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A fundamental conflict of care: nurses’ accounts of balancing sleep with taking vital signs observations at night

A fundamental conflict of care: nurses’ accounts of balancing sleep with taking vital signs observations at night
A fundamental conflict of care: nurses’ accounts of balancing sleep with taking vital signs observations at night
Aims and objectives

To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night.

Background

Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why.

Design

A qualitative interpretative design informed this study.

Methods

Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used.

Results

At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored.

Conclusion

In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions.

Relevance to clinical practice

Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.
0962-1067
1860-1871
Hope, Joanna
5d49099e-13bc-49d2-88d8-48e1ec6d25fc
Recio Saucedo, Alejandra
d05c4e43-3399-466d-99e0-01403a04b467
Fogg, Carole
42057537-d443-462a-8944-c804252c973b
Griffiths, Peter
ac7afec1-7d72-4b83-b016-3a43e245265b
Smith, Gary
de9679ac-afc8-41bb-9cf9-9e728843fa87
Westwood, Greta
473889ae-57b2-49bd-a77e-fc1330a036b0
Schmidt, Paul
c9e432f6-ef71-45a7-a42f-51f8208850cd
Hope, Joanna
5d49099e-13bc-49d2-88d8-48e1ec6d25fc
Recio Saucedo, Alejandra
d05c4e43-3399-466d-99e0-01403a04b467
Fogg, Carole
42057537-d443-462a-8944-c804252c973b
Griffiths, Peter
ac7afec1-7d72-4b83-b016-3a43e245265b
Smith, Gary
de9679ac-afc8-41bb-9cf9-9e728843fa87
Westwood, Greta
473889ae-57b2-49bd-a77e-fc1330a036b0
Schmidt, Paul
c9e432f6-ef71-45a7-a42f-51f8208850cd

Hope, Joanna, Recio Saucedo, Alejandra, Fogg, Carole, Griffiths, Peter, Smith, Gary, Westwood, Greta and Schmidt, Paul (2018) A fundamental conflict of care: nurses’ accounts of balancing sleep with taking vital signs observations at night. Journal of Clinical Nursing, 27 (9-10), 1860-1871. (doi:10.1111/jocn.14234).

Record type: Article

Abstract

Aims and objectives

To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night.

Background

Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why.

Design

A qualitative interpretative design informed this study.

Methods

Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used.

Results

At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored.

Conclusion

In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions.

Relevance to clinical practice

Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.

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A fundamental conflict of care - nurses' accounts of balancing sleep - Accepted Manuscript
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Hope et al 2018 Journal of Clinical Nursing - Version of Record
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More information

Accepted/In Press date: 12 December 2017
e-pub ahead of print date: 12 March 2018
Published date: May 2018

Identifiers

Local EPrints ID: 417898
URI: http://eprints.soton.ac.uk/id/eprint/417898
ISSN: 0962-1067
PURE UUID: f5bd27cd-0520-4096-9602-9a4ebea4b0c2
ORCID for Joanna Hope: ORCID iD orcid.org/0000-0002-8939-7045
ORCID for Alejandra Recio Saucedo: ORCID iD orcid.org/0000-0003-2823-4573
ORCID for Carole Fogg: ORCID iD orcid.org/0000-0002-3000-6185
ORCID for Peter Griffiths: ORCID iD orcid.org/0000-0003-2439-2857

Catalogue record

Date deposited: 16 Feb 2018 17:30
Last modified: 18 Feb 2021 17:39

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Contributors

Author: Joanna Hope ORCID iD
Author: Carole Fogg ORCID iD
Author: Peter Griffiths ORCID iD
Author: Gary Smith
Author: Greta Westwood
Author: Paul Schmidt

University divisions

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