identification and management of deteriorating patients, simultaneously improving nurses' confidence.

Critical Incidents Involving the Medical Emergency Team: A 5-Year Retrospective Assessment for Healthcare Improvement

BACKGROUND

Medical emergency teams (METs), which have been established in several countries, contribute to a reported decrease in deteriorated patients' in-hospital mortality. To date, no data have been published on critical incidents that occurred in METs affecting patients' safety.

OBJECTIVES

The aim of the study was to identify and describe critical incidents that occurred during METs' activities in a large academic Italian hospital.

METHODS

The data, which were stored in the official incident reporting system of the hospital and included all critical incidents that occurred and were reported in anonymous and voluntary forms over a 5-year period, were retrospectively analyzed.

RESULTS

Overall, 17 critical incidents emerged, during both the team alert stage (n = 10) and its performance (n = 7), with approximately 3 events per year and an incident rate of 1.7 for every 1000 MET interventions.

DISCUSSION

Medical emergency teams' critical incidents are rare and mainly due to the lack of compliance with protocols and of training and supplies, which require appropriate educational and organizational strategies.

Challenges in the recognition and management of paediatric sepsis - The journey

Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings

AIMS AND OBJECTIVE

To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer.

BACKGROUND

Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting.

METHOD

An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward-based nurses (n = 64) and nurse unit managers (n = 8). This paper follows the COREQ guidelines for reporting qualitative health research.

RESULTS

Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment).

CONCLUSION

The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer.

RELEVANCE TO CLINICAL PRACTICE

Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.