A fundamental conflict of care: Nurses’ accounts of balancing patients' sleep with taking vital sign observations at night

Abstract

Aims and objectivesTo explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night.BackgroundRegular 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.DesignA qualitative interpretative design informed this study.MethodsSeventeen 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.ResultsAt 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.ConclusionIn 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 practiceNurses 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.

Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis

“…The findings reported here were examined in a qualitative study aimed at exploring factors related to adherence with the EWS protocol at night. The study by Hope et al., complemented the picture presented here, showing that the EWS focus on preventing deterioration required fine‐tuning to incorporate exceptions created by patients requiring long‐term management or those in palliative care trajectories (Hope et al., ). The approach of calculating EWS without considering variations in patient groups with conditions such as COPD or dementia resulted in observations being determined more by clinical judgement than by the EWS.…”

“…This was also evident in the way that paediatric wards were the exception in the associations of characteristics with the workload and resources factors. Regression results showed that paediatric wards differed from the other wards with regard to adequate resources, implying that staff perceived that they had enough re- (Hope et al, 2018). The approach of calculating EWS without considering variations in patient groups with conditions such as COPD or dementia resulted in observations being determined more by clinical judgement than by the EWS.…”

What is the nursing time and workload involved in taking and recording patients’ vital signs? A systematic review

“…If nursing staff perceive the vital signs workload as excessive, they may choose to prioritise other activities and follow their clinical judgement rather than an observation schedule dictated by a protocol (Hope et al, ) At present, there is no evidence to determine whether the nursing workforce is sufficient to accommodate existing demand—or potentially an increase in demand—arising from increasing compliance with current observation protocols, or from changing such protocols because the demand is not clearly quantified. Based on the current literature, we cannot yet tell whether observations for all patients in a 30‐bed unit might require an hour of work (2 min per patient) or two and a half hours (5 min per patient) or indeed considerably more or less if these estimates are inaccurate, or suboptimal systems are in place.…”

The association between nurse staffing levels and the timeliness of vital signs monitoring: a retrospective observational study in the UK

“…We were unable to exclude observations from our analysis that were missed for valid clinical or logistic reasons, such as when patients were away from the ward (eg, for radiological or surgical procedures). A previous study in the same hospital also showed that nursing staff are more reluctant to wake patients at night,33 which could account for some missed observations.…”