Sub-study III

A modified Nurses’ Attitudes toward the MET instrument was applied in sub-study III (Appendixes 5 and 7) to investigate the factors influencing nurses’ clinical competence in managing deteriorating patients. The original instrument was developed in 2006 (Jones et al. 2006) but was modified later by others (Azzopardi et al. 2011; Bagshaw et al. 2010; Jackson, Penprase and Grobbel 2016; Radeschi et al. 2015). The instrument contained 17 items on a five-point Likert scale scored as follows: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree.

For sub-study III, one item was excluded because of its ambiguity, and a small terminology adjustment was applied (including substituting the term MET with the term NEWS in the questionnaires for British nurses). The questionnaire also gathered demographic characteristics, including age, work experience, and previous ICU work experience. The items in the study were classified into three categories: RRS benefits (six items), RRS barriers (eight items), and patient management (two items). The RRS benefits were defined as having a preventive role in cardiac and respiratory arrest, providing help for a worrisome patient, providing support when physician is unavailable, providing support in

management of a stable (normal vital signs) but worrisome patient, suppressing and preventing problems, and its educational role in managing deteriorating patients.

In this sub-study, the term “worrisome patient” referred to a patient who, despite presenting normal vital signs and being considered stable from a medical standpoint, makes nurses worried that something is wrong with the patient. The RRS barriers were defined as negative attitude toward RRS, relying on physicians, fear of criticism, feelings about overusing RRS, negative impacts of RRS on nurses’

skills, increased workload, and non-adherence to RRS guidelines. Lastly, patient management was defined as RRS required due to inadequate patient

management by nurses or physicians. Figure 9 presents the structure of sub-study III.

Data analysis

IBM SPSS Statistics 23 was applied for data analysis. To assess the participants’

demographic characteristics and attitudes, Descriptive statistics including

frequencies, percentages, means, and standard deviations were used. The differences between the Finnish and British nurses in nurses’ demographic information and attitudes were examined by chi-square tests (χ²). The level of significance was set at p ≤ 0.05. An exploratory factor analysis was performed to identify the possible factors among the 16 items in the tool. The sample sufficiency was determined by the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy.

According to the KMO results, the sample sufficiency for this study was 0.68, which comfortably exceeds the recommended value of 0.5. The Bartlett’s test of

sphericity revealed a significant value of 0.001. The varimax rotation Kaiser

normalization was applied in factor analysis to grant free formation of factors, with an eigenvalue ≥ 1 and communalities ≥ 0.3. As a result, three factors were

identified. Cronbach’s alpha (α) coefficient was applied to evaluate the internal consistency of the revealed factors. Values of Cronbach’s α ≥ 0.7 were accepted.

Consequently, two factors (containing nine total items) were retained: factor one (α = 0.738) and factor two (α = 0.740). After calculating the means of the items in each factor, two computed sum variables were created: RRS barriers and patient management (factors one and two, respectively). The differences in computed sum variables between the Finnish and British nurses were assessed by the Mann–

Whitney U test. Among the remaining seven items that did not show acceptable internal consistency (Cronbach’s alpha ≤ 7), one item was assigned to the RRS barriers category, and the remaining six items comprised a new category presented as RRS benefits. The items under the umbrella of RRS benefits were analyzed individually because of the unacceptable level of internal consistency (Cronbach’s alpha ≤ 7).

Nonparametric tests such as Mann–Whitney U and Kruskal–Wallis tests were conducted to examine the differences between nurses’ demographic information (age, work experience, and previous ICU/CCU work experience) and the computed sum variables (RRS barriers and patient management), The appropriate test was chosen depending on the number of categories contained by the demographic variable: Mann–Whitney U tests were chosen for the previous ICU/CCU work experience variable, and Kruskal–Wallis tests were chosen for the age and work experience variables.

A linear regression analysis was performed to assess the correlations between the sum variables (RRS barriers and patient management) with all possible predictors (age, work experience, and previous ICU/CCU work experience). The data were presented as B-coefficients with 95% confidence intervals and p-values.

Pairwise comparisons were also performed. The significance level to identify significant results was set at p ≤ 0.05.

Figure 9. Sub-study III; Participants: Medical and surgical registered nurses Barriers:

- The RRS is not helpful in managing sick patients in the

unit.

- When one of my patients is unstable, I call the covering

physician before calling the RRS.

- I am reluctant to activate the RRS for my patient because I will be criticized if

they are not unwell.

- I think that the RRS is overused in managing

hospital patients.

- I don’t like calling the RRS because I will be criticized for not looking after

my patient well enough.

- RRS calls reduce my skills in managing sick patients

- Using the RRS system increases my workload when

caring for a sick patient.

- If my patient fulfills the listed RRS criteria (triggers) but does not look unwell, I would not activate the RRS.

Benefits:

- The RRS prevents unwell patients from having

cardiac and respiratory arrests.

- The RRS allows me to seek help for my patients when I am worried about

them.

- If I cannot contact the covering physician about my sick patient, I activate

the RRS.

- I would call RRS on a patient about whom I am worried, even if his/her vital

signs are normal.

- The RRS can be used to prevent a minor problem

from becoming a major problem.

- The RRS teaches me how to manage sick patients in my unit better.

Patient the physician was

inadequate

4.2.4 Sub-study ІV