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Journal of Clinical Nursing - 2022 - Burke - Factors That Influence Hospital Nurses Escalation of Patient Care in Response

This systematic review synthesizes qualitative evidence from 18 studies across 7 countries to identify factors that influence hospital nurses' decisions to escalate patient care based on their early warning score (EWS). Four key themes emerged: 1) nurses strive to balance adhering to EWS protocols with using their own clinical judgement; 2) the importance of effective communication; 3) EWS protocols are both helpful and restrictive; and 4) navigating the complexities of the hospital system. The review supports the use of EWS as a system rather than just a score, and recognizes that nurses aim to balance multiple factors when deciding whether to escalate care for a deteriorating patient.

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Journal of Clinical Nursing - 2022 - Burke - Factors That Influence Hospital Nurses Escalation of Patient Care in Response

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Received: 13 September 2021 | Revised: 18 January 2022 | Accepted: 19 January 2022

DOI: 10.1111/jocn.16233

SPECIAL ISSUE ARTICLE

Factors that influence hospital nurses’ escalation of patient

care in response to their early warning score: A qualitative
evidence synthesis

Catherine Burke RGN, MSc, Nursing1 | Yvonne Conway MSc, Lecturer2

1
St Johns Hospital Urgent Care Center St
Johns Hospital St Johns Square, Limerick, Abstract
Ireland
Background: The Early Warning Score (EWS) is a validated tool that has improved pa-
2
Department of Nursing, Health Sciences
and Integrated Care, Galway Mayo
tient outcomes internationally. This scoring system is used within the hospital setting
Institute of Technology, Galway, Ireland to identify potentially deteriorating patients, thus expediting referral to appropriate

Correspondence
medical personnel. It is increasingly recognised that there are other influencing fac-
Yvonne Conway, Department of Nursing, tors along with EWS, which impact on nurses’ decisions to escalate care.
Health Sciences and Integrated Care,
Galway Mayo Institute of Technology,
Aim: The aim of this review was to identify and synthesise data from qualitative stud-
Galway, Ireland. ies, which examined factors influencing nurses’ escalation of care in response to pa-
Email: [email protected]
tients’ EWS.
Funding information Methods: The systematic search strategy and eligibility criteria were guided by the
No sources of funding or sources of
support in the form of grants, equipment
SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) frame-
and drugs were given to the authors in the work. Eleven databases and five grey literature databases were searched. Titles and
process of conducting this research.
abstracts were independently screened in line with pre-established inclusion and
exclusion criteria using the cloud-based platform, Rayyan. The selected studies un-
derwent 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.

Abbreviations: (I)SBAR, Identify, Situation, Background, Assessment, Recommendation; ANP, Advanced Nurse Practitioner; CASP, Critical Appraisal Skills Programme; COPD, Chronic
Obstructive Pulmonary Disease; DOH, Department of Health; ENTREQ, Enhancing transparency in reporting the synthesis of qualitative research; EQUATOR, Enhancing the QUAlity
and Transparency Of health Research; EWS, Early Warning Score; GRADE–CERQual, Grading of Recommendations Assessment Development and Evaluation–Confidence in the
Evidence form Reviews of Qualitative Research; INEWS, Irish National Early Warning Score; INEWSv2, Irish National Early Warning System Version 2; MEWS, Modified Early Warning
Score; NCEC, National Clinical Effectiveness Committee; NCG, National Clinical Guideline; NEWS, National Early Warning Score; NICE, National Institute for Health and Care
Excellence; ORC, Observation & Response Chart; PICO, Population, Intervention, Comparison, Outcome; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-
Analyses; QES, Qualitative Evidence Synthesis; QESs, Qualitative Evidence Syntheses; RCOP, Royal College of Physicians; RETREAT, Review question/Epistemology/Time/Resources/
Expertise/Audience and Purpose/Type of Data; RGN, Registered General Nurse; SAEs, Serious Adverse Events; SMART, Specific/Measurable/Achievable/Realistic/Timely; SPIDER,
Sample, Phenomenon of Interest, Design, Evaluation, Research Type; T&T, Track and Trigger; ViEWS, Vital Pac Early Warning Score; WHO, World Health Organisation.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.

J Clin Nurs. 2023;32:1885–1934. wileyonlinelibrary.com/journal/jocn | 1885

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 an-
swer 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.

KEYWORDS
clinical deterioration, early warning system, escalation of care, nurse, qualitative research

1 | I NTRO D U C TI O N
What does this paper contribute to the wider
To prevent serious adverse events (SAEs), hospitals require tools
global clinical community?
that help them recognise patients at risk and guide them in giv-
1. Supports the use of the Early Warning Score as a system
ing the right care at the right time (Alam et al., 2014). SAEs such
rather than a score and recognises that nurses strive
as sepsis, cardiac arrest and even death are frequently preceded by
to strike a balance between adherence to EWS proto-
physiological abnormalities (Alam et al., 2014; Connolly et al., 2017).
cols, using their own clinical judgement and manage the
Early Warning Score (EWS) tools are observation charts that have
communication complexities present within hospital
been designed to enable users to gradually and consistently track
domains.
and chart patient's vital signs (Elliott et al., 2015). It uses a numeri-
2. Highlights the multifactorial nature of processes used by
cal scoring system, which signals physiological changes that detect
nurses when deciding whether to escalate care based
patients in danger of deterioration.
on patients EWS score and suggests consideration of
The EWS is used predominately by nurses for documenting vital
information garnered from other sources
signs and escalating care in response to patient acuity (Flenady et al.,
3. Underscores nurses’ perceptions that the Early Warning
2020). The National Institute for Health and Care Excellence (Centre
Score facilitates multidisciplinary SMART communica-
for Clinical Practice at NICE [UK] 2007) guidelines recommend the
tion and optimally results in expedited care and positive
use of vital sign parameters to calculate an overall score which cate-
patient outcomes but can have its flaws depending on
gorises patient's acuity level and subsequently triggers nursing staff
its use and if used in isolation.
to request a medical evaluation (Mitchell et al., 2010). A National
4. Nurses lack of commentary on the (I) SBAR communica-
Early Warning Score (NEWS) system was introduced in Ireland
tion tool raises the question of its perceived relevance
in 2013 and was updated in September 2020 as INEWSv2 (Irish
and utilisation, especially given the complexity of clini-
National Early Warning System, version 2) (Department of Health,
cal decision making related to acuity and deterioration.
2020) (Figure 1). Modifications of EWS are used internationally;
Comparison of communication systems in differing
however, they all have the same purpose to ensure prompt detec-
healthcare systems is required to provide insight into
tion of the unwell patient and activate a response (Foley & Dowling,
optimal ways in which to communicate patient deterio-
2019; Jensen et al., 2019). EWS use can be seen throughout health
ration and escalation
services in the United Kingdom, Europe, Australia and America
(Gerry et al., 2020).

of patients’ vital signs (Dalton et al., 2018; Jensen et al., 2019). This is
1.1 | Problem Identification recognised in the INEWSv2 which in response to a systematic review
by the Health Research Board Collaboration for Clinical Effectiveness
Nurses are the largest professional group in any acute setting and as Reviews (2018) included the proviso that a registered nurse may use
such have a strong role to play in the surveillance and interpretation his/her own clinical judgement and defer escalation of care (max.
|

F I G U R E 1 INEWS Chart (Department of Health 2020) [Colour figure can be viewed at wileyonlinelibrary.com]

30 min) in response to patients EWS (Department of Health, 2020). et al., 2021). Moreover, the scoping exercise identified several ad-
This amendment to the national clinical guidelines prompted the ditional relevant qualitative studies which had not been included in
principal researcher to conduct an initial scoping exercise. Initial previous reviews (Dalton et al., 2018; Ede et al., 2020; Flenady et al.,
scoping strategies are recommended prior to QES as it allows a re- 2020; Foley & Dowling, 2019; Jensen et al., 2019). These discover-
searcher to extend their knowledge, familiarise themselves with the ies aided in the development of inclusion and exclusion criteria and
topic prior to commencing a comprehensive systematic search and provided the rationale for conducting a QES that solely examined
identify all relevant available data (Gusenbauer & Haddaway, 2020a). nurse's decision making in the context of EWS use.
The initial search in this instance found studies which confirmed
the predictive power and reliability of the EWS and its positive ef-
fect on patient outcomes—ICU transfer, cardiac arrest and in hospi- 2 | A I M S A N D M E TH O DS
tal mortality (Fu, Li.-Heng et al., 2020). However, others suggested
that nurses experienced organisational, clinical and behavioural The aim of this review was to identify and synthesise data from pri-
challenges when identifying and acting on patient deterioration mary qualitative studies, which examined the factors influencing
(Massey et al., 2016). Griffiths et al. (2018) revealed 44% of patients nurses’ decisions to escalate care in response to patients’ EWS.
in high acuity categories (EWS 6+) were not escalated. Credland Booth et al. (2018) seven domain RETREAT framework was
et al. (2018) found nurses experienced some frustration with EWS used to inform the principal considerations when selecting QES
use and its perceived inflexibility with a resultant lack of compliance approaches and Thomas and Harden’s (2008) thematic synthesis
reflected in issues around inaccurate scoring, chart omissions, in- method used for analysis. Thematic synthesis allows for an organised
correctly calculated EWS and non-adherence with monitoring fre- and structured approach to the development of descriptive analyti-
quency and escalation protocols. Significantly, previous QES did not cal themes drawn from the primary data (Flemming & Noyes, 2021).
examine nurses exclusively in the context of their decision making Whilst quantitative evidence can examine empirical evidence such
and EWS use, rather they had broader sample inclusion criteria, thus as utilisation, cost and clinical effectiveness, it cannot measure other
enabling the addition of studies which recruited health care workers outcomes such as the choices people make or the factors that influ-
(HCW) as part of the study population (Connolly et al., 2017; O'Neill ence why people make certain choices (Curry et al., 2009). Qualitative
|

research delves into people's experiences or their perceptions in a [C.B.] and [MO’N.] with resolution of conflicts from [Y.C.]2, resulting
particular setting. In healthcare it strives to explain the phenomena in 18 studies being selected for synthesis (Table 3). Full text screen-
of interest by exploring individual experiences, behaviours and the ing was employed to ensure articles fully complied with set inclusion
environment in which social interactions take place (Lockwood et al., criteria. Pre-set inclusion and exclusion criteria were systematically
2015). Using the QES process allows a researcher to acquire a bet- applied to the title and the abstract, thus ensuring the studies fit
ter understanding of these experiences, beliefs and perceptions, by the criteria and were relevant to the review question (Dundar &
combining the results of the individual studies in such a way that adds Fleeman, 2017).
quality or complexity to the original findings (Flemming et al., 2019). The Preferred Reporting Items for Systematic reviews and Meta-
The research question for the review was as follows: What are the Analyses (PRISMA) guidelines (Moher et al., 2009) were employed
factors that influence nurses to escalate care in response to patients’ and are illustrated in a flow chart (Figure 2).
Early Warning Scores? The findings were synthesised and reported
using ENTREQ guidelines (Enhancing Transparency in Reporting the
Synthesis of Qualitative Research, Supplementary File 1). 2.3 | Quality Assessment

Quality appraisal of the eighteen studies using the CASP tool was
2.1 | Search Strategy carried out simultaneously with data extraction (Noyes and Lewin
2011). The WHO and Cochrane endorse CASP for novice research-
The search strategy began with refining the research question using ers when undertaking a QES (Long et al., 2020). The results of the
the SPIDER framework (Sample, Phenomenon of Interest, Design, quality assessment were tabulated and presented (Table 4). Studies
Evaluation, Research) (Cooke et al., 2012). This allowed for exten- were not excluded even if their CASP score suggested weaknesses
sion of the question formulation and best suited the nature of the as they can still make a significant contribution to a QES (Boland
question being asked (Flemming & Noyes, 2021). Main headings et al., 2017; Thomas & Harden, 2008). GRADE–CERQual analysis
and search strings were formulated with the assistance of a senior (Lewin et al., 2018) examined confidence in the eighteen review
medical librarian as database knowledge of truncation and wildcard findings (Table 7).
operators is essential (Butler et al., 2016) (Table 1). The structure of
the SPIDER framework was also adapted to map the inclusion and
exclusion criteria in an unambiguous manner (Table 2). 2.4 | Data Extraction and thematic analysis
A 3-part comprehensive strategy was employed using databases,
hand-searching and grey literature searches (Butler et al., 2016). An adapted version of Houghton et al.’s, (2016) data extraction form
Eleven databases and five grey literature databases were searched (permission given) was used as a blueprint to specify and exhibit each
(Appendix 1). The goals of a systematic search are the identification of the studies in terms of context (setting, participants and inter-
of all available relevant papers, in a transparent and reproducible way vention) as well as study design, methodology, findings and quality
(Gusenbauer & Haddaway, 2020a). Booth et al. (2016) and Salah et al. of the study (Noyes & Lewin, 2011). This format assisted with both
(2014) emphasise the importance of including grey literature as it re- the interpretation and subsequent codifying of the data. All studies
duces the risk of publication bias. The database searches were aug- were treated in the same way, which paved the way for a more ana-
mented by citation chaining (Dundar & Fleeman, 2017), and the search lytical and interpretive data synthesis later. A characteristics table
concluded with a Google Scholar check. Google scholar is recom- displaying individual study methods, participants, results and CASP
mended as an overall control check (Gusenbauer & Haddaway, 2020b) score was developed (Table 3).
and is cited as useful in identifying unique references and enhancing Thematic analysis was undertaken by CB and YC. Thomas and
overall recall when used in combination with other databases (Bramer Harden’s (2008) three-step approach was used to synthesise the
et al., 2017). A total of 1,846 studies were imported into Endnote ver- findings. Firstly, line-by-line coding was performed, secondly, these
sion x9. Removal of duplicates resulted in 821 papers being uploaded codes were grouped together which resulted in the development of
into the Rayyan database for eligibility screening (Figure 2). descriptive themes. Lastly, these themes were further refined and
led to the generation of the four analytical themes which answer the
research question (Table 5). Quotations reflective of the descriptive
2.2 | Screening and Study Selection themes were tabulated (Table 6).
After data synthesis and analysis, the findings were examined
To ensure transparency, screening was carried out in two stages by using GRADE–CERQual to determine levels of confidence in the
two reviewers (Waffenschmidt et al., 2019) using the Rayyan soft- evidence. This results in a judgement of confidence in each find-
ware platform to assist with the screening and selection of studies. ing under four components: methodological limitations, relevance,
The first stage saw [C.B.]1 and [M. O’N.]3 independently review the coherence and adequacy of data (Lewin et al., 2018). The use of
title and abstract of 821 studies using pre-determined inclusion/ex- GRADE–CERQual assessments is increasingly considered best prac-
clusion criteria. Full text screening was carried out on 55 studies by tice by reviewers (Flemming & Noyes, 2021) (Table 7).
TA B L E 1 SPIDER Search strings

D
BURKE and CONWAY

Design R
S P -I Descriptive Research E Research
Sample Phenomenon of Interest Incorporating Evaluation Qualitative
SPIDER Registered Nurses Early Warning score experiences Escalation of care Or Mixed Method

Search: Keyword:1: Keyword 2: Keyword 3: Keyword 4:

Note: Column D (Design) & Column Nurse* Early Warning Score MH ‘Focus group*’ OR Escalation of care Qualitative Research
R (Research) also combined and all fields Interview* MH
searched with Boolean Operator searched OR ‘Observation’ OR
OR before all elements were Phenomen*
combined with Boolean AND OR
Synonyms: AND ‘Early Warning System’ AND ‘Grounded theory’ AND ‘escalation of care’ ‘Qualitative’ OR
OR OR Ethnograph* OR OR ‘Mixed Method’
‘warning system’ Lifeworld ‘Escalate Care’ OR
OR OR ‘Conversation OR ‘Mixed Methods’
‘warning score’ analysis’ ‘clinical deterioration’
OR OR OR
‘EWS’ ‘Action research’ ‘deterioration’
OR OR Hermeneutic OR OR ‘deteriorating’ OR
‘physiological monitoring’ Narrative ‘response team’
OR ‘physiological scoring OR OR
system’ ‘Content analysis’ ‘rapid response’
OR OR OR
‘MEWS’ Colaizzi* ‘medical emergency
OR OR team’
‘Modified Early Warning Score’ Heidegger OR
OR OR ‘outreach’
‘national early warning score’ ‘Van Manen’ OR OR
OR ‘Merleau Ponty’ ‘critical care
‘NEWS’ OR outreach’
OR Husserl OR
NEWS2 OR Questionnaire ‘worsening vital
OR signs’
‘Track and Trigger system’
OR
‘vital signs’ OR
‘vital sign score’
| 1889

TA B L E 2 Inclusion and Exclusion Criteria using SPIDER Framework

SPIDER Inclusion Criteria Exclusion Criteria

S Sample Registered Nurses Undergraduate / Student Nurses.

Only studies involving adult patients ≥16 years of Enrolled Nurses/ LPN (licensed practical nurse)
age will be included. -work under the guidance of a Registered
Rationale: Nurse they do not interpret clinical data.
To represent the specific populations under study in Rationale:
the research question. The research question is specific to qualified
registered nurses only.
Midwives/ Student midwives.
Paediatric Nurses.
Critical Care Nurses.
Emergency Nurses.
Rationale: Worthy of their own study
P of I Phenomenon of Interest Studies must include the main concepts of the Studies that do not include Registered Nurses and
question and the research design: track and trigger systems.
1. Registered Nurses. Studies outside the acute hospital setting, that is
2. Early Warning Score or System, different community, long term settings.
iterations can be included, that is EWS/MEWS/ Studies in critical care areas (intensive care and
Track and Trigger/ Views/NEWS/NEWS2/ORC. high dependency).
3. Escalation of Care or Clinical deterioration or Studies in Accident and Emergency or Psych unit.
Rapid Response. Rationale:
Rationale: These are different phenomena of interest that are all
To answer the research question worthy of their own study.
Exclude Studies:
Studies on Paediatric warning scores
Studies on Obstetric warning scores
Rationale:
The scoring systems used in paediatric patient (i.e.,
aged <16 years) populations are different and/or
pregnant patients.
D Design Include: Exclude:
Qualitative studies or Mixed Method Studies Quantitative Studies or Mixed methods studies
where qualitative element is clearly presented. without the qualitative element clearly
Studies with Focus Groups/ Observations/Case presented.
Study/Realist Evaluation/ Semi-structured Studies where data is collected qualitatively and
Interviews/Interviews. then use descriptive analysis (e.g. quantitative
The design, methodology and type of analysis analysis).
must be qualitative and clearly reported (e.g. Rationale:
thematic analysis or grounded theory). There are many quantitative studies on the validity
Rationale: of the EWS system in monitoring deteriorating
These designs provide the rich data that is the essence patients and they have shown positive outcomes.
of good qualitative research. There are quantitative studies that identified patterns
of compliance with the EWS system, but this
review is looking at what factors influence nurses
in their escalation of care in response to patients
EWS –a qualitative evidence synthesis.
E Evaluation Escalation of Care
R Research Studies must be empirical and provide a description Literature reviews or Editorials are excluded
of the sampling approach and data collection because they are not primary studies.
processes and type of analysis used.
Language English language Non-English language
Be published in a peer-reviewed journal (Grey Studies where full text is unavailable.
literature excluded). Every effort will be made to obtain the full text of
Rationale: studies (e.g. unpublished theses). This may be
Ensures rigour. done by interlibrary loans or by contacting the
authors directly. Due to time constraints if the
text cannot be acquired within 2 weeks it will
have to be excluded.
|

F I G U R E 2 PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources
[Colour figure can be viewed at wileyonlinelibrary.com]

3 | R E S U LT S 3.1 | Theme 1: Marrying Clinical Judgement

with EWS
Eighteen studies across seven countries were included in the final
synthesis (12 qualitative studies, 4 mixed methods and 2 case 3.1.1 | Finding 1: Nurses strongly value using
studies) (Table 3). The studies were published between 2005 and clinical judgement concurrently with the EWS tool
2020 and spread across three continents. Over 235 nurses are
represented in the studies reflecting a diverse picture of nurs- Twelve studies illustrated nurses’ confidence in their clinical judge-
ing grades and years of experience (ranging from 5 months to ment when responding to patient deterioration and EWS (Andrews
30 years). The track and trigger scoring tools used by nurses in & Waterman, 2005; Donohue & Endacott, 2010; Ede et al., 2020;
the included studies were EWS (10 studies), MEWS (4 studies), Elliott et al., 2015; Flenady et al., 2020; Foley & Dowling, 2019;
NEWS (2 studies), T&T (1 study) and ORC (1 study). A sample Jensen et al., 2019; Lydon et al., 2016; Mackintosh, 2012; Mc
verbatim quotation reflective of each finding is presented here Gaughey, 2013; Petersen et al., 2017; Suokas, 2010).
with further illustrative quotes reported in (Table 7). Quotation
pseudonyms are written as they appeared in primary studies. All ‘You must use the tool and your clinical judgement. You
findings have several representative quotes apart from finding must collect vital signs and think about the measure-
18 which refers to the hospital environment and its impact on ments, but you also must look at, touch, and listen to the
nurses’ escalation of care. This finding has only one quote reflec- patient and, together with the score, create a clinical pic-
tive of this sub-t heme, and as a result is listed as being of low ture; then all you have done has value. The whole point is
confidence in CERQual Table (Table 7). This approach is deemed that all of this is part of being a good clinician’. (Camilla,
appropriate with arguments made for the inclusion of low quan- 22 years of experience) (Jensen et al., 2019, p. 4393)
tity data as it can highlight areas for further research (Glenton
et al., 2018). The resultant four analytical themes were (1)
Marrying clinical judgement and EWS (2) SMART communication 3.1.2 | Finding 2: The EWS tool should not be used
(3) EWS protocol—A blessing and a curse (4) Hospital domain. in isolation
A conceptual model depicting the role of the nurse in balancing
these competing suppositions in the context of a patients EWS Solely relying on the EWS to determine whether a patient was de-
was developed (Figure 3). teriorating and consequently escalating care on this basis alone was
| 1892

TA B L E 3 Study characteristics

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

1 Andrews and 2005 U.K. Qualitative data in the Purposive sampling; one surgical and one Grounded theory (Glaser and To investigate Ward 9/10
Waterman form of Interviews and medical ward of a teaching hospital. Strauss 1967), cyclical nature, staff experiences -Researcher
Observations. 30 Nurses each interview was coded, open of the EWS reflexivity
44 interviews with a mean 7 Doctors coding continued until patterns system when not
time of 55minutes. 7 Healthcare support workers. emerged followed by selective communicating illustrated.
Observations lasting coding. physiological -Limitation:
between 3 and 8 hours deterioration. confined to
long. two wards
only.
2 Cherry and 2015 U.K. Mixed Methods Design: Convenience sampling was chosen Quant part: Descriptive and To explore the attitudes 9/10
Jones Questionnaire and Focus qualified nursing staff on the AMU demographic data were of qualified nursing -Issues around
Group. were recruited. presented using SPSS. staff using the Recruitment
Quant Part: 9 nurses a questionnaire was Qual Part: Focus group findings MEWS system in strategy.
given to 3 nurses from each of the were transcribed verbatim, and an AMU in an acute
NHS bands: a framework analysis technique hospital.
Band5/Band6/Band7. was used. This involves reading
Qual Part: The focus group consisted of and reviewing of transcripts,
6 nurses, one band 7, one band 6 and identifying codes and themes from
four staff nurses. the data and refining them.
3 Dalton et al 2018 U.K. Qualitative, generic Purposive sampling, Medical and Surgical Traditional content analysis by To discover what 9/10
approach, semi- wards within an acute NHS trust. researcher and participants factors, influence -Researcher
structured interviews. 10 Registered Nurses themselves were asked to how nurses reflexivity
A modified validated with 2 years post-reg experience and validate the transcript as a true assess patient not
questionnaire was used who can recall a retrospective or reflection of their interview. acuity and their illustrated.
with permission from prospective account of caring for a Followed by Thematic analysis response to patient
Mc Donnell et al 2013. deteriorating patient. of data was selected this was deterioration.
chosen due to its compatibility
with generic qualitative analysis.
4 Donohue and 2010 U.K. Qualitative design with Purposive Sampling Thematic Analysis was used and To examine nurses 8/10
Endacott Critical Incident 11 Registered nurses applied to individual interview and critical care -Researcher
Technique to structure The nurses experience and seniority transcripts and then across outreach staff reflexivity
data collection. were evenly distributed transcripts to identify themes perceptions of not
Semi-structured interviews All had managed a deteriorating patient, and categories in the data. management of illustrated.
with nurses who had 3 were members of outreach team. deteriorating -Ethics not
managed a patient patients. addressed in
referred to Outreach text.
team.
BURKE and CONWAY

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

5 Ede et al 2020 U.K. Qualitative Observational 55hrs of qualitative observations were Thematic analysis using a grounded To map the barriers and 9/10
research with semi- conducted on 12 different medical theory approach. facilitators to the -Recruitment
structured ad hoc and surgical wards at two hospital Data were open coded. All text escalation of care process not
interviews. sites in one national health service was coded under dominant in the acute ward detailed
trust themes present in passage of setting and identify ad hoc
text and then axial coding took those that are interviews.
place where relationships were modifiable. -COREQ
determined between themes 32-point
followed by selective coding to checklist for
further explore themes of high reporting
relevance to research question. was used.
6 Elliot et al 2015 Australia Qualitative Focus Groups: Purposive sample: Thematic snalysis using Examines initial clinical 8/10
Semi-structured focus 8 trial sites were recruited, inductive reasoning guided user experiences -Unclear sample
groups conducted by 44 focus groups with 218 clinical ward by Gibbs framework of and views following very broad
the site project officers. staff. 1) transcription 2) code implementation of description:
Semi-structured Focus Groups. Median building 3) dis/confirmatory Observation and ‘most were
participants per group was 5 most theme development 4) data Response Charts nurses’.
were nurses. consolidation and Interpretation (ORC) a Track and -Researcher
Staff had received training and used the Trigger System reflexivity
charts in practice 2–6 weeks prior to in adult general not
study. Site medical and surgical illustrated.
wards.
7 Flenady et al 2020 Australia Qualitative Interpretive Purposive and snowball sampling, Thematic Analysis following To explore sociocultural 9/10
Study. participants were encouraged to Braun and Clarkes six stage factors influencing -Researcher
Phone interviews (none share website link with colleagues. Framework. Thematic review acute care reflexivity
longer than 60 mins) A total of 30 participants and theming of definitions clinician's not
were performed by 10 medical officers (8 male, 2 female) was conducted independently compliance with illustrated.
two members of the 20 nurses (2 male 18 female). by three researchers who an EWS used in
research team. Located across 3 different hospital sites discussed and documented Queensland public
rural/ regional/ metro. findings during group meetings. hospitals, Australia
This added to the rigour of the
study.

(Continues)
| 1893

TA B L E 3 (Continued)

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

8 Foley and 2019 Ireland Case Study design was 9 nurses and 2 HCAs participated. Systematic Text condensation was To describe how nurses 9/10
Dowling adopted to explore (2 HCAS were observed, and 7 nurses used (Maltreud, 2012). This is a use the EWS in -Researcher
views and experiences were observed and interviewed) An 4-step approach to analysis that an acute medical reflexivity
of nurses using the EWS 8th nurse was interviewed but not is influenced by Giorgi's four ward and their not
on an acute medical observed. step phenomenological method. compliance with the illustrated.
ward. -Interview and Observation data EWS and to explore
Data Triangulation was used were read to gain an overall their views and
including impression. experiences of the
-non-participant -Units of meaning were identified EWS.
observation that focused on EWS practice
-semi-structured interviews and were collated together.
-document analysis. -Units of meaning were then
reviewed by authors in the
context of the documents
reviewed.
-L astly, the overall units were
synthesised into relevant
themes incorporating all three
data collection methods.
9 Gazarian et al 2010 U.S.A. Qualitative, descriptive Purposive sampling assured the inclusion Cognitive Task Analysis consisting To describe the cues −9/10
study using the critical of several types of incidents (CPA, of four phases: and factors that -Researcher
decision-making method transfer to ICU or a RRS consult) -Preparation influence nurses reflexivity
to describe the nurse's and ensured these events involved a -Data Structuring in their decision- not
decision-making process staff nurse competent in identifying -Discovering Meanings making process illustrated.
in a prearrest period. patient deterioration and activating -Representing Findings. when identifying
Interviews were conducted. RRS. Two complementary approaches to and interrupting
13 female Registered Nurses on four analysis were used in the study a potentially
medical wards who had experience A structured approach using a priori preventable
of a prearrest period participated. framework based on research cardiopulmonary
questions. In this process arrest.
unanticipated patterns and
themes emerged.
Followed by analysis of emergent
themes.
BURKE and CONWAY

Study CASP
BURKE and CONWAY

No. Author Year Country Design/Method Sample Analysis Study Focus Score

10 Greaves 2017 U.K. Qualitative study using Purposive Sampling: taken from 2 acute Thematic analysis: To investigate how 9/10
constructivist grounded healthcare trusts in the North of themes were identified that issues between -Recruitment
theory. England. A general surgical and a provide a description of the professions, issues strategy
40 interviews were medical admissions unit both using observed phenomena, core between disciplines, issues: The
conducted. the same MEWS system. Doctors, concepts emerged, allowing the and authority refusal of any
Interview tool was piloted. Nurses, and Healthcare assistants: construction of theory. patterns affect the of the nurses
Data triangulation (n = 40). medical and nursing from the
took place across Foundation year 1 (House officer) team's responses Philippines
participants, professions Doctors: 6 to critical events to take
and teams. Foundation year 2 (Senior House Officer) in the context part in the
Doctors: 6 of formalised study which
ST Trainees (Senior House Officer) protocols for the made up
Doctors: 4 management 10% of the
ST Trainees (Senior Registrar) Doctors: 2 of adult patient workforce
Consultants:4 deterioration. and were
Staff Nurses: 6 employed on
Ward Sisters: 6 grade 5 the
Ward Managers: 2 most junior
Care Assistants: 6 level of the
Executive Director of Nursing:1 RN bands.
Executive Director of Patient Safety:1
11 Jensen et al 2019 Norway Qualitative study with a Purposive sampling Thematic Analysis was used to To explore hospital 9/10
hermeneutic design, 14 nurses (1 male, 13 female) from analyse the data (Braun and ward nurses’ -Recruitment
semi-structured in- different medical-surgical and Clarke 2006). experiences with strategy did
depth interviews. rheumatology wards in a state A hermeneutic circle was used to the NEWS and its not elaborate
funded hospital. facilitate a deeper impact on their on why
Nursing leaders in hospital asked bedside understanding of the interview text, professionalism. participants
nurses to participate. this involved moving back and were
Participation was voluntary. forth between parts of the data selected
All participants held a 3-year bachelor's and data set when interpreting from these
degree in nursing and professional findings. wards in
certification. particular.
Experience ranges from 5months to
22 years.
The data were collected 1 year after the
implementation of the NEWS.

(Continues)
| 1895

TA B L E 3 (Continued)

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

12 Lydon et al 2016 Ireland Mixed Methods: Participants were recruited using Qual Part: Deductive content To examine the 8/10
Qualitative phase, nurses judgement and snowball techniques, Analysis was used to analyse perceptions of -Issues around
and doctors participated interns were asked to identify other data. Qualitative analysis a national PTTS Recruitment
in a series of semi- potential participants. using the Theory of Planned amongst nurses strategy.
structured interviews. Qual part: 30 participants comprised of Behaviour (TBP) paradigm and doctors and -Researcher
Quantitative phase, nurses −10 nurses which provided background to identify the reflexivity
and doctors responded −2 NCHD for the Construction of a TPB variables that not
to a questionnaire −18 interns questionnaire for Quant phase. impact on intention illustrated.
designed to assess Quant part:215 Quant Part: Questionnaire used: to comply with
attitudes towards the Participants (24.1% response rate) Cronbachs α’s to analyse data protocol.
PTTS and factors that −80 nurses following these subscales were
influence adherence to −29 interns scored. Descriptive statistics
protocol. −58 NCHDS were used.
−31Consultant
−17 respondents did not specify
13 Mackintosh 2012 U.K. Qualitative methodology: Ethnographic fieldwork over a 12 The Framework approach was To explore rescue 9/10
Ethnographic approach month period in two UK NHS Trusts followed, which involves a practices to draw -Data collection
was chosen as an general medicine was selected in series of interconnected stages that out the associated Issues:
effective means of both sites. The research included enable the researcher to move interplay of Interviews
exploring frontline work health care assistants, nurses, back and forth across the data sociocultural and were largely
practices. doctors, managers and documentary until a logical report emerges organisational done with
Observation of interactions analysis. (Ritchie & Spencer 1994, Ritchie processes and the Senior staff
amongst multi- 180 hours of Observations & Lewis 2003). context of clinical as opposed
professional healthcare Interviewees were purposively selected This enables both inductive and work to junior
staff and patient for theoretical representativeness, deductive coding frames to be within medical wards. staff.
management processes, in terms of categories, substructures linked together and develop a
and semi-structured and networks from the social conceptual framework (Smith &
interviews. organisation. Firth 2011).
35 interviews:
Doctors:14
Ward Nurses: 7
Critical Care nurses: 2
Healthcare Assistants:4
Safety Leads and Managers:6
Trust Lawyer: 1
BURKE and CONWAY

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

14 Mc Donnell 2013 U.K. Mixed Methods Design: Quant Survey: All Nursing staff who Quant Part: data analysed using To Evaluate a new Track 9/10
et al before and after study. undertook observations on the 12 SPSS (paired t tests, McNemar and Trigger model -Researcher
BURKE and CONWAY

Survey and Semi-structured wards included in the study and tests) for the detection relationship
Interviews. were eligible to attend training Qual part: interviews analysed using and management or
The questionnaire was session on the new track and thematic framework analysis of deteriorating background
based on a pre-existing trigger tool. Participants were given (Ritchie and Spencer 1994) this patients on nursing not
instrument with face questionnaires at the start of each approach allows the integration staffs Knowledge illustrated.
and content validity. training session and six weeks after of pre-existing themes into and Confidence in
The questionnaire was the introduction of the new tool. the emerging data analysis an acute hospital.
piloted with staff on a Total surveyed: 213 and provides a clear analytical
ward not included in the Qual Part: structure.
study. Purposive Sample 15 Nursing Staff Five techniques:
were selected to ensure a range of Familiarisation
participants in terms of grade/ward/ identifying a thematic framework.
years qualified. Participants were Indexing charting
interviewed before the training and Mapping.
six weeks after the introduction of interpretation.
the new tool.
15 Mc Gaughey 2013 Northern Multiple Case Study Purposive sampling A cross-c ase analysis of the To evaluate factors 9/10
Ireland approach of four wards Stage 1: Interviews with policymakers. findings from the interviews, that enabled -Researcher
(Belfast) in two hospitals in Stage 2: key informants’ Individual observation and audit data or constrained relationship
Northern Ireland. It interviews and focus group allowed similarities and implementation not
followed the principles interviews differences to be identified and service delivery illustrated.
of realist evaluation Focus groups included: across case sites, medical of early warnings
research which allowed ▪ 6–8 ward nurses from each ward and surgical wards and key systems (EWS) and
empirical data to be (Medical & Surgical) in the two informants. The qualitative acute care training
gathered to test and case sites who have experience and quantitative data analysed in practice to
refine RRS programme and knowledge of EWS and ALERT from Stage 1 and 2 were provide direction
theory. A variety (n = max 32) triangulated to enhance the for enabling
of mixed methods ▪ 6–8 health care assistants from each completeness and robustness their success and
were used to test the ward (Medical & Surgical) in the two of the conclusions. The sustainability.
programme theories case sites involved in recording and transcripts were coded
including individual and reporting patient observations and according to the seven key
focus group interviews, using EWS (n = max 32) factors from the Greenhalgh
observation, and Non-participant observation was used to et al (2004) framework to
documentary analysis collect data about the organisation, allow indexing and retrieval
of EWS compliance structure and working conditions of in NViVO7 software (QRS
data and ALERT training the ward. EWS compliance data were 2006). To enhance reliability
records. collected to provide information on and reduce bias, the emerging
accurate completion of EWS charts categories were cross-checked
in practice. by a member of the supervisory
|

team.

(Continues)
1897

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

16 Petersen et al 2017 Denmark Qualitative study focus Purposeful sample. Potential participants Krippendorff's components of text To examine the barriers 9/10
groups were conducted were nominated by the head nurse of driven content analysis: and facilitators -Few verbatim
with nurses from a each ward. Only nurses with at least -Unitising amongst acute care quotes
medical acute care ward 3 months of employment on the ward -Sampling nurses to three provided
and a surgical acute care were eligible to participate. 18 nurses -Coding aspects of EWS more
ward. were enrolled: -Reducing protocol: sufficient
7 surgical (26% of total nurse staff) -Abductively and Inductively 1) adherence to data needed
and 11 medical (20% of total nurse inferring contextual phenomena monitoring to support
staff). Participation was voluntary. -Formulating answers to the frequency. findings.
Five Focus groups with a total of research questions. 2) call for junior doctors
3–5 participants in each. Aim was to to patients with an
include 2 nurses from each ward in a elevated EWS.
focus group. 3)call for the medical
emergency team.
17 Stewart et al 2014 USA Mixed Method design: Voluntary sample of 11 nurses who Quant part: Statistical package for The study had two 8/10
Quantitative Part: a worked on three medical and social sciences (SPSS) and graph parts: -Recruitment
retrospective review surgical wards units under study. pad were used. To retrospectively strategy
of medical records All registered nurses who worked Statistical methods: descriptive review medical issues.
from before and after on these units were eligible to statistics, independent sample t records -Ethics not
implementation of a participate in the focus groups. tests and ᵪ2 tests pre-and post- addressed in
MEWS system. −5 focus groups with between 1–4 Qual Part: Thematic Analysis was implementation of text.
Qualitative Part: nurse-led attendees were conducted. used. The Principal investigator the MEWS system
focus groups exploring and a research assistant in relation to RRS
the use of the MEWS in held a debriefing session. activations and
clinical practice. Transcripts were analysed using Cardiopulmonary
a qualitative technique like that arrests amongst
described by Casey (1998). The non-monitored
summation of responses to each patients in
question from all 5 focus groups 3 medical-surgical
was merged into one transcript. units.
Themes were extracted through Nurse-led focus groups
commonly used words and explored use of
phrases. A third independent the MEWS in
researcher not associated with clinical practice and
the hospital or subject matter nurses’ perceptions
provided an in-depth thematic of barriers and
analysis of the transcripts. facilitators to use
The principal investigator of the MEWS at the
and independent researcher bedside.
discussed their interpretations
until agreement was reached.
BURKE and CONWAY

TABLE 3 (Continued)

Study CASP
No. Author Year Country Design/Method Sample Analysis Study Focus Score

18 Suokas 2010 U.K. Qualitative design: Purposive sampling to engage a range of Situational Analysis: an extension To describe and 9/10
ethnography different healthcare staff who use or of the grounded theory conceptualise an -Issues around
interviewing and participant manage the early warning system. analysis developed by Glaser organisational recruitment
observation. 37 semi-structured interviews were and Strauss (1967). Clarkes process that strategy
Phase 1 data collection: conducted with doctors, nurses, medical Situational Analysis approach involves construction, purposely
Interviews and and nursing staff who respond to which is useful in multimodal execution and selected
ethnographic EWS alerts, and staff from patient research makes 3 kinds of maps contestation of participants
observations in four safety and risk management. to analyse the data: situational the procedural for
medical wards: 28 days The sample included: maps, social worlds and standards interviewing
of observation and −7 doctors positional maps. prescribed by early that
50 staff interviews. −7 senior nurses Firstly, deductive methods were warning systems to researcher
Phase 2 data collection: −7 staff nurses used to develop research detect and manage felt would
Interviews and −2 healthcare assistants questions and ideas for data the deteriorating be key
ethnographic −6 members of staff from outreach/ collection, which will then patient. informants
observations in four hospital-at-night teams influence the analysis. Then following
medical wards: 20 days −8 members of staff from patient safety/ an inductive approach was field
of observation risk management followed, the analysis of observation.
and 41 staff interviews. interview transcripts explored
Phase 3 data collection: the processes of recognition
Co-facilitated focus and and response that emerged
ward-based feedback from the data and produced a
groups: Eight focus thematic coding framework.
groups and seven ward-
based feedback groups.
| 1899

TA B L E 4 CASP (2017) quality assessment table

6. Has the
4. Was the relationship
1. Was recruitment between the 8. Was 9. Is there
there a clear 2. Is a 3. Was the research strategy 5. Was the data researcher and 7. Have ethical the data a clear 10. How
statement of qualitative design appropriate appropriate to collected in a way participants issues been analysis statement valuable
the aims of methodology to address the aims the aims of the that addressed the been adequately taken into sufficiently of is the
the research appropriate? of the research research? research issue? considered? consideration? rigorous? findings? research?

1. Andrews and YES YES YES YES YES YES YES YES YES
Waterman (2005)
2. Cherry and Jones YES YES YES YES YES YES YES YES YES
(2015)
3. Dalton et al. (2018) YES YES YES YES YES YES YES YES YES
4. Donohue and YES YES YES YES YES YES YES YES
Endacott (2010)
5. Ede et al. (2020) YES YES YES YES YES YES YES YES YES
6. Elliott et al. (2015) YES YES YES YES YES YES YES YES
7. Flenady et al. (2020) YES YES YES YES YES YES YES YES YES
8. Foley and Dowling YES YES YES YES YES YES YES YES YES
(2019)
9. Gazarian et al. (2010) YES YES YES YES YES YES YES YES YES
10. Greaves (2017) YES YES YES YES YES YES YES YES YES
11. Jensen et al. (2019) YES YES YES YES YES YES YES YES YES
12. Lydon et al. (2016) YES YES YES YES YES YES YES YES
13. Mackintosh (2012) YES YES YES YES YES YES YES YES YES
14. Mc Donnell YES YES YES YES YES YES YES YES YES
et al (2013)
15. Mc Gaughey (2013) YES YES YES YES YES YES YES YES YES
16. Petersen et al. YES YES YES YES YES YES YES YES YES
(2017)
17. Stewart et al. (2014) YES YES YES YES YES YES YES YES
18. Suokas (2010) YES YES YES YES YES YES YES YES YES
BURKE and CONWAY

perceived negatively. It was viewed as a far more multifaceted issue et al., 2019; Mackintosh, 2012; McDonnell et al., 2013; Mc Gaughey,
which requires consideration of data gathered from other sources, 2013; Petersen et al., 2017; Suokas, 2010).
even if the other sources are less tangible. Participants in six studies
voiced the importance of using clinical judgement, visually assessing ‘I have many years under my belt within this speciality. I know
and listening to the patient together with the knowledge gained from when a patient is unwell and know what would happen if I
the EWS (Flenady et al., 2020; Greaves, 2017; Jensen et al., 2019; Mc don’t act upon it, so I would ask the doctor to review the
Gaughey, 2013; Stewart et al., 2014; Suokas, 2010). patient and document it’ (PO1) (Dalton et al., 2018, p214).

‘.. you need to still be able to look at observations or even

still look at your patient without having to use an Early 3.1.4 | Finding 4: EWS use enhances
Warning Chart to tell if your patient is unwell or not. It sense of accountability and makes individual
should be an in-hand system, but it shouldn’t be a “the” responsibilities explicit
system. I think it’s a combination of knowing your patient
and being able to use the tool’. (Surgical ward staff nurses Nurses’ awareness of their responsibility and how they can be held ac-
02[07]) (Mc Gaughey 2013, p. 199) countable for their actions when deciding whether to escalate care or
not in response to EWS was a prevalent theme in seven papers (Dalton
et al., 2018; Donohue & Endacott, 2010; Greaves, 2017; Jensen et al.,
3.1.3 | Finding 3: Nurses value their knowledge, 2019; Mackintosh, 2012; Mc Gaughey, 2013; Suokas, 2010).
experience and intuition in assessing risk
‘We can trace back as to who was looking after the patient so
Thirteen studies demonstrated nurses’ use of experience, knowl- there’s more accountability. You know, we can say to people
edge and intuition when escalating care (Dalton et al., 2018; well, look this person’s EWS score was five and you didn’t do
Donohue & Endacott, 2010; Ede et al., 2020; Elliott et al., 2015; anything about it, why is that… so yeah, they do take more
Foley & Dowling, 2019; Gazarian et al., 2010; Greaves, 2017; Jensen responsibility’ (Senior Nurse (33)) (Suokas, 2010, p 156).

TA B L E 5 Summary of thematic development

DEVELOPMENT OF FINDINGS TABLE

(Visual Map of Theme Development using Thomas & Harden's Three Stage
Thematic Synthesis Approach to Data Analysis)

Four emerging themes

1) Marrying Clinical Judgement 2) SMART 3) EWS protocol a blessing and a 4) Hospital Domain
and EWS Communication curse

Descriptive Theme (below) Supporting the above Analytical Themes

STAGE TWO
a) Confidence in Clinical a) Credible objective measure. EWS protocol a blessing a) Hierarchical Influences.
judgement. b) Perception of communication a) Nurse empowerment. b) Staffing, workload and lack of
b) Responsibility and and teamwork. b) Supports decision making. resources.
Accountability. c) Effectual EWS training. c) Protection from liability. c) Delayed medical response.
c) Experiential knowledge and d) Challenges of EWS EWS protocol a curse d) Out of hours support.
Intuition. modifications. d) When abnormal is normal. e) Physical Environment.
d) Seeing the patient not just the e) Restrictively prescriptive.
numbers. f) Not fool-proof.
Coded findings (line by line coding) contributing to the above descriptive and later analytical themes
STAGE ONE
a) As confidence grows there is a a) EWS provides you with a a) EWS protocol removes fear and a) Senior nursing position instils
greater emphasis on clinical formula to escalate care and empowers. confidence in not only escalating
judgement than EWS. get a response. b) EWS findings validate and care but to whom one escalates
b) Nurses are responsible for b) Non-medical language can strengthen decision making. care.
collecting and acting on vital expose you to ridicule. c) Backed up by policy and protocol. b) Unachievable targets due to
signs. c) Incorrect calculation of EWS d) COPD patients’ abnormal heavy workload.
c) Natural intuition develops score. measurements is their normal. c) Delays in doctor response and
through experience. d) Reluctance from doctors e) EWS chart can be overly attendance.
d) An in-hand system not ‘the to write down EWS prescriptive. d) High score at night requires more
system’ need to look at your modifications. f) MEWS score failed to signal precision when escalating.
patient. deterioration e) Modern hospital layout.
| 1902

TA B L E 6 Themes and illustrative quotations

Marrying Clinical judgement and EWS

Confidence in Clinical ‘Sometimes still you're saying, ‘They're scoring 4 but that's probably quite good for her because she's back from ITU’. So again, you'd report it to the doctor, but you'd say, ‘I don't
judgement think it's a particular problem.’ So, you'd try and put some perspective on it, so that they're not abandoning somebody else who is quite poorly’. (Sister14 years) (Andrews &
Waterman, 2005, p478).
‘I don't call a Doctor when the MEWS [score] tells me to; I’d call them when I think the patient needed it'. (CIA) (Donohue & Endacott, 2010, p12).
‘Ward 12: …discussed the [EWS]…from his experience…patients rarely trigger on the ward, but if they do, he uses his clinical judgement as well as the [EWS] to assess the
situation, he states he does not solely rely on the numbers generated and looks at the individual patient's history and current management’. (Ede et al., 2020, p 174).
P10_RN reports: ‘there is some open hostility to the form from staff who've been around for 20–30 years. They'll tell you day in and day out that the form's a load of sh..t and
takes away from clinical judgement’. (Flenady et al., 2020, p4 of 9).
‘I use my own judgement no matter what NEWS indicates. I summon the doctor when I think my patient is deteriorating, regardless of the NEWS score. Maybe other nurses
summon support earlier and faster than me. I see the advantage of NEWS as a tool if you are new and have little experience, so I can see that it can be helpful, but I think, for
my part, I would have made the same assessment regardless of whether I had it [NEWS] or not’. (Gunhild, nine years of experience) (Jensen et al., 2019 p4392).
‘Senior nurses might see a high NEWS but use clinical judgement to assess the patient and inform the intern that, even though the NEWS is high, the patient is stable’. (Nurse 4)
(Lydon et al., 2016, p690).
‘In acute medicine, as I mentioned earlier, somebody's EWS score can be slightly elevated at baseline and as we get to know our patients, particularly in acute medicine the nurses
can use their judgement to decide how frequently to do somebody's obs and to apply a rule, ‘they must be done 6 hourly, 8 hourly, 12 hourly…’, doesn't lend itself to the
uniqueness of medicine … I’ve worked in medicine, I’ve worked in surgery, cardiology, theatres, ICU, I’ve been all over and there's different reasons for doing obs at different
frequencies in all of those areas, but I think you have to allow us to interpret it to use it at its best advantage’. (Medical Ward, Nurse Manager 01 [02]) (Mc Gaughey, 2013,
p200).
b. Responsibility and ‘If you had a patient you considered to be deteriorating in health and their MEWS score was 7 or above, but the doctor on the ward said, ‘this is fine, we already know about this’,
Accountability what would be your action?’ ‘I would document I had spoken to the doctor and his/her reply; that's their decision, not mine’. (P06) (Dalton et al., 2018, p214).
‘We are responsible for following up on what is being done or what we are going to do. It's not such a dramatic difference, really. We have always been responsible for collecting
vital signs, for following up, and for paying extra attention to deteriorating patients’. (Heidi, four years of experience) (Jensen et al., 2019, p4393).
‘In a way, you could say that you have less responsibility for patient care. When NEWS and the prescribed frequency of measurements and response are followed, you have done
the right thing. So, if something happens, at least you've followed the recommendations, and you can blame NEWS. However, I feel that it is my responsibility; I should have
detected changes, since I am in charge of the patient’. (Fiona, one year of experience) (Jensen et al., 2019, p4394).
‘We can trace back as to who was looking after the patient so there's more accountability. You know, we can say to people well, look this person's EWS score was five and you
didn't do anything about it, why is that… so yeah, they do take more responsibility’. (Senior Nurse (33)) (Suokas 2010, p156).
‘if the doctor doesn't come as soon as I’d like, it's the doctor's decision, but at the same time it's my patient and my ward and I would still feel responsible for them. If I felt strongly,
I would contact someone else rather than just [accepting] ‘oh I’ve spoken to whoever and this is the situation’. (Westborough, Nurse, 5) (Mackintosh, 2012, p214).
‘You see I’d been off, and I came back in… we had a lady who had been running a tachy of a hundred and thirty plus for three days and we were doing [the obs] on a regular basis
and telling the doctors, telling the doctors, nothing happening. I said she cannot sustain this, I said she's elderly, she is not going to sustain this rate for much longer. I really to
this day do not understand the rationale for why nothing was done […] one of her other medications could have been increased to try and have an impact on this … whether
everybody was waiting for a consultant decision or whatever I do not know. I said she's definitely going to go off and she did, but they were all aware so that's how come they
were able to resuscitate her and bring her back, but unfortunately it wasn't a very successful resuscitation. My consultant said what did you bother for, and I said because she
was for all active treatment, she is somebody's mother, and nothing was documented anywhere to say that I shouldn't … I’m my patient's advocate, and I said if nobody else
will do it that's my job, I will’. (Senior Nurse (32)) (Soukas, 2010, p259).
‘I want them to take it seriously. They really should come and look. I know they have got a lot on, but when a patient suddenly scores it's their job to sort out’. (Sister 2, line 75)
(Greaves, 2017, p136).
BURKE and CONWAY

Marrying Clinical judgement and EWS

c. Experiential Knowledge ‘I have many years under my belt within this speciality. I know when a patient is unwell and know what would happen if I don't act upon it, so I would ask the doctor to review the
and Intuition patient and document it’ (PO1) (Dalton et al., 2018, p214).
‘I’d like to think that it hasn't made any difference to me being able to detect my patient deteriorating’. (FG I1) (Elliot et al., 2015, p70).
‘I went to nursing school for three years—I know when it's time to ring the doctor’. (FG A4) (Elliot et al., 2015, p70).
‘Knowing that he was away from his baseline, at baseline he was a little vague, but just by knowing him you could tell’. (Gazarian et al., 2010, p29).
‘Yeah, I think to be honest the more experienced staff it is a complete insult to give them an early warning score they must follow because if you can't use your skill and knowledge
base to actually look at a patient to say you're not well then I think it is a disgrace. I think at grades of staff I think people are promoted far too quickly in grades anyway and
they still lack the basic experience about a few years of developing their expertise and some people will stay on one Ward for all of their career and I would challenge their
expertise and their knowledge and maybe they need another system to be able to help them in their diagnosis and recognition of deterioration. So, I don't think grades come
into it as such but certainly experience yes as less experienced people need a guide whereas experienced staff sometimes it is just a bit of paper which will work which they will
fill in and get help anyway’. (Modern Matron 2 line 60) (Greaves, 2017, p163).
‘That's something I’ve learnt was listen to your intuition. Because I found more often than not that it was telling me things that I should have been listening to anyway, so since
then I think I do listen to it, I don't just dismiss it straightaway. [I would] just keep an eye on them, keep going back to them. [..] Yeah, it's just like looking for other signs like
they're not being themselves’. (Eastborough, Nurse, 5) (Mackintosh, 2012, p188).
‘they can also not score anything and still not be you know, there's something wrong and you can see that. And often like nurses who have experience their intuition us telling
them that there's something wrong’. (3) (Mc Donnell et al., 2013, p48).
‘(…) we [nurses] use our clinical intuition to see the patient an extra time and take an extra set of vitals, because you have some alarm bells ringing. If something just doesn't seem
right, I prefer to take an extra EWS score even though nothing sticks out, because there is something you just can't define (…)’. (Petersen et al., 2017, p5 of 9).
d. Seeing the patient not the P22_RN ‘this is a blunt tool; I know how to deal with this patient and get the help that I need when I need it…. the vital signs are the beginning of your nursing assessment really.
numbers If someone has abnormal respiratory rate, then I’m much more concerned about that than what number they're showing. If I have an asthmatic patient and their respiratory
says only 24 but you can hear them wheezing and they're really tight and there's not a lot of air moving, then I’m much more concerned about that, and would escalate that
much quicker’. (Flenady et al., 2020, p4 of p9).
‘When I use my clinical judgement or my intuition, my gut feeling, I don't only look at the measurements; I look at how the person is affected by the measurements. I consider their
breathing … are they wheezing, are there any sounds? I look at and touch the patients. I have been a nurse for a while, so you learn to look at the patients in a slightly different
way than just using the system’. (Marie, five years of experience) (Jensen et al., 2019, p4393).
‘.. you need to still be able to look at observations or even still look at your patient without having to use an Early Warning Chart to tell if your patient is unwell or not It should be
an in-hand system but it shouldn't be a ‘the’ system..I think it's a combination of knowing your patient and being able to use the tool’. (Surgical ward staff nurses 02[07]) (Mc
Gaughey, 2013, p. 199)
‘Everybody is different –we treat the patient, not the numbers’.
‘One patient may be very stable with a MEWS of 4; another patient might not do as well. You treat the individual’. (Stewart et al., 2014, p226).
‘It's a guideline; you're still looking at the patient, that's the one thing that everyone tends to forget. You can be working with a patient all day, and even if you did do obs once in
the morning and once in the afternoon, you'll still get a better idea how well that patient is doing just by looking at them and being in contact with them’. (Senior nurse (31))
(Suokas 2010, p243).

(Continues)
| 1903

2) SMART Communication

a. Credible Objective ‘It provides what you need to get a doctor there, I think. It gives you…your full objective facts. They can't argue with a score of 5 or 6. They'll just come. It's a complete measure
Measure which they do agree to attend to, and it helps your patients more than anything, which is important’. (Staff nurse, 1 year) (Andrews & Waterman, 2005, p478).
‘WARD 7: …took over a patient who had only had 100mls of urine … in 11 hours, … patient was quite unwell …felt the thing that worked well…once she flagged up the problem…she
had good communication between the team and the doctors acted on her concerns very quickly’.
(Ede et al., 2020, p175).
P14_RN commented: ‘the more junior nurses say I have a 5, this is what I need to be doing’. P08_RN pointed out the usefulness of a score: ‘it gives them (junior nurse clinicians) a
concise idea of how sick their patient is’
(Flenady et al., 2020, p4 of 9).
[Extract from field notes, Westborough, FN6]. ‘On a nightshift, E, the nurse in charge and I are discussing the nurses’ role in escalation of care. She notes she has witnessed
others being bullied, where doctors have said they have been too busy to come, often saying that there were other patients just as sick. E comments that these nurses were too
descriptive in calling for help and not assertive enough. She contrasts this with her behaviour; ‘I just come to the point, I’ll say, Patient's drowsy, hasn't passed urine, is scoring
and is clammy. If the doctors say they are too busy and can't come I’ll say, Well, I’ll find someone who can’. She notes one recent instance where she called the registrar and the
registrar said, ‘Why isn't the F1 coming to see the patient?’ She explained that the F1 said she was too busy to see the patient, and the registrar said, ‘Well that's fine, I’ll take it
up with the F1 and sort it out,’ and five minutes later the F1 was on the ward’. (Mackintosh, 2012, p213).
‘Depending on what you tell them on the phone determines how urgent they consider it to be. It's just having the experience to know what to do with it (the score) and then following
it through and getting somebody to actually look at this or come and review this patient’ (4) RGN 1–5 years’ experience (Mc Donnell et al., 2013, p46).
‘MEWS is helpful if you say, ‘the patient is a MEWS 4 or 5’. Physicians recognize that they need to see the patient right away’.
(Stewart et al., 2014, p226).
b. Perception of ‘It's easier to act dumb and say, ‘This lady in here, her breathing is very fast’, rather than ‘She's got a high respiration rate’. I think it can come across to them (doctors) that you don't
communication and know what you're talking about. They question everything, so you might as well just say that's what you've seen in lay terms’. (Staff nurse, 1 year) (Andrews & Waterman,
teamwork 2005, p 477).
‘Even though you ask them, it doesn't matter just come, they are lazy’. (P1) (Cherry & Jones, 2015, p 816).
‘We have a mutual respect. My knowledge is ward-based, so we work well together. I can point them in the right direction, and they respect my experience. They always call the
shots -their knowledge is far greater than mine’. P03 (Dalton et al., 2018, p214).
‘I have often spoke to the doctor and said, ‘this lady is really not right, but her MEWS score is 3’ and the doctor just says, ‘If I get time, I come and see the patient, but I have a
number of things to do first.’ You feel stupid sometimes if you're wasting people's time’. (P05) (Dalton et al., 2018, p214).
‘Ward 4: Observed interaction between doctors and nursing staff –very tense. Doctor storms off. ‘I guess we'll agree to disagree’. …Would be difficult for someone not confident to
escalate problems to someone who is very dismissive. When discussing patients, he is not giving eye contact and showing defensive postures’ (Ede et al., 2020, p176).
‘Because they knew me, and what type of nurse I was, and I knew them, we were able to trust each other’. (Gazarian et al., 2010, p27).
‘I sometimes think that the medical staff don't appreciate what the nurses do to look after the patients, and the MEWS is a way to get them involved’. Staff Nurse 1 line 81
(Greaves, 2017, p171).
‘Sometimes we reflect in the patient's room, but also in the staff room. This weekend we discussed an unspecified patient … all the vital signs were normal, but the patient's
consciousness had changed, and the patient had an infection and liver failure. We were waiting for the doctor's supervision and we started to plan what we might have to
do. … Working with other experienced nurses helps you feel more confident; you can ask questions and get some feedback and support in assessment’. (Heidi, four years of
experience) (Jensen et al., 2019, p4395).
‘Where I came from, we used to have a registrar there, I think he's been there for many years; if I walk into the hospital on a weekend and he's on-call I’m confident. [..] But here,
because you have so many doctors to deal with, it's really very difficult to … to assess their competence’. (Eastborough, Nurse, 6) (Mackintosh, 2012, p252).
‘I think it's sometimes about personalities because sometimes you find that personalities of both nurses and doctors and it's just their own personality in itself, there's nothing you
can do to change that, makes it difficult in some ways for them because some nurses are quite timid, and they maybe don't have the confidence and are afraid then to make that
call. Whereas other nurses are confident, but they could also meet with a very confident young doctor who thinks, ‘I know it all’, and ‘what are you calling me for?’ So, you do
have that and sometimes it is, and that's going to be a very hard thing when you're dealing with actual people's personalities to overcome’. (Senior Nurse Manager C 02 [27])
(Mc Gaughey, 2013, p221).
BURKE and CONWAY

TA B L E 6 (Continued)

2) SMART Communication

c. Effectual EWS training ‘One of the things I have a problem with, I suppose I don't use the proper correct language, maybe. I haven't gone any deeper into physiological training or physiological terms
necessarily, and I feel that probably I don't use the right language when I’m trying to get a doctor to come and see the patient’. (Sister, 10 years) (Andrews & Waterman, 2005,
p477).
‘Not being taught properly,’ P1. ‘She had scored, I think, a 1 when it was really a 3,’ P2. ‘You get some people who do not even ask if they have passed water or checked if [they have]
by going back but just put a 0 anyway,’ P5. (Cherry & Jones, 2015, p816).
‘We should be educating junior staff to look for more than just teaching them to use colours’ (FG A6) (Elliott et al., 2015, p 70)
‘Well, I had a case with a patient who came in, who actually seemed to be in pretty good shape apart from an elevated respiratory rate. Before we had learned something from
NEWS, I didn't think much about the respiratory rate, but because it was elevated, I had to take new measurements in a few hours, and by then his condition had deteriorated.
Then I saw that respiratory rate is often one of the first things affected when the patient is deteriorating. … I have realised that the respiratory rate is important and, if I had not
used NEWS, then I might not have conducted that reassessment’. (Fiona, one year of experience) (Jensen et al., 2019, p4393).
‘what we found was, repeatedly, that their scores weren't being done correctly, they were missing some parameters, the higher the score the more chance there was that it wasn't
added up correctly and that was a frequent finding that whenever they had totted them up they had got the wrong number and obviously that could change the response that
was required. The other thing is that at all of our Crash calls we will document what the Early Warning Score was prior to the Crash call and the time and we are finding that
yes, sometimes and on a regular basis the scores are low but quite often their scores aren't low, they're high, maybe 6 hours earlier but their obs haven't been repeated’. (Senior
Nurse A 01[03]) (Mc Gaughey, 2013, p205).
‘I think if you compare it to maybe two or three years ago then there is an improvement, but there is still room for [improvement]. There are still some patients that are slipping
through the net, and there are still some areas where Early Warning Scores are being triggered and the appropriate action is not taking place’. (Senior nurse (15)) (Suokas,
2010, p175).
d. Challenges of EWS ‘getting the doctors to fill in the modification … a nightmare’. (FG I3) (Elliot et al., 2015, p69).
Modifications P16_RN explained: ‘I’ve rung the doctor; they didn't do the mods (did not write modifications on the EWS chart) that they'd written on the chart (patient notes within the chart)
that they would do. I could do a MET call, but they've written in the chart (patient notes) that this is their mods, nurses have to cherry-pick doctors’.
(Flenady et al., 2020, p5 of 9).
‘SHOs do not set parameters yet they are the ones re-viewing the patient…. you ring the Reg to review the patient as per the protocol and they will say ‘get the SHO’ to review’.
(Nurse F)
(Foley & Dowling, 2019, p1187).
‘Sometimes it is very hard to get a variance signed. So, patients, because of the MEWS system, now tend to, whether it is right or wrong, to have observations done maybe hourly for
in a tachycardic patient, because they have an idea of what it is related to, but the Doctors aren't very keen to sign a variance’. (Staff Nurse 3, line 39) (Greaves, 2017, p145).
‘but they would always run it by the doctor but it's always very verbally, there's never really much written in their notes, like, the doctor wouldn't really write in their notes, ‘staff
nurse informed; patient's Mews 3; went and assessed patient; or this is what I have suggested’, or whatever, it's always very verbal’. (Surgical ward sister 01[19]) (Mc Gaughey,
2013, p228).

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3) EWS protocol a blessing and a curse

EWS protocol a blessing

a. Nurse ‘You see, with the early warning system you have got more ammunition, haven't you? You're not just taking it off your own (bat) to say, ‘I'm now going, I'm not happy with the care
Empowerment they're receiving from you –I am going to get in touch with the anaesthetist.’ You've got it down that is the protocol’. (Staff nurse, 18 years) (Andrews and Waterman, p478).
‘Yes, say look this patient is deteriorating and you can see that the MEWS score is getting higher and shove it in front of them and they [have] got to look at it, haven't they?’ (Cherry &
Jones, 2015, p816).
‘it ‘certainly gives you a bit more bravery to pick up the phone’ (FG G6) (Elliot et al., 2015, p70).
P34_RN, EWS is an empowering tool for the nurse clinician: ‘it gives you the confidence to say, ‘you need to come review this patient immediately, because they're scoring a 5’. (Flenady
et al., 2020, p5 of 9).
‘It is good in a way, because, to look at the patient they were laughing, talking and joking on, but because of the MEWS system, and the score the patient had, you could tell you had to
refer up’. (Staff Nurse 3 line) (Greaves, 2017, p125).
‘I think it empowers the juniors because they've got a tool to say this is the guideline and this needs acting on. So, I think it's given them the confidence to do that’. (ID: 10,
RGN > 20 years) (Mc Donnell et al., 2013, p47).
‘We have some standardised permitted orders. If the patient has an elevated heart rate, we can give some fluids; if they have a temperature, we can give paracetamol without having
to involve the doctor. So, we can try to correct the deviation, but if it persists, we need to call the doctor. … I think, since we started using NEWS, we've started to take some actions
earlier than we did before. We've become more aware; if a patient has elevated NEWS, you must do something about it. It pushes me to do a little more’ (Bente, five years of
experience) (Jensen et al., 2019, p4395).
‘I’ll look after the patient and if it gets worse, I’ll take an extra EWS, but otherwise we follow the [escalation] protocol’. (Petersen, 2017, p5).
‘I think they're very aware of somebody's observations being out of normal range. I just think when they're junior it's how empowered they feel about talking to somebody else about
them’. Senior nurse (15) (Suokas,2010, p194).
b. Supports decision ‘Well, it's given a framework that you can say, ‘Look at this.’ And they actually tell you if you can actually go to who you want. But I think it's ‘cause it's a framework and it makes them
making come’. (Staff nurse, 28 years) (Andrews & Waterman, 2005, p478).
‘I think the MEWS system is good, even if I thought, ‘OK, I have the situation under control now’, I would still ring the nurse practitioner. This is what I have done; they are still MEWS
high at the level they were before, but they will need a look at later’. (P02) (Dalton et al., 2018, p215).
‘You do use the score to rate how sick they are and what you need to do about it’. (Nurse G) (Foley & Dowling, 2019, p1187).
‘I use it [NEWS] every day. I had a rather complicated patient a while ago. I collected vital signs, saw that the total score had increased, and summoned the doctor. The doctor was
not concerned because the patient had been stable for a while. The total score had now increased; the doctor didn't find it significant, but I didn't like it and reacted. During the
following night, the patient became very unstable, so the system is useful. NEWS is really good to have. It supports us. I contacted the doctor, and that was the right decision. With
NEWS, I feel safer and more self-confident and have more to say to the doctor. I had a gut feeling that something was happening. I felt that I did the right thing. I felt a little stupid,
but then I thought that I did the right thing’. (Nina, five months of experience) (Jensen et al., 2019, p4392).
‘When you first walk onto the floor, it (the MEWS) catches my attention…especially if you are juggling 5 or 6 patients; you can glance at the MEWS scores and if the score is elevated
say, OK there is something going on here and I need to see this patient right away’. (Stewart et al., 2014, p226).
‘[Patient care is] improved as the [NEWS] makes it very clear when a patient should be reviewed and when to consider transferring a patient to high dependency’. (Nurse 5) (Lydon
et al., 2016).
‘It does highlight patients that are actually deteriorating quicker than you would if you'd just got a normal TPR chart’. (6) RGN 1–5 years’ experience. (Mc Donnell et al., 2013, p46).
‘..I go to someone and their observations say are sitting at a 4 and I would look and see what is making it a 4, is it change, is it something new and if I don't feel that there's action
required, I’d say, ‘they're pyrexic, they've a high temperature and they've a fast pulse rate and they need a couple of paracetamol and they need cultured’, I would document it on
the back, ‘blood cultures and whatever’, or, ‘no action required’. So that whoever's coming behind me knows that I made that decision’. (Senior Nurse Manager C 02 [27]) (Mc
Gaughey, 2013, p222).
‘When you first walk onto the floor, it (the MEWS) catches my attention…especially if you are juggling 5 or 6 patients; you can glance at the MEWS scores and if the score is elevated
say, OK there is something going on here and I need to see this patient right away’. (Stewart et al., 2014, p226).
BURKE and CONWAY

3) EWS protocol a blessing and a curse

c. Protection from ‘I always have my evidence there to say why I want them [the outreach team] and I think because I know what they want before they come, I am able to get over to them how serious or
liability how acute the situation is’ (CI/H) (Donohue & Endacott, 2010, p12).
BURKE and CONWAY

‘I think if you had of asked me like a year ago, I would have said no not at all. I knew when something was wrong, but I don't think I would have had the voice to say it but as you get
to know groups of Doctors that really helps, and they know when you are worried that it must be something as you don't ring for everything and that has helped. I do feel more
confident and also I know by doing everything that is set and by protocol that I am always backed up by that because that is the policy, and I am happy to raise concerns’. (Staff
Nurse 2, line 131) (Greaves, 2017, p141).
‘Using the charts gives you a bit more confidence when you are raising causes for concern, because it is, like evidence’ (Staff Nurse 4, line 34) (Greaves, 2017, p141).
‘If you don't follow the NEWS and something goes wrong then the blame rests on you and you've got nothing to back you up…whereas, once you call, you're protected’. (Nurse 3) (Lydon
et al., 2016, p691).
‘We now use it on every single patient that we have on the ward and obviously they all get a score at the end of it, so I think it just rings more alarm bells if you like if a patient is unwell
or is deteriorating, whereas just recording a patient's observations, you know, you might miss something’. ((15) RGN 1–5 years’ experience) (Mc Donnell et al., 2013, p46).
‘Sometimes you're doing obs all the time, ‘why am I doing these obs all the time?’, and it takes someone to actually say, ‘look this patient is quite stable, they're not acutely ill’, and to
make them tid or even bd, it's very rarely…I think you're scared… ‘Oh what if something went wrong!’ and you've been the one who has changed them to twice a day. So sometimes
you could find yourself doing obs a lot when there's no need’. (Surgical ward staff nurses 01[08]) (Mc Gaughey, 2013, p206).
‘There was very much a fear aspect to begin with like, don't get me wrong [the OBS charts] were excellent and they were really good for us to be able to say, ‘oh right there's something
wrong [with the patient] here’. But we did take that literally, I know I took it literally to begin with because I sort of panicked, I thought right this is a legal documentation’. (Staff
nurse (26))
(Suokas, 2010, p245).

EWS protocol a curse

d. When abnormal is ‘Like somebody who is on COPD, their sats 92 on room air
normal that might be normal for them, isn't [it]?’ (P2). (Cherry & Jones, 2015, p816).
‘Yes but sometimes you know the most saturation would be
80 to 92. Sometimes that patient would score 2 or 3 on the
COPD [because of the COPD]’ (P4) (Cherry & Jones, 2015, p816).
‘Sometimes, you know, the renal patient, they say ‘I only pee once a day’, that is normal for her. Like in a renal patient. And sometimes they don't for 2, that is normal for them, but we
score them 3, isn't [it]? Because she [has] not PU [passed urine]’. (P5) (Cherry & Jones, 2015, p816).
‘… she was MEWsing [had a MEWs score of] at the time 5 and 6 principally because of her resps. She was a COPD sufferer, so I wasn't overly concerned’. (CI/H) (Donohue & Endacott,
2010, p12).
‘Yeah, the main patients we find are the respiratory patients because of what is flagged up on the early warning scores. So, for example if we have a COPD patient who is on home
oxygen the very fact that they are on oxygen scores them a 2 the sats in a COPD patient you want them slightly lower so that will automatically score them a 2 or a 3 so straight
away when they are at their norm and what is good for them, they may be scoring a 4 or a 5. Then if you add in a slightly low blood pressure or a temperature very slightly up and
before you know it, they could be scoring a 6 or a 7 which in another patient would be quite alarming but in a respiratory patient that can often be the norm for them’. (Staff Nurse
4, line 38) (Greaves, 2010, p 144).
‘Someone with COPD is not going to have a resp rate of 12 to 16, It's going to be more elevated generally, but that is normal for them. So, it's inappropriate to be phoning doctors all
the time with a COPD patient who might have a resp rate of 24 when that might be perfectly normal for them. Using your clinical judgement to determine what is normal for that
patient and I think parameters that are set on PAR scoring system, as well as your own judgement, are enough to be able to identify patients that are at risk’. ((9) RGN 1–5 years)
(Mc Donnell et al., 2013, p48).
‘This raises one of our problems with a generic document like this because a lot of our patients have got a high respiration rate and that is their normal, you know nothing we're gonna
do is gonna change that. So, although we could have someone with a respiratory rate of high twenties or low thirties, that is the patient's regular respirations and we're never gonna
improve on that, so you will get a false reading from the EWS’. (Senior nurse (31)) (Suokas, 2010, p214).
|

(Continues)
1907

TA B L E 6 (Continued)

EWS protocol a curse

e. Restrictively ‘We don't tend to use MEWS score simply because most of our patients would come out as [be identified as] needing to go to HDU [high dependency unit]’. (CI/G) (Donohue &
prescriptive Endacott, 2010, p12).
‘…the nurse in charge would be constantly reviewing twenty-eight patients and that's all they would do all shift, because at some time, each patient would fall into the orange section for
some reason’. (FG H2) (Elliott et al., 2015, p71).
‘It will tell you that this blood pressure is low, the values are low, do you accept that or not? So, what I do is I will check the blood pressure three times to make sure, so if it's low three
times I’ll accept. Yes. I check usually three times, both arms’. (Eastborough, nurse 7) (Mackintosh, 2012, p172).
‘(old charts were) plotted, say blood pressure or pulse, you were able to see the trend straight off just looking at it Whenever you're looking at this (EWS chart) you're looking at colours
and you're looking at what score but someone has originally come in with a blood pressure of 160 systolic and now have a blood pressure of 101 which is quite low for them but it is
still the same MEWS so, you can't really see that it's different for them unless you physically look at the two numbers, you can't see the trend’ (Surgical ward staff nurses 02[07])
(Mc Gaughey, 2013, p208).
‘We never have a baseline for patients when they come into the hospital. We assume that the oxygen level will be anything up to ninety-eight, ninety nine percent, but it's very seldom
that with one of our chronic chest patients. […] I think we often have a tendency to over-treat patients. We are trying to get them back to the circulatory status of a thirty-year-old
fit healthy person, and that's sometimes where prescriptive charts like this can fail because we don't take into account the patient’. (Senior nurse (31)) (Suokas, 2010, p229).
f. Not fool-proof ‘I don't know for certain; I’m thinking of specific examples. If somebody is getting slowly, yes it does. And if you are dealing with maybe a junior Nurse who is not recognising that, then
yes it does. But very often a senior nurse, an experienced nurse knows a patient is getting sick, knows when to call the doctor and the MEWS score is then added, sort of a red flag
message for the doctor to come quickly but I can think of specific examples when it didn't; for example, a gentleman who arrested without warning whilst waiting to go home. MEWS
was of no indicator benefit there and I suppose it was usually expected to warn of a sudden arrest. I am thinking of indications where a patient has had a sustained high MEWS score
for a period of almost days and there was no great change in the patient's management. So, there are extremes in anomalies within the MEWS score but by and large it does help’.
(Medical ward Nurse Manager 01[02]) (Mc Gaughey, 2013, p197).
‘We had a patient in [another ward] who had a EWS score of one, and a continued EWS score of one, but that patient eventually died. There was no clinical reason to have summoned
attention apart from the fact that you looked at this patient and they did not look well, but there was no reason. So, it's not fool proof’. (Senior nurse (31)) (Suokas,2010, p232).
4) Hospital Domain
a. Hierarchical ‘We don't get a relationship with a senior doctor P6. Very hard to approach. Find it also hard to document. P3. It makes a difference that I am in navy blue. Being in navy blue makes a
influences difference’. (P5) (Cherry & Jones, 2015, p816).
‘Before the [medical] registrar came there is always a running debate as things are happening about this and that…. when the registrar [arrived] it was’ ‘right this is what we are going to
do’. (CI/G) (Donohue & Endacott, 2010, p14).
P34_RN elaborated: ‘before we hit that staff alarm, if we can escalate straight to a senior doctor in ED…my experience is that 99.99% of the time, they will come immediately’.
(Flenady et al., 2020, p6 of 9).
‘We had a patient who went into flash PE and the doctor was trying to handle it and probably for 45 minutes the guy was in respiratory distress and then we called the rapid response’.
(Gazarian et al., 2010, p30)
‘As a first port of call if we become concerned about a patient we would go to the F1. If we felt that they were out of their depth or they weren't responding quickly enough probably the
junior Nurses would go to the SHO but I would tend to go to a Registrar or a Consultant probably because I have a better relationship with them and I feel able to ring them where as
other people don't’.(Sister 1 line 51) (Greaves, 2017, p. 142).
‘It would probably be your F1 because they're ward based but obviously you wouldn't undermine them, you would tell them but if you felt that maybe they weren't taking onboard then
you would just bleep someone more senior’. (Surgical ward sister 01 [19]) (Mc Gaughey, 2013, p215).
BURKE and CONWAY

EWS protocol a curse

b) Staffing, workload ‘Ward 7: if there was just one thing, she would generally improve the ward it would be staffing. …last Saturday…she was the only permanent member of staff from that ward. There were
and lack of 2 agency nurses and there was one member of staff who was familiar with the trust but wasn't familiar with the ward, so she didn't know where anything was, she wasn't able to
resources open doors cos she didn't know codes, she wasn't able to just do simple dressings without being told where everything was…’ (Ede et al., 2020, p176).
BURKE and CONWAY

P34_RN reported: ‘we don't use trends (electronic patient movement software) to estimate nursing hours whether we end up with 7 or 17 patients, we have the same amount of
staffing’. (Flenady et al., 2020, p6 of 9).
‘So, a staff nurse can potentially be looking after 8 patients you can't have someone scoring a 7 that is monitoring at 15-minute observations and it is just not possible’. (Staff Nurse 2,
line 64) (Greaves,2010, p130).
‘If it's busy on the ward and you have relatively healthy patients and the measurements were fine yesterday, then it's tempting to skip the measurements. … I have to prioritise. If there is
no change in the patient's condition, I must prioritise other patients’. (Bente, five years of experience) (Jensen et al., 2019, p4396).
‘We are supposed to do them [the observations] once a shift. But it's whether we actually get round to doing them … if you're doing all the drugs then that's not likely to happen’
(Eastborough, nurse 5) (Mackintosh, 2012, p167).
‘.. We most certainly have less staff than we would have had, we have less qualified staff and we most certainly have sicklier patients, I mean, maybe 10 or 15 years ago patients were
nursed in HDU now they are nursed on a ward with constant IVs and blood transfusions and all that, you know, the same one Nurse to the whole section with her other number of
patients in that section, whereas HDU or ICU you may have 1:1 nursing or even 1:2. On the ward you are 1:8 or more, in some cases 1:10. If there is no student there, no auxiliary
there, the Staff Nurse is doing all of those jobs and they can't all be done at the same time to the same degree’. (Medical ward Nurse Manager 01[02]) (Mc Gaughey, 2013, p202).
‘We let the nursing supervisor know about patients who have an elevated MEWS score. It gives them (administrators) a ‘just-in-time’ sense of how the unit is operating, what our
immediate staffing needs are, and plan for the possibility that a patient may need to be transferred to a higher level of care’. (Stewart et al., 2014, p226).
‘Oh, there are workload issues all the time. There are staffing resources …your resources are not always the best; it's a very busy high dependency ward. There was something 10, 11 IVs
and a lot of those patients at 3 and 4 IVs and there are 2 central lines in there at the moment, there are 2 patients on TPN, it's very demanding’. (Medical ward sister 02 [16]) (Mc
Gaughey, 2013, p201).
c) Delayed medical ‘Sometimes they [surgeons] are in clinics or in other hospitals and you can't always get them’. (CI/E) (Donohue & Endacott, 2010, p13).
response ‘2300 Patient desaturated. Called Senior House Officer (SHO), told to call ICU, ICU told to call ENT, ENT didn't answer. ITU came at request of SHO. ENT consultant called by nurse,
SHO told to review. ITU and ENT disagreeing about need for trachy’. (Ede et al., 2020, p175).
‘Some doctors are better than others for reviewing immediately, others you have to chase and chase’. (Nurse D) ‘You are often ringing and ringing them to come up…. The other day I
spent an hour trying to get a doctor to review a patient because of their EWS’. (Nurse G) (Foley & Dowling, 2019, p1187).
‘Doctors should have been called, and initially I think the Doctor had been called, but there was a huge delay between the Doctor being called and the Doctor actually attending’. (Staff
Nurse 6, line 158) (Greaves, 2017, p138).
‘If you don't get any joy from your medical staff, or you feel that their decision was inappropriate, you've got other ports of call that you can go to outreach nurses and the anaesthetics’.
(Senior nurse (15)) (Suokas, 2010, p161).
Out of hours support ‘I think the factors may be the level of Doctor and sometimes the lack of Doctors on nightshift … they are tied up with someone who is also critically unwell for a good few hours and (we)
are left with a more junior down here who may be not making those decisions’. (Staff Nurse 6, line 113) (Greaves, 2017, p138).
‘.. So obviously a high score, you're going to want a doctor to see the patient; if you have a high score at night you have to go through the hospital night team and give the report to
indicate the urgency by suggesting what the MEWS score is and what your interpretation is and what your anxiety is and then the hospital might push and will then refer the
doctor to you urgently if it is deemed to be the case. But during the daytime you have ready access to the medical team, so you don't have to have the same clarity of thought and
justification’. (Medical ward Nurse Manager 01[02]) (Mc Gaughey, 2013, p218).
‘Certainly, out of hours it's quite hard to get a decision because, I think probably rightly so, the doctors feel they don't know the patient and the full situation, and certainly, some of
the more junior ones are quite worried about making a decision, which I think is quite sensible really. Sometimes there's … there was a gentleman over the weekend who became
unwell, and it was difficult, the doctors were all a bit confused about which bleep they should have, and I think it's difficult to get the person you needed. So, we ended up with a
medical registrar there for someone who's effectively kind of palliative care needs, and they made the decision to make them not for resuscitation. So, it wasn't their team, but it was
someone more senior, and more experienced’. (Westborough, Nurse, 5) (Mackintosh, 2012, p249).
Physical Environment. ‘[Patients’ speaking up] is very important. And much more because … the type of layout that we have in hospitals now does not really allow for close monitoring of patients, so I think
|

most of the time the patient has a lot to do with alerting the nurses, and the relatives also, when they are visiting. [From] the nurses’ station now, you cannot see any patients, all you
can see is the wall. Not like in the old days where you have it at the centre of the ward and it's an open ward, so that makes it easier for close monitoring. So, I think the role of the
1909

patient and the relatives is quite important’. (Eastborough Nurse, 6) (Mackintosh, 2012, p189).

13652702, 2023, 9-10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16233 by Cochrane Portugal, Wiley Online Library on [18/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TA B L E 7 GRADE-CERQual, Confidence in the individual review findings
| 1910

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 1: Twelve studies ‘I use my own judgement no matter what NEWS indicates. I summon Minor No or very minor No concerns, Highly relevant High Confidence
Nurses strongly (1, 4, 5, 6, 7, 8, 11, 12, the doctor when I think my patient is deteriorating, regardless of methodological concerns thick data to the review Finding graded as
value using 13, 15, 16, 18) the NEWS score. Maybe other nurses summon support earlier and limitations about seen across question. high confidence,
clinical Andrews & Waterman, faster than me. I see the advantage of NEWS as a tool if you are No methodological coherence. studies 11, minor
judgement 2005. new and have little experience, so I can see that it can be helpful, limitations (1, 4, 13, 15, 18. methodological
concurrently Donohue & Endacott, but I think, for my part, I would have made the same assessment 7, 8, 15, 16, 18) limitations
with the EWS 2010. regardless of whether I had it [NEWS] or not’. (Gunhild, nine years Minor regarding
tool. Ede et al., 2020. of experience) (Jensen et al., 2019 p4392). Methodological recruitment
Elliott et al., 2015. ‘In acute medicine, as I mentioned earlier, somebody's EWS score can Limitations strategies,
Flenady et al., 2020. be slightly elevated at baseline and as we get to know our patients, (5, 11, 12, 13) one moderate
Foley & Dowling, 2019. particularly in acute medicine the nurses can use their judgement Moderate Limitation limitation
Jensen et al., 2019. to decide how frequently to do somebody's obs and to apply a rule, study (6) sample regarding
Lydon et al., 2016. ‘they must be done 6 hourly, 8 hourly, 12 hourly…’, doesn't lend number of unclear sample,
Mackintosh, 2012. itself to the uniqueness of medicine … I’ve worked in medicine, I’ve nurses not very minor
Mc Gaughey, 2013. worked in surgery, cardiology, theatres, ICU, I’ve been all over and provided. concerns
Petersen et al., 2017. there's different reasons for doing obs at different frequencies in regarding
Suokas, 2010. all of those areas, but I think you have to allow us to interpret it relevance
to use it at its best advantage’. (Medical ward Nurse Manager 01 coherence and
[02]) (Mc Gaughey, 2013, p200). adequacy.
‘Senior nurses might see a high NEWS but use clinical judgement to Rich thick data.
assess the patient and inform the intern that, even though the
NEWS is high, the patient is stable’. (Nurse 4) (Lydon et al., 2016,
p690).
‘Ward 12: …discussed the [EWS]…from his experience…patients rarely
trigger on the ward, but if they do he uses his clinical judgement
as well as the [EWS]to assess the situation, he states he does not
solely rely on the numbers generated and looks at the individual
patient's history and current management’. (Ede et al., 2020, p
174).
P10_RN reports: ‘there is some open hostility to the form from staff
who've been around for 20–30 years. They'll tell you day in and
day out that the form's a load of sh..t and takes away from clinical
judgement’.
(Flenady et al., 2020, p4 of 9).
‘I don't call a Doctor when the MEWS [score] tells me to; I’d call them
when I think the patient needed it’ (CIA) (Donohue & Endacott,
2010, p12).
‘Sometimes still you're saying, ‘They're scoring 4 but that's probably
quite good for her because she's back from ITU’. So again, you'd
report it to the doctor, but you'd say, ‘I don't think it's a particular
problem.’ So, you'd try and put some perspective on it, so that
they're not abandoning somebody else who is quite poorly’.
(Sister14 years) (Andrews & Waterman, 2005, p478).
BURKE and CONWAY

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 2: Six studies P22_RN ‘this is a blunt tool; I know how to deal with this patient Minor Minor concerns Minor concerns Relevant Moderate
The EWS tool (7, 10, 11, 15, 17, 18) and get the help that I need when I need it…. the vital signs are methodological about Thick data confidence
should not Flenady et al., 2020. the beginning of your nursing assessment really. If someone has limitations coherence. found in Finding graded
be used in Greaves, 2017. abnormal respiratory rate, then I’m much more concerned about No methodological Consistent studies 7, 11, as moderate
isolation. Jensen et al., 2019. that than what number they're showing. If I have an asthmatic limitations (7, 15) across six 15, 18 confidence as
Mc Gaughey, 2013. patient and their respiratory says only 24 but you can hear them Minor studies. thick data found
Stewart et al., 2014. wheezing and they're really tight and there's not a lot of air Methodological in only 4 studies
Suokas, 2010. moving, then I’m much more concerned about that, and would limitations (10, and the finding
escalate that much quicker’. (Flenady et al., 2020, p4 of p9). 11, 17, 18) has moderate
‘When I use my clinical judgement or my intuition, my gut feeling, I relevance to the
don't only look at the measurements; I look at how the person review question.
is affected by the measurements. I consider their breathing …
are they wheezing, are there any sounds? I look at and touch the
patients. I have been a nurse for a while, so you learn to look at
the patients in a slightly different way than just using the system’.
(Marie, five years of experience) (Jensen et al., 2019, p4393).
‘.. you need to still be able to look at observations or even still look at
your patient without having to use an Early Warning Chart to tell
if your patient is unwell or not. It should be an in-hand system, but
it shouldn't be a ‘the’ system. I think it's a combination of knowing
your patient and being able to use the tool’. (Surgical ward staff
nurses 02[07]) (McGaughey 2013, p199).
‘Everybody is different –we treat the patient, not the numbers’.
‘One patient may be very stable with a MEWS of 4; another patient
might not do as well. You treat the individual’. (Stewart et al.,
2014, p226).
‘It's a guideline; you're still looking at the patient, that's the one thing
that everyone tends to forget. You can be working with a patient
all day, and even if you did do obs once in the morning and once
in the afternoon, you'll still get a better idea how well that patient
is doing just by looking at them and being in contact with them’.
(Senior nurse (31)) (Suokas 2010, p243).

(Continues)
| 1911

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 3: Thirteen Studies ‘I have many years under my belt within this speciality. I know when a Minor Very well No concerns, Strong relevance High Confidence
Nurses value their (3, 4, 5, 6,8, 9, 10, 11, patient is unwell and know what would happen if I don't act upon methodological supported Thick data to review Findings graded as
knowledge, 13, 14, 15,16,18) it, so I would ask the doctor to review the patient and document it’ limitations data found found in question high confidence
experience, Dalton et al., 2018. (PO1) (Dalton et al., 2018, p214). No methodological across studies (3, as very minor
and intuition in Donohue & Endacott, ‘Knowing that he was away from his baseline, at baseline he was a limitations (3, studies 8, 9, 10,11, concerns
assessing risk. 2010. Ede et al., little vague, but just by knowing him you could tell’. (Gazarian 4, 8, 9, 13, 14, 13, 15) with only one
2020. et al., 2010, p29). 15,16) moderate
Elliott et al., 2015. ‘Yeah, I think to be honest the more experienced staff it is a complete Minor methodological
Foley & Dowling, 2019. insult to give them an early warning score they must follow Methodological concern
Gazarian et al., because if you can't use your skill and knowledge base to actually limitations (5 10, regarding an
2010. look at a patient to say you're not well then I think it is a disgrace. 11, 18) unclear sample,
Greaves, 2017. I think at grades of staff I think people are promoted far too Moderate limitation overall, very rich
Jensen et al., 2019. quickly in grades anyway and they still lack the basic experience study (6) sample data across most
Mackintosh, 2012. about a few years of developing their expertise and some people number of studies.
Mc Donnell et al., 2013. will stay on one Ward for all of their career and I would challenge nurses not
Mc Gaughey, 2013. their expertise and their knowledge and maybe they need another provided.
Petersen et al., 2017. system to be able to help them in their diagnosis and recognition
Suokas, 2010. of deterioration. So, I don't think grades come into it as such but
certainly experience yes as less experienced people need a guide
whereas experienced staff sometimes it is just a bit of paper which
will work which they will fill in and get help anyway’. (Modern
Matron 2 line 60) (Greaves, 2017, p163).
‘I’d like to think that it hasn't made any difference to me being able
to detect my patient deteriorating’ (FG I1) and ‘I went to nursing
school for three years—I know when it's time to ring the doctor’
(FG A4) (Elliot et al., 2015, p70).
‘That's something I’ve learnt was listen to your intuition. Because
I found more often than not that it was telling me things that
I should have been listening to anyway, so since then I think, I
do listen to it, I don't just dismiss it straightaway. [I would] just
keep an eye on them, keep going back to them. [..] Yeah, it's just
like looking for other signs like they're not being themselves’.
(Eastborough, Nurse, 5) (Mackintosh, 2012, p188).
‘they can also not score anything and still not be you know, there's
something wrong and you can see that. And often like nurses
who have experience their intuition us telling them that there's
something wrong’. (3) (Mc Donnell et al., 2012, p48).
‘(…) we [nurses] use our clinical intuition to see the patient an extra
time and take an extra set of vitals, because you have some alarm
bells ringing. If something just doesn't seem right, I prefer to take
an extra EWS score even though nothing sticks out, because there
is something you just can't define (…)’. (Petersen et al., 2017, p5
of 9).
BURKE and CONWAY

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 4: Seven Studies ‘We are responsible for following up on what is being done or what we Minor Minor concerns Minor concerns Moderate Moderate
EWS use enhances (3, 4, 10, 11, 13, 15, 18) are going to do. It's not such a dramatic difference, really. We have methodological regarding about Relevance to Confidence
sense of Dalton et al., 2018. always been responsible for collecting vital signs, for following up, limitations coherence adequacy review Finding graded
accountability Donohue & Endacott, and for paying extra attention to deteriorating patients’. (Heidi, No methodological 7 studies, as moderate
and makes 2010. four years of experience) (Jensen et al., 2019, p4393). limitations (3, 4, 4 with rich owing to minor
individual Greaves, 2017. ‘We can trace back as to who was looking after the patient so there's 13, 15) data (10, concerns
responsibilities Jensen et al., 2019. more accountability. You know, we can say to people well, look Very minor concerns 11, 15, 18) regarding
explicit. Mackintosh, 2012. this person's EWS score was five and you didn't do anything about (10,11,18) thin data in limitations and
Mc Gaughey, 2013. it, why is that… so yeah, they do take more responsibility’. (Senior studies 3, minor concerns
Suokas, 2010. Nurse (33)) (Suokas 2010, p156). 4, 13) regarding
‘if the doctor doesn't come as soon as I’d like, it's the doctor's decision, thickness of data
but at the same time it's my patient and my ward and I would in some studies.
still feel responsible for them. If I felt strongly, I would contact
someone else rather than just [accepting] ‘oh I’ve spoken to
whoever and this is the situation’. (Westborough, Nurse, 5)
(Mackintosh, 2012, p214).
‘It can be hours before the doctors get a plan sorted between them
and we are left not knowing what is going on’. (Sister 2, line 70)
‘What do you want the doctor to do when you phone them about
a score?’ Interviewer ‘I want them to take it seriously. They really
should come and look. I know they have got a lot on, but when a
patient suddenly scores it's their job to sort out’ Sister 2 line 75
(Greaves, 2017, p135-136).
‘If you had a patient you considered to be deteriorating in health and
their MEWS score was 7 or above, but the doctor on the ward
said, ‘this is fine, we already know about this’, what would be your
action?’ ‘I would document I had spoken to the doctor and his/her
reply; that's their decision, not mine’. (P06) (Dalton et al., 2018,
p214).

(Continues)
| 1913

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 5: Nine Studies ‘It provides what you need to get a doctor there, I think. It gives you… Minor Very minor very minor minor concerns Moderate
Persuasive (1, 5, 7, 10, 12, 13, your full objective facts. They can't argue with a score of 5 or 6. methodological concerns concerns, about Confidence
Credibility of 14,15, 17) They'll just come. It's a complete measure which they do agree to limitations. about adequate relevance Finding graded
EWS. Andrews & Waterman, attend to, and it helps your patients more than anything, which is No methodological coherence rich data as moderate
2005. Ede et al., important’. (Staff nurse, 1 year) (Andrews & Waterman, 2005, concerns (1,7,14, confidence
2020. p478). 15) due to minor
Flenady et al., 2020. ‘WARD 7: …took over a patient who had only had 100mls of urine Minor concerns (5, concerns
Greaves, 2017. … in 11 hours, … patient was quite unwell …felt the thing that 10, 12, 13, 17) regarding
Lydon et al., 2016. worked well…once she flagged up the problem… she had good methodological
Mackintosh, 2012. communication between the team and the doctors acted on her limitations,
Mc Donnell et al., 2013. concerns very quickly’. (Ede et al., 2020, p175). coherence,
Mc Gaughey, 2013. P14_RN commented: ‘the more junior nurses say I have a 5, this is and relevance.
Stewart et al., 2014. what I need to be doing’. P08_RN pointed out the usefulness of a However, data
score: ‘it gives them (junior nurse clinicians) a concise idea of how found was rich
sick their patient is’ (Flenady et al., 2020, p4 of 9). and adequate.
[Extract from field notes, Westborough, FN6]
‘On a nightshift, E, the nurse in charge and I are discussing the nurses’
role in escalation of care. She notes she has witnessed others
being bullied, where doctors have said they have been too busy
to come, often saying that there were other patients just as sick.
E comments that these nurses were too descriptive in calling
for help and not assertive enough. She contrasts this with her
behaviour; ‘I just come to the point, I’ll say, Patient's drowsy,
hasn't passed urine, is scoring and is clammy. If the doctors say
they are too busy and can't come I’ll say, Well, I’ll find someone
who can’. She notes one recent instance where she called the
registrar and the registrar said, ‘Why isn't the F1 coming to see the
patient?’ She explained that the F1 said she was too busy to see
the patient, and the registrar said, ‘Well that's fine, I’ll take it up
with the F1 and sort it out,’ and five minutes later the F1
was on the ward’. (Mackintosh, 2012, p213).
‘Depending on what you tell them on the phone determines how
urgent they consider it to be. It's just having the experience to
know what to do with it (the score) and then following it through
and getting somebody to actually look at this or come and review
this patient’ (4) RGN 1–5 years’ experience (Mc Donnell et al.,
2012, p46).
‘MEWS is helpful if you say, ‘the patient is a MEWS 4 or 5’. Physicians
recognize that they need to see the patient right away’. (Stewart
et al., 2014, p226).
BURKE and CONWAY

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 6: Seven Studies ‘getting the doctors to fill in the modification … a nightmare’. (FG I3) Minor Minor concerns Minor concerns, Very minor Moderate
The modification (6, 7, 8, 10, 11, 12, 15) (Elliot et al., 2015, p69). methodological thick data concerns Confidence
of EWS Elliot et al., 2015 P16_RN explained: ‘I’ve rung the doctor; they didn't do the mods (did limitations in (7, 8, 10), Finding graded as
parameters is Flenady et al., 2020 not write modifications on the EWS chart) that they'd written No methodological thin data in moderate, minor
complex. Foley & Dowling, 2019 on the chart (patient notes within the chart) that they would do. limitations (7, (6, 11, 12, to moderate
Greaves, 2017 I could do a MET call, but they've written in the chart (patient 8, 15) 15) concerns noted
Jensen et al., 2019 notes) that this is their mods, nurses have to cherry-pick doctors’. Minor with regards
Lydon et al., 2016 (Flenady et al., 2020, p5 of 9). methodological methodological
Mc Gaughey, 2013 ‘SHOs do not set parameters yet they are the ones re-viewing the limitations (10, limitations and
patient…. you ring the Reg to review the patient as per the 11, 12) minor concerns
protocol and they will say ‘get the SHO’ to review’. (Nurse F) Moderate limitations regards
(Foley & Dowling, 2019, p1187). study (6) sample coherence
‘Sometimes it is very hard to get a variance signed. So, patients, number of adequacy and
because of the MEWS system, now tend to, whether it is right nurses not relevance.
or wrong, to have observations done maybe hourly for in a provided.
tachycardic patient, because they have an idea of what it is
related to, but the Doctors aren't very keen to sign a variance’.
(Staff Nurse 3, line 39) (Greaves, 2017, p145).
‘but they would always run it by the doctor but it's always very
verbally, there's never really much written in their notes, like, the
doctor wouldn't really write in their notes, ‘staff nurse informed;
patient's Mews 3; went and assessed patient; or this is what I have
suggested’, or whatever, it's always very verbal’. (Surgical ward
sister 01[19]) (Mc Gaughey, 2013, p228).

(Continues)
| 1915

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 7: Eleven Studies ‘It's easier to act dumb and say, ‘This lady in here, her breathing is very Minor Minor Minor Concerns, Minor concerns Moderate
Nurses (1, 2, 3, 5, 7, 9, 10, 11, fast’, rather than ‘She's got a high respiration rate’. I think it can Methodological Concerns there is Confidence
communicating 13, 15, 18) come across to them (doctors) that you don't know what you're Limitations. adequate data Finding graded
risk of patient Andrews & Waterman, talking about. They question everything, so you might as well No methodological to support as moderate,
deterioration 2005. Cherry & just say that's what you've seen in lay terms’. (Staff nurse, 1 year) limitations (1, 3, finding. minor concerns
to medical Jones, 2015. (Andrews & Waterman, 2005, p 477). 7, 9, 15), Minor with regards
colleagues Dalton et al., 2018. ‘Even though you ask them, it doesn't matter just come, they are lazy’. methodological methodological
reflected Ede et al., 2020. (P1) (Cherry & Jones, 2015, p 816). limitations (2, 5, limitations
both positive Flenady et al., 2020. ‘We have a mutual respect. My knowledge is ward-based, so we work 10, 11, 13, 18) mainly
and negative Gazarian et al., 2010. well together. I can point them in the right direction, and they recruitment
experiences Greaves, 2017. respect my experience. They always call the shots -their knowledge strategies
and influences Jensen et al., 2019. is far greater than mine’. P03 (Dalton et al., 2018, p214). employed and
teamwork. Mackintosh, 2012. ‘I have often spoke to the doctor and said, ‘this minor concerns
Mc Gaughey, 2013. lady is really not right, but her MEWS score regarding
Suokas, 2010. is 3’ and the doctor just says, ‘if I get time, I coherence
come and see the patient, but I have a number adequacy and
of things to do first’. You feel stupid sometimes relevance.
if you're wasting people's time’. (P05) (Dalton et al., 2018, p214).
‘Ward 4: Observed interaction between doctors and
nursing staff—very tense. Doctor storms off. ‘I guess
we'll agree to disagree’. …Would be difficult for someone not confident to
escalate problems to someone
who is very dismissive. When discussing patients, he is
not giving eye contact and showing defensive postures’. (Ede et al.,
2020, p176).
‘Because they knew me, and what type of nurse I was, and I knew them,
we were able to trust each other’. (Gazarian et al., 2010, p27).
‘I sometimes think that the medical staff don't appreciate what the
nurses do to look after the patients, and the MEWS is a way to get
them involved’. Staff Nurse 1 line 81 (Greaves, 2017, p171).
‘Working with other experienced nurses helps you feel more confident;
you can ask questions and get some feedback and support in
assessment’. (Heidi, four years of experience) (Jensen et al., 2019,
p4395).
‘Where I came from, we used to have a registrar there, I think he's been
there for many years; if I walk into the hospital on a weekend and
he's on-call I’m confident. [..] But here, because you have so many
doctors to deal with, it's really very difficult to … to assess their
competence’. (Eastborough, Nurse, 6) (Mackintosh, 2012, p252).
BURKE and CONWAY

Explanation
BURKE and CONWAY

Summary of review Studies contributing to Methodological Adequacy of of CERQual

finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

I think it's sometimes about personalities because sometimes you find

that personalities of both nurses and doctors and it's just their own
personality in itself, there's nothing you can do to change that,
makes it difficult in some ways for them because some nurses are
quite timid, and they maybe don't have the confidence and are afraid
then to make that call. Whereas other nurses are confident, but
they could also meet with a very confident young doctor who thinks,
‘I know it all’, and ‘what are you calling me for?’ So, you do have
that and sometimes it is, and that's going to be a very hard thing
when you're dealing with actual people's personalities to overcome’.
(Senior Nurse Manager C 02 [27]) (Mc Gaughey, 2013, p221).

Finding 8: Seven Studies ‘One of the things I have a problem with, I suppose I don't use the Minor Minor concerns. Moderate Relevant to Moderate
Nurses seek (1, 2, 6, 10, 11, 15, 18) proper correct language, maybe. I haven't gone any deeper into Methodological concerns communication Confidence
continuous Andrews & Waterman, physiological training or physiological terms necessarily, and I feel limitations. about processes. Finding regarded
training/ 2005. that probably I don't use the right language when I’m trying to get No methodological adequacy as moderate
updates on Cherry & Jones, 2015. a doctor to come and see the patient’. (Sister, 10 years) (Andrews limitations (1, 7 studies confidence, as
physiological Elliot et al., 2015. & Waterman, 2005, p477). 15) only. there was minor
terminology and Greaves, 2017. ‘Not being taught properly’, P1. ‘She had scored, I think, a 1 when it Minor limitations (2, 2 studies to moderate
physiological Jensen et al., 2019 was really a 3’, P2. ‘You get some people who do not even ask if 10, 11, 18) with methodological
processes to Mc Gaughey, 2013 they have passed water or checked if [they have] by going back but Moderate limitation rich data limitations in
support them in Suokas, 2010 just put a 0 anyway’, P5. (Cherry & Jones, 2015, p816). study (6) sample remaining five studies.
communicating ‘We should be educating junior staff to look for more than just number of studies thin Minor to
and escalating teaching them to use colours’ (FG A6) (Elliott et al., 2015, p 70) nurses not data. moderate
patient care ‘Well, I had a case with a patient who came in, who actually seemed to provided. concerns
in response to be in pretty good shape apart from an elevated respiratory rate. regarding
EWS. Before we had learned something from NEWS, I didn't think much coherence and
about the respiratory rate, but because it was elevated, I had to adequacy of the
take new measurements in a few hours, and by then his condition data.
had deteriorated. Then I saw that respiratory rate is often one of
the first things affected when the patient is deteriorating. … I have
realised that the respiratory rate is important and, if I had not
used NEWS, then I might not have conducted that reassessment’.
(Fiona, one year of experience) (Jensen et al., 2019, p4393).

(Continues)
| 1917

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

‘what we found was, repeatedly, that their scores weren't being done
correctly, they were missing some parameters, the higher the score
the more chance there was that it wasn't added up correctly and
that was a frequent finding that whenever they had totted them
up, they had got the wrong number and obviously that could
change the response that was required. The other thing is that at
all of our Crash calls we will document what the Early Warning
Score was prior to the Crash call and the time and we are finding
that yes, sometimes and on a regular basis the scores are low but
quite often their scores aren't low, they're high, maybe 6 hours
earlier but their obs haven't been repeated’. (Senior Nurse A
01[03]) (Mc Gaughey, 2013, p205).
‘I think if you compare it to maybe two or three years ago then there is
an improvement, but there is still room for [improvement]. There
are still some patients that are slipping through the net, and
there are still some areas where Early Warning Scores are being
triggered and the appropriate action is not taking place’. (Senior
nurse (15)) (Suokas, 2010, p175).

Finding 9: Eleven studies ‘You see, with the early warning system you have got more Minor Minor concerns Very minor Very relevant High Confidence
EWS use empowers (1, 2, 4, 6, 7, 10, 11, 14, ammunition, haven't you? You're not just taking it off your methodological concerns, EWS protocol In spite of minor
nurses. 16, 17,18) own (bat) to say, ‘I'm now going, I'm not happy with the care Limitations lots of influences to moderate
Andrews & Waterman, they're receiving from you –I am going to get in touch with the No methodological rich data nurses in their methodological
2005. Cherry anaesthetist.’ You've got it down that is the protocol’. (Staff nurse, limitations (1, 4, throughout response to limitations
& Jones, 2015. 18 years) (Andrews and Waterman, p478). 7, 14, 16) the patients EWS findings
Donohue & ‘Yes, say look this patient is deteriorating and you can see that the Minor limitations (2, 11 studies graded as high
Endacott, 2010. MEWS score is getting higher and shove it in front of them and 10, 11, 17, 18) confidence
Elliot et al., 2015. they [have] got to look at it, haven't they?’ (Cherry & Jones, Moderate limitation because of the
Flenady et al., 2020. 2015, p816). in study (6), overall adequate
Greaves, 2017. ‘it certainly gives you a bit more bravery to pick up the phone'. (FG G6) sample number rich data across
Jensen et al., 2019. (Elliot et al., 2015, p70). of nurses not the studies.
Mc Donnell et al., 2013. P34_RN ‘EWS is an empowering tool for the nurse clinician: it gives provided.
Petersen et al., 2017. you the confidence to say, you need to come review this patient
Stewart et al., 2014. immediately, because they're scoring a 5’. (Flenady et al., 2020,
Suokas, 2010 p5 of 9).
‘I think it empowers the juniors because they've got a tool to say this is
the guideline and this needs acting on. So, I think it's given them
the confidence to do that’. (ID: 10, RGN > years) (Mc Donnell
et al., 2012, p47).
BURKE and CONWAY

13652702, 2023, 9-10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16233 by Cochrane Portugal, Wiley Online Library on [18/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TA B L E 7 (Continued)
Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment
BURKE and CONWAY

‘We have some standardised permitted orders. If the patient has

an elevated heart rate, we can give some fluids; if they have a
temperature, we can give paracetamol without having to involve
the doctor. So, we can try to correct the deviation, but if it
persists, we need to call the doctor. … I think, since we started
using NEWS, we've started to take some actions earlier than we
did before. We've become more aware; if a patient has elevated
NEWS, you must do something about it. It pushes me to do a little
more. ….’ (Bente, five years of experience) (Jensen et al., 2019,
p4395).
‘I think they're very aware of somebody's observations being out of
normal range. I just think when they're junior it's how empowered
they feel about talking to somebody else about them’. Senior nurse
(15) (Suokas,2010, p194)

Finding 10: Nine Studies ‘Well, it's given a framework that you can say, ‘Look at this.’ And they Minor Minor concerns No or very minor Minor concerns High Confidence
The EWS helps (1, 3, 8, 11, 12, 14, 15, actually tell you if you can actually go to who you want. But I think Methodological about concerns about Finding graded as
nurses to 17, 18) it's ‘cause it's a framework and it makes them come’. (Staff nurse, limitations coherence about relevance high confidence
prioritise Andrews & Waterman, 28 years) (Andrews & Waterman, 2005, p478). No methodological adequacy as there was
patients most 2005. Dalton ‘I think the MEWS system is good, even if I limitations lots of only minor
at risk and et al., 2018 Thought’, ‘OK, I have the situation under control (1,3,8, 14,15) rich data methodological
supports their Foley & Dowling, 2019. Now’, I would still ring the nurse practitioner. Minor limitations especially limitations and
decision-making Jensen et al., 2019. This is what I have done; they are still MEWS (11, 12, 17, 18) studies very minor
processes. Lydon et al., 2016. high at the level they were before, but they will (1,8, 11, 15,18) concerns
Mc Donnell et al., 2013. need a look at later’. P02 (Dalton et al., 2018, p215). regarding
Mc Gaughey, 2013. ‘You do use the score to rate how sick they are and what you need to coherence,
Stewart et al., 2014. do about it’. (Nurse G) (Foley & Dowling, 2019, p1187). adequacy, and
Suokas, 2010. ‘I use it [NEWS] every day. I had a rather complicated patient a while relevance.
ago. I collected vital signs, saw that the total score had increased,
and summoned the doctor. The doctor was not concerned because
the patient had been stable for a while. The total score had now
increased; the doctor didn't find it significant, but I didn't like it
and reacted. During the following night, the patient became very
unstable, so the system is useful. NEWS is really good to have.
It supports us. I contacted the doctor, and that was the right
decision. With NEWS, I feel safer and more self-confident and
have more to say to the doctor. I had a gut feeling that something
was happening. I felt that I did the right thing. I felt a little stupid,
but then I thought that I did the right thing’. (Nina, five months of
|

experience) (Jensen et al., 2019, p4392).

1919

(Continues)

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

‘When you first walk onto the floor, it (the MEWS) catches my
attention…especially if you are juggling 5 or 6 patients; you can
glance at the MEWS scores and if the score is elevated say, OK
there is something going on here and I need to see this patient
right away’. (Stewart et al., 2014, p226).
‘[Patient care is] improved as the [NEWS] makes it very clear when a
patient should be reviewed and when to consider transferring a
patient to high dependency’. (Nurse 5) (Lydon et al., 2016).
‘It does highlight patients that are actually deteriorating quicker than
you would if you'd just got a normal TPR chart’. (6) RGN 1–5 years’
experience. (Mc Donnell et al., 2012, p46).
‘..I go to someone and their observations say are sitting at a 4 and
I would look and see what is making it a 4, is it change, is it
something new and if I don't feel that there's action required, I’d
say, ‘they're pyrexic, they've a high temperature and they've a
fast pulse rate and they need a couple of paracetamol and they
need cultured’, I would document it on the back, ‘blood cultures
and whatever’, or, ‘no action required’. So that whoever's coming
behind me knows that I made that decision’. (Senior Nurse
Manager C 02 [27]) (Mc Gaughey, 2013, p222).
‘When you first walk onto the floor, it (the MEWS) catches my
attention…especially if you are juggling 5 or 6 patients; you can
glance at the MEWS scores and if the score is elevated say, OK
there is something going on here and I need to see this patient
right away’. (Stewart et al., 2014, p226).
BURKE and CONWAY

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 11: Six Studies ‘I always have my evidence there to say why I want them [the outreach Minor Minor concerns Moderate No or minor Moderate
BURKE and CONWAY

EWS acts as a form (4, 10, 12, 13, 14, 18) team] and I think because I know what they want before they Methodological about concerns concerns about Confidence
of evidence Donohue & Endacott, come, I am able to get over to them how serious or how acute the limitations coherence about relevance Finding graded
and can protect 2010. situation is’ (CI/H) (Donohue & Endacott, 2010, p12). No methodological adequacy, as moderate
nurses from Greaves, 2017. ‘I think if you had of asked me like a year ago, I would have said no limitations (4, six studies because
liability. Lydon et al., 2016. not at all. I knew when something was wrong, but I don't think I 13, 14) only. of minor
Mackintosh, 2012. would have had the voice to say it but as you get to know groups Minor limitations methodological
Mc Donnell et al., 2013. of Doctors that really helps, and they know when you are worried (10, 12, 18) limitations
Suokas, 2010. that it must be something as you don't ring for everything and and moderate
that has helped. I do feel more confident and also I know by doing concerns about
everything that is set and by protocol that I am always backed adequacy of the
up by that because that is the policy, and I am happy to raise data.
concerns’. (Staff Nurse 2, line 131) (Greaves, 2017, p141).
‘Using the charts gives you a bit more confidence when you are raising
causes for concern, because it is, like evidence’ (Staff Nurse 4, line
34) (Greaves, 2017, p141).
‘If you don't follow the NEWS and something goes wrong then the
blame rests on you and you've got nothing to back you up…
whereas, once you call, you're protected’. (Nurse 3) (Lydon
et al., 2016, p691).
‘We now use it on every single patient that we have on the ward and
obviously they all get a score at the end of it, so I think it just rings
more alarm bells if you like if a patient is unwell or is deteriorating,
whereas just recording a patient's observations, you know, you
might miss something (15) RGN 1–5 years’ experience’.
(Mc Donnell et al., 2012, p46).

‘Sometimes you're doing obs all the time, ‘why am I doing these obs all
the time?’, and it takes someone to actually say, ‘look this patient
is quite stable, they're not acutely ill’, and to make them tid or even
bd, it's very rarely…I think you're scared…‘Oh what if something
went wrong!’ and you've been the one who has changed them to
twice a day. So sometimes you could find yourself doing obs a lot
when there's no need’. (Surgical ward staff nurses 01[08]) (Mc
Gaughey, 2013, p206).
‘There was very much a fear aspect to begin with like, don't get me
wrong [the OBS charts] were excellent and they were really good
for us to be able to say, ‘oh right there's something wrong [with the
patient] here’. But we did take that literally, I know I took it literally
to begin with because I sort of panicked, I thought right this is a
legal documentation’. (Staff nurse (26)) (Suokas, 2010, p245).
| 1921

(Continues)

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 12: Six Studies ‘Like somebody who has COPD, their sats 92 on room air, that might Minor Minor concerns Moderate Very relevant Moderate
Nurses reflected (2, 4, 10, 13, 14, 18) be normal for them. Isn't it?’ (P2). (Cherry & Jones, 2015, p816). methodological with concerns to review Confidence
how patients Cherry & Jones, ‘Yes, but sometimes the saturations would be 80 to 92. Sometimes limitations coherence regarding question Finding graded
with chronic 2015. Donohue & that patient would score 2 or 3 on the MEWS (because of the No methodological adequacy. as moderate
conditions like Endacott, 2010. COPD]’ (P4) (Cherry & Jones, 2015, p816). limitations (4, Only Six confidence, due
COPD have Greaves, 2017; ‘… she was MEWsing [had a MEWs score of] at the time 5 and 6 13, 14) studies, to concerns
different EWS Mackintosh, 2012 principally because of her resps. She was a COPD sufferer, so I Minor limitations (2, however rich regarding
baseline values Mc Donnell et al., 2013 wasn't overly concerned’. (CI/H) (Donohue & Endacott, 2010, 10, 18) data found adequacy of
and that EWS Soukas, 2010. p12). in studies. data, minor
is a generic ‘Yeah, the main patients we find are the respiratory patients because methodological
document of what is flagged up on the early warning scores. So, for example limitations, and
solely designed if we have a COPD patient who is on home oxygen the very fact minor concerns
with a young fit that they are on oxygen scores them a 2 the sats in a COPD regarding
healthy person patient you want them slightly lower so that will automatically coherence.
in mind. score them a 2 or a 3 so straight away when they are at their
norm and what is good for them, they may be scoring a 4 or a 5.
Then if you add in a slightly low blood pressure or a temperature
very slightly up and before you know it, they could be scoring a
6 or a 7 which in another patient would be quite alarming but in
a respiratory patient that can often be the norm for them’. (Staff
Nurse 4, line 38) (Greaves, 2010, p 144).
‘Someone with COPD is not going to have a resp rate of 12 to 16, It's
going to be more elevated generally, but that is normal for them.
So, it's inappropriate to be phoning doctors all the time with a
COPD patient who might have a resp rate of 24 when that might
be perfectly normal for them. Using your clinical judgement to
determine what is normal for that patient and I think parameters
that are set on PAR scoring system, as well as your own
judgement, are enough to be able to identify patients that are at
risk’. ((9) RGN 1–5 years) (Mc Donnell et al., 2012, p48).

‘This raises one of our problems with a generic document like this
because a lot of our patients have got a high respiration rate
and that is their normal, you know nothing we're gonna do is
gonna change that. So, although we could have someone with
a respiratory rate of high twenties or low thirties, that is the
patient's regular respirations and we're never gonna improve on
that, so you will get a false reading from the EWS’. (Senior nurse
(31)) (Suokas, 2010, p214).
BURKE and CONWAY

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment
BURKE and CONWAY

Finding 13: Four Studies ‘…I can think of specific examples when it didn't; for example, a Minor Moderate Moderate Moderate concerns Low confidence
EWS should not (10, 13, 15, 18) gentleman who arrested without warning whilst waiting to go Methodological concerns concerns regarding Finding graded
be considered Greaves, 2017. home. MEWS was of no indicator benefit there and I suppose it concerns about relevance to as low, due
a fool-proof Mackintosh, 2012. was usually expected to warn of a sudden arrest. I am thinking of No methodological adequacy, the review to moderate
document, Mc Gaughey, 2013. indications where a patient has had a sustained high MEWS score limitations (13, limited data question concerns
care needs to Suokas, 2010. for a period of almost days and there was no great change in the 15) regarding
be taken as patient's management. So, there are extremes in anomalies within Minor coherence, data
there can be the MEWS score but by and large it does help’. (Medical ward methodological adequacy and
anomalies with Nurse Manager 01[02]) (Mc Gaughey, 2013, p197). limitations (10, relevance to
the chart. ‘We had a patient in [another ward] who had a EWS score of one, and 18) review question.
a continued EWS score of one, but that patient eventually died. Two papers
There was no clinical reason to have summoned attention apart contained rich
from the fact that you looked at this patient and they did not look data 15, 18,
well, but there was no reason. So, it's not fool proof’. (Senior nurse whilst the other
(31)) (Suokas,2010, p232). two papers data
was moderately
thin.

Finding 14: Seven studies ‘It makes a difference that I am in navy blue. Being in navy blue makes Minor Minor concerns Minor concerns Very minor Moderate
Positions of (2, 4, 5, 7, 9, 10, 15) a difference’. (P5) (Cherry & Jones, 2015, p816). Methodological regarding regarding concerns about Confidence
seniority in Cherry & Jones, ‘Before the [medical] registrar came there is always a running limitations coherence. adequacy. relevance Finding graded
nursing instil 2015. Donohue & debate as things are happening about this and that…. when the No methodological as moderate
confidence in Endacott, 2010. Ede registrar [arrived] it was ‘right this is what we are going to do’. limitations (4, 7, confidence.
escalating care et al., 2020. (CI/G) (Donohue & Endacott, 2010, p14). 9, 15) Minor
and escalating Flenady et al., 2020. P34_RN elaborated: ‘before we hit that staff alarm, if we can escalate Minor methodological
care to a more Gazarian et al., 2010. straight to a senior doctor in ED…my experience is that 99.99% methodological concerns and
senior level was Greaves, 2017. of the time, they will come immediately’. (Flenady et al., 2020, limitations (2, minor concerns
favoured. Mc Gaughey, 2013. p6 of 9). 5, 10) with coherence
‘We had a patient who went into flash PE and the doctor was trying to and adequacy,
handle it and probably for 45 minutes the guy was in respiratory very minor
distress and then we called the rapid response’. (Gazarian concerns
et al., 2010, p30) regarding
‘As a first port of call if we become concerned about a patient, we relevance.
would go to the F1. If we felt that they were out of their depth
or they weren't responding quickly enough probably the junior
nurses would go to the SHO, but I would tend to go to a Registrar
or a Consultant probably because I have a better relationship with
them and I feel able to ring them where as other people don't’.
(Sister 1, line 51) (Greaves, 2017, p142).
|

(Continues)
1923

TA B L E 7 (Continued)

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

‘It would probably be your F1 because they're ward based but

obviously you wouldn't undermine them, you would tell them but
if you felt that maybe they weren't taking onboard then you would
just bleep someone more senior’. (Surgical ward sister 01 [19]) (Mc
Gaughey, 2013, p215).

Finding 15: Five studies ‘Sometimes they [surgeons] are in clinics or in other hospitals and you Minor Minor concerns Minor concerns Very relevant Moderate
Challenges when (4, 5, 8, 10, 18) can't always get them’. (CI/E) (Donohue & Endacott, 2010, p13). Methodological on adequacy to review confidence
trying to Donohue & Endacott, ‘2300 Patient desaturated. Called Senior House Officer (SHO), told limitations of data only question Findings graded as
escalate care 2010. Ede et al., to call ICU, ICU told to call ENT, ENT didn't answer. ITU came No methodological 5 studies. moderate, as
in response to 2020. at request of SHO. ENT consultant called by nurse, SHO told to limitations (4, 8) despite there
EWS. Foley & Dowling, 2019 review. ITU and ENT disagreeing about need for trachy’. (Ede Minor only being
Greaves, 2017. et al., 2020, p175). methodological 5 studies data
Soukas, 2010. ‘Doctors should have been called, and initially I think the Doctor had limitations (5, was strong and
been called, but there was a huge delay between the Doctor being 10,18) there were only
called and the Doctor actually attending’. (Staff Nurse 6, line 158) minor concerns
(Greaves, 2017, p138). regarding
‘Some doctors are better than others for reviewing immediately, others coherence and
you have to chase and chase’. (Nurse D) (Foley & Dowling, 2019, methodological
p1187). limitations.
‘You are often ringing and ringing them to come up…. The other day I
spent an hour trying to get a doctor to review a patient because of
their EWS’. (Nurse G) (Foley & Dowling, 2019, p1187).
‘If you don't get any joy from your medical staff, or you feel that their
decision was inappropriate, you've got other ports of call that you
can go to outreach nurses and the anaesthetics’. (Senior nurse
(15)) (Suokas, 2010, p161).

Finding 16: Eight studies ‘Ward 7: if there was just one thing, she would generally improve Minor No or very minor Minor concerns High relevance High Confidence
Challenges for (5,7,10,11,13,15,17,18) the ward it would be staffing. …last Saturday…she was the only methodological concerns around to review Finding graded as
nurses in Ede et al., 2020. permanent member of staff from that ward. There were 2 agency limitations about adequacy, question. high confidence
adhering to Flenady et al., 2020. nurses and there was one member of staff who was familiar with No methodological coherence well very minor
EWS escalation Greaves, 2017. the trust but wasn't familiar with the ward, so she didn't know limitations (7, supported concerns
protocols due Jensen et al., 2019. where anything was, she wasn't able to open doors cos she didn't 13,15) data in regarding
to reduced Mackintosh, 2012. know codes, she wasn't able to just do simple dressings without Minor 8 studies methodological
staffing levels, Mc Gaughey, 2013. being told where everything was…’ (Ede et al., 2020, p176). methodological limitations,
higher levels of Stewart et al., 2014. P34_RN reported: ‘we don't use trends (electronic patient movement limitations (5, 10, coherence,
patient acuity Suokas, 2010. software) to estimate nursing hours whether we end up with 7 11, 17,18) and adequacy.
and lack of or 17 patients, we have the same amount of staffing’. (Flenady Finding well
resources. et al., 2020, p6 of 9). supported by
data.
BURKE and CONWAY

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
BURKE and CONWAY

finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

‘.. We most certainly have less staff than we would have had, we have
less qualified staff and we most certainly have sicklier patients,
I mean, maybe 10 or 15 years ago patients were nursed in HDU
now they are nursed on a ward with constant IVs and blood
transfusions and all that, you know, the same one Nurse to the
whole section with her other number of patients in that section,
whereas HDU or ICU you may have 1:1 nursing or even 1:2. On
the ward you are 1:8 or more, in some cases 1:10 If there is no
student there, no auxiliary there, the Staff Nurse is doing all of
those jobs and they can't all be done at the same time to the same
degree’. (Medical ward Nurse Manager 01[02]) (Mc Gaughey,
2013, p202).
‘So, a staff nurse can potentially be looking after 8 patients you
can't have someone scoring a 7 that is monitoring at 15-minute
observations and it is just not possible’. (Staff Nurse 2, line 64)
(Greaves,2010, p130).
‘If it's busy on the ward and you have relatively healthy patients and
the measurements were fine yesterday, then it's tempting to skip
the measurements. … I have to prioritise. If there is no change in
the patient's condition, I must prioritise other patients’. (Bente,
five years of experience) (Jensen et al., 2019, p4396).
‘We are supposed to do them [the observations] once a shift. But it's
whether we actually get around to doing them…if you're doing all
the drugs then that's not likely to happen’. (Eastborough, nurse 5)
(Mackintosh, 2012, p167).
‘We let the nursing supervisor know about patients who have an
elevated MEWS score. It gives them (administrators) a ‘just-in-
time’ sense of how the unit is operating, what our immediate
staffing needs are, and plan for the possibility that a patient
may need to be transferred to a higher level of care’. (Stewart
et al., 2014, p226).
‘Oh, there are workload issues all the time. There are staffing resources
…your resources are not always the best; it's a very busy high
dependency ward. There was something 10, 11 IVs and a lot of
those patients at 3 and 4 IVs and there are 2 central lines in there
at the moment, there are 2 patients on TPN, it's very demanding’.
(Medical ward sister 02 [16]) (Mc Gaughey, 2013, p201).
|

(Continues)
1925

TA B L E 7 (Continued)
|

Explanation
Summary of review Studies contributing to Methodological Adequacy of of CERQual
finding the review finding Examples of Supporting Quotes Limitations Coherence data Relevance assessment

Finding 17: Three Studies ‘I think the factors may be the level of Doctor and sometimes the lack Minor Minor concerns Moderate Relevant to Low confidence
Nurses felt out (10, 13, 15) of Doctors on nightshift … they are tied up with someone who is Methodological about concerns the review Finding graded as
of hours Greaves, 2017. also critically unwell for a good few hours and (we) are left with a limitations coherence about question as low confidence
escalation of Mackintosh, 2012. more junior down here who may be not making those decisions’ No methodological adequacy influences because
care in response Mc Gaughey, 2013. (Staff Nurse 6, line 113) (Greaves, 2017, p138). limitations (13, only and impacts although there
to EWS could ‘.. So obviously a high score, you're going to want a doctor to see the 15) 3 studies on nurses in were only
benefit from patient; if you have a high score at night you have to go through Minor with rich responding to minor concerns
the availability the hospital night team and give the report to indicate the methodological data EWS. regarding
of more urgency by suggesting what the MEWS score is and what your limitations (10) methodological
senior medical interpretation is and what your anxiety is and then the hospital limitations and
decision might push and will then refer the doctor to you urgently if it is coherence. The
makers. deemed to be the case. But during the daytime you have ready adequacy of the
access to the medical team, so you don't have to have the same data was lacking
clarity of thought and justification’. (Medical ward Nurse Manager only 3 studies
01[02]) (Mc Gaughey, 2013, p218). (2 qual and one
‘Certainly, out of hours it's quite hard to get a decision because, I think multiple case
probably rightly so, the doctors feel they don't know the patient study approach)
and the full situation, and certainly, some of the more junior ones
are quite worried about making a decision, which I think is quite
sensible really. Sometimes there's … there was a gentleman over
the weekend who became unwell, and it was difficult, the doctors
were all a bit confused about which bleep they should have, and I
think it's difficult to get the person you needed. So, we ended up
with a medical registrar there for someone who's effectively kind
of palliative care needs, and they made the decision to make them
not for resuscitation. So, it wasn't their team, but it was someone
more senior, and more experienced’. (Westborough, Nurse, 5)
(Mackintosh, 2012, p249).

Finding 18: One study ‘[Patients’ speaking up] is very important. And much more because … Minor Minor concerns Major concerns Very relevant Low confidence
The modern (13) the type of layout that we have in hospitals now does not really methodological about about to review Finding graded as
hospital layout Mackintosh, 2012. allow for close monitoring of patients, so I think most of the limitations coherence adequacy question on low because
can influence time the patient has a lot to do with alerting the nurses, and the Minor due to only the factors major concerns
nurses in their relatives also, when they are visiting. [From] the nurses’ station methodological 1 study. that influence regarding data
escalation now, you cannot see any patients, all you can see is the wall. Not limitations nurses when adequacy, only
of care. The like in the old days where you have it at the centre of the ward and escalating care one study.
patient and it's an open ward, so that makes it easier for close monitoring. So, in response to
their family's I think the role of the patient and the relatives is quite important’. EWS.
role in (Eastborough Nurse, 6) (Mackintosh, 2012, p189).
escalating care
was highlighted
BURKE and CONWAY

F I G U R E 3 Conceptual Model [Colour

figure can be viewed at wileyonlinelibrary.
com]

3.2 | Theme 2: SMART Communication more than anything, which is important’. (Staff nurse, 1
year) (Andrews and Waterman 2005, p. 478).
The theme of SMART (Specific, Measurable, Achievable, Relevant/
Realistic and Timely) communication emerged from exploring
nurses’ experiences of using the EWS to communicate and esca- 3.2.2 | Finding 6: The modification of EWS
late patient care episodes. The acronym SMART was first used in parameters is complex
1981 by Doran who developed it towards setting effective meas-
urable goals (Revello & Fields, 2015). This review demonstrated Seven studies saw nurses remark that doctors are reluctant to de-
that nurses’ experiences of communicating EWS not only revealed viate away from the set parameters laid out in the tool and getting
alignment to the SMART acronym but also reflected their need for these adjustments documented is time consuming, frustrating and in-
this SMART focus in other areas of communication as well. stigated in the main by nurses (Elliott et al., 2015; Flenady et al., 2020;
Foley & Dowling, 2019; Greaves, 2017; Jensen et al., 2019; Lydon
et al., 2015; Mc Gaughey, 2013).
3.2.1 | Finding 5: Persuasive Credibility of EWS
‘getting the doctors to fill in the modification … a
Nurses in nine studies identified that EWS provides them with a spe- nightmare’ (FG I3) (Elliott et al., 2015, p. 69).
cific formula that prompts a response (Andrews & Waterman, 2005;
Ede et al., 2020; Flenady et al., 2020; Greaves, 2017; Lydon et al.,
2015; Mackintosh, 2012; McDonnell et al., 2013; Mc Gaughey, 2013; 3.2.3 | Finding 7: Nurses communicating risk of
Stewart et al., 2014). Three of these studies saw nurses describe EWS patient deterioration to medical colleagues reflected
as a measurable numerical language, concise and precise for staff both positive and negative experiences and
(Flenady et al., 2020; Greaves, 2017; McDonnell et al., 2013). Nurses influences teamwork
in two of the studies recognised how the EWS allows staff who are un-
familiar with each other to escalate care and communicate patient de- The ease of escalating care using EWS when there is mutual respect,
terioration thereby achieving its aim (Mackintosh, 2012; Mc Gaughey, trust and support amongst colleagues was referred to in five stud-
2013). EWS was seen as a familiar tool, common across hospital set- ies (Dalton et al., 2018; Flenady et al., 2020; Gazarian et al., 2010;
tings making it relevant (Greaves, 2017). EWS ability to demand and Jensen et al., 2019; Mackintosh, 2012). Similarly, five studies suggest
convey a sense of urgency whilst securing a timely response was re- that tensions between the doctor and nurse, and their personalities
flected in five studies (Andrews & Waterman, 2005; Ede et al., 2020; can make escalation of care difficult (Cherry & Jones, 2015; Ede
Lydon et al., 2015; McDonnell et al., 2013; Stewart et al., 2014). The et al., 2020; Flenady et al., 2020; Mc Gaughey, 2013; Suokas, 2010).
EWS as a SMART form of communication was evident.
‘Ward 4: Observed interaction between doctors and
‘It provides what you need to get a doctor there, I think. It nursing staff –very tense. Doctor storms off. I guess we'll
gives you…your full objective facts. They can't argue with agree to disagree. …Would be difficult for someone not
a score of 5 or 6. They'll just come. It's a complete measure confident to escalate problems to someone who is very
which they do agree to attend to, and it helps your patients dismissive’ (Ede et al., 2020, p176).
|

Nevertheless, EWS ability to encourage teamwork by connecting its ability to assist them in arguing for escalation of care (Andrews &
the nurse and doctor and jointly involving them in patients’ plan of care Waterman, 2005; Cherry & Jones, 2015; Donohue & Endacott, 2010;
was recognised (Greaves, 2017). Elliott et al., 2015; Flenady et al., 2020; Greaves, 2017; Jensen et al.,
2019; McDonnell et al., 2013; Petersen et al., 2017; Stewart et al.,
‘I sometimes think that the medical staff don’t appreci- 2014; Suokas, 2010).
ate what the nurses do to look after the patients, and the
MEWS is a way to get them involved’ (Staff Nurse 1, line 81) ‘…it gives you the confidence to say, you need to come re-
(Greaves 2017, p171). view this patient immediately, because they're scoring a 5’
(P34, RN) (Flenady et al., 2020, p.5 of 9).

3.2.4 | Finding 8: Nurses seek continuous training/

updates on physiological terminology and physiological 3.4.2 | Finding 10: The EWS helps nurses to
processes to support them in communicating and prioritise patients most at risk and supports their
escalating patient care in response to EWS decision-making processes

Nurses verbalised the importance of measuring respirations cor- Nine studies saw nurses describe how EWS protocols helps to vali-
rectly and viewed respirations as the first indicator of patient de- date, strengthen and prioritise patient care (Andrews & Waterman,
terioration following EWS training (Andrews & Waterman, 2005; 2005; Dalton et al., 2018; Foley & Dowling, 2019; Jensen et al.,
Jensen et al., 2019; Suokas, 2010). The need for continuous effec- 2019; Lydon et al., 2016; McDonnell et al., 2013; Mc Gaughey, 2013;
tual EWS training was remarked on in seven studies (Andrews & Stewart et al., 2014; Suokas, 2010).
Waterman, 2005; Cherry & Jones, 2015; Elliott et al., 2015; Greaves,
2017; Jensen et al., 2019; Mc Gaughey, 2013; Suokas, 2010). ‘You do use the score to rate how sick they are and what
you need to do about it’ (Nurse G) (Foley & Dowling,
‘I suppose I don’t use the proper correct language 2019, p. 1187).
maybe. I haven’t gone any deeper into physiological
training or physiological terms necessarily…’ (Sister, 10
years) (Andrews and Waterman 2005, p. 477). 3.4.3 | Finding 11: EWS acts as a form of
evidence and can protect nurses from liability
Nurses’ fear of being judged by colleagues if using medical terms in
the wrong context when escalating care was reflected in two studies Six studies remarked on the legality of the EWS document and how it
(Andrews & Waterman, 2005; Dalton et al., 2018). offers nurses’ protection from liability (Donohue & Endacott, 2010;
Greaves, 2017; Lydon et al., 2016; Mackintosh, 2012; McDonnell
‘I feel that probably I don't use the right language when I’m et al., 2013; Suokas, 2010).
trying to get a doctor to come and see the patient’ (Sister,
10 years) (Andrews & Waterman, 2005, p. 477). ‘If you don’t follow the NEWS and something goes wrong
then the blame rests on you and you’ve got nothing to
back you up…whereas, once you call, you’re protected’
3.3 | Theme 3: EWS Protocol—A Blessing and (Nurse 3) (Lydon et al., 2016, p. 691).
a Curse

EWS protocol could be construed as a double-edged sword with 3.5 | EWS Protocol—A Curse
both favourable and unfavourable consequences for nurses.
The unfavourable consequences of using the EWS tool and related
protocols, that is the curse aspect of it was also evident in many of
3.4 | EWS Protocol—A Blessing the studies. The tool was felt to be narrow and restrictively pre-
scriptive due to its specificity and sensitivity (Donohue & Endacott,
3.4.1 | Finding 9: EWS use empowers nurses 2010; Elliott et al., 2015). For patients with chronic conditions
whose ‘normal’ values reflected a deviation away from the param-
Nurse's sense of empowerment and enablement was reflected in eters as outlined in the EWS tool, this was particularly problematic
eleven papers. Nurses appreciated the strength of the EWS tool and and burdensome for nurses.
|

3.5.1 | Finding 12: Nurses reflected how patients Endacott, 2010; Ede et al., 2020; Flenady et al., 2020; Gazarian et al.,
with chronic conditions like COPD have different EWS 2010; Greaves, 2017; Mc Gaughey, 2013).
baseline values and that EWS is a generic document
solely designed with a young fit healthy person in mind ‘As a first port of call if we become concerned about a pa-
tient we would go to the F1. If we felt that they were out
Six studies reflected this finding (Cherry & Jones, 2015; Donohue & of their depth or they weren't responding quickly enough
Endacott, 2010; Greaves, 2017; Mackintosh, 2012; McDonnell et al., probably the junior Nurses would go to the SHO, but I
2013; Suokas 2010). would tend to go to a Registrar or a Consultant probably
because I have a better relationship with them and I feel
‘Someone with COPD is not going to have a resp rate of able to ring them whereas other people don't’ (Sister 1
12 to 16, It’s going to be more elevated generally, but that line 51) (Greaves 2017, p. 142).
is normal for them. So, it’s inappropriate to be phoning
doctors all the time…’ ((9) RGN 1-5 years) (McDonnell
et al. 2013, p48). 3.6.2 | Finding 15: Challenges when trying to
escalate care in response to EWS

3.5.2 | Finding 13: EWS should not be considered a Nurses in five studies commented on their frustration when es-
fool-proof document, care needs to be taken as there calating care, be it in accessing a doctor on the phone or in them
can be anomalies with the chart attending to review the patient (Donohue & Endacott, 2010;
Ede et al., 2020; Foley & Dowling, 2019; Greaves, 2017; Suokas,
Four studies described episodes where the EWS chart did not func- 2010).
tion as expected (Greaves, 2017; Mackintosh, 2012; Mc Gaughey,
2013; Suokas, 2010). Two of these studies revealed scenarios where ‘You are often ringing and ringing them to come up….
one patient had a cardiac arrest and one patient had died. In both The other day I spent an hour trying to get a doctor
these cases, the EWS had failed to signal patient deterioration, sug- to review a patient because of their EWS’ (Nurse G)
gesting EWS tools are not infallible and there can be inconsistencies (Foley & Dowling, 2019, p. 1187).
with the score (Mc Gaughey, 2013; Suokas, 2010).

‘We had a patient in [another ward] who had a EWS 3.6.3 | Finding 16: Challenges for nurses in
score of one, and a continued EWS score of one, but that adhering to EWS escalation protocols due to reduced
patient eventually died. There was no clinical reason to staffing levels, higher levels of patient acuity and
have summoned attention apart from the fact that you lack of resources
looked at this patient and they did not look well, but
there was no reason. So, it’s not fool proof’ (Senior nurse Nurses described diminished staffing levels, unrealistic workloads
(31)) (Suokas, 2010, p232). and sicker patients as obstacles in the escalation of care in response
to EWS in seven papers (Flenady et al., 2020; Greaves, 2017; Jensen
et al., 2019; Mackintosh, 2012; Mc Gaughey, 2013; Stewart et al.,
3.6 | Theme 4: Hospital Domain 2014; Suokas, 2010).

This theme emerged from nurses’ experiences of the in-house day- ‘So, a Staff Nurse can potentially be looking after 8
to-day workings of the hospital and how this impacted their escala- patients you can't have someone scoring a 7 that is
tion of care in response to EWS. monitoring at 15-minute observations and it is just not
possible’ (Staff Nurse 2, line 64) (Greaves 2017, p. 130).

3.6.1 | Finding 14: Positions of seniority in nursing

instil confidence in escalating care and escalating care 3.6.4 | Finding 17: Nurses felt out of hours
to a higher level was favoured escalation of care in response to EWS could
benefit from the availability of more senior medical
Senior nurses in three studies reflected on how their nursing posi- decision makers
tion gave them confidence to escalate care to a higher level (Cherry
& Jones, 2015; Greaves, 2017; Mc Gaughey, 2013). The positive A link between out-of-hours medical support and decision making
impact of escalating to a higher level in terms of patient outcomes was revealed. Nurses in three studies remarked on how reduced
was iterated in seven studies (Cherry & Jones, 2015; Donohue & numbers of senior doctors on nights and weekends makes escalation
|

of care more complicated (Greaves, 2017; Mackintosh, 2012; Mc workers (Moi et al., 2019). However, this review exposed a lack
Gaughey, 2013). of discussion from nurses about the use and merits of (I)SBAR as
a communication tool when escalating care, which is surprising as
‘I think the factors may be the level of Doctor and some- it is used in the UK where most of the included studies originated
times the lack of Doctors on nightshift … they are tied up from. Surprisingly, only two studies in this review provided verba-
with someone who is also critically unwell for a good few tim quotes from nurses on (I)SBAR, which stated that it was not ac-
hours and we are left with a more junior down here who tively used and that (I)SBAR was the subordinate to the EWS (Foley
is maybe not making those decisions’ (Staff Nurse 6, line & Dowling, 2019, p1188; Mackintosh, 2012, p225). One nurse ac-
113) (Greaves 2017, p.138). knowledged that while she endeavoured to use (I)SBAR, in stressful
situations, it was difficult (Foley & Dowling, 2019, p1188). A study
by Ludikhuize et al. (2011) similarly showed how only one out of 47
3.6.5 | Finding 18: The modern hospital layout nurses used (I)SBAR when escalating care. More recent studies on (I)
can influence nurses in their escalation of care. The SBAR suggest summarising complex cases can be difficult (Burgess
patient and their family's role in escalating care was et al., 2020) and in addition, there is a perception that (I)SBAR can
highlighted take years to master, suggesting more training and simulation may be
needed (Moi et al., 2019).
One study illustrated the possible role of the patient themselves and The paucity of commentary on (I)SBAR in this review could be
family in escalation of care (Mackintosh, 2012). because of the challenges nurses face when using the tool, but it
also raises the issue of its perceived relevance. The review found
‘… the type of layout that we have in hospitals now does that nurses valued EWS information due to its SMART evidence and
not really allow for close monitoring of patients, so I think common language, which strengthened their argument to prompt
most of the time the patient has a lot to do with alerting an initial medical response. Further escalation requires multifaceted
the nurses, and the relatives also…’ (Eastborough, Nurse, communication amongst multidisciplinary team members. This is
6) (Mackintosh 2012, p. 189). unlikely to take the (I)SBAR format, given the complexity of clinical
decision making related to acuity and deterioration. This review il-
luminated the need for further studies around the communication
4 | DISCUSSION processes, which are aligned to the EWS tool and protocols and in
particular the use of (I)SBAR.
This QES demonstrates that EWS tools are used and valued by Whilst the specificity and timely nature of the EWS tool func-
nurses though there are challenges and frustrations in adhering to tioned well for nurses when escalating care, this review found the
the protocols, and these can be compounded by complex hospital process for modification of EWS parameters proved challenging.
domain issues. Whilst EWS may be perceived as a unidimensional Communication processes were hindered by the reluctance of doc-
scoring tool, it requires a multidimensional approach including con- tors to modify and document EWS parameters. Previous QESs simi-
sideration of data garnered from other less explicit sources such as larly described doctors’ aversion to EWS modifications as a barrier to
nurses’ clinical judgement. EWS protocol (Connolly et al., 2017; O'Neill et al., 2021). While it is
The theme of marrying nurses’ clinical judgement with the use of seen principally as the doctor's role to modify parameters some stud-
the EWS is supported and reflected in the findings of previous QESs, ies appear to suggest a possible role for nurses. Foley and Dowling
which also recognised the role clinical judgement played in facilitating (2019) suggested that it may be plausible for nurses to adjust EWS
escalation of care by healthcare staff (Connolly et al., 2017; O'Neill parameters. However, Jensen et al. (2019) argued that most nurses
et al., 2021). Nurse's value their own clinical judgement, experience, due to their varying levels of competence and experience consid-
intuition, physical assessment findings and decision-making skills ered this to be a doctor's task. The review findings demonstrate that
when recognising the deteriorating patient. A recently published QES a clearer process is required in relation to the modification of EWS
that explored the role human factors played in deciding whether to parameters and distinct policies and structures outlining with whom
escalate care reflected a similar repertoire of skills (Ede et al., 2021). this responsibility lies are required.
Effective communication is imperative for nurses responding The recent COVID-19 crisis has given rise to increased staff
to deteriorating patients (Loftus & Smith, 2018). The communica- shortages and heavier workloads and accessing doctors to adjust
tion methods/tools/processes used by nurses to convey an EWS parameters have proved difficult. From an Irish perspective, the rec-
and related clinical judgement information to other members of ognised reluctancy of physicians to alter EWS parameters has been
the multidisciplinary team, and the credibility ascribed to it by their addressed and circumvented in the revised INEWSV2 recommenda-
medical colleagues warrants review. The (I)SBAR (Identify Situation tions, which states that parameters must not be altered (Department
Background Assessment Recommendation) is a patient safety of Health, 2020, p.2). Furthermore, it recommends that the INEWS
communication tool that is used in conjunction with EWS to facil- escalation and response protocol must not be modified for the first
itate structured and effective communication between healthcare 24 hours following admission to hospital. Thereafter, a registrar or
|

consultant may modify only the escalation and response protocol, 4.1 | Implications for clinical practice
whilst not veering from the accepted EWS scoring mechanism (DOH
2020, p.5). Ongoing research and clinical audits will be required to Global healthcare policy places great emphasis on prevention of prob-
measure the impact of these recommendations on patient care and lems before they occur, and this can be supported through early sur-
staff workload. veillance and strengthening of EWS response systems. This review
The theme of the EWS being perceived as both a blessing and demonstrates that in clinical practice, nurses view EWS as a SMART
a curse by nurses was clearly exhibited in the review. Nurses de- communication tool for escalating care and securing a response; how-
scribed the sense of empowerment EWS gave them not only in ever, solely relying on the EWS tool alone when assessing the patient
supporting their decisions but at the same time offering them legal is ill-advised. A significant finding of this review was that the EWS
protection. This was similarly supported in the literature by O'Neill tool is not infallible and there can be inconsistencies with the score;
et al. (2021), which highlighted the governance the EWS protocol nurses must be mindful of using a multidimensional approach in the
provided to escalation of care processes. Whilst acknowledging the assessment of patients in clinical practice. This approach is supported
sense of control the EWS protocol brought to the escalation process, in the Irish healthcare domain as the first recommendation on the re-
conversely, nurses recounted their experiences of the excessive vised national INEWSV2 chart is that the EWS is used as an adjunct
EWS triggering that can result from patients whose baseline vital to clinical judgement. This acknowledgement of the value of clinical
signs lie outside the normal range with chronic illnesses, for example judgement in the anticipation, recognition, escalation, response and
COPD. These sentiments were corroborated by O'Neill et al. (2021) appraisal of patient deterioration supports the recommended multidi-
who found that the inability of the tool to cater for these patients is mensional approach aligned to the findings of this review.
persistently problematic and challenging. In view of an aging popu-
lation living with comorbidities, nurses need an EWS tool that has
a greater capacity for adaptation or a better degree of flexibility to 4.2 | Potential for future research
support patients’ needs.
The impact of the hospital domain on nurses use of EWS was ev- The findings of this review reflect nurses’ experiences spanning seven
idenced in this review particularly in issues around hierarchy, cross countries across three continents. The differences in health care sys-
professional communication processes and boundaries, poor staff- tems and the nuances within, may account for the lack of commentary
ing, increased workloads and delayed medical response. Similar find- from nurses on (I)SBAR when describing escalation of care episodes.
ings have been echoed in recent QES’s (Connolly et al., 2017; Ede Comparison of communication systems in differing healthcare sys-
et al., 2021; O'Neill et al., 2021). Cross professional communication tems may provide insight into optimal ways in which to communicate
processes were a common key theme and though EWS is recognised patient deterioration and escalation. In particular, examination of
as valuable in this respect, equally it causes feelings of frustration the communication processes used to instigate an escalation of care
and conflict as unwritten role boundaries are not observed, since namely (I)SBAR and nurses’ views around its effectiveness warrants
referrals may go outside the usual hierarchical line of communica- analysis. Studies are needed to investigate nurses’ experiences of
tion. Ede et al. (2021) discusses the concept of a “flattened hier- using updated versions of EWS protocols that consider nurses clini-
archy” whereby any staff member may refer to another, but this is cal judgement and impact on patient outcome. The impact of hospital
nonspecific and problematic. A flattened hierarchy is an admirable physical environment on nurses decision making is worth investigating
ideal, however, this review found that senior nurses were more con- to determine validity. The potential role patients and families play in in-
fident when escalating care and most nurses favoured escalating to stigating or encouraging an escalation of care will need to be explored.
a higher level, suggesting hierarchical influences within the hospital
domain prevail.
In addition, nurses remarked on an ill-equipped out-of-hours 4.3 | Strengths and Limitations
service in hospitals, reflecting a need for access to increased senior
medical decision makers during out-of-hours time. A further challenge This review strengthens the arguments for an EWS systematic ap-
within the hospital domain was the impact of the physical environ- proach and the use of the EWS tool as a SMART form of communi-
ment on work practices. Infection control has been amplified in the cation when escalating care. Using GRADE–CERQual, we assessed
recent COVID-19 pandemic, resulting in patients requiring individ- confidence in the eighteen review findings. The estimation of high
ual rooms on admission to hospital. International healthcare bodies confidence in five review findings was influenced by the studies’
support the engagement of patient participation as an essential part broad geographical spread and rich data provided. Another strength
of person-centred care (Oxelmark et al., 2018). The layout of some of the review was the team approach undertaken for the synthe-
modern hospitals may not always allow nurses the required visualisa- sis (Centre for Reviews & Dissemination, 2001). Whilst the search
tion of patients to optimise their safety and care needs (Mackintosh, strategy was accurate, only studies published in the English language
2012), thus illuminating the conceivable future role of the patient in were included, and all included nurses from Westernised cultures in
self-escalation. economically advanced countries.
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org/10.1111/scs.12486 Factors that influence hospital nurses’ escalation of patient
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Nurse Adherence in Eliciting Patient Daily Goals. Rehabilitation

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Journal of Clinical Nursing - 2022 - Burke - Factors That Influence Hospital Nurses Escalation of Patient Care in Response

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Journal of Clinical Nursing - 2022 - Burke - Factors That Influence Hospital Nurses Escalation of Patient Care in Response

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Received: 13 September 2021 | Revised: 18 January 2022 | Accepted: 19 January 2022

SPECIAL ISSUE ARTICLE

Factors that influence hospital nurses’ escalation of patient

Catherine Burke RGN, MSc, Nursing1 | Yvonne Conway MSc, Lecturer2

J Clin Nurs. 2023;32:1885–1934. ﻿ wileyonlinelibrary.com/journal/jocn | 1885

Search: Keyword:1: Keyword 2: Keyword 3: Keyword 4:

TA B L E 2 Inclusion and Exclusion Criteria using SPIDER Framework

SPIDER Inclusion Criteria Exclusion Criteria

S Sample Registered Nurses Undergraduate / Student Nurses.

3 | R E S U LT S 3.1 | Theme 1: Marrying Clinical Judgement

TA B L E 4 CASP (2017) quality assessment table

‘.. you need to still be able to look at observations or even

TA B L E 5 Summary of thematic development

DEVELOPMENT OF FINDINGS TABLE

Four emerging themes

Descriptive Theme (below) Supporting the above Analytical Themes

TA B L E 6 Themes and illustrative quotations

Marrying Clinical judgement and EWS

Marrying Clinical judgement and EWS

3) EWS protocol a blessing and a curse

EWS protocol a blessing

3) EWS protocol a blessing and a curse

EWS protocol a curse

EWS protocol a curse

EWS protocol a curse

Summary of review Studies contributing to Methodological Adequacy of of CERQual

I think it's sometimes about personalities because sometimes you find

‘We have some standardised permitted orders. If the patient has

experience) (Jensen et al., 2019, p4392).

‘It would probably be your F1 because they're ward based but

F I G U R E 3 Conceptual Model [Colour

3.2.4 | Finding 8: Nurses seek continuous training/

3.6.1 | Finding 14: Positions of seniority in nursing

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J Clin Nurs. 2023;32:1885–1934. wileyonlinelibrary.com/journal/jocn | 1885