NHS Improvement (2016) suggested that 7% of reported deaths and severe harm incidents in acute hospitals for 2015 related to a ‘failure to recognise or act on deterioration’. This statistic highlights the fact that the challenges of recognising and responding to deteriorating patients remain an ongoing concern, despite the widespread use of track and trigger systems (TTS). Research by both Massey et al (2016) and McGaughey et al (2017) suggested that more research is needed to identify why logical TTS models do not always work in clinical practice. This article discusses the cultural and behavioural elements relating to compliance with using these models and their use in practice (Table 1).
| Limitations | Rationale |
|---|---|
| The accuracy of performing vital signs |
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| Skill mix and staffing levels |
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| Over-reliance |
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Evidence relating to preventable deaths
As in any robust discussion, it is important to appraise the available evidence. A report from the National Audit Office (NAO) (2005), A Safer Place for Patients, indicated that there are 34 000 preventable deaths in acute NHS hospitals every year. The National Patient Safety Agency (NPSA) (2007) estimated that about 23 000 of in-hospital cardiac arrests were potentially avoidable. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2012) in its report, Time to Intervene, suggested that, with better care, 38% (413) of cardiac arrests could be avoided.
Although the statistics are concerning, it is important to emphasise that these figures provide only an estimate and should be interpreted with caution. Hogan (2014) identified limitations in the methodology for the collection of evidence used to make the NAO (2005) and NPSA (2007) estimates and suggested that there was a continuing lack of reliable data relating to preventable deaths. The inconsistences in the figures may be due to how an ‘avoidable death’ is defined; however, what are absent from the data are patients who developed avoidable physiological harm without progressing to full cardiac arrest or death. Therefore, the suboptimal care statistics relating to deteriorating patients are likely to be higher.
Evidence relating to suboptimal care
The findings of NCEPOD reports published between 2009 and 2017 are summarised in Table 2 to illustrate the suboptimal care statistics. To appreciate the significance of these figures fully it is important to identify the meaning of the term ‘less than good care’. NCEPOD suggests that ‘good care’ is a standard that its reviewers would expect of themselves, of trainees and any employing institution. Therefore, ‘less than good care’ is a standard of care below this level.
| NCEPOD* reports | Date | Suboptimal care statistics |
|---|---|---|
| Acute Kidney Injury: Adding Insult to Injury. A Review of the Care of Patients Who Died in Hospital with a Primary Diagnosis of Acute Kidney Injury (Acute Renal Failure) | 2009a |
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| Caring to the End? A Review of Patients Who Died in Hospital Within Four Days of Admission | 2009b |
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| An Age Old Problem. A Review of the Care Received by Elderly Patients Undergoing Surgery | 2010 |
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| Knowing the Risk. A Review of the Peri-Operative Care of the Surgical Patient | 2011 |
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| Time to Intervene. A Review of Patients Who Underwent Cardiopulmonary Resuscitation as a Result of an In-hospital Cardiorespiratory Arrest | 2012 |
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| Time to Get Control? A Review of the Care Received by Patients Who Had a Severe Gastrointestinal Haemorrhage | 2015a |
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| Sepsis: Just Say Sepsis. A Review of the Process of Care Received by Patients with Sepsis | 2015b |
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| Acute Non-invasive Ventilation: Inspiring Change | 2017 |
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The NCEPOD reviewers are selected on the basis that they are clinical practitioners who are regularly exposed to the areas of care they review. They adopt a retrospective cohort study approach to assess care and reach their findings. However, there are advantages and disadvantages to these types of studies (Sedgwick, 2014). However, to minimise bias NCEPOD requires each reviewer to justify their decision to a panel. Angelow and Black (2011) suggested that there are limitations in the extent to which review panel findings such as those of NCEPOD could be extrapolated to other clinical areas because restrospective cohort reviews are impaired by a lack of controls and facts about the study population.
Although there is debate about the severity of suboptimal care and avoidable deaths, some nurses are nonetheless reluctant to acknowledge that these problems exist. However, recognition of the issues by nurses is fundamental because the first stage of change is to accept that a problem exists and to acknowledge that change is needed. Although this is a multidisciplinary problem, nurses can play a key role in improving the recognition of, and response to, the deteriorating patient. Table 3 presents the common themes identified with the suboptimal care of the deteriorating patient and the associated nursing responsibilities that have emerged in evidence.
| Themes |
Suboptimal care statistics |
|---|---|
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Staffing levels and skill mix
A potential issue that is likely to affect adherence to, and the use of, TTS is that of safe staffing levels. The Royal College of Nursing (RCN) (2010) suggested that poor skill mix and staffing levels are recurring themes that emerge in cases of suboptimal care. An integrated review by Massey et al (2016) identified that staff nurses were under pressure to juggle time between completing observations and other ward priorities. This resulted in charts not always being completed on time or accurately.
This finding that there is a link between poor skill mix, staffing levels and suboptimal care was supported by Hill (2017), who conducted a systematic review and concluded that there was a direct relationship between nurse staffing levels and the complications experienced by patients. McHugh et al (2016) examined how work environments and nurse-to–patient ratios affected rates of survival following cardiac arrest. Their review found that each additional patient per nurse on a medical-surgical unit was associated with a 5% lower odds of survival. Furthermore, the same study illustrated that poor work environments resulted in 16% lower odds of survival for patients. Research by Aiken et al (2014) and Griffiths et al (2016) has shown that manageable workloads and safe staffing levels are influencing factors for effective recognition of, and response to, the deteriorating patient. Therefore, increased workloads, staff shortages and inadequacies in skill mix will foster environments where human error and suboptimal care are likely to occur.
Despite this evidence, there has been a resistance to legislate on the minimum nurse-to-patient ratio. The National Institute for Health and Care Excellence (NICE) (2014) has advised only that the ratio should be no more than one nurse to eight patients. Without supporting legislation, however, this is vulnerable to poor adherence or being regularly exceeded. The Keogh review (2013), which explored higher than expected mortality rates in 14 NHS trusts, found that there was a disparity between the number of nurses ‘on the ground’ and the number of nurses that the administrative data recorded.
As workload levels and staff shortages remain an ongoing concern, staff will inevitably make decisions concerning the best use of their time versus the number of patients in their care. The Nursing Midwifery Council (NMC) (2016) has produced a briefing acknowledging the impact of staffing in care environments, which illustrates the issues that nurses must justify when care is impacted by staffing (Box 1).
The widespread adoption of long-day shift patterns may have reduced the impact and severity of safe staffing levels. A scoping review by Harris et al (2015) identified that 12-hour shift patterns (long days) were widely implemented to help manage human and financial pressures. However, the RCN (2012) raised concerns relating to patient safety and the effect of nurse numbers on patient care, suggesting that cost savings are the primary driver. Table 4 illustrates this by comparing traditional early and late shifts with long days. The findings of the Harris et al (2015) review had insufficient evidence to justify the adoption or withdrawal of this shift pattern. However, the review revealed a decline in the education and continuing professional development of staff who worked long-day shift patterns. This was due to the absence of an overlap between early and late shifts, which could potentially release staff for educational activities and team meetings (Harris et al, 2015).
| Traditional early and late shift pattern: |
Introduction of long days: |
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| Mon | Tue | Wed | Thu | Fri | Sat | Sun | Mon | Tue | Wed | Thu | Fri | Sat | Sun |
| E | L | L | DO | DO | E | E | E/L | E/L | DO | DO | DO | E/L | DO |
| L | E | DO | L | L | E | DO | DO | E/L | E/L | DO | E/L | DO | DO |
| DO | L | E | DO | DO | L | L | DO | DO | DO | E/L | E/L | DO | E/L |
| E | L | L | DO | DO | L | DO | DO | E/L | E/L | DO | E | DO | E/L |
| In a 4-week month a nurse working full time (37.5 hours) will cover 20 shifts. |
Long-day (LD) shifts cover both early (E) and late (L) shifts, which means that in a 4-week month a nurse working full time (37.5 hours) will cover 25 shifts (5 additional shifts). |
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| Early shift: |
Long day: |
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| Total hours of registered nurse care in a 24-hour period: |
Total hours of registered nurse care in a 24-hour period: |
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| NB: Some ward areas may have increased nurse-to-patient ratio to compensate | |||||||||||||
McGaughey et al (2017) identified that experienced nurses were better able to use protocols effectively to support their clinical judgement in identifying the deteriorating patient, thus emphasising the importance of an adequate skill mix. However, Aiken et al (2017) suggested that the NHS has one of the lowest ratios of professional nurse to assistive nursing personnel skill mix in Europe. Furthermore, the results of their cross-sectional study identified that diluting nursing skill mix by adding nursing associates and other categories of assistive nursing personnel may contribute to preventable deaths and erode quality of care (Aiken et al, 2017). A previous study by Griffiths et al (2016) suggested that the current plans for workforce development in England pointed towards a reduction in the number of registered nurses and an increase in the number of assistive nursing personnel.
Culture of just ‘doing the obs’
The Care Quality Commission (CQC) (2018) has predicted that the NHS is likely to face increased pressures and further economic constraints, warning that there is ‘a limit to the resilience of health care staff’. Therefore, it is likely that environments conducive to suboptimal care will persist (RCN, 2018). It is tempting at this stage for nurses to absolve themselves from responsibility and to simply place blame on organisational flaws.
James et al (2010) and Douglas et al (2014) expressed increasing concern that the recording and documenting of vital signs is viewed as a menial task, often delegated to assistive nursing personnel. They described a culture that is ritualistic, task oriented and is referred to in clinical practice as ‘doing the obs’. This is a culture that leads to a reduction in a detailed and holistic patient assessment that can compromise patient safety and reduce the individualised focus of care (Massey et al, 2016).
The pressures and constraints discussed so far offer a possible explanation for how this culture develops. However, this should act as a rallying call to nurses to recognise that the culture needs to change. To reduce suboptimal care statistics it is necessary for nurses to place greater priority on assessing and interpreting patient deterioration, supported by an understanding of the limitations of TTS systems (Grant, 2018; Grant and Crimmons, 2018).
Physiological understanding
A literature review by Perkins (2018) identified a trend that undervalues bioscience knowledge both in nurse education and clinical practice. It indicates that an inadequate physiological understanding correlates with avoidable death and suboptimal care. This concern may be exacerbated by TTS systems because they do little to promote physiological understanding of patient conditions or the clinical relevance of the identified changes. Therefore, nurses escalating patient concerns may do so based on a score instead of relying on their clinical judgement and physiological understanding (Grant and Crimmons, 2018).
Large and Aldridge (2018) have provided further evidence of the devaluing of bioscience and suggested the need for a nurse ‘worry indicator’—based on intuition—to escalate concerns. However, Odell et al (2009) raised concerns related to relying solely on nursing intuition, suggesting that such intuitive feelings have to have been triggered by some change in the patient's condition, which then needs to be assessed. Consequently, the focus should be to structurally assess the patient to identify and interpret the changes that have roused that intuition. This will enable the nurse to articulate any specific changes, thus allowing the doctor to prioritise their workload and formulate an adequate response time.
The Royal College of Physicians (RCP) (2017) has produced the National Early Warning Score 2 (NEWS 2), which makes recommendations about clinical response. It advises that when a patient has a score of 1–4 a registered nurse should be informed to undertake a patient assessment. This would indicate that the RCP has the expectation that vital signs observations will be undertaken not by a registered nurse, but by a level of assistive nursing personnel. Although it could simply be that the RCP (2017) is acknowledging the widespread delegation of this role within the NHS, this advice could easily be interpreted that the college is advocating that this role should be delegated to assistive nursing personnel. This is a significant shift in national guidance in view of the fact that NICE (2007) has stated:
‘Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.’
This raises the following questions:
Effective prioritisation
Jones (2016) suggested that delayed or missed nursing care is often attributable to ‘time scarcity’ and effective support is needed to improve decision making during these times. Improved staffing levels would clearly reduce time scarcity; however, it is important to emphasise that there will always be unpredictable events, so it is unlikely that the occurrence of this can be eliminated completely (Jones, 2016).
Consequently, there will always be a need for nurses to prioritise care effectively. Massey et al (2016) expanded on this and identified the juggling of priorities as a factor that has a negative influence on the effective recognition of, and response to, deteriorating patients. In a comparative study, Kalisch et al (2012) identified that the prioritisation of tasks was affected by how the nursing team perceived the importance of individual tasks. They suggested that this was motivated by ‘fear of group sanction’ for engaging in tasks that are perceived to be trivial. This is a reference to the pressure that nurses are under to complete individual tasks in a time-effective and efficient manner (Jones, 2016). James et al (2010) suggested that this urgency to complete tasks is a barrier to interpreting deterioration. Sometimes the greatest priority is to stop to think and understand the meaning of the information that has been collected.
Conversely, in a study by Perkins and Kisiel (2013), many nursing students (with supernumerary status) suggested that, in clinical practice, time was frequently not available to interpret patient observations. One nurse's statement illustrates this:
‘You don't get time to do it … I don't think I have ever actually had time to stand there after taking some observations and go: now this could mean this and this could mean that.’
The Parliamentary Health Service Ombudsman's annual report (2017) stated that NHS complaints rose from 14 701 in 2012 to 22 965 in 2017. The consequences of such a rise in complaints are likely to filter down through senior managers, increasing pressure on nurses to prioritise and adapt care decisions to avoid patient complaints (Jones, 2016). This is within a workplace culture that, according to Kalisch et al (2012), already puts nurses under pressure from employers and regulatory agencies to prioritise those care activities that are audited. Kear and Ulrich (2015) suggest that it is these pressures that can result in a culture that places less value on patient safety.
Consider what patients are most likely to complain about: discomfort, delays, being left in wet beds, served cold meals, delayed discharge and poor communication (NHS Digital, 2018). What people rarely complain about is whether they were assessed accurately or whether their observations were performed and interpreted correctly (Flenady et al, 2016). The reason for this is simple: many patients do not know what occurred. It is therefore essential that nurses are able to articulate the rationales to justify their care decisions to prioritise patient safety over the avoidance of patient complaints.
The CQC (2018) inspection and ratings programme has identified that safety remains a ‘real concern’ in 40% of NHS acute hospitals. Consequently, nurses are likely to face difficult decisions in prioritising care and must strive to remember that the skill of prioritising involves performing the most important jobs in order of clinical importance (Hendry and Walker, 2004). This is a skill that requires senior management support, experience, knowledge and a clinical culture that ensures ward nurses feel supported when they prioritise patient deterioration (McGaughey et al, 2017).
Accuracy of performing and recording vital signs
An influencing factor that nurses need to consider when using NEWS and TTS is that these approaches are only as useful as the accuracy of the vital signs recorded. Therefore, each nurse needs to reflect honestly on how effectively the haemodynamic observations are performed and recorded in their clinical environment. This has been identified as a long-term issue, with Hogan (2006) suggesting that there are many inadequacies in the recording of patient observations and emphasising that respiratory rates were recorded accurately less than 50% of the time.
Studies by James et al (2010), Douglas et al (2014) and Badawy (2017) provided further evidence of poor documentation of vital signs, raising concerns about an over-reliance on electronic devices. The findings of a grounded theory study by Flenady et al (2016) illustrated that forced compliance with documenting vital signs led to emergency department nurses recording patient respiratory rates without actually counting the number of breaths. Therefore, it is easy to conceive that this ‘menial cultural’ approach to recording vital signs may also influence the performance and accuracy of documenting all vital signs across a multitude of areas. This has been supported in a recent NHS Improvement (2018) patient safety alert, which suggested that an oxygen saturation probe designed for the finger should not be placed on the ear because this can result in as much as a 50% lower reading or conversely a 30% higher reading.
The results of the 2016 annual NHS staff survey demonstrated substantial gaps in knowledge (NHS Survey Coordination Centre, 2016). This raised the question: what other gaps in knowledge exist in relation to the accuracy of performing vital signs? It follows from this that it is essential that registered nurses adopt a leadership role over junior nurses and assistive personnel and challenge poor practice. In relation to delegation of work, the NMC (2018) Code states that nurses must:
‘Only delegate tasks and duties that are within the other person's scope of competence, making sure that they fully understand your instructions.
Make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care.
Confirm that the outcome of any task you have delegated to someone else meets the required standard.’
The CQC (2018) identifies many variations in the quality of care provided across the UK. Therefore, the purpose of the reflection tool developed by the author (Table 5) is to prompt each nurse to examine and challenge how accurate observations are performed in their clinical environment.
| Theme | Question |
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| Timing of observations |
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| Blood pressure |
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| Heart rate |
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| Oxygen saturations |
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| Temperature |
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| Respiratory rate |
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| Cultural influences |
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| Reflection |
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Over-reliance on TTS
With any clinical tool or guideline there are likely to be limitations due to the varied nature of clinical settings. It is therefore essential that nurses acknowledge these limitations and use TTS as an adjunct to their patient-assessment skills, analytical thinking, clinical judgement and decision making. None the less, a mixed methods study by Perkins and Kisiel (2013) identified a developing cultural belief that TTS systems alone are adequate to identify acute deterioration. In their study, one nurse's statement illustrates this attitude:
‘I think it is true, we do rely on them. It is, like, pretty much a culture now. As long as they are not getting MEWSs [modified early warning score] of 3s or 4s, then it's pretty much okay on this ward.’
The findings of an integrative review by Massey et al (2016) supported this view: they suggested that ‘ward nurses feared looking stupid, being reprimanded or being ridiculed when responding to the deteriorating patient’, thus delaying the escalation of care. Therefore, nurses may feel more reassured with the validation of TTS scores, leading to a growing culture of dependency on them. It appears that this problem may not be isolated to nursing: for example, NCEPOD (2012) suggested that escalation from junior doctors to more senior doctors occurred ‘infrequently’. This raises important questions that merit further exploration: are some registered nurses becoming reliant on the results of TTS over their own clinical judgement? Are they simply waiting for the TTS to be significant enough to trigger a medical team review?
Conclusion
This review has used evidence to posit that, despite the widespread use of TTS, the recognition and response to the deteriorating patient continues to be of concern. This problem is multifactorial and involves cultural and behavioural elements. The article discussed the pressures and constraints faced by nurses and how this increases the risk of human error. It emphasises the importance of prioritisation in striving to maintain and improve a culture of positive patient safety. It raises concerns that the introduction of TTS and NEWS may have had a negative influence on the critical interpretation nurses use to identify the deteriorating patient and their application of physiological understanding. Of greatest concern is the growing dependency and over-reliance that some nurses and organisations are developing in relation to the use of TTS systems.
If we are to be successful in reducing the suboptimal care statistics identified by NCEPOD, it is essential to ensure that registered nurses are aware of the limitations of both NEWS and TTS (Grant, 2018). It is vital that nurses develop the knowledge and confidence to rely on their own clinical assessment skills and physiological interpretation to identify patient deterioration and escalate their concerns to trigger a review by doctors.