The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study

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Abstract

Background

Registered nurses and midwives play an essential role in detecting patients at risk of deterioration through ongoing assessment and action in response to changing health status. Yet, evidence suggests that clinical deterioration frequently goes unnoticed in hospitalised patients. While much attention has been paid to early warning and rapid response systems, little research has examined factors related to physical assessment skills.

Objectives

To determine a minimum data set of core skills used during nursing assessment of hospitalised patients and identify nurse and workplace predictors of the use of physical assessment to detect patient deterioration.

Design

The study used a single-centre, cross-sectional survey design.

Setting and participants

The study included 434 registered nurses and midwives (Grades 5–7) involved in clinical care of patients on acute care wards, including medicine, surgery, oncology, mental health and maternity service areas, at a 929-bed tertiary referral teaching hospital in Southeast Queensland, Australia.

Methods

We conducted a hospital-wide survey of registered nurses and midwives using the 133-item Physical Assessment Skills Inventory and the 58-item Barriers to Registered Nurses’ Use of Physical Assessment Scale. Median frequency for each physical assessment skill was calculated to determine core skills. To explore predictors of core skill utilisation, backward stepwise general linear modelling was conducted. Means and regression coefficients are reported with 95% confidence intervals. A p value <.05 was considered significant for all analyses.

Results

Core skills used by most nurses every time they worked included assessment of temperature, oxygen saturation, blood pressure, breathing effort, skin, wound and mental status. Reliance on others and technology (F = 35.77, p < .001), lack of confidence (F = 5.52, p = .02), work area (F = 3.79, p = .002), and clinical role (F = 44.24, p < .001) were significant predictors of the extent of physical assessment skill use.

Conclusions

The increasing acuity of the acute care patient plausibly warrants more than vital signs assessment; however, our study confirms nurses’ physical assessment core skill set is mainly comprised of vital signs. The focus on these endpoints of deterioration as dictated by early warning and rapid response systems may divert attention from and devalue comprehensive nursing assessment that could detect subtle changes in health status earlier in the patient's hospitalisation.

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

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