Recognising and responding to deteriorating patients: what difference do national standards make?

Factors Associated With Junior Nurses Ability to Recognise and Respond to Clinical Deterioration: A Cross-Sectional Study in Tertiary Hospitals in Malawi

RATIONALE

Recognising and responding swiftly to patient deterioration is critical for preventing adverse events. Junior nurses play a vital role in identifying the signs of clinical deterioration and initiating interventions. No prior studies have assessed junior nurses' abilities to manage clinical deterioration in Malawi.

OBJECTIVES

This study aimed to assess junior nurses' ability to recognise and respond to clinical deterioration in Malawian tertiary hospitals and identify associated factors.

METHODS

The institutional based cross-section study design was used which included 322 junior nurses across all departments of four tertiary hospitals in Malawi (November-December 2023). Data collection utilised a questionnaire for clinical deterioration recognition and response ability in junior nurses. Chi-square, Fisher's exact, and logistic regression tests were used for data analysis.

FINDINGS

Junior nurses achieved a median score of 71 with an interquartile range of 68-75 on the clinical deterioration questionnaire. According to the study, nurses with more work experience, those who worked in intensive care units, and those who participated in discussions about clinical deterioration had better scores. In contrast, nurses with less than 1 year of experience were 5.5 times more likely to struggle with recognising and responding to clinical deterioration than those with 5 years of experience (OR: 5.506, p = 007). Additionally, working in the paediatric department decreased junior nurses' ability to recognise and respond to clinical deterioration six times compared to working in the intensive care unit (OR: 6.068, p = 0.018). Furthermore, junior nurses who had never engaged in discussions related to clinical deterioration had a seven times higher likelihood of poor ability to recognise and respond to clinical deterioration (OR = 6.954, p = 0.005).

CONCLUSION

This study highlights the need for specialised training programmes related to clinical deterioration that incorporate active learning, such as clinical scenarios and practical applications, along with mentorship initiatives to enhance junior nurses' skills and confidence in recognising and responding to clinical deterioration.

'White lies and safety nets': The perceptions of nurses on the use of early warning systems and the development of higher-order thinking skills

BACKGROUND

Algorithmic tools such as early warning systems (EWSs) have been embedded into clinical practice globally to facilitate the early recognition of patient deterioration and to guide the escalation of care. Concerns have been raised that the mandated use of these EWS tools may impact the development of nurses' higher-order thinking. However, the relationship between EWS tools and the development of higher-order thinking is poorly understood.

OBJECTIVES

This paper provides the qualitative results of a larger study that sought to explore the impact of EWS tools on the development of nurses' higher-order thinking. The objective of this component of the study was to ascertain the thoughts and perceptions of nurses on the use of EWSs and how this related to the development of higher-order thinking skills.

METHODS

A mixed-method, concurrent study design was used to explore the concept of the development of nurses' higher-order thinking in the context of EWS tools. The qualitative responses from a Qualtrics survey were thematically analysed and presented.

FINDINGS

Two major themes were uncovered: White Lies and Safety Nets. Our analysis of the data suggested that some nurses amend their documentation practice to accommodate the EWS's escalation process, uncovering a view that the tool did not account for clinical reasoning. Parallel to this, some nurses found that these systems supported clinical decision-making and helped to build confidence, thus acting as a safety net for their practice.

CONCLUSION

Reliance on EWSs can both hinder and/or support the development of higher-order thinking. Early warning systems are useful tools in ensuring patient safety but should be used in conjunction with nurses' higher-order thinking.

A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey

BACKGROUND

Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours.

OBJECTIVE

(i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour.

DESIGN

A cross-sectional survey.

SETTING

Nurses employed in public hospitals across Queensland, Australia.

PARTICIPANTS

Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey.

METHODS

Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis.

RESULTS

Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (β 0.29, p<.05), perceived value of escalation (β 0.24, p<.05) and perceived ease or difficulty complying with documentation (β -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (β 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (β 0.20, p<.05). Perceptions of control over one's clinical actions (β -0.24, p<.05) and early warning system training (β -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (β -0.31, p<.05) directly influenced the perceived value of escalating.

CONCLUSIONS

The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals.

TWEETABLE ABSTRACT

A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration

BACKGROUND

Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof.

OBJECTIVES

This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration.

METHODS

This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation.

RESULTS

From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001).

CONCLUSION

Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system

BACKGROUND

The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier.

METHODS

The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression.

RESULTS

A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001).

CONCLUSIONS

Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.

Factors influencing nursing students' ability to recognise and respond to simulated patient deterioration: A scoping review

AIM

The aim of this scoping review was to identify empirical literature on simulation used to develop undergraduate nursing student's clinical assessment skills to recognise and respond to patient deterioration.

BACKGROUND

Early recognition and response to clinical deterioration is necessary to ensure the best outcome for the patient. Undergraduate nursing students have limited exposure to deteriorating patient situations, therefore simulation is widely implemented in nursing courses to address this educational need. It is imperative to identify the simulation modalities and features that best optimise student learning.

DESIGN

Scoping review using the Joanna Briggs Institute scoping reviews methodology and the Arksey and O'Malley framework.

REVIEW METHODS

Seven health databases were searched electronically for relevant literature and complemented with hand searching for additional relevant sources. A total of 344 potential articles were identified from the seven databases: Cumulative Index to Nursing and Allied Health Literature (n = 234); PubMed (n = 16); Medline (n = 51); Scopus (n = 21); Embase (n = 3); American Psychological Association PsychInfo (n = 13); and JBI (n = 6). After applying inclusion and exclusion criteria, 15 research articles were included in the review.

RESULTS

Most research on clinical deterioration simulation was quantitative (n = 12), two were qualitative and one used a mixed method approach. Findings included a lack of situational awareness, distractors causing incomplete patient assessment and failure to recognise deterioration. Repeated simulation showed positive results.

CONCLUSIONS

Findings of this review suggest students lack situational awareness, perform incomplete assessment and fixate on single cues rather than an entire clinical picture. The use of a variety of simulation modalities was effective in improving student performance. Repeated practice within a single simulated learning experience, was shown to improve performance and situational awareness. This approach to simulation is under-researched in nursing and needs further exploration.

Evaluation of the effectiveness of an eLearning program in the nursing observation and assessment of acute surgical patients: A naturalistic observational study

AIM/OBJECTIVE

The aim of this study was to evaluate the effectiveness of an eLearn program in changing surgical nurses' approach to clinical assessment.

BACKGROUND

Nurses need to have the knowledge and skills to recognise and respond to changes in patients' physiological condition in a timely manner. A private health service in Melbourne, Australia developed an online (eLearn) program highlighting the importance of clinical assessment and provided nurses with an overview of the Airway,Breathing, Circulation, Disability, Exposures ('ABCDE') approach.

DESIGN

A before and after study design that involved naturalistic observation of nurse-patient interactions and nurses' performing patient clinical assessments was undertaken on two surgical wards.

METHODS

The intervention ward nurses received standard education and exposure to the eLearning program. The comparison ward nurses received standard workplace education on patient assessment. The nurses were observed from May to August 2018.

RESULTS

Following completion of the eLearn, intervention ward nurses were observed to spend more time with their patients conducting clinical assessment. On both wards, not all nurses performed comprehensive ABCDE assessment and there was variability associated with the sequencing of ABCDE assessment.

CONCLUSIONS

This study provides some evidence that completion of an eLearn can change clinical practice, however the intensity of the intervention was insufficient to achieve optimal practice in the conduct of clinical assessments.