The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study
Introduction
The changing profile of hospitalised patients means sicker patients with more complex needs are at greater risk of becoming seriously ill during their hospital stay. Rates of unanticipated in-hospital morbidity and mortality have been estimated between 12 and 48% (Buist et al., 2004, Jacques et al., 2006, Kause et al., 2004). A deteriorating patient moves from one clinical state to a worse clinical state, increasing their individual risk of morbidity and death (Jones et al., 2013, p. 1031). Missed signs of deteriorating health status can result in a failure to rescue patients from clinical deterioration and subsequent poorer outcomes (Chan et al., 2010, McGaughey et al., 2009, Silber et al., 1992).
In response to the changing acuity of hospital ward patients there has been a focus on the patient safety and quality agenda and imperatives for efficient and effective health service systems. Government agencies worldwide have promoted and commissioned guidelines for recognition of and response to acute clinical deterioration (ACSQH, 2012, IHI, 2008, NICE, 2007). Globally, these hospital safety initiatives have resulted in the uptake of early warning systems and rapid response teams to recognise and respond to clinical deterioration. Early warning systems and rapid response teams are predicated on the recognition of predetermined criteria to alert special teams (e.g. rapid response teams (RRT), medical emergency teams (MET), critical care outreach teams (CCOT)) to attend to and intervene in situations where physiological indicators of patients’ health status lie within the parameters of predetermined criteria. Despite the prolific and growing body of literature on the institution-wide implementation of a systems approach to clinical deterioration, the state of the science generally remains inconclusive on the effectiveness of these initiatives (Chan et al., 2010, Gao et al., 2007, McGaughey et al., 2009, McNeill and Bryden, 2013, Ranji et al., 2007, Winters et al., 2013). Although beneficial effects of rapid response systems are becoming more apparent in some local contexts, these benefits are not achieved consistently by all programs (Chan et al., 2010, Winters et al., 2013).
It has been known for some time that patients exhibit signs of clinical deterioration prior to cardiac arrest, unplanned intensive care unit admission or death, and these signs are often not recognised or acted upon (Buist et al., 2004, Franklin and Mathew, 1994, Goldhill and McNarry, 2004, Hogan, 2006, Lighthall et al., 2009, Schein et al., 1990). Moreover, several large prospective, observational studies identified changes in vital signs, such as blood pressure, respiratory rate, heart rate, arterial oxygen saturation and level of consciousness, as the most common predictors of clinical deterioration (Buist et al., 2004, Kause et al., 2004, Lighthall et al., 2009). Most early warning systems and rapid response teams are based upon vital signs observations and the recognition of abnormal vital signs to trigger the response.
Clinical frontline nurses play an essential role in detecting changes in patients’ health status through ongoing health assessment and timely, appropriate action in response to changes, or deterioration, in health status (Considine and Botti, 2004, Odell et al., 2009, Yeung et al., 2012). Despite the centrality of health assessment in nursing education, previous research suggests that only 11–29% of the physical assessment skills taught in nursing programs are regularly used by RNs in practice (Birks et al., 2012, Giddens, 2007, Secrest et al., 2005). Questions were raised about the need for nursing students to learn such a large range of physical assessment skills to practice nursing – skills which were derived from a medical model and whereby only a small set of these skills were used in practice (Giddens, 2007, Secrest et al., 2005). An alternative explanation has been offered in that, perhaps, nurses were not being used to their full capacity (Giddens, 2007). Birks et al. (2012) later argued that the relevance of the skill may have little bearing on frequency of skill use and other issues, such as time pressures, area of practice, and clarity of practice scope, may have more impact.
The literature is clear that surveillance is essential to detect patients at risk of clinical deterioration, but we know little about the assessment activities of acute care registered nurses and midwives and less about the organisational and contextual factors that influence assessment practices. The assessment activities of the registered nurse in detecting subtle cues or cue clusters of a deteriorating clinical situation, and the action that follows, can have an immediate impact on patient outcome (Yeung et al., 2012). These actions may be the key to understanding why some patients do well and others experience complications during the course of their care. Knowing and understanding what core physical assessment skills registered nurses/midwives consistently perform as well as their attitude and beliefs about physical assessment will advance our understanding of this practice activity that is so central to patient care. This study is part of a larger research program exploring nursing and midwifery assessment practices. The objectives of this study were: (1) to explore the scope of physical assessment practices of acute care registered nurses and midwives to determine a minimum data set of core skills used during nursing assessment of hospitalised patients; and (2) to identify nurse and workplace predictors of the use of physical assessment. Findings from this study will extend understanding of clinical frontline nurses’ and midwives’ capacity to rescue, which will have further implications for patient safety related to recognition and response to clinical deterioration of hospitalised patients in acute care wards.
Section snippets
Study design
A single-centre, cross-sectional survey design was used to explore nursing assessment practices.
Setting
The study was conducted at a 929-bed, quaternary and tertiary referral teaching hospital in Southeast Queensland, Australia. The hospital provides most major health specialties including medicine, surgery, mental health, oncology, maternity services, trauma services and more than 30 subspecialties. It is typical of quaternary hospitals across Australia in terms of size, average length of stay,
Nurse and workplace characteristics
Of the 1591 surveys distributed, 183 were returned unopened; this was primarily due to staff on leave or no longer working in that area. A total of 434 acute care registered nurses/midwives completed the survey (see Table 1), giving a response rate of 30.8%. The mean age was 38.9 years (standard deviation (SD) = 11.5). The majority of the sample were female (90.6%), university-prepared (62.4%) and spoke English as a first language (85.7%). In terms of clinical roles, most participants identified
Discussion
Given the clinical and demographic profile of the contemporary acute hospital patient and increasing effort to achieve early recognition of clinical deterioration in this patient population this research is both timely and significant to inform optimum utilisation of nursing service. Our findings indicate that, on average, the physical assessment skill set that nurses/midwives regularly use in clinical practice is small and mainly comprised of routine vital signs. The results are consistent
Conclusion
The increasing acuity profile of the contemporary acute care ward patient mandates for more vigilant patient surveillance. However, our study suggests that nurses are drawing on an increasingly diminished physical assessment skill set. In some ways this is not surprising, in light of the global focus on implementing institutional measures to detect clinical deterioration such as the use of early warning and rapid response systems; systems integrally directing collection of vital signs by front
Conflicts of interest
The authors confirm no conflicts of interest.
Funding
There was no external funding for this research.
Ethical approval
Ethical approval was obtained from the Queensland University of Technology (Approval Ref No. QUT 1300000190) and Queensland Government (Approval Ref No. HREC/13/QRBW/13).
Acknowledgements
RBWH Patient Assessment Research Council (members: Kathleen Richter (Chair), Catriona Booker, Robyn Fox, Dale Dally-Watkins, Melanie Foster, Thea-Grace Collier, Elizabeth Main, Kathrin Peisker, Margaret Buda) – highlighting clinical issue, contribution to conception of research design, organisational support for study. Research Assistants (Mary Batch, Olivia Hollingdrake) – design of study materials, conducted hospital-wide participant information sessions, acquisition of data, data entry, and
References (48)
- et al.
Features and outcomes of patients receiving multiple Medical Emergency Team reviews
Resuscitation
(2010) - et al.
Physiological abnormalities in early warning scores are related to mortality in adult patients
Br. J. Anaesth.
(2004) - et al.
Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting
Resuscitation
(2006) - et al.
Defining clinical deterioration
Resuscitation
(2013) - et al.
Abnormal vital signs are associated with an increased risk for critical events in US veteran inpatients
Resuscitation
(2009) - et al.
Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review
Resuscitation
(2013) - et al.
Clinical antecedents to in-hospital cardio-pulmonary arrest
Chest
(1990) - et al.
Physical assessment skills: a descriptive study of what is taught and what is practiced
J. Prof. Nurs.
(2005) Characteristics associated with increasing the response rates of web-based surveys
Pract. Assess. Res. Eval.
(2007)Quick-start Guide to Implementing National Safety and Quality Health Service Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
(2012)
Australian Hospital Statistics 2002–03
Self-efficacy
Organizational research: determining appropriate sample size in survey research
Inf. Technol. Learn. Perform. J.
The use of physical assessment skills by registered nurses in Australia: issues for nursing education
Collegian
Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study
Resuscitation
Rapid response teams: a systematic review and meta-analysis
Arch. Intern. Med.
Sampling Techniques
Who, when and where? Identification of patients at risk of an in-hospital adverse event: implications for nursing practice
Int. J. Nurs. Pract.
Mail and Internet Surveys: The Tailored Design Method – 2007 Update with New Internet, Visual and Mixed-Mode Guide
What factors influence nurses’ assessment practices? Development of the Barriers to Nurses’ use of Physical Assessment Scale
J. Adv. Nurs.
Physical assessment: a continuing need for clarification
Nurs. Forum
Developing strategies to prevent in hospital cardiac arrest: analysing responses of physicians and nurses in the hours before the event?
Crit. Care Med.
Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward
Intensive Care Med.
A survey of physical assessment techniques performed by RNs: lessons for nursing education
J. Nurs. Educ.
Cited by (78)
Transforming nursing assessment in acute hospitals: A cluster randomised controlled trial of an evidence-based nursing core assessment (the ENCORE trial)
2024, International Journal of Nursing StudiesDevelopment and validation of an instrument for measuring junior nurses’ recognition and response abilities to clinical deterioration (RRCD)
2023, Australian Critical CareCitation Excerpt :However, being a licenced junior nurse is quite different than being a nursing student.30 In 2015, Osborne et al. proposed that the abilities of clinical nurses to manage clinical deterioration should be assessed by evaluating their abilities to perform physical assessment.31 The self-report tool included the 133-item physical assessment skills inventory and the 58-item barriers to use of the scale.
Vital signs-based deterioration prediction model assumptions can lead to losses in prediction performance
2023, Journal of Clinical EpidemiologyFrontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study
2023, International Journal of Nursing Studies