Nurses’ competencies in rapid response systems for managing deteriorating patients : a comparative cross-sectional study between Finnish and British nurses

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DISSERTATIONS | MINA AZIMIRAD | NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING ... | No 645

MINA AZIMIRAD

Nurses’ competencies in rapid response systems for managing deteriorating patients:

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

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NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING DETERIORATING

PATIENTS:

A COMPARATIVE CROSS-SECTIONAL STUDY BETWEEN FINNISH AND BRITISH NURSES

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Mina Azimirad

NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING DETERIORATING

PATIENTS:

A COMPARATIVE CROSS-SECTIONAL STUDY BETWEEN FINNISH AND BRITISH NURSES

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in MS302 Auditorium,

Kuopio

November 19^th, 2021, at 12 o’clock noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

No 645

Department of Nursing Science University of Eastern Finland, Kuopio

2021

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Lecturer Tarja Välimäki, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto PunaMusta Joensuu, 2021

ISBN: 978-952-61-4313-2 (print) ISBN: 978-952-61-4314-9 (PDF)

ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF)

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral programme in Health Sciences Supervisors: Professor Hannele Turunen, Ph.D.

Department of Nursing Science University of Eastern Finland Kuopio University Hospital KUOPIO

FINLAND

Docent Ilkka Parviainen, MD, Ph.D.

Kuopio University Hospital KUOPIO

FINLAND

Reviewers: Professor Simon Cooper, Ph.D.

Department of Midwifery and Healthcare Federation University Australia

CHURCHILL AUSTRALIA

Adjunct Professor Miia Jansson, Ph.D.

Research Unit of Medical Imaging, Physics and Technology University of Oulu

OULU FINLAND

Opponent: Professor Kristina Mikkonen, Ph.D.

Research Unit of Nursing Science and Health Management University of Oulu

OULU FINLAND

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Azimirad, Mina

NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING

DETERIORATING PATIENTS: A comparative cross-sectional study between Finnish and British Nurses

Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 645. 2021, 181 p.

ISBN: 978-952-61-4313-2 (print) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-4314-9(PDF) ISSN: 1798-5714 (PDF)

ABSTRACT

Rapid response systems (RRSs) were introduced more than twenty years ago in health care to improve patient safety and to avoid preventable hospital mortality.

RRS function is based on early recognition of a patient’s worsening condition to help the patient recover and avoid preventable death. Close assessments by nurses are essential in the management of deteriorating patients.Well-trained nurses secure the safety of deteriorating patients. Nurses’ clinical competencies in identifying and managing deteriorating patients depend on their knowledge, skills, attitudes and their levels of expertise, ranging from novice to expert. Different hospitals have implemented various RRS models to help nurses with identification and management of deteriorating patients, including the medical emergency team (MET) and national early warning score (NEWS). Finland implemented MET in 2009.

However, MET usage is not optimal in Finland. Finland uses the MET criteria as a guideline to help nurses manage deteriorating patients, whereas the UK uses the NEWS.

The purpose of this study was to assess Finnish and British nurses’ competencies in identifying patients’ worsening vital signs and managing deteriorating patients.

The study was consisted of four sub-studies, including assessment of nurses’

competencies in timely RRS activation, self-reported impact of in-service education as nurses’ continuing clinical competency in managing deteriorating patients, influencing factors on nurses’ clinical competency in managing deteriorating

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patients based on nurses’ self-reports, and teamwork-related needs within the MET based on MET nurses’ self-reports.

This was a comparative cross-sectional correlational study. Sub-studies 1–3 were carried out as comparative studies in acute tertiary care hospitals in Finland and in the UK, but sub-study 4 was conducted in an acute hospital in Finland only.

For sub-studies 1–3, registered nurses from medical and surgical wards were recruited by random sampling (Total: N = 388; Finland: n = 180, UK: n = 208). For sub-study 4, ICU-registered nurses of the RRS group were recruited by random sampling (Finland: n = 80). The applied data collection instruments were modified questionnaires. The original questionnaires were adopted from the literature with an established content validity and were modified based on the aim of this study.

The validity and reliability of the modified questionnaires were reassessed through piloting in both countries, confirmation of their face validity by a multiprofessional and international expert team, and the reassessment of the internal consistency among the items (Cronbach’s alpha ≥ 0.7). A total of 180 nurses responded to the paper-based questionnaire for sub-studies 1–2 (Total: N = 180; Finland: n = 94; UK:

n = 86), and 179 nurses responded to the paper-based questionnaire for sub- study 3 (Total: N= 179; Finland: n= 93; UK: n= 86). For sub-study 4, 50 ICU nurses who were MET members responded to the paper-based questionnaire (Finland: n

= 50). Data were analyzed using the IBM SPSS Statistics 23. Statistical tests included descriptive tests, chi square, Mann–Whitney U, Kruskal–Wallis H, exploratory factor analysis, univariate analysis of variance method, regression analysis, and reliability test (Cronbach’s alpha).

Findings of this study revealed that nurses failed to activate RRS on time in approximately half of the case scenarios, with no statistically significant difference between Finnish and British nurses. Additionally, according to the nurses’ self- reflections on their practices concerning management of deteriorating patients, one-fourth to one-fifth of deteriorating patients were missed. In general, nurses had positive views on RRS and found in-service education regarding RRS

beneficial. According to the nurses’ self-reports, the remaining barriers to RRS activation following in-service education included nurses’ low confidence, fears of criticism, and delays caused by the hospitals’ routines and cultures. Finnish and British nurses’ attitudes toward RRS activation varied when asked about managing a worrisome but stable (normal vital signs) patient: Finnish nurses were more likely to activate RRS for such patients and rely on their intuition. The study also revealed another barrier to RRS activation based on the nurses’ self-reports:

physician’s influence. Furthermore, teamwork-related needs of RRS in need of

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improvement were uncovered, namely decision-making and conflict resolution skills, team-member valuation, and team leadership.

The study findings are important for improving nurses’ clinical competencies in managing deteriorating patients and providing nurses with information that may help them to transition into the expert stage. Moreover, the study revealed key teamwork skills of the RRS that need strengthening. The findings of this study may contribute to optimizing RRS function and the management of deteriorating patients.

Keywords: Attitude; Clinical Competency; Clinical Deterioration; Early Warning Score; Hospital Rapid Response Team; In-service Training; Nurses; Nursing Care;

Patient Care Team; Patient Safety

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Azimirad, Mina

SAIRAANHOITAJIEN OSAAMINEN POTILAAN TILAN ÄKILLISEN HEIKKENEMISEN SEURAUKSENA KÄYNNISTETYSSÄ SAIRAALANSISÄISESSÄ ENSIHOITOKETJUSSA:

Suomalaisia ja brittiläisiä sairaanhoitajia vertaileva poikkileikkaustutkimus Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 645. 2021, 181 s.

ISBN: 978-952-61-4313-2 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-4314-9 (PDF) ISSN: 1798-5714 (PDF)

TIIVISTELMÄ

Sairaalansisäinen ensihoitoketju (“Rapid Response System, RRS”) kehitettiin yli kaksi vuosikymmentä sitten parantamaan potilasturvallisuutta ja vähentämään estettävissä olevia sairaalakuolemia. Ensihoitoketjun toiminta perustuu potilaan voinnin heikkenemisen varhaiseen tunnistamiseen, potilaan toipumisen

tukemiseen ja estettävissä olevien kuolemien ehkäisemiseen. Sairaanhoitajan suorittamalla arvioinnilla on erittäin tärkeä rooli potilaan voinnin heikentyessä.

Hoitajien tiedot, taidot, asenteet ja työkokemus vaikuttavat heidän kykyynsä tunnistaa potilaat, joiden vointi äkillisesti heikkenee sekä kykyyn vastata potilaiden tarpeisiin. Sairaaloissa on otettu käyttöön erilaisia sairaalansisäisiä

ensihoitoketjumalleja, joiden tarkoituksena on auttaa sairaanhoitajia

tunnistamaan ja hoitamaan peruselintoiminnoitaan heikkeneviä potilaita. Näitä malleja ovat mm. sairaalansisäinen ensihoitoryhmä (medical emergency team, MET) ja varhaisen varoituksen pisteytysjärjestelmä (national early warning score, NEWS). MET-malli on ollut Suomessa käytössä vuodesta 2009 lähtien. Mallin käyttö Suomessa ei kuitenkaan ole ollut optimaalisella tasolla. Tilanteessa, jossa potilaan tila heikentyy, hoitajien tukena on käytetty Suomessa MET-kriteereitä, kun taas Isossa-Britanniassa käytössä on NEWS-pisteytys.

Tämän väitöstutkimuksen tarkoituksena oli arvioida suomalaisten ja brittiläisten sairaanhoitajien osaamista peruselintoiminnoitaan heikentyvien potilaiden tunnistamisessa ja hoitamisessa. Tutkimus koostuu neljästä osatutkimuksesta, joissa arvioitiin hoitajien osaamista liittyen sairaalansisäisen ensihoitoketjun oikea-

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aikaiseen käynnistämiseen, täydennyskoulutuksen vaikutuksia hoitajien kliiniseen osaamiseen ja hoitajien potilaan tilan huononemiseen liittyvään osaamiseen vaikuttavia tekijöitä itsearvioituna sekä tiimityöhön liittyviä tarpeita MET-ryhmässä MET-hoitajien itsearvioinnin perusteella.

Tutkimus oli vertaileva poikkileikkaus- ja korrelaatiotutkimus. Osatutkimukset 1-3 toteutettiin vertailevina tutkimuksina Suomessa ja Isossa-Britanniassa

sijaitsevissa erikoissairaanhoidon yksiköissä. Osatutkimus 4 toteutettiin vain suomalaisessa erikoisairaanhoidon yksikössä. Osatutkimuksiin 1-3 valittiin satunnaisotannalla hoitajia sairaanhoidon ja kirurgian osastoilta (yht. N=388;

Suomi: n=180, Iso-Britannia: n=208), ja osatutkimukseen 4 ensihoitotiimiin kuuluvia tehohoidon hoitajia (Suomi: n=80). Aineistonkeruussa käytetiin aiemmin kehitettyjä mittareita, jotka muokattiin tähän tutkimukseen sopiviksi. Mittareiden luotettavuutta arvioitiin monitieteisessä asiantuntijaryhmässä, pilotoimalla ne molemmissa maissa sekä Cronbachin alfa kertoimella (≥ 0.7). Yhteensä 180

hoitajaa täytti osatutkimusten 1-2 kyselylomakkeen (yht. N= 180; Suomi: n= 94; Iso- Britannia: n= 86) ja 179 hoitajaa täytti osatutkimuksen 3 kyselylomakkeen (yht. N=

179; Suomi: n= 93; Iso-Britannia: n= 86). Osatutkimuksessa 4 yhteensä 50 MET- ryhmään kuuluvaa tehohoidon sairaanhoitajaa täytti kyselyn (Suomi: n=50).

Aineistot analysoitiin IBM SPSS Statistics 23 -ohjelmistolla. Tilastollisina

analyysimenetelminä käytettiin kuvailevia testejä, χ²-testiä, Mann-Whitneyn U- ja Kruskal Wallisin H-testiä, faktorianalyysia, yksisuuntaista varianssianalyysiä, regressioanalyysiä ja reliabiliteettikerrointa (Cronbachin alfa).

Tutkimustulosten perusteella hoitajat eivät käynnistäneet sairaalansisäitä ensihoitoketjua ajoissa noin puolessa tarkastelluista case skenaario -tapauksissa.

Suomalaisten ja brittiläisten sairaanhoitajien välillä ei havaittu tilastollisesti merkitsevää eroa. Hoitajien itsearvioinnin perusteella heiltä oli jäänyt

havaitsematta yksi neljäs- tai viidesosa potilaan tilan heikkenemisistä. Hoitajien näkemykset ensihoitoketjusta olivat pääosin positiivisia ja he pitivät aiheeseen liittyvää täydennyskoulutusta hyödyllisenä. Hoitajien itsearvioinnin perusteella ensihoitoketjun käynnistämisen oli täydennyskoulutuksen jälkeen estänyt hoitajien heikko luottamus omiin taitoihinsa, arvostelun pelko sekä sairaalan rutiinien ja kulttuurin aiheuttamat viivästykset. Suomalaisten ja brittiläisten hoitajien asenteissa ensihoitoketjun aktivointia kohtaan havaittiin ero tilanteessa, jossa potilaan tila oli huolestuttava, mutta vakaa (normaalit elintoiminnot):

suomalaiset sairaanhoitajat käynnistivät todennäköisemmin ensihoitoketjun ja luottivat omaan intuitioonsa tällaisissa tilanteissa. Hoitajien itsearviointien perusteella paljastui myös toinen ensihoitoketjun käynnistämiseen liittyvä este:

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lääkärin vaikutus. Tutkimuksessa selvisi myös ryhmätyöskentelytaitoihin liittyvää kehitystarvetta ensihoitoketjussa koskien päätöksentekoa, konfliktien

ratkaisutaitoja, muiden ryhmän jäsenien arvostamista ja ryhmän johtamista.

Tutkimustulosten avulla voidaan kehittää hoitajien kliinisiä taitoja tilanteessa, jossa potilaan vointi heikkenee. Lisäksi tutkimuksessa paljastui, mitä tärkeitä ryhmätyötaitoja tulisi kehittää ensihoitoketjussa. Tuloksista voi olla hyötyä sairaalansisäisen ensihoitoketjun toiminnan optimoinnissa ja hoidon toteuttamisessa potilaalle, jonka tila heikkenee.

Avainsanat: Asenne; Kliininen osaaminen; Potilaan kliinisen tilan heikkeneminen;

Varhaisen varoituksen pisteytysjärjestelmä; Sairaalansisäinen ensihoitoryhmä;

Täydennyskoulutus; Sairaanhoitajat; Hoitotyö; Hoitotiimi; Potilasturvallisuus

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www.Tumgir.com

Adam’s sons are like limbs of one body Who are in their creation from one essence Should one limb be in pain

The other limbs could not be left at ease If thou careless of people’s suffering

Thou are unworthy to be called a human being (Saadi Shirazi, Gulistan Book, 1210-1291/1292)

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ACKNOWLEDGEMENTS

This study was carried out at the University of Eastern Finland, Department of Nursing Science, as part of the Doctoral programme in Health Sciences. First and for most, I wish to express my sincere appreciation to Allah (

ﷲ

) who has guided me, blessed me, and shown mercy on me in my entire life. Further, I would like to take this opportunity to express my gratitude to everyone who has supported me in this scientific journey and helped me to complete it successfully.

Firstly, my sincere gratitude goes to my dear supervisors Professor Hannele Turunen from the University of Eastern Finland and Docent Ilkka Parviainen MD from the Kuopio University Hospital. You have not only guided me through this journey and shared your expertise with me, but also believed in me when I had my moments of doubt and patiently supported me through the way. I have learned precious lessons from you that can enrich my professional life as well as my personal life. I will hold you dear to my heart forever.

I would like to offer my deepest respect and gratitude to the pre-examiners of this dissertation: Professor Simon Cooper from the Federation University Australia and Adjunct Professor Miia Jansson from the University of Oulu. You are well- known experts in this field and I had read many of your articles, but I could never imagine that you would accept evaluating my work. I am honored and thankful for the time you took. Your valuable comments and constructive feedback has

improved this dissertation. A further thank goes to Professor Kristina Mikkonen from the University of Oulu who honored me by accepting to act as my opponent.

I would like to thank my co-authors: PhD Carin Magnusson from the University of Surrey, Doctorate of Clinical Practice Alison Wiseman from the Brunel University London, who helped me a lot during my data collection in the United Kingdom, as well as Biostatistician Tuomas Selander from the Kuopio University Hospital.

Without you, I would not be able to proceed with this study. Moreover, my sincere thanks go to the involved organizations and contact people in Finland and in the United Kingdom who contributed to this study. Further, my deepest gratitude goes to study participants for their valuable contribution to the study.

My warmest gratitude goes to the funding organizations who granted this study including Finnish Cultural Foundation North Savo region Funds (Suomen

Kulttuurirahasto Pohjois-Savon maakuntarahasto), Finnish Nursing Education Foundation (Sairaanhoitajien Koulutussäätiö), Otto A.Malm donations fund, and Marja-Terttu Korhonen's fund. I also had the opportunity of holding a full-time

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Early Srage Position for part of this study which was funded by the University of Eastern Finland, Faculty of Health Sciences. I am tremendously thankful to these organizations that funded this study and made it possible.

Moreover, my sincere thanks go to my colleagues and friends at the

department of Nursing Science who created a friendly academic environment and welcomed me among themselves. Especially I would like to thank Professor Katri Vehvilainen-Julkunen who arranged classes with international guest professors for discussing doctoral students’ proposals and getting their points of view. Further, my thanks go to my fellow doctoral students who shared their academic journey with me.

I would like to thank leaders and partners of the SLIPPS (Sharing Learning from Practice to improve Patient Safety) and ENhANCE (European Curriculum for Family and Community Nurses) projects. Working in international research projects alongside my doctoral studies not only has given me the opportunity of working on academic papers but also has greatly improved my research experience.

I am extremely grateful for supervising a Master’s thesis in Nursing Science of Riina Paloniitty, and for ADUCATE (University of Eastern Finland Open University) for providing me the opportunity of teaching experiences.

Finally, I wish to express my heartfelt appreciation to my family and dedicate this book to my intelligent, kind and beloved father Mohammad Ali Azimirad, my precious, golden heart beautiful and beloved mother Marzieh Sharbatmaleki (Marzan joonam), and my sweet brothers Arash Azimirad, MD. Afshin Azimirad, and Ashkan Azimirad. You have been in this journey with me since the beginning until the end, and you shared with me all my small successes and defeats. Now, my biggest professional success in life belongs to you who constantly showered me with your love and support. Please accept this book as my little gesture of appreciation while there are no words to describe my love for you. Allah bless you.

September 2021

Mina Azimirad

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LIST OF ORIGINAL PUBLICATIONS

This dissertation is based on the following original publications:

I Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I and Turunen H. Nurses' ability to timely activate rapid response systems for deteriorating patients: A comparative case scenario study between Finnish and British nurses, Intensive and Critical Care Nursing. Original Studies. 60: 102871, 2020 II Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I and Turunen

H. British and Finnish Nurses’ Attitudes, Practice, and Knowledge on Deteriorating Patient In-Service Education: A study in Two Acute Hospitals, Nurse Education in Practice. Original Studies. 54: 103093, 2021.

III Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I and Turunen H. A clinical competence approach to examine British and Finnish nurses’

attitudes towards the rapid response system model: A study in two acute hospitals, Australian Critical Care. Original Studies. Online ahead of print.

IV Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I and Turunen H. Identifying teamwork-related needs of the medical emergency team:

Nurses’ perspectives, Nursing in Critical Care. Original Studies. Online ahead of print.

The publications were adapted with the permission of the copyright owners.

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ABBREVIATIONS

AHA American Heart

Association

AHRQ Agency for Healthcare Research and Quality ALF Afferent Limb Failure

ANA Ammerican Nurse

Association

ANMC Australian Nursing &

Midwifery Accreditation Council

AVPU Alert, Voice, Pain, Unresponsive

CCU Cardiac Care Unit

COVID-19 Coronavirus Disease 2019

CPR Cardiac Pulmonary

Resuscitation

CVD Cardiovascular Disease

DH Department of Health

EQUATOR Enhancing the QUAlit and Transparency Of health Research

EU SPSS

ICU

European Union Statistical Package for the Social Sciences Intensive Cardiac care Unit

IHI Institute for Healthcare Improvement

IOM Institute of Medicine ISRRS International Society for Rapid Response Systems

KMO Kaiser-Meyer-Olkin

KUH Kuopio University Hospital

M Mean

MET Medical Emergency

Team

mm/Hg Millimetre of mercury NEWS National Early Warning

Score

NHS National Health Service

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NICE National Institute for Health and Care Excellence

NMC Nursing & Midwifery Council

NPSG National Patient Safety Goals

OER Open Educational

Resources

RN Registered Nurse

SD Standard Deviation

STROBE Strengthening The Reporting of

OBservational Studies in Epidemiology

TAQ Team Assessment

Questionnaire TeamSTEPPS Team Strategies and

Tools to Enhance Performance and Patient Safety

UK United Kingdom

WHO World Health

Organization

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1 INTRODUCTION

Nurse competence in providing quality care at medical and surgical wards is among the most common reasons for preventable harm in health care settings (Panagioti et al. 2019). In many occasions, patients become victims of hospital harm because of an unrecognized or poor management of deterioration in general wards (ISRRS 2021). To enhance patient safety, rapid response systems (RRS)were introduced more than twenty years ago in health care. The RRS function is based on recognizing a patient’s worsening condition early enough to help the patient recover and avoid preventable hospital harm (DeVita et al. 2017).

Each year a significant population of people becomes a victim of in-hospital cardiac arrests (AHA 2016). Cardiac pulmonary resuscitation (CPR) is commonly used, but the CPR survival rate is low with a range of 15-35% at 30 days/hospital discharge (European Resuscitation Guideline 2021). In many of the cases, it fails to save the patient’s life (European Resuscitation Guideline 2021; AHA 2016). Even after successful CPR, patients often develop cardiovascular disease (CVD), which is a chronic heart disease and costs the hospital more than any other diagnostic group (AHA 2016). Evidence demonstrates that RRS implementation is associated with decreased in-hospital cardiac arrest and hospital mortality (Teuma Custo and Trapani 2020). Other adverse outcomes associated with delayed or failed RRS activation include ahigh rate ofICU admissions and prolonged hospitalization (Lee et al. 2018; Reardon et al. 2018).

The RRS was developed based on the safety theory and was expected to improve patient safety (DeVita et al. 2017). Despite of the importance of RRS, the body of evidence demonstrates that nurse activation for RRS is inconsistent, with one-third of RRS cases not being activated by nurses(Wood, Chaboyer and Carr 2019; Kitto et al. 2015). These statistics may indicate nurses’ lack of competency in RRS activation along with other possible reasons such as lack of sensitivity of the current RRS models, nurses’ shortage and overwork, poor communication and teamwork among nurses and RRS team, healthcare policy and unsupportive culture in workplace, and physician’s influence (Allen, Elliott and Jackson 2017;

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). Nonetheless, the statistics highlight the need for a deep understanding of nurses’ competency in using RRS. Especially since hospitals are currently

overburdened with epidemics and pandemics, such as COVID-19, nurses

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experience increased pressure concerning the management of deteriorating patients (Mo et al. 2020). Nurses’ vigilance and competence are crucial in the identification and management of deteriorating patients (McColl and Pesata 2016;

Choi, Skrine Jeffers and Logsdon 2020). Well-trained and competent nurses secure the safety and proper management of deteriorating patients (Welch, Thorpe and Rafferty 2020). Nurses’ clinical competencies in recognizing and managing

deteriorating patients depend on their knowledge, skills, attitudes (DH 2008), and levels of expertise, ranging from novice to expert (Benner 1984).

This study was designed to assess Finnish and British nurses’ clinical competencies in the recognition of patients’ worsening vital signs and the management of deteriorating patients. This researchadopted a comparative design between Finnish and British nurses with four main focuses that were set in four sub-studies.

For sub-studies І - III, the study employed registered medical and surgical nurses from one acute care hospital in Finland and one acute care hospital in the UK to answer the questionnaires. The focuses included assessing nurses’

competencies in timely RRS activation using case scenarios, evaluating the self- reported impact of RRS in-service education on nurses’ competencies in the management of deteriorating patients, and providing state-of-the-art knowledge on facilitators and barriers for RRS activation by exploring nurses’ attitudes regarding RRS.

However, sub-study ІV was conducted among the registered ICU nurses’ who were members of RRS in an acute Finnish hospital and focused on determining teamwork-related needs of RRS based on MET nurses’ self-reports. The

associations between amounts of work experience in RRS, RRS education, and the RRS team’s teamwork perceptions were explored as well.

The data collection tools for all sub-studies were modified questionnaires. The original questionnaires were adopted from the literature with an established content validity and were modified based on the aim of this study. The validity and reliability of the modified questionnaires were reassessed through piloting in both countries, confirmation of their face validity by a multiprofessional and

international expert team, and the reassessment of the internal consistency among the items (Cronbach’s alpha ≥ 0.7).

Importantly, in sub-studies I – III, a comparative study was designed to assess nurses’ competencies in the identification and management of deteriorating patients in acute hospitals of two countries with different RRS models. Notably, various countries have implemented different versions of RRS models—tailored to

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their specific local needs (NICE 2007)—to help their nurses with proactive identification of deteriorating patients. The RRS models provide nurses with a guided management protocol specified for patients whose conditions are

deteriorating and are in need of emergency care (AHRQ 2021; ISRRS 2021). Finland implemented the medical emergency team (MET) at Kuopio University Hospital (KUH) in 2010 (Azimirad et al. 2016). However, MET usage is still sub-optimal in Finland (Tirkkonen et al. 2013). At the time of this study, Finland mostly used the MET criteria as a guideline to help nurses in deteriorating patient identification and management, whereas the UK used the national early warning score (NEWS).

However, the Finnish Nurse Association currently recommends using the NEWS (Finnish Nurse Association 2021).

Generally, this study aims to provide in depth knowledge on nursing

competencies regarding the RRS and the management of deteriorating patients, covering both aspects of competencies, including competencies of medical and surgical registered nurses who identify deteriorating patients and use the RRS services to enhance the patient management, as well as the teamwork skills of the RRS team who are delivering the emergency assistance to the deteriorating patient.

This study aligns with the research strategy of the Department of Nursing Science, University of Eastern Finland, which addresses the preventive nursing science, safety and effectiveness of nursing (UEF Department of Nursing Science 2021).

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2 RAPID RESPONSE SYSTEM AND NURSES’

COMPETENCIES IN MANAGING DETERIORATING PATIENTS

2.1 LITERATURE SEARCH

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

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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

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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

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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

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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

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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).

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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

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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.

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2.2 DEFINITIONS OF THE MAIN CONCEPTS

2.2.1 Origins and structure of the rapid response system (RRS)

The rapid response system (RRS) is used as a generic term referring to the emergency assistance that is offered by a highly specialized team in response to patients’ deterioration at acute hospitals. The goal is providing early identification and response to patients who are in need of emergency care, thereby preventing clinical complications, avoidable in-hospital cardiac arrests, and mortality (Devita et al., 2006; Devita et al. 2017).

Considering that the primary aim of the RRS is to assist nurses with early identification of the patient’s deterioration, it is critically important to provide a clear understanding of clinical deterioration. According to the literature, there is a gap in the knowledge about the definition of the clinical deterioration of a patient.

However, a recent conceptual analysis suggests the following definition: “A dynamic state experienced by a patient compromising hemodynamic stability, marked by physiological decompensation accompanied by subjective or objective findings” (Padilla and Mayo 2018).

Assessments of vital signs (e.g., temperature, respiratory rate, heart rate, and blood pressure) are an essential part of physical examinations that determine a patient’s overall appearance. Temperature may be assessed orally, rectally, or axillary. In adults, the average oral temperature is 37 °C; however, it may vary slightly in the morning compared to the evening between 35.8 and 37.3 °C. Rectal temperature is usually higher than oral temperature. In adults, the normal range for rectal temperature is 0.4–0.5 °C takes about 5–10 minutes and is less accurate compared to oral temperature. Generally, the axillary temperature is one degree lower than oral temperature. In an assessment of respiratory rate, the rate, rhythm, depth, and effort of breathing are important. The respiratory rate may be assessed by counting the respiration in one minute via visual inspection or using a stethoscope. In adults, 14–20 breaths a minute in a regular pattern is considered normal. In a patient with a regular heart rhythm, the normal heart rate range is between 60 and 100 heartbeats in one minute. By examining arterial pulses (such as radial pulse), heart rate can be counted. If the heart rhythm is regular, the heart rate can be calculated for 15 seconds and multiplied by four. If the rhythm is irregular, the heart rate needs to be calculated for 60 seconds. Regarding the assessment of blood pressure, either systolic blood pressure or diastolic blood pressure may be considered high. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure identified six levels of systolic

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and diastolic blood pressure for adult patients (aged 18 years or older; Bickley and Szilagyi 2012; Bickley et al. 2020; Table 1).

Table 1. Classification of blood pressure (adults)¹

Category Diastolic mm/Hg Systolic mm/Hg

Optimal < 80 < 120

Normal < 85 < 130

High Normal 85–89 130–139

Hypertension

Stage 1 (mild) 90–99 140–159

Stage 2 (moderate) 100–109 160–179

Stage 3 (severe) ≥110 ≥180

The idea of the RRS initially originated in 1990, when critical care physicians observed the process that patients go through prior to cardiac arrests and unplanned intensive care unit (ICU) admissions in hospitals (Devita et al., 2006;

Devita et al. 2017). Signs and symptoms of deterioration often accompanied cardiac arrests on general wards. Patients presented signs of clinical deterioration six to eight hours before the cardiac arrest occurrence, and in many cases, the clinical antecedents were documented within eight hours of the in-hospital cardiac arrest (Schein et al. 1990). However, patient safety was not the focus in health care settings until the release of the Institute of Medicine (IOM) report entitled “To err is human: Building a safer health system” in 1999. The report highlighted the

importance of patient safety and brought attention to the strategic actions that need to be taken for that improvement (Donaldson, Corrigan and Kohn 2000). The establishment of RRS was recommended as part of the Institute for Healthcare Improvement’s 100,000 Lives campaign to reduce the number of medical errors and improve patient safety (IHI 2008). Similarly, it was one of the Joint Commission National Patient Safety Goals (Revere and Eldridge 2008). Consequently, the RRS was built as a patient-safety initiative to provide extra help to bedside nurses regarding the identification and management of patients in need of emergency care outside of the ICU (Devita et al., 2006; Devita et al. 2017).

An optimal RRS is composed of four main components, including afferent limb, efferent limb, governance and administrative structures, and analytic mechanisms.

The afferent limb refers to the process of identifying the deterioration based on

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the agreed abnormalities in the patient’s vital signs, physiological values, or other observations, and of instigating the RRS. The efferent limb refers to the prompt response of the RRS to clinical deterioration. The governance and administrative structures are responsible for organizing RRS services and functions. Finally, the analytic mechanisms are responsible for adopting evidence-based quality

improvements in RRS (Devita et al., 2006; Devita et al. 2017; ISRRS 2021; Figure 2).

1Source: Bickley, L. and Szilagyi, P.G., 2012. Bates’ guide to physical examination and history-taking. Lippincott Williams & Wilkins.

Bickley, L.S., Szilagyi, P.G., Hoffman, R.M. and Soriano, R.P., 2020. Bates’ pocket guide to physical examination and history taking. Chapter 3, Beginning the physical examination:

General surveys and vital signs, Page 79. Lippincott Williams & Wilkins.

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Figure 2. Rapid Response System (RRS)²

2Source: DeVita, M.A., Hillman, K. and Bellomo, R., 2006. Textbook of Rapid Response Systems.

Springer.

DeVita, M.A., Smith, G.B., Adam, S.K., Adams-Pizarro, I., Buist, M., Bellomo, R., Bonello, R., Cerchiari, E., Farlow, B., Goldsmith, D., Haskell, H., Hillman, K., Howell, M., Hravnak, M., Hunt, E.A., Hvarfner, A., Kellett, J., Lighthall, G.K., Lippert, A., Lippert, F.K., Mahroof, R., Myers, J.S., Rosen, M., Reynolds, S., Rotondi, A., Rubulotta, F. and Winters, B. 2010, ““Identifying the hospitalised patient in crisis”--a consensus conference on the afferent limb of rapid response systems”, Resuscitation, vol. 81, no. 4, pp. 375-382.

DeVita, M.A., Hillman, K., Bellomo, R., Odell, M., Jones, D.A., Winters, B.D. and Lighthall, G.K. eds., 2017. Textbook of rapid response systems: concept and implementation. Springer.

Management of deteriorating Afferent limb

(Identification of clinical deterioration)

by RNs

Efferent limb (Prompt response to the clinical deterioration)

by RRS team Governance and administrative limb

Analytic mechanisms limb (Evidence-based quality improvement)

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2.2.2 RRS Models: Medical Emergency Team (MET) and National Early Warning Score (NEWS)

To ease up nurses’ decision-making processes for RRS instigation, different RRS models have been developed (NICE 2007; NICE 2021). The RRS model is a broad term that includes the MET and NEWS (Heal et al. 2017). Following the Royal College of Physicians’ publication on the NEWS in 2012, the National Health Services (NHSs) of the UK and Ireland instructed the use of the NEWS nationwide (DH, 2020; Royal College of Physicians 2012)

.

The NEWS is widely used in the UK, and since 2012 it has been updated (NHS 2019; NICE 2021). Finland previously used the MET criteria, but the Finnish Nurse Association currently recommends using the NEWS (Finnish Nurse Association 2021; Tirkkonen et al. 2013).

Nevertheless, all current RRS models define the clinical deterioration with the presence of an abnormality in vital signs or other clinical observations. The attempt is to assist the clinicians with predicting the subsequent risks

prospectively and, thereby, assist nurses with the early identification and proper management of deterioration in patients (Jones 2013).

The MET criteria and NEWS criteria are instruments that command the first responder to trigger the RRS for the deteriorating patient. However, there is a great difference between them: NEWS functions are based on the overall acquired score, which enables nurses to recognize more subtle changes (NEWS e-learning program 2021), whereas MET criteria functions are mainly based on the presence of one single change in one defined parameter (Finnish Nurse Association 2020).

Due to improper evidence-based knowledge, the best RRS model cannot be identified. Thus, the RRS models’ trigger thresholds are advised to be set locally (NICE 2007; NICE 2021). However, some studies suggest that the aggregated weighted scoring system appears to be more efficient compared to a single parameter system because they are more sensitive in identifying at-risk patients (McNeill and Bryden 2013; Smith et al. 2013). According to Smith et al. (2013), NEWS provided nurses greater capability in identification of deteriorating patients in comparison with a single-based parameter derangement instrument, such as MET.

The MET defines seven parameters: systolic blood pressure, heart rate,

respiratory rate, O2sat level, nurses’ concern, patient’s overall condition, and other reasons (such as check-up visits). In the MET, one single derangement in an

individual parameter is enough to trigger RRS instigation (Table 2).

The NEWS is an established physiological scoring system (Subbe 2013) in which identification is through an aggregated weighted scoring system (NICE 2007; NICE

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2021). The NEWS defines seven parameters: temperature, systolic blood pressure, heart rate, respiratory rate, O2sat level, O2 supplement, and level of

consciousness. The NEWS uses the patient’s responses to alert, voice, pain, or being unresponsive (AVPU) to assess the level of consciousness. The alert refers to a patient who is awake, but who might not be oriented. An alert patient provides some response to a nurse if the nurse talks to him or her. Voice is assigned to a patient who provides a vocal response to a nurse. Voice applies to a patient’s response in the form of a moan, grunt, or even the small movement of a limb. The pain refers to a patient who responses to a pain stimulus. Unresponsive refers to a patient who is unable to communicate. Each parameter represents a value

between zero to three (Figure 3). Nurses assign a value in accordance to the level of abnormality of each parameter. The sum of the scores determines the actions that need to be taken for the patient (Table 3). In other words, the NEWS provides an algorithm that guides nurses with identification and management of

deteriorating patients. For instance, a total score of zero instructs nurses to recheck the observations every 12 hours. A total score of one to four instructs nurses to check the observations every four to six hours and to inform a

registered nurse about the situation. The total scores of more than five, or three in one single parameter, instruct nurses to inform the medical team and recheck the observations hourly. Finally, a total score greater than seven mandates nurses instigate RRS immediately (NEWS e-learning program 2021). Moreover, the NEWS provides a color-coded observational chart to facilitate the process.

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Table 2. MET criteria at the Finnish hospital³

MET Criteria Physiological

parameters

Respiratory rate 30 < RR < 8

SPO2 SPO2 < 90

Heart rate 140 < HR < 40

Systolic blood pressure SBP <90

Nurse’s concern Yes

Patient’s general condition Yes

Other Yes

RR means respiratory rate SPO2 mean oxygen saturation HR means heart rate

SBP means systolic blood pressure

3Source: Finnish Nurse Association. Available at

https://sairaanhoitajat.fi/artikkeli/news-aikaisen-varoituksen-pisteytysjarjestelma/

Retieved 28 Jan 2020.

Finnish Nurse Association. Available at https://sairaanhoitajat.fi/ammatti-ja- osaaminen/ammatilliset-tyokalut/ Retieved 6 Feb 2021.

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Physiological parameters

3 2 1 0 1 2 3

Temperature ≤ 35.0 35.1–

36.0

36.1–

38.0

38.1–

39.0

≥39.1

Heart rate ≤ 40 41–50 51–90 91–110 111–130 ≥ 131

Systolic Blood Pressure

≤ 90 91–100 101–110 111–219 ≥ 220

Respiratory rate

≤ 8 9–11 12–20 21–24 ≥ 25

O2 saturation ≤ 91 92–93 94–95 ≥ 96

O2

supplement

Yes No

Level of consciousness

A V,P,U

O2 means oxygen

AVPU means alert, voice, pain, or being unresponsive

Figure 3. NEWS at the UK hospital⁴

4Source: Royal College of Physicians. 2012. National Early Warning Score (NEWS):

Standardising the assessment of acuteillness severity in the NHS. Report of a working party.

London: RCP.

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Table 3. Outlined clinical response to NEWS triggers at the UK hospital setting⁵

NEWS Score Frequency of

Monitoring

Clinical Response

0 Minimum of every

12 hours

Continue routine NEWS monitoring with every set of observations

Total 1–4 Minimum of every 4–6 hours

Inform a RN who must assess the patient;

RN to decide if increased frequency of monitoring and/or escalation of clinical care is

required; and Inform nurse in charge Total 5 or 6

Or 3 in one parameter

Increased frequency to minimum of every 1

hour

Nurse in charge to be informed;

RN urgently informs the clinical team caring for the patient, who should attend within 30

minutes;

Contact RRS

Urgent assessment by a clinician with core competencies to assess actually ill patients; and

Plan for appropriate escalation/nonescalation of care Total 7 or more Continuous

monitoring of vital signs

Activate NEWS;

RN immediately informs clinical team caring for the patient, this should be at least at the

specialist registrar level;

Emergency assessment by a clinical team with critical care competencies, which also includes a practitioner/s with advanced airway

skills; and Plan for appropriate escalation/nonescalation of care

5Source: Royal College of Physicians. 2012. National Early Warning Score (NEWS):

Standardising the assessment of acuteillness severity in the NHS. Report of a working party.

London: RCP.

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2.3 THEORETICAL BASIS

2.3.1 Nurses’ clinical competencies in managing deteriorating patients The main theoretical framework that backbones this study is the “nurses’

competence” theory (Benner 1984; Figure 4). In acute care hospitals, all nurses are required to have competencies in the proper management of deteriorating

patients (NICE 2007; NICE 2021) because nurses’ clinical competencies significantly influence the patients’ outcomes (Waldie, Tee and Day 2016). Investment in

improving nurses’ clinical competencies enhances patient safety and the effectiveness of delivering health care to deteriorating patients and, thereby, reduces unnecessary deaths (Waldie, Tee and Day 2016).

Following the guidelines for recognition and response to deteriorating patients (NICE 2007; NICE 2021), the Department of Health of the UK published a

competency framework. The underlying principles of the framework were based on the guideline’s “Chain of Response,” in which levels of care for deteriorating patients were defined as low, medium, and high, corresponding to primary, secondary, and tertiary responses (DH 2008). Regardless of the level of care, the response requires competent nurses to deliver high quality care to the

deteriorating patient (NICE 2007; NICE 2021). The structure of the competencies in the framework were rooted in nurses’ knowledge, skills, and attitudes to assure competent deteriorating patient management and enhanced patient safety. In other words, nurses’ clinical competencies in recognizing and managing

deteriorating patients depends on their knowledge, skills, attitudes (DH 2008) and levels of expertise, ranging from novice to expert (Benner 1984). According to Benner’s theory, there are five different stages of nurses’ competency, which result in different levels of nurses’ performance (Benner 1984; Figure 4).

The nursing conceptual framework defines nurses’ clinical competency as a holistic approach with an integration of knowledge, skills, attitudes, thinking ability, and values (Benner 1984; Duff 2013; Fukada 2018; Takase et al. 2011). The holism theory underlines the significance of the clinical situation that nurses face while managing a deteriorating patient and points out that the complex combination of these elements and the nurses’ abilities to use them in different clinical situations demonstrates nurses’ clinical competencies (Duff 2013; Fukada 2018; Takase et al.

2011).

Nurses’ clinical competency in managing deteriorating patients is closely linked to the concepts of capability and capacity (Duff 2013; Gardner et al. 2008; Lindbom et al. 2015). The concept of capacity refers to nurses’ abilities to advance their

Nurses’ competencies in rapid response systems for managing deteriorating patients : a comparative cross-sectional study between Finnish and British nurses

MINA AZIMIRAD

Nurses’ competencies in rapid response systems for managing deteriorating patients:

Dissertations in Health Sciences

NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING DETERIORATING

PATIENTS:

Mina Azimirad

NURSES’ COMPETENCIES IN RAPID RESPONSE SYSTEMS FOR MANAGING DETERIORATING

PATIENTS:

ABSTRACT

TIIVISTELMÄ

ACKNOWLEDGEMENTS

ﷲ

Mina Azimirad

LIST OF ORIGINAL PUBLICATIONS

CONTENTS

ABBREVIATIONS

1 INTRODUCTION

2 RAPID RESPONSE SYSTEM AND NURSES’

COMPETENCIES IN MANAGING DETERIORATING PATIENTS

2.1 LITERATURE SEARCH

2.2 DEFINITIONS OF THE MAIN CONCEPTS

.

2.3 THEORETICAL BASIS