Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

Paediatric family activation rapid response (FARR) in acute care: a qualitative study for developing a multilingual application (app) intervention

BACKGROUND

Delayed recognition of clinical deterioration can result in harm to patients. Parents/carers can often recognise changes in the child's condition before healthcare professionals (HCPs). To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response (FARR) systems are part of family-integrated care. Mechanisms for parents/carers to escalate concerns regarding their child's clinical status remain limited to direct verbal communication, which may impede those with communication/linguistic challenges.

AIM

To develop a digital multilingual intervention by which families/carers can escalate their concerns directly to the rapid response team while in acute paediatric care.

METHODS

A single-centre qualitative, co-design app development study was conducted. Evidence synthesis from a systematic review of the international literature informed interviews on intervention prototype development using co-design focus groups. Participant recruitment targeted underserved communities for multilingual functionality validity. Data were analysed using qualitative content analysis.

RESULTS

Thirty parents/carers (n=16) and HCPs (n=14) participated in the study. Three themes were generated from the data analysis: (1) relational considerations; communication, professional and parental attributes, and collaborative working; (2) technology considerations; app content, usage and outcomes; and (3) individual and environmental considerations; parental and professional elements, and workload. A FARR app prototype was developed based on the data.

CONCLUSION

The prototype app provides a platform to develop a coordinated and consistent technological approach to paediatric FARR that acknowledges cultural nuances and preferences, ensuring that parents can communicate in a manner that aligns with their cultural background and communication abilities, thereby enhancing the quality of care delivered.

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

REVIVE Is an Evidence-Based Approach for Nurses to Universally Apply Trauma-Informed Care in Maternity Settings

The principles of trauma-informed care-safety, compassion, collaboration, communication, autonomy, and empowerment-are also the domains most vulnerable to implicit bias and most cited in adverse outcomes in maternal health. Perinatal nurses can practice trauma-informed care universally and thereby foster and advance person-centered care for all individuals with respect to race, ethnicity, religion, or lived experiences. In this article, we present evidence-based nursing interventions, collectively called REVIVE, that are known to promote principles of trauma-informed care. Taken together, the REVIVE interventions may improve health outcomes and reduce disparities in maternal health outcomes because they are proactive nursing interventions independent of implicit bias. REVIVE is described here and intended for use by individual nurses or health care teams to implement and evaluate in different maternity settings.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention

AIM

To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.

BACKGROUND

Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability.

DESIGN

A narrative inquiry.

METHODS

Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data.

RESULTS

The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation.

CONCLUSION

Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

The consumer researcher was involved in design, data analysis and publication preparation.

Influences of Leadership, Organizational Culture, and Hierarchy on Raising Concerns About Patient Deterioration: A Qualitative Study

BACKGROUND

Raising concerns is essential for the early detection and appropriate response to patient deterioration. However, factors such as hierarchy, leadership, and organizational culture can impact negatively on the willingness to raise concerns.

OBJECTIVES

This study aims to delve into how leadership, organizational cultures, and professional hierarchies in healthcare settings influence healthcare workers, patients, and caregivers in raising concerns about patient deterioration and their willingness to do so.

METHODS

The study used a qualitative approach, conducting focus group discussions (N = 27), utilizing authentic audio-visual vignettes to prompt discussions about raising concerns. Deductive thematic analysis was employed to explore themes related to hierarchy, leadership, and organizational culture.

RESULTS

Positive leadership that challenged traditional professional hierarchies by embracing multidisciplinary teamwork, valuing the input of all stakeholders, and championing person-centered practice fostered a positive working culture. This culture has the potential to empower clinical staff, patients, caregivers, and family members to confidently raise concerns. Staff development, clinical supervision, and access to feedback, all underpinned by psychological safety, were viewed as facilitating the escalation of concerns and, subsequently, have the potential to improve patient safety.

CONCLUSIONS

This study offers crucial insights into the intricate dynamics of leadership, hierarchy, and organizational culture, and their profound impact on the willingness of staff and patients to voice concerns in healthcare settings. Prioritizing the recommendations of this study can contribute to reducing avoidable deaths and elevating the quality of care in healthcare settings.

Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings

BACKGROUND

Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system.

METHODS

A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis.

RESULTS

A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation.

CONCLUSION

Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Night-time detection and response in relation to deteriorating inpatients: A scoping review

BACKGROUND

Although detection and response to clinical deterioration have been studied, the range and nature of studies focused on night-time clinical setting remain unclear.

AIM

This study aimed to identify and map existing research and findings concerning night-time detection and response to deteriorating inpatients in usual care or research settings.

STUDY DESIGN

A scoping review method was used. PubMed, CINAHL, Web of Science, and Ichushi-Web databases were systematically searched. We included studies focusing on night-time detection and response to clinical deterioration.

RESULTS

Twenty-eight studies were included. These studies were organized into five categories: night-time medical emergency team or rapid response team (MET/RRT) response, night-time observation using the early warning score (EWS), available resources for physicians' practice, continuous monitoring of specific parameters, and screening for night-time clinical deterioration. The first three categories were related to interventional measures in usual care settings, and relevant findings mainly demonstrated the actual situation and challenges of night-time practice. The final two categories were related to the interventions in the research settings and included innovative interventions to identify at-risk or deteriorating patients.

CONCLUSIONS

Systematic interventional measures, such as MET/RRT and EWS, could have been sub-optimally performed at night. Innovations in monitoring technologies or implementation of predictive models could be helpful in improving the detection of night-time deterioration.

RELEVANCE TO CLINICAL PRACTICE

This review provides a compilation of current evidence regarding night-time practice concerning patient deterioration. However, a lack of understanding exists on specific and effective practices regarding timely action for deteriorating patients at night.

Am I safe? An Interpretative Phenomenological Analysis of Vulnerability as Experienced by Patients With Complications Following Surgery

Abdominal surgery carries with it risks of complications. Little is known about patients' experiences of post-surgical deterioration. There is a real need to understand the psychosocial as well as the biological aspects of deterioration in order to improve care and outcomes for patients. Drawing on in-depth interviews with seven abdominal surgery survivors, we present an idiographic account of participants' experiences, situating their contribution to safety within their personal lived experiences and meaning-making of these episodes of deterioration. Our analysis reveals an overarching group experiential theme of vulnerability in relation to participants' experiences of complications after abdominal surgery. This encapsulates the uncertainty of the situation all the participants found themselves in, and the nature and seriousness of their health conditions. The extent of participants' vulnerability is revealed by detailing how they made sense of their experience, how they negotiated feelings of (un)safety drawing on their relationships with family and staff and the legacy of feelings they were left with when their expectations of care (care as imagined) did not meet the reality of their experiences (care as received). The participants' experiences highlight the power imbalance between patients and professionals in terms of whose knowledge counts within the hospital context. The study reveals the potential for epistemic injustice to arise when patients' concerns are ignored or dismissed. Our data has implications for designing strategies to enable escalation of care, both in terms of supporting staff to deliver compassionate care, and in strengthening patient and family involvement in rescue processes.

When patients (and families) raise the alarm: Patient and family activated rapid response as a safety strategy for hospitals

Patients and those close to them often have an intimate understanding of their condition and can participate in a broad range of clinical processes. During times of deterioration, their concerns might go unheard. Advocacy of family and friends can fulfil an important safety function and can support patients and healthcare professionals looking after them. If concerns by patients are not heard by the patient's primary team in hospital, patient and family activated rapid response systems allow patients and family members to alert critical care outreach teams directly. These types of systems are stipulated by regulators in Australia and in parts of the USA, and there are examples in the UK built around the 'Call for Concern' model championed by the Royal Berkshire Hospital. Implementation is not without its problems and requires a deep understanding of barriers and enablers. Empowering patients to escalate directly might help to change safety culture and have protective effects for patients and staff. Policy makers are urged to consider standardised regulation to aid implementation.