Warning tool signs

You can download the tool here and a checklist poster. Significant Care aims to help carers both at home and in a care home setting to identify the signs of deterioration in the person specifically related to their skin, toilet habits, mobility and levels of confusion, and take prompt action. It contains easy to use prompts to help recognise if someone is becoming unwell and how to call for help.

You can aso download a checklist and poster. Updated report of a working party. London: RCP, More information here. The films on this page are part of a Health Education England e-learning package. To obtain a certificate of learning, it is recommended that you access the films as part of the full training on their e-Learning for Healthcare e-LfH hub.

These documents are available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University. As the data analysis progressed and the codes and preliminary themes within each element of the activity system were reviewed, tensions within or between these elements emerged. In the further stages of analysis, attention was directed towards these tensions, which are thematized as findings in this study.

The themes were named in terms of tensions revealed in relation to particular elements in the activity system model. The system consists of a shared aim of practice, which is to work with the patient the object to achieve specific goals and outcomes. It also includes the nurses the subjects who work with patient care, the instruments used in the work to meet needs and solve problems the tools , the implicit and explicit regulations and guidelines that influence actions the rules , the general hospital wards with nurses and doctors the community of practitioners and the organization of personnel and the responsibilities of those involved in the activity the division of labour.

Finally, a consensus was obtained on how to understand and report the findings. The researchers received written permission from the current director of the hospital, who also granted access. Information regarding the study was given to the heads of the different units and to the participants before each seminar and simulation.

Any information that might have revealed the identity of participants was altered in the field notes and during the study process to prevent any possibility of recognition. During the sessions, it became apparent that the participating nurses had quite different opinions about NEWS. However, it was widely acknowledged that the need for NEWS was linked to experience. Some nurses believed that NEWS was incomplete and they were worried that the attention to the vital measurements connected with NEWS would be at the expense of other observations such as skin status, pain, urine output, facial expressions and conversations and general contact with patients.

This is illustrated in a seminar field note:. One of the nurses, called Gina, starts talking about a recent patient they had in the unit. Gina describes her perception of the situation. She says that the doctors were preoccupied with the measurement and that the patient did not score high enough on the SOFA criteria.

Gina considered the patient to be ill, she observed changes in skin colour and increasing confusion and she described how she was really worried.

Gina felt that the observations she conveyed were not listened to by the doctors because the patient did not score high enough on the SOFA criteria. The tool referred to is the Sequential Organ Failure Assessment SOFA score, which numerically quantifies the number and severity of failed organs in patients with suspected sepsis.

According to the nurses, using a score in some situations could undermine the use of their own clinical judgement. Everything is going to be standardized. Observations of the nurses during the sessions showed how they engaged and interacted with each other and the instructor.

During the simulation sessions in particular, it became apparent how the nurses collaborated and constantly supported each other with advice. Some nurses assumed that NEWS could help the unit to obtain an overview of the patients in the practice community and to identify which patients needed to be closely monitored. Others expressed concern that the level of stress and anxiety in their practice community would increase after implementation of NEWS, especially when seeing a red extreme score on the NEWS chart:.

The seminar instructor distributed the pocket cards with the NEWS score. It remained quiet for a while as the nurses looked at the card they had received. Then one nurse commented [on] how NEWS will lead nurses to quickly become alarmed and get stressed, particularly when there is a red score and the requirement is continuous monitoring.

Other nurses followed up by pointing out that during shifts with fewer nurses in the ward, especially the night shift, feeling alarmed and stressed could be pertinent. The instructor allowed the nurses to talk about it and asked about their current practice of taking measurements seminar field notes. The practice community in hospital wards includes doctors and some nurses expressed that implementing NEWS would have an impact on the collaboration with doctors.

Some expressed hope that the focus on vital signs might help them to communicate more succinctly with the doctors, while others feared that the communication might be reduced to a summarized score in which the underlying objective vital signs would not be reported. The nurses were taught in all the seminars that an anaesthesiologist should be summoned when the score requires it. Some of the nurses found it reassuring to know that an anaesthesiologist could be contacted, while others feared that they could be criticized for contacting a busy anaesthesiologist.

During the seminars, the nurses were taught that NEWS could help improve the system and structure for patient assessments. The instructor introduced the changes in the guidelines that point out which measurements are to be taken, how they are to be taken and how to write them in the new chart and in the observation scheme. One of the nurses commented that NEWS would help them to structure activities that are not performed very systemically today.

There seemed to be a general consensus that NEWS could provide a better structure and system for assuring the quality of vital sign measurements as well as raising awareness of their importance. However, the simulation sessions revealed how nurses assessed patients differently and that many forgot to measure the respiratory rate. In the simulation session debriefings, the participants discussed this and admitted that they did not comply with NEWS.

The nurses seemed to agree to place a greater emphasis on respiratory rate, showing each other techniques for carrying out the measurement. The discussions illustrated how NEWS response and escalation recommendations were perceived in a variety of ways.

Some nurses thought they were compulsory, while others believed they were optional depending on the situation. A common view among the participating nurses at the time of the study was that they worked independently and took responsibility to correct symptoms and vital signs that were affected.

During several simulation session debriefings, they talked about how they would treat patients and undertake prescribed actions that they had at their disposal before referring patients to doctors. The instructor has presented the NEWS pocket cards and the nurses are talking about their practice in the unit and how several patients will have a bad [high] score that will lead to frequent calls to the doctor, increased monitoring frequency and more work.

One of the nurses commented that they will have to call and pester the doctors and use resources that are intended for both the doctors and the nurses themselves. However, they also mentioned how NEWS could lead to high scores and frequent measurements and referrals among other patients with chronic diseases and the elderly. The nurses feared that doctors would not provide adequate plans for observing the patients with individually accepted values and that the nurses would be unable to comply with the response recommendations.

The overall impression gained from observing the nurses was that they appeared to have a strong commitment to patient safety and placed considerable emphasis in their role to recognize and respond to early signs of patient deterioration. The nurses in our study underlined the particular utility value of NEWS for new and inexperienced nurses and described it as a tool that could enable them to more readily identify deteriorating patients. However, it is interesting to note the ambivalence that the nurses displayed towards NEWS.

On the one hand, they welcomed the tool as a helpful aid in the assessment of patients and as a reminder of the importance of vital signs in clinical practice. On the other hand, they seemed concerned that using a standardized tool like NEWS would affect and somehow hamper their ability to rely on and use their professional competence in the assessment of patients.

The nurses in our study seemed to perceive the situation in a somewhat less harmonious light. Their reactions were partly linked to the possibility that nurses might somehow become too dependent on numeric tool scores and hence undervalue their own clinical judgement of a situation. The first step is for nurses to actually perform the measurements and record vital signs and ensure that the measurements and score calculation are performed accurately. The second and this is the crucial point, is for nurses to perform according to the recommended response.

During the professional training in the simulation sessions, the nurses became more aware of the importance of vital sign measurements. This is in line with findings by Bliss and Aitken In particular, the respiratory rate was emphasized as significant, especially since the simulation sessions revealed that quite a few nurses tended to pay little attention to and overlook the respiratory rate.

Other studies have found that an increased focus on respiratory rate improves the recording and documentation of this vital sign Considine et al. Compliance and adherence to monitoring frequency and escalation recommendations are crucial to the functioning of NEWS.

Previous studies have shown that adherence to recommended monitoring frequency may sometimes fall by the wayside during busy periods due to prioritization of other tasks, a lack of monitoring equipment and different understandings of how to apply escalation recommendations Elliott et al. This might have led to an emphasis on findings confirming this. As a nurse in one of the units, the first author knows the field as an insider and is familiar with the group being studied Mercer, This insider status facilitated access and was important for assembling data and conducting analyses.

The other researchers RS and BT therefore read and discussed the research processes and findings to protect the report from such influence. This study was conducted at a hospital in Norway, and observations were made of general hospital ward nurses participating in seminars and simulation sessions. This study may indicate common categories or links between the setting observed and similar settings.

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