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Table 2 Key themes of the barriers of escalation amongst healthcare professionals

From: Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Key Themes

Sub-themes

Characteristics of studies from which sub-themes were derived: Type of participant and setting

Illustrative quotations

(Italicised text = primary quote from a study participant; non-italicised text = secondary quote from study authors)

Governance

Lack of accountability [20, 21, 32]

Enrolled nurses (non-registered nurses who assist registered nurses) in 1 Singaporean hospital [32]; HCAs, nurses, physicians, critical care staff and managers in 2 UK hospitals [20, 21]

A few participants strongly reiterated the need for some form of nursing documentation which specified that they had informed the RN-in-charge of patient deterioration. This was to safeguard the ENs from being blamed for not reporting patient deterioration: “The EN should have charting and documentation that indicates this staff nurse had been informed. .. so then at least we know that we’re safe and we don’t get into trouble. (P3)” [32]

Standardisation

-Lack of clear policies/protocols [19, 20, 24, 29]

-Lack of knowledge of policies/protocols [16,17,18,19, 25, 29]

-Lack of standardised education/training [17, 18, 24, 25, 30, 32]

HCAs, nurses, physicians, critical care staff and managers in 2 UK hospitals [20]; Senior resident surgeons, surgical postgraduates year 1, intensivists, and critical care outreach team members from 3 UK hospitals [19]; Nurses in 1 US hospital [25]; Mainly doctors and nurses in 8 Australian hospitals [16]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Australian hospital [18]; Enrolled nurses (non-registered nurses who assist registered nurses) in 1 Singaporean hospital [32]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; Nurses in 1 US hospital [29]; Nurses in 1 UK hospital [24]

On a number of occasions I’ve had difficulties contacting a senior because there is no fixed framework for doing so” [19].

Maybe if we had a clearer-cut criteria on when we do call an RRT and when we wait. You know?. .. People aren’t sure. Do we wait until they get this bad. .. or their O2 requirements are at this level? At what point do we need to call them?.. .” [29]

“I think it’s probably a lack of understanding of the MET and how it should be used. People don’t see it as an early intervention thing; I am not sure how you go about changing that. I can see that the patient is deteriorating and I can see that poor decisions are being made and it’s very frustrating, yet a MET is not called because the patient is not sick enough for a MET; it’s amazing” [18].

A few participants stated they had not received any education other than when the RRT was first developed. One nurse indicated she had not attended any RRT educational sessions [25].

Resources

-Staffing shortages [9, 16, 19, 23, 26, 29, 30, 32]

-Poor communication/use of handover tools [16, 19, 30]

-Perceived workload of RRT [16, 19, 23, 25, 30, 32]

HCPs from 1 US hospital [26]; Mainly doctors and nurses in 8 Australian hospitals [16]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; Enrolled nurses (non-registered nurses who assist registered nurses) in 1 Singaporean hospital [32]

Senior resident surgeons, surgical postgraduates year 1, intensivists, and critical care outreach team members from 3 UK hospitals [19]; Nurses and doctors from 1 UK hospital [23]; Nurses in 1 US hospital [25]

“Adherence to the NEWS protocol was impaired or impossible due to insufficient staffing levels...” [33]

Communicating actions recommended by the chart to escalate care was also sometimes challenging for participants, especially when attempting to obtain a response from medical officers [16].

Perceived busyness of the ICU nurses discouraged participants from RRT activation. Participants noted that responding RRT members occasionally talked about how busy they were [25].

RRT Response

RRT Behaviours

- Lack of professionalism [9, 17,18,19, 25, 28, 29, 31]

-Negative response/Lack of response [9, 17,18,19, 24, 25, 28, 31]

Nurses in 1 US hospital [25]; HCPs in 3 UK hospitals [19]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Australian hospital [18]; Nurses in 1 Norwegian hospital [31]; Nurses in 1 US hospital [28]

“They don’t want to listen to our side of the story or what we have to say. They are just more like, “I’m in charge and this is what you have to do,” so they’re more like barking out orders rather than kind of flowing with whatever we’ve already been doing and working as a team...” [29]

Sometimes team members complained about the need for the RRT call: “Why did you call? This wasn’t necessary”. “Once a nurse gets attitude (from RRT members), they don’t want to call again” [25].

Fear

-Fear of reprimand [9, 17,18,19, 29]

Nurses in 1 US hospital [25]; HCPs in 1 US hospital [26]; HCPs in 3 UK hospitals [19]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Australian hospital [18].

“Nurses feel like they are going to be told off for wasting the medical emergency team’s time. Even though worried or concerned is on the little cards that we all carry around. That message has not been embraced by the nursing staff because people are still frightened I think. Talking to people they still think they are going to get told off or there are going to be repercussions.” (Mary) [34].

-Fear of looking stupid [17,18,19, 25, 26]

This theme is understood as either refusing to activate a MET or pausing before activating a MET. Participants said, “I don’t know if it would be the right thing to do”, “I don’t want to look like an idiot” [18].

Professional Boundaries

Increased Conflict [17, 18, 20, 23, 25, 26, 30]

Nurses and doctors from 1 UK hospital [23]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Australian hospital [18]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCAs, nurses, physicians, critical care staff and managers in 2 UK hospitals [20]; Nurses in 1 US hospital; (25) HCPs in 1 US hospital [26]

RRT improved morale between nurses and RRT but increased conflict between nurses and physicians [26].

Interns frequently cite the NEWS as a source of conflict between doctors and nurses. For example an intern commented that: “some nurses see NEWS as something where they bring you and then wash their hands - they’re rung someone, anyone, so their job is now done” (Intern 5) [30]

Hierarchy (ownership and control, jurisdictional boundaries) [17, 19,20,21, 24,25,26, 29]

Doctors & nurses in 4 Australian hospitals [17]; HCPs in 3 UK hospitals [19]; HCAs, nurses, physicians, critical care staff & managers in 2 UK hospitals [20]; Nurses in 1 US hospital [25]; HCPs in 1 US hospital [21, 26]

“Sometimes they [primary ward physician]….have a bit of an attitude thing, oh I can handle this. This is my patient. I know this patient. I didn’t want a rapid response to be called. You know we get a fair amount of that, but not as much as we did in the beginning. In the beginning....nurses were being yelled at by the primary team....how dare you call a rapid response on my patient... they seem to be more receptive now [SWAT nurse]” [26].

Clinical Experience

Clinical over confidence [9, 19, 23, 25, 29]

Lack of clinical confidence [18, 25, 29]

-Unable to recognise deterioration

-Doubting own ability/skills

Nurses & doctors from 1 UK hospital [23]; HCPs in 3 UK hospitals [19]; Nurses in 1 US hospital [25]

Nurses in 1 Australian hospital [18]; Nurses in 1 US hospital [25]

“Sometimes it’s overconfidence or false confidence that you think you are in control of the situation... You could spend slightly less time with a person and then go back to them and realise their condition has changed but not noticed those subtle changes because you haven’t seen them for an hour or so.” (R6, Nurse) [23]

“Maybe questioning my decisions: Am I over-reacting here? Is this real or am I just panicking?”(Tanya) [18]

“I think that the main thing is questioning, self-doubt.. Is the patient really sick enough to call? Can I handle this myself?” [25]

EWS

Patient variability [9, 16, 20,21,22, 27, 30, 32]

-Sub-populations who fall outside the normal vital sign ranges

-Need for parameter adjustments

Nurses in 1 US hospital [27]; Doctors & nurses in 8 Australian hospitals [16]; Senior NCHDs & nurses in 1 Irish hospital [30]; ENs in 1 Singaporean hospital [32]; HCAs, nurses, physicians, critical care staff & managers in 2 UK hospitals [20, 21] Nurses in 1 UK hospital [22]

When asked how they would improve the current MEWS, most participants responded that they would customize the preset “normal” vital sign values to account for individual patient variances. Nurses addressed the variance by documenting that the abnormal value represented the patient’s baseline or was a desired effect of an intervention, but the system required physician notification added to nursing workload. The inability of the MEWS to tailor alarm settings and limits to accommodate patients whose vital sign measurements normally fell outside predetermined thresholds was cited by focus group participants as a major barrier to effective use of the system [27].

Participants reported that parameters were rarely reviewed or adjusted and that this was a continual problem for interns and nurses “If parameters aren’t charted you’re expected to check the observation and inform the intern more than is necessary” (Nurse 4) [30].

  1. Legend: EN: Enrolled nurse; EWS: Early warning system; HCA: Healthcare assistant; HCP: Healthcare Professional; ICU: Intensive care unit; MET: Medical emergency team; NCHD: Non consultant hospital doctor; NEWS: National Early warning System; RRT: Rapid response team; UK: United Kingdom; US: United States