A systematic literature search was conducted to identify the relevant and recent studies on the RRS and nurses’ competencies in managing deteriorating patients (published between years 2016–2021). The search terms were identified with the help of the information specialist and from the Medical Subject Headings (MeSH) database as the following: patient Safety, clinical deterioration, clinical
competence, early warning score, patient care team, hospital rapid response team, nursing care, nurses, attitude, and in-service training. To improve the systematic search, three major electronic databases were chosen: Pubmed, CINAHL, and Scopus. To secure the quality of search, Covidence was used which is a browser-based tool for conducting systematic search. Additionally, Covidence integrates the Preferred Reporting Item for Systematic Reviews (PRISMA) checklist and flow diagram. The inclusion criteria were peer-reviewed studies published between 2016 and 2021 in the English language. The exclusion criteria were studies related to maternity, pediatric and infants, and patients with brain damages or low level of consciousness. The exclusion criteria were set because this study is designed for RRS for adult patients (16 years and above) and the fact that a low-level of consciousness interferes with RRS criteria and influences nurses’ clinical judgments.
The initial search of the key terms identified 782 articles. The exclusion criteria were applied to screen the articles based on their titles. Consequently, 483 articles were retained. Of whom, 163 articles were duplicates and were excluded. A total of 320 articles were screened based on their abstracts, of which 154 articles were chosen for the full-text assessment of eligibility. Afterward, 94 articles were excluded due to not being specific about the aim of this study. For instance,
articles regarding patient and family members’ involvements in RRS activation, RRS implementation, developing new models and limitations of the existing models, and RRS impact on hospital and patient outcomes were excluded because they did not meet the aim of this study. Furthermore, articles that assessed RRS in a
specific population, such as malignancies, were excluded as well. Consequently, 60 articles were included in this study (Figure 1).
Figure 1. PRISMA flow diagram of systematic literature search 782 studies identified
and screened based on title
320 studies screened based on abstract
154 full-text studies
assessed for eligibility 94 studies excluded
166 studies irrelevant 163 duplicates
removed
299 studies removed
483 studies imported to Covidence
60 studies included
These 60 studies were categorized based on their topics into three main categories including nurses’ competencies in timely RRS activation and its influencing factors (36 studies), in-service education’s impact on nurses’
competence in RRS activation (19 studies), and teamwork among the MET (5 studies). However, due to the large number of studies in category one, this category was divided thematically into seven sub themes.
Category 1: Nurses’ competencies in timely RRS activation and its influencing factors Out of the 60 articles, 36 studies assessed nurses’ competencies in timely RRS activation and its influencing factors (Appendix 1). Of which, most were conducted by the United States (n = 8), the UK (n= 7), and Australia (n = 5). The other countries included Denmark (n = 2), Finland (n = 2), Norway (n = 2), Singapore (n = 2), Brazil (n = 1), Canada (n = 1), Ireland (n = 1), Italy (n = 1), Korea (n = 1), Netherland (n = 1), and Sweden (n = 1). Interestingly, among these 36 articles, there were 16 literature review studies (systematic review: n = 10; integrative review: n = 3; scoping review:
n = 2; narrative review: n = 1). Based on their specific subjects, these 36 studies could be categorized into seven sub-themes.
Sub-theme 1: Nurses’ competencies in identifying clinical deterioration
The first theme (including six studies) focused on nurses’ knowledge of clinical deterioration and their competencies in identifying early signs and cues of clinical deterioration (Allen 2020; Dalton et al. 2018; Hart et al. 2016; Mohammmed Iddrisu et al. 2018; Mushta, Rush and Andersen 2018; Orique et al. 2019). Nurses’
lack of competency in identifying early signs and cues of clinical deterioration is known as “failure to rescue” and is attributed to several factors, including omission in care, missing signs of clinical deterioration, poor communication, and failure to make the decision (Mushta, Rush and Andersen 2018). However, nurses were generally aware of their roles in identifying clinical deterioration and found the RRS models helpful in identifying deteriorating patients (Mohammmed Iddrisu et al. 2018), but there was a difference among novice to expert nurses in this regard.
Novice, beginner, and competent nurses demonstrated a lower ability for
perceiving clinical deterioration cues compared with proficient and expert nurses (Orique et al. 2019). Moreover, the amount of work experience was found to be an influential factor in nurses’ perceptions of clinical deterioration (Allen 2020; Orique et al. 2019). Other influential factors include inadequate knowledge of vital sign
changes, intuition, and nurses’ own clinical judgement, confidence, continuous monitoring and checking of patient, communication and collegial relationships, technical skills, and work environment, and workload (Allen 2020; Dalton et al.
2018; Hart et al. 2016).
Sub-theme 2: Afferent limb failure and influential factors for its delay
The focus of the second theme (including four studies) was more specific to the afferent limb failure and nurses’ behavioral patterns, experiences, and influential factors for its delay (Difonzo 2019;Smith et al. 2020; Smith et al. 2021; Tirkkonen et al. 2020). The afferent limb behaviors deviated from the RRS models (Smith et al.
2020), and nurses showed poor compliance to RRS activation criteria (Difonzo 2019). A study (Tirkkonen et al. 2020) revealed that, in 17%, afferent limb failure existed up to four hours prior to RRS activation. Other influential factors on afferent limb failure include nurses’ knowledge and education; poor
documentation of vital signs; over reliance on clinical judgement; cultural and social factors; improper decision-making processes; lack of having a clear idea of their professional roles and goals, and resources; and context of work (Difonzo 2019; Smith et al. 2021).
Sub-theme 3: Facilitators and barriers to RRS activation
The third theme (including 11 studies) focused on nurses’ facilitators and barriers to RRS activation (Allen, Elliott and Jackson 2017; Chua et al. 2017; Clayton 2019;
Douglas et al. 2016; Jackson, Penprase and Grobbel 2016; McColl and Pesata 2016;
Moreira et al. 2018; Padilla, Urden and Stacy 2018; Tilley and Spencer 2020; Treacy and Caroline Stayt 2019; Walker et al. 2021). According to a study (Treacy and Caroline Stayt 2019), nurses’ timely RRS activation is suboptimal. Failure of timely RRS activation is linked to a failed synergy between nurses’ competencies and patients’ needs (Clayton 2019). Nurses’ perceptions, experiences, education, and support from other colleagues affect RRS activation and may play as facilitators in nurses’ RRS activation (Chua et al. 2017). A contributing factor to failed RRS activations could be lack of guidelines concerning hierarchical culture and other barriers for RRS activation (Douglas et al. 2016). For instance, there are not
standard rules regarding nurses’ decision-making for RRS activation and whether it needs to be based on analytic thinking or intuitive thinking (McColl and Pesata 2016). Other barriers to nurses’ RRS activation include lack of knowledge about
clinical deterioration, lack of constant education, low amount of work experience, insufficient resources, increased workload, reduced skills, interprofessional hierarchies, interactions between the RRS team and the initiator of the RRS call, previous negative experiences, fears of criticism, patient’s subtle changes and difficulty in feeling the necessity of RRS activation, difficulty in making the decision, unsupportive cultures in work environments, physician’s influence, staff levels, and poor communication between professionals, patients, and physicians (Jackson, Penprase and Grobbel 2016; Moreira et al. 2018; Padilla, Urden and Stacy 2018;
Tilley and Spencer 2020; Treacy and Caroline Stayt 2019; Walker et al. 2021).
Moreover, a study (Allen, Elliott and Jackson 2017) used the interprofessional collaborative practice competency framework to explore main influential factors on nurses’ RRS activation, which revealed “organizational culture, communication, teamwork, role awareness, and interprofessional learning” as influential.
Sub-theme 4: Nurses’ compliance with the early warning scores
The fourth theme (including 12 studies) focused on nurses’ use and compliance with the early warning scores (including NEWS) and its influence on nurses’
competence in the identification and management of deteriorating patients (Credland, Dyson and Johnson 2018; Eddahchouri et al. 2021; Foley and Dowling 2019; Jensena, Skår and Tveit 2019; Jensen, Skår and Tveit 2018; Lee et al. 2020;
Petersen 2018; Petersen, Rasmussen and Rydahl-Hansen 2017; Psirides, Hill and Jones 2016; Rehman and Ali 2020; Spångfors, Molt and Samuelson 2020; Wood, Chaboyer and Carr 2019). Nurses found the early warning score to be a useful tool (Spångfors, Molt and Samuelson 2020). It improved nurses’ competencies in identifying clinical deterioration, patient management, decision-making for RRS activation, communication, and coping experiences (Jensen, Skår and Tveit 2018).
Overall, nurses’ clinical performance and professional practice were improved, especially in terms of the frequency of documentation of vital signs (Jensena, Skår and Tveit 2019; Lee et al. 2020). However, studies revealed that nurses’ compliance to the early warning score model was poor (Credland, Dyson and Johnson 2018;
Eddahchouri et al. 2021; Petersen 2018; Petersen, Rasmussen and Rydahl-Hansen 2017). In fact, according to a study (Psirides, Hill and Jones 2016), nurses activate only 75% of RRS calls, of which 56% were based on following the early warning score model and 26% on the nurses’ worries (Psirides, Hill and Jones 2016).
Nurses’ low compliance to the early warning score was identified in various fields, including accuracy of score calculation and frequency of monitoring and
clinical response (Credland, Dyson and Johnson 2018). Different factors have been attributed to nurses’ low compliance to the early warning score, such as increased workloads (Rehman and Ali 2020; Wood, Chaboyer and Carr 2019). Similarly, lack of time and staff shortages were identified as the main reasons for nurses’ not adhering to frequent monitoring of patients (Petersen 2018). One-fourth of the nurses’ documentation of vital signs were incomplete, even though the early warning score model had recommended frequent vital sign monitoring (Eddahchouri et al. 2021). Some nurses also revealed that they view the early warning score more as a task and less as an assisting tool and would not adhere to the model if it interfered with their own intuition (Foley and Dowling 2019). Nurses’
nonadherence to the early warning score model when it interfered with their intuition complemented the findings of other studies, in which nurses were recommended to incorporate their clinical judgements, professional competence, and accountability with NEWS and use holistic physical assessments in patient management (Jensena, Skår and Tveit 2019; Rehman and Ali 2020; Wood, Chaboyer and Carr 2019). Other influential factors in using the early warning score model were physicians’ unresponsiveness, nurses’ work experience, confidence, culture, nurses’ previous negative experiences with RRS teams and the subsequent fears of disapproval, and the RRS team’s lack of nontechnical skills (Petersen 2018;
Petersen, Rasmussen and Rydahl-Hansen 2017; Rehman and Ali 2020; Spångfors, Molt and Samuelson 2020; Wood, Chaboyer and Carr 2019). Of note, nurses with less work experience had a more positive attitude toward NEWS (Spångfors, Molt and Samuelson 2020).
Sub-theme 5: Nurses and physicians’ collaboration
The fifth theme (including one study) focused on the nurses and physicians’
collaboration and revealed that nurses’ MET activation is influenced by hierarchy between physicians and nursing professionals (Chua et al. 2020).
Sub-theme 6: Nontechnical skills’ influence on nurses’ competencies in RRS activation The sixth theme (including one study) focused on the nontechnical skills that influence nurses’ competencies in RRS activation and highlighted the importance of situational awareness in nursing care (Large and Aldridge 2018).
Sub-theme 7: Nurses’ worry in MET activation
Finally, the seventh theme (including one study) focused on the role of nurses’
worry in MET activation and identified physician’s unavailability and subjective changes in patients as main reasons for nurses’ worry (Kalliokoski et al. 2019).
Category 2: In-service education’s impact on nurses’ competence in RRS activation Of the 60 articles included in this study, 19 studies assessed the effect of in-service education on nurses’ identification and management of deteriorating patients (Appendix 2). Of which, five studies explored the impact of simulated in-service education (Bliss and Aitken 2018; Connell et al. 2016; Elder 2017). Two studies assessed the effect of post-registration in-service education (Butler 2018; Duff, El Haddad and Gooch 2020). Two studies assessed the effect of web-based and face-to-face in-service education (Chung et al. 2018; Cooper et al. 2016). Three studies examined the impact of web-based in-service education (Liawa et al. 2017; Liawb et al. 2017; Liawc et al. 2016). One study assessed the effect of web-based simulation in-service education (Liawd et al. 2016). One study assessed the effect of e-learning in-service education (Mak and White 2021). One study assessed the effect of just-in-time in-service education (Peebles et al. 2020), and one study assessed the effect of multi-model in-service education (Duff et al. 2018). Generally, studies found in-service education beneficial in nurses’ identification and management of deteriorating patients. However, only a few studies (n = 5) assessed the effect of in-service education regarding RRS models (MET or NEWS) on nurses’
competencies in identifying and managing deteriorating patients.
Out of these five studies, one study was dedicated to assess the impact of MET in-service education on nurses’ clinical performance (Leppänen et al. 2019). Due to the small number of studies on MET in-service education, the impact of it remains unclear on nurses’ performance; however, simulation team training on MET may improve nurses’ performance (Leppänen et al. 2019). The other four studies were dedicated to assess the impact of Early Warning Score on nurses’ clinical
performance (Damayanti, Trisyani and Nuraeni 2019; Jensenb, Skår and Tveit 2019;
Saab et al. 2017; Warren et al. 2021). Early Warning Score in-service education improved nurses’ knowledge, calculation of scores, and documentation of vital signs in short term (Saab et al. 2017), but nurses still felt some tensions while using NEWS. The tensions were related to nurses’ feelings about solely relying on the tool or relying on their intuition, stress and anxiety because of using the tool, full compliance to the tool, and finally increased workload (Jensenb, Skår and Tveit 2019). The findings were conflicted regarding the impact of simulated early warning score in-service education on nurses’ knowledge, as one study did not find it effective (Damayanti, Trisyani and Nuraeni 2019), and another study found it effective (Warren et al. 2021). Nonetheless, simulated early warming score in-service education was found to be effective on nurses’ confidence (Warren et al.
2021) and clinical performance (Damayanti, Trisyani and Nuraeni 2019).
Category 3: Teamwork among the MET
Out of 60 articles that were included in this study, five studies assessed teamwork among the MET (Appendix 3). Teamwork is an important area of knowledge and skill for managing deteriorating patients (Curreyb et al. 2018), yet findings indicate that there is room for improvement (Curreya, Allen and Jones 2018;Saunders et al. 2020).
According to a study (Topple et al. 2016), MET members demonstrate different nontechnical skills during MET events, such as reviewing the investigation; taking histories; managing management plans; and explaining to bedside nurses, physicians, other health professionals, and the patient’s family. However, areas of nontechnical skills that need further education are shared expectations, shared goals, self-efficacy, team leader self-efficacy, reflective practice, and team cohesion (Fein et al. 2016).
There is a gap in the previous literature (Appendices 1, 2, and 3) regarding the comparison of nurses’ competencies in the identification and management of deteriorating patients between countries that use different RRS models. Notably, various RRS models function differently and require specific sets of knowledge and skills for activation (AHRQ, 2020; ISRRS, 2020; NICE, 2021). This studyhas been designed to address this gap.