Developing a sociocultural framework of compliance: an exploration of factors related to the use of early warning systems among acute care clinicians

A retrospective evaluation of SwePEWS use in paediatric patients with COVID-19 and RSV infection

AIM

As early detection of deterioration is a challenge in children, the Swedish Paediatric Early Warning Score (SwePEWS) is used to systematically assess paediatric patients' clinical state. Here, we aimed to evaluate the use and predictive ability of SwePEWS.

METHODS

Electronic health records of paediatric patients admitted due to respiratory syncytial virus infection or COVID-19 were reviewed retrospectively. Registered vital signs were compared to the assigned SwePEWS score and monitored vital sign values to identify discrepancies. Additionally, SwePEWS's ability to predict transfer to the paediatric intensive care unit (PICU) was assessed.

RESULTS

Among 1374 SwePEWS assessments, one-third were either incomplete or contained errors. Incomplete SwePEWS assessments were more frequent during night-time. Single measurements of oxygen saturation presented lower values compared to average saturation from continuous monitoring. SwePEWS's ability to predict PICU transfer was low.

CONCLUSION

There was a surprisingly high occurrence of underestimated SwePEWS scores. This study provides new insights into pitfalls when developing and implementing paediatric early warning scores for systematic re-evaluations in paediatric patients.

[Experience of nurses using the COVID-19 Early Warning Score in the care of COVID-19 patients: A qualitative study]

Experience of nurses using the COVID-19 Early Warning Score in the care of COVID-19 patients: A qualitative study Abstract: Background: In all phases of the COVID-19 disease, patients are at risk of acute deterioration. In order to identify patients at risk at an early stage, the COVID-19-EWS Salzburg was implemented in April 2020 at the University Hospital Salzburg. So far, the applicability, practicability and relevance of the EWS for acute inpatient COVID-19 care are unknown. Aim: The aim of this qualitative study was to describe the relevance and practicability of the COVID-19-EWS Salzburg as a risk assessment tool for acute inpatient COVID-19 care, based on the experiences of the nursing staff. Methods: Nine semi-structured expert interviews were conducted with the nursing staff of the COVID-19 acute care unit. The data were analysed by qualitative content analysis. Results: Nurses described the EWS as relevant to practice because the score facilitates decision-making, increases patient safety, and enhances interprofessional communication. Both the Early Warning Score (EWS) and experience in caring for COVID-19 patients were found to be relevant for decision-making in the context of managing clinical deterioration. The score provided a sense of security in the care of COVID-19 patients, particularly to new and inexperienced nurses. Conclusion: The participating nurses describe the COVID-19-EWS Salzburg as a useful and practical risk assessment instrument, complementing clinical judgment. A need for adaptation concerning the parameters oxygen saturation and oxygen requirement was identified.

Acknowledging: A classic grounded theory explaining how nurses' employ clinical judgement when complying with early warning system protocols

BACKGROUND

Recognition and response to clinical deterioration of hospitalised patients is a worldwide health priority area. In response to this concern, international bodies have implemented early warning systems to help clinicians keep people safe and prevent patient deterioration. Registered nurses hold a significant role in managing care provision and utilise early warning system tools to support their clinical judgement when making decisions about patient care.

OBJECTIVE

To generate a theory explaining how registered nurses employ their clinical judgement when complying with an early warning system protocol.

DESIGN

Classic grounded theory.

PARTICIPANTS

Participants included twenty registered nurses working with early warning systems who are currently employed in a state health care system within Australia. Data were collected via interviews generated from a grand tour question in line with classic grounded theory.

METHODS

Classic grounded theory methodology and methods were used. This approach facilitated the identification of the participants main concern and supported the generation of a theory explaining how the participants resolved this issue.

RESULTS

Analysis of data, including associated field notes and memos, identified participants often experienced unease when complying with an early warning system protocol and employing clinical judgement. The mental discomfort participants voiced in the interviews described internal conflicts that are reflective of the term 'cognitive dissonance'. How the participants sought to resolve their cognitive dissonance, revealed participants' main concern as: Compliance with early warning systems is sometimes incongruent with nurses' use of clinical judgement. The outcome of this study is a grounded theory that explains how nurses resolve this concern through 'Acknowledging'. Nurses acknowledge the efficacy of early warning systems, whilst valuing their clinical judgement and the importance of patient safety, through the subcategories of Acting and Pausing.

CONCLUSION

The Theory of Acknowledging explains how nurses overcome their main concern when employing clinical judgement and complying with early warning systems, whilst acknowledging the importance of ensuring patient safety. Reconciling the dissonance caused by trusting their clinical judgement and remaining compliant with early warning systems, enables nurse-led assessment of the patient, promoting patient safety. Tweetable abstract The theory of Acknowledging - How nurses employ clinical judgement when complying with early warning systems @Jusconnor25.

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.

Classic grounded theory: identifying the main concern

Grounded theory comprises a family of research approaches designed to support the generation of a theory explaining a phenomenon experienced by a group of participants. One style of grounded theory, Classic grounded theory, is used less often than other types of grounded theory. The less frequent use of Classic grounded theory may be attributed to the limited availability of clearly articulated processes for conducting this method. Particularly important within Classic grounded theory, and not used in other forms of grounded theory, is identifying the participants' main concern. Identifying the participants' main concern is a signature feature of Classic grounded theory and is a prerequisite for ascertaining the core category and subsequent discovery of theory. In this article we provide a detailed explanation of how to identify the participants' main concern, and in so doing, we offer an exemplar to illustrate the process involved.

How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review

INTRODUCTION

Physiological signs of clinical deterioration are known to occur in the hours preceding a serious adverse event. As a result, track and trigger systems known as early warning systems (EWS) were introduced and routinely implemented as patient observation tools to trigger an alert in the presence of abnormal vital signs.

OBJECTIVE

The objective aimed to explore the literature pertaining to EWS and their utilisation in rural, remote and regional health care facilities.

DESIGN

The Arksey and O'Malley's methodological framework was used to guide the scoping review. Only studies reporting on rural, remote and regional health care settings were included. All four authors participated in the screening, data extraction and analysis process.

FINDINGS

Our search strategy yielded 3869 peer-reviewed articles published between 2012 and 2022, with six studies ultimately included. Collectively, the studies included in this scoping review examined the complex interaction between patient vital signs observation charts and recognition of patient deterioration.

DISCUSSION

Whilst rural, remote and regional clinicians use EWS to recognise and respond to clinical deterioration, noncompliance dilutes the tool's effectiveness. This overarching finding is informed by three contributing factors: documentation, communication and challenges specific to the rural context.

CONCLUSION

The success of EWS relies on accurate documentation and effective communication within the interdisciplinary team to support appropriate responses to clinical patient decline. More research is required to understand the nuances and complexities of rural and remote nursing and to address challenges associated with the use of EWS in rural health care settings.

Exploration of a rapid response team model of care: A descriptive dual methods study

BACKGROUND

Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE

To explore the characteristics of a collaborative rapid response team model.

DESIGN

Dual methodology was used for this descriptive study.

SETTING

The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS

Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS

A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS

The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation.

CONCLUSIONS

Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Clinical judgement in nursing - An evolutionary concept analysis

AIMS

The aim of this concept analysis was to develop a contemporary operational definition of Clinical Judgement in nursing.

DESIGN

Concept analysis.

METHODS

Rodgers' evolutionary method of concept analysis. Throughout the study, the authors followed the SRQR checklist.

RESULTS

This concept analysis guided the development of an operational definition of clinical judgement, within the context of nursing, articulated as Clinical judgement is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion.

CONCLUSION

The purpose of this concept analysis was to propose a detailed definition of clinical judgement in nursing, that reflected its theoretical base within today's contemporary healthcare system. Using Rodgers' evolutionary method of concept analysis, surrogate terms, attributes, antecedents and consequences were identified, and a contemporary definition was developed. No patient or public contribution was required to design or undertake this research.

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.

Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Background

Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.

Methods

A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.

Results

Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.

Conclusions

Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03411-1.

Temporal patterns in vital sign recording within and across general hospital wards

Introduction

The use of mobile devices on hospital wards to record patient vital signs and Early Warning Scores provides opportunity for secondary analysis of the data collected. This research investigated how such analysis can contribute to the understanding of the complexities of managing clinical care in hospital environments.

Methods

The influence of ward type and the distribution of patient observation intervals was evaluated in relation to the timing of vital signs observation patterns in data collected from eight adult in-patient wards over a 12-month period. Actual and projected observation times were compared across patients with higher and lower National Early Warning Scores (NEWS).

Results

Both ward type and the distribution of patient observation intervals were significant predictors of temporal observation patterns. Observation patterns showed evidence of grouping of observation recordings. This was, however, not found for observations of patients with higher NEWS scores (3 or more).

Conclusions

Secondary analysis of vital signs observation data can reveal insights into how ward operate. The patterns of observation recordings within a ward are a reflection of ward type and the distribution of patient observation intervals. The grouping of observation recordings of patients with low NEWS (<3) result in late or early observations to fit activity peaks characteristic of the ward culture.

A scoping review of barriers, facilitators and tools to escalation of care processes in the emergency department

INTRODUCTION

Escalation of care is the timely recognition and communication of deterioration in a previously stable patient. Delays in escalating care may lead to unnecessary patient morbidity and mortality. There is currently a paucity of synthesis of work focused on the initiation of escalation of care in the emergency department (ED), where unique challenges may be present. We sought to complete a scoping review to investigate: (1) factors (barriers and/or facilitators) affecting clinicians in escalating care in the ED; and (2) tools that support clinicians in ED escalation of care processes.

METHODS

We conducted a scoping review guided by the Arksey & O'Malley framework, and in accordance with PRISMA Scoping Reviews (PRISMA-ScR) checklist. Searches were conducted in MEDLINE, EMBASE and CINAHL on November 30th, 2020. Extracted data was analyzed via qualitative content analysis. Review and data abstraction were completed by two independent reviewers. Discrepancies were resolved via consensus meetings with a third reviewer.

RESULTS

Of the 4527 unique records identified, 13 studies met our inclusion criteria. Studies described standard escalation practices including detection, reporting, and response. Factors influencing escalation of care were described on individual (confidence, comfort, and expertise), interpersonal (communication and the nurse-physician relationship), organizational (workload and staffing), and environmental (distractions and layout) levels. Four ED-specific tools for escalation of care were also identified.

CONCLUSION

This scoping review identified 13 studies that contained information on processes, factors influencing and/or tools used to facilitate escalation of care in the ED. They may serve as valuable starting points for ED clinicians and administrators who are building or reforming local escalation of care processes.

Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis

BACKGROUND

The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care.

AIM

The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS.

METHODS

The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings.

RESULTS

Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain.

CONCLUSION

Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.