Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review

Abstract

IntroductionNurses often recognize deterioration in patients through intuition rather than through routine measurement of vital signs. Adding the ‘worry or concern’ sign to the Rapid Response System provides opportunities for nurses to act upon their intuitive feelings. Identifying what triggers nurses to be worried or concerned might help to put intuition into words, and potentially empower nurses to act upon their intuitive feelings and obtain medical assistance in an early stage of deterioration. The aim of this systematic review is to identify the signs and symptoms that trigger nurses’ worry or concern about a patient’s condition.MethodsWe searched the databases PubMed, CINAHL, Psychinfo and Cochrane Library (Clinical Trials) using synonyms related to the three concepts: ‘nurses’, ‘worry/concern’ and ‘deterioration’. We included studies concerning adult patients on general wards in acute care hospitals. The search was performed from the start of the databases until 14 February 2014.ResultsThe search resulted in 4,006 records, and 18 studies (five quantitative, nine qualitative and four mixed-methods designs) were included in the review. A total of 37 signs and symptoms reflecting the nature of the criterion worry or concern emerged from the data and were summarized in 10 general indicators. The results showed that worry or concern can be present with or without change in vital signs.ConclusionsThe signs and symptoms we found in the literature reflect the nature of nurses’ worry or concern, and nurses may incorporate these signs in their assessment of the patient and their decision to call for assistance. The fact that it is present before changes in vital signs suggests potential for improving care in an early stage of deterioration.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0950-5) contains supplementary material, which is available to authorized users.

Non-technical skills required to recognise and escalate patient deterioration in acute hospital settings

“…Nurses in McDonnell et al's (2013) study knew when to follow their intuition, disregarding normal vital signs, which was concurrent with Hart et al's (2016) findings, who also suggested that without close assessment and intuition, deterioration on acute wards can be missed as patients with normal vital signs may not be flagged for attention by support staff as they may not recognise the more subtle signs. The use of vital sign monitoring was also noted as different between inexperienced and experienced nurses, with experienced nurses using objective data tools such as EWS to validate intuitive feelings, rather than relying on this to be the first clue to deterioration (Odell et al 2009, Douw et al 2015, Mok et al 2015, and to provide objective data to use during escalation. Findlay et al's (2012) study showed that many in hospital cardiac arrests were predictable and with the correct use of an EWS and a full systematic assessment, incorporating nursing intuition, they could have potentially been avoided.…”

Rapid Response Systems: how to interpret levels of evidence

“…A comparison between objective and subjective criteria of the MET calls detected that the "worried" criterion was the most frequent reason for MET activation [102]. Douw and colleagues [103] suggested that signs underlying the worry or concern of the nurses, present before changes in vital signs, were potential early indicators of deterioration.…”

User acceptance of observation and response charts with a track and trigger system: a multisite staff survey

“…Exploration of the optimal ranges for vital sign parameters (Kyriacos et al 2011), interprofessional communication and collaboration within the context of clinical deterioration , Elliott et al 2015, and what other factors influence nurses' decisions in complex sociotechnical workplaces (Jones et al 2011, Astroth et al 2013, Douw et al 2015, Elliott et al 2015 during an identified episode of clinical deterioration, require further evaluation.…”