1. Organisational factors
Factors influencing the recognition & appropriate management of the deteriorating patient
Michelle Treacy, Senior Lecturer, Adult Intensive/Critical Care. For further information please
Introduction
Research has identified there are a large proportion of patients who receive suboptimal care in the NHS. This is largely due to their deterioration not being recognised or acted upon in a timely manner (NCEPOD, 2017; Kyriacos et al., 2014).
The aim of the integrative literature review was to identify the factors that influence the recognition and appropriate management of the deteriorating patient in acute hospitals.
Methods
Integrative literature review, using methodology from Whittemore and Knalf (2005).
Databases included: CINAHL, PubMed and Web of Science. Reference lists screened of papers, resulted in 8 primary research studies included.
Each study was critiqued using Coughlan, Cronin and Ryan (2007) critical appraisal tools.
Themes identified through analytical coding.
Results
3 main themes emerged, there were shortcomings identified in all elements:
Findings
It was revealed that basic vital sign assessment was not always completed with competence or accuracy. Assessment of respiratory rate and conscious level was particularly lacking.
Practitioners lacked the assessment skills required, such as the ability to complete a comprehensive ABCDE assessment.
Evidence of hierarchy remains present, with ‘trust issues’ evidenced among HCPs.
Over-reliance on healthcare assistants to assess patients despite no assessment of their competence by registered nurses.
Discrepancies evident in hospital protocols, often lack of protocols or implementation.
Education
Assessment skills
Management & escalation of care
Organisational factors
Guidelines & policies
Documentation
Communication
Inter-professional
Nurse-patient
Discussion
Despite national guidance on staff requirements for clinical competence (NICE, 2007; Department of Health, 2009), these are not abided by or possibly not implemented in practice.
Financial implications (NHS, 2014) may be possible for lack of investment in post qualifying education.
Lack of motivation evident in staff to attend post qualifying courses (Philippou, 2011), even when opportunity available.
Lack of senior clinical nursing staff (NMC, 2017; RCN 2014) to support staff in acute areas.
Staffing shortages contributing to sub-optimal care (UNISON, 2016), along with delegation of vital signs to unregistered staff with no appropriate training (Moseley et al., 2007).
Hierarchy evident in today’s society between nurses and doctors (Green at al., 2017), concerns identified between nurses and HCAs (Wilson, 2002).
Despite the release of NEWS (RCP, 2012) and NEWS2 (RCP, 2017), failure to implement evident, with inaccuracies in documentation and lack of correct escalation (Odell, 2014).
Cognitive impairment and language barriers may be a factor in patient’s deterioration going undetected.
Teaching and assessment methods not standardised across the UK.
Recommendations & Conclusion
Motivate qualified nurses to participate in post qualifying education, career progression is key.
Identity the gap in knowledge around recognising deterioration in the adult nursing workforce to create a specialised module to ensure the necessary skills are obtained.
Implementation of NEWS2 across the NHS, with regular audits of care.
To utilise the use of simulation as a teaching method, especially a MDT approach.
Encourage the role of the Nursing Associate.
References available on request, please the author for the full list.