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

Abstract

Background: Early warning systems (EWS) are most effective when clinicians monitor patients' vital signs and comply with the recommended escalation of care protocols once deterioration is recognised. Objectives: To explore sociocultural factors influencing acute care clinicians' compliance with an early warning system commonly used in Queensland public hospitals in Australia. Methods: This interpretative qualitative study utilised inductive thematic analysis to analyse data collected from semi-structured interviews conducted with 30 acute care clinicians from Queensland, Australia. Results: This study identified that individuals and teams approached compliance with EWS in the context of 1) the use of EWS for patient monitoring; and 2) the use of EWS for the escalation of patient care. Individual and team compliance with monitoring and escalation processes is facilitated by intra and inter-professional factors such as acceptance and support, clear instruction, inter-disciplinary collaboration and good communication. Noncompliance with EWS can be attributed to intra and inter-professional hierarchy and poor communication. Conclusions: The overarching organisational context including the hospital's embedded quality improvement and administrative protocols (training, resources and staffing) impact hospital-wide culture and influence clinicians' and teams' compliance or non-compliance with early warning system's monitoring and escalation processes. Successful adoption of EWS relies on effective and meaningful interactions among multidisciplinary staff.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

“…What remains unknown is the impact of ward medical staff on the treatment of ward patients and escalation to external teams for clinical support. Studies have reported challenges encountered by nurses with ward medical staff and nurses’ fear of escalating without approval 38 39. One study showed nurses bypassing ward medical staff by manipulating VS and calling the external RRS 26.…”

“…Nurses’ decision making during clinical deterioration has been under-represented in research, which has focused on the failure to escalate when indicated. However, recognition of the various roles and responsibilities of health professionals within the clinical context is long overdue in studies investigating clinical deterioration 38 40. Mackintosh et al 41 used a sociological framework to challenge the idea of rescuing patients as a technical fix to suggest that structural and professional inequalities require closer scrutiny.…”

“…They suggested that a failure to rescue is not only an individual responsibility but spans the collective across various hierarchies. Similarly, a sociocultural framework developed after interviewing 30 clinicians explained the impact of intraprofessional and interprofessional factors and context on escalation 38. Bingham et al 26 interviewed 30 nurses who reported balancing uncertainty and managing complex interdisciplinary team dynamics for deteriorating patients.…”

Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

“…[11,[57][58][59] Guidance on developing, implementing, evaluating and publishing complex interventions are available [13,59], but there are few actual case studies of implementing complex interventions in healthcare and relating to early warning systems. [60,61] The early warning or rapid response literature has focused broadly on 'does the score/response team work' [1,2,3,8,10] and, more recently, attempts to understand why the score/response team appears to work in single-centre studies and not large multi-centre studies [3,10,25,56,62,63]. It could be that the score/response team doesn't work or it could be that the implementation science is key.…”

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

“…Moreover, as the process creates a set of individual observation schedules, it has been argued that conformance is further impacted by the complexity of competing clinical priorities. 4 While conformance challenges have been demonstrated in specific case studies, 5. , 6.…”