Assessing acute functional decline in older patients in home nursing care settings using the Modified Early Warning Score: A qualitative study of nurses’ and general practitioners’ experiences

Abstract

Aims and objectives The study describes experiences of registered nurses and general practitioners when using the Modified Early Warning Score (MEWS) to assess acute functional decline in older home nursing care patients. Background Acute functional decline is common among older home nursing care patients; typically characterised by nonspecific symptoms and a mix of manifestations. Early warning score systems for detecting clinical deterioration have been thoroughly evaluated in hospital settings, but few studies have evaluated these systems used with older people in a community care setting. Methods A descriptive exploratory research design and a qualitative approach. 36 nurses and eight general practitioners were purposively sampled. Data were collected in seven mixed focus groups and analysed using an inductive thematic content analysis in an iterative process that moved between text, codes, categories and themes. The COREQ checklist was used. Results Two main themes were developed in the analysis. The first theme derived, was that the MEWS along with medical‐technical equipment and clinical judgement, was used to support nurses’ and general practitioners’ clinical decisions in assessing older deteriorating patients. The second theme referred to nurses’ and general practitioners’ experiences with several adjustments when using the MEWS with the older patient group and in complying with its trigger recommendations. Conclusion The use of the MEWS when assessing older patients in home nursing care is potentially useful in supporting clinical reasoning. However, the tool's usefulness is limited because it is not experienced as sufficiently adapted to neither the home nursing care services nor to older patients. Implications for practice This study increases our knowledge of how the MEWS tool is used in a community care setting and highlights the importance of adjustment of assessment procedures for older persons with acute functional decline.

Experiences and challenges of the use Subacute and Acute Dysfunction in the Elderly‐SAFE Work team coordinators experiences and challenges in the introduction and use of SAFE in home‐based nursing: A qualitative study from the Norwegian context

“…This study shows that using SAFE systemizes patient‐centred work and increases nurses' professional self‐confidence. The results are in line with recent studies on assessment tools for physical function which found that the assessment tool MEWS facilitated nurses' clinical reasoning and decision making when acute functional decline was detected in home nursing patients (Jeppestøl et al, 2022 ; Roney et al, 2015 ). The findings of a study by Moi et al ( 2019 ) on the use of ISBAR in clinical practice showed that the participants felt more confident about their ability to quickly obtain an overview of patient situations (Moi et al, 2019 ).…”

Early warning scores and trigger recommendations must be used with care in older home nursing care patients: Results from an observational study

“…Heart rate was the second most frequent deviating vital sign in the habitual state (19.6%), a result supported by research showing that an increased resting heart rate is common in the habitual state of older persons (Coupé et al, 2009 ). However, studies have also shown that slightly increased respiratory rate and/or heart rate are associated with possibly higher levels of clinical responses and death (Bunkenborg et al, 2019 ; Jeppestøl et al, 2021b ). This study contributes important knowledge that elevated respiratory‐ and/or heart rate may represent a combination of physiological normal aging processes and chronic diseases, as well as acute disease for older multimorbid home nursing care patients.…”

“…Previous research has investigated staff experiences using the EWS in prehospital, primary care and community settings (Brangan et al, 2018) and among older patients in cases of acute functional decline in home nursing care (Jeppestøl et al, 2022b).…”

“…Previous research has investigated staff experiences using the EWS in prehospital, primary care and community settings (Brangan et al, 2018 ) and among older patients in cases of acute functional decline in home nursing care (Jeppestøl et al, 2022b ). These studies found that the use of EWS strengthened healthcare personnel's communication, but they also indicated the need for adjustments of the tools' reference values and trigger recommendations to the context and patient groups.…”

“…Research regarding the use of EWS in clinical practice shows broad, if implicit, agreement that these tools do not replace healthcare personnel's clinical judgement; rather, they should be used to support clinical reasoning and decision‐making processes (Chester & Rudolph, 2011 ; Downey et al, 2017 ; Dundar et al, 2016 ; Foley & Dowling, 2019 ; Fox & Elliot, 2015 ; Fullerton et al, 2012 ; Jensen et al, 2017 ; Jeppestøl et al, 2022a ; Jeppestøl et al, 2021b ; Stafseth et al, 2015 ; Subbe et al, 2001 ).…”