A CASE STUDY TO EXPLORE HOW NURSES MAKE CLINICAL DECISIONS ABOUT MEASURING VITAL SIGNS WHEN MONITORING ACUTELY ILL PATIENTS AND THE FACTORS THAT MAY AFFECT THEIR DECISIONS

  • Susan Quayle

Student thesis: Phd

Abstract

The aim of this study was to investigate the organisational factors that influence how nursing staff made clinical decisions when measuring, documenting, interpreting and reporting vital signs to detect deterioration in adult patients in acute health care settings. The National Early Warning Score (NEWS) was developed as a standardised tool to detect patient deterioration (RCP, 2017). However, taking vital signs occurred in a challenging environment with many organisational pressures. The literature revealed nurses’ attitudes towards vital signs assessment, but no study was found to examine how nurses made clinical decisions within the organisational context. A single Instrumental case study was chosen using the interpretivist approach to study the phenomenon of vital signs and the context in which they were taken. The sample consisted of observing nursing staff involved in the taking of vital signs in an AMU in an NHS foundation trust over 20 shifts and 120 hours, and eight post-observation interviews from nurses who had been observed. Key-informant interviews were obtained from 14 managers involved in the monitoring of vital signs and patient safety. 36 organisational documents were analysed. Braun and Clarke’s (2019) thematic analysis was used to analyse the data. The first theme showed the NEWS, in itself, was not adequate, and nurses used their clinical judgement to detect patient deterioration. This involved using visual cues such as colour, audible cues, assessment of breathing, hydration and nutrition, and communication from other staff members, patients and relatives which alerted them to patients at risk of deterioration. Staff also used their own knowledge of illnesses from education and past experiences and combined these together to form a judgement about the patient. Nurses frequently took an extra set of vital signs as confirmation of their clinical judgment and to determine an appropriate action, rather than waiting for when the routine NEWS was due. The second theme showed how nurses prioritised the deteriorating patient and juggled many competing demands. The workload consisting of four main themes; routine demands, the demands of highly-dependent patients, the need to re-prioritise the rapidly changing workload and interruptions and distractions. These parts continuously competed with each other, resulting in the nurses juggling numerous competing demands throughout the shift. The third theme showed many organisational factors affected the nurses’ ability to detect and respond to patient deterioration. These included an inadequate supply of registered nurses, a diluted skill mix, a high turnover of patients and the demands of quality assurance processes. These resulted in a low morale and potentially affected the detection of patient deterioration. Intuition shows how nurses use cues to detect deterioration (Klein, 1998). Sensemaking and mindful organising explains how nurses comprehend, activate and communicate their concerns through the use of the NEWS and within the context of the organisation (Weick and Sutcliffe, 2001). Nurses pass this knowledge on to others within their communities of practice (Wenger, 1998) which enabled all levels of nurses in this study to use cues to detect deterioration.
Date of Award31 Dec 2020
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorMoira Attree (Supervisor) & Hannah Cooke (Supervisor)

Keywords

  • Vital signs
  • patient deterioration
  • Organisational factors

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