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

AIMS AND OBJECTIVES: To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores. BACKGROUND: While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown. DESIGN: Systematic review. METHODS: A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist. RESULTS: Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed. CONCLUSIONS: Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible. RELEVANCE TO CLINICAL PRACTICE: There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study.

AIM: To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol. BACKGROUND: Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses' practice in hospital wards. METHOD: Seventeen acute hospital nursing staff participated in semi-structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device. RESULTS: Before electronic EWS data was used to monitor compliance, staff combined protocol-led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration. CONCLUSIONS: Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign 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.

Erratum to "The Quality of Interactions Schedule (QuIS) and person-centred care in acute hospitals: concurrent validity" [International Journal of Nursing Studies Advances, Volume 1, November 2019, 100001].

[This corrects the article DOI: 10.1016/j.ijnsa.2019.100001.].

How long do nursing staff take to measure and record patients' vital signs observations in hospital? A time-and-motion study.

INTRODUCTION: Monitoring vital signs in hospital is an important part of safe patient care. However, there are no robust estimates of the workload it generates for nursing staff. This makes it difficult to plan adequate staffing to ensure current monitoring protocols can be delivered. OBJECTIVE: To estimate the time taken to measure and record one set of patient's vital signs; and to identify factors associated with the time required to measure and record one set of patient's vital signs. METHODS: We undertook a time-and-motion study of 16 acute medical or surgical wards across four hospitals in England. Two trained observers followed a standard operating procedure to record the time taken to measure and record vital signs. We used mixed-effects models to estimate the mean time using whole vital signs rounds, which included equipment preparation, time spent taking vital signs at the bedside, vital signs documentation, and equipment storing. We tested whether our estimates were influenced by nurse, ward and hospital factors. RESULTS: After excluding non-vital signs related interruptions, dividing the length of a vital signs round by the number of vital signs assessments in that round yielded an estimated time per vital signs set of 5 min and 1 second (95% Confidence Interval (CI) = 4:39-5:24). If interruptions within the round were included, the estimated time was 6:26 (95% CI = 6:01-6:50). If only time taking each patient's vital signs at the bedside was considered, after excluding non-vital signs related interruptions, the estimated time was 3:45 (95% CI = 3:32-3:58). We found no substantial differences by hospital, ward or nurse characteristics, despite different systems for recording vital signs being used across the hospitals. DISCUSSION: The time taken to observe and record a patient's vital signs is considerable, so changes to recommended assessment frequency could have major workload implications. Variation in estimates derived from previous studies may, in part, arise from a lack of clarity about what was included in the reported times. We found no evidence that nurses save time when using electronic vital signs recording, or that the grade of staff measuring the vital signs influenced the time taken. CONCLUSIONS: Measuring and recording vital signs is time consuming and the impact of interruptions and preparation away from the bedside is considerable. When considering the nursing workload around vital signs assessment, no assumption of relative efficiency should be made if different technologies or staff groups are deployed.

Development and validation of a methodology to measure the time taken by hospital nurses to make vital signs observations.

BACKGROUND: Several time and motion studies have sought to quantify the nursing work involved in observing patients' vital signs. However, none of these studies offered a validated methodology that can be replicated. This is reflected in the high variation between these studies in the mean times for measuring and recording observations. AIM: To describe the development and inter-rater reliability of a methodology for observing the nursing time and workload involved in measuring and recording patients' vital signs. DISCUSSION: The authors developed a methodology that used the quality of interactions (QI) tool ( Bridges et al 2018 ) to measure and record the start and finish times of the rounds of nurses observing vital signs and individual observations clustered in rounds. Two raters concurrently documented their observations of nurses undertaking patient observations in a simulated setting. The tool and associated documentation were found to be easy to use, and there was a high level of agreement in measurements by different observers. CONCLUSION: The authors' methodology can be used to reliably measure the time involved in taking vital signs. IMPLICATIONS FOR PRACTICE: Using the QI tool may increase precision when timing and classifying nursing activities concerning observing vital signs. The authors anticipate that it could be adapted effectively to measure several other nursing activities and so support researchers interested in capturing different aspects of nurses' work.

Older people's experiences in acute care settings: Systematic review and synthesis of qualitative studies.

BACKGROUND: There is no recent synthesis of primary research studies into older people's experiences of hospital care. OBJECTIVE: To synthesise qualitative research findings into older people's experiences of acute health care. DESIGN: Systematic procedures for study selection and data extraction and analysis. Comparative thematic approach with meta-ethnographic features for synthesis. DATA SOURCES: Worldwide grey and published literature written in English between January 1999 and December 2018 identified from databases: CINAHL, Medline, British Nursing Index, EMBASE Psychiatry, International Bibliography of the Social Sciences, PsychINFO, and AgeInfo. REVIEW METHODS: Systematic review and synthesis of 61 qualitative studies and two systematic reviews describing older patients' experiences of care in acute hospital settings. RESULTS: The physical and social environment of the hospital positioned many older patients as insignificant and powerless to influence the care they received. Patients subjugated their needs to those of staff and other patients, holding back information and requests for help. Patient knowledge of the time-based schedules for care, and experiences of waiting for care and of staff limiting their time with them served to reinforce patients' feelings of insignificance and powerlessness, reflecting the perceived primacy of bureaucratic organisation of care over individual needs and preferences. Highly negative experiences would result if these aspects of context were not mediated by individualised relational work by staff, nursing staff in particular. Some groups of patients were at particular risk of negative experiences: people with dementia and/or delirium; people with difficulty communicating, hearing or understanding; people from ethnic minority groups, especially where there was a language difference; people with low functional/physical ability; people with low literacy; and people without regular visitors and/or family support. Three key features of care consistently mediated negative feelings and were linked to more positive experiences were: "maintaining identity: see who I am", "building relationships: connect with me", and "partnering in care: involve me". CONCLUSION: Older people's care experiences in hospital may be negative in the absence of relational work by nurses to maintain people's identity, establish caring connections and ensure that individual patient needs, preferences and values are honoured in the care that is delivered. Relational care by nurses can mediate powerful institutional drivers that may otherwise result in negative experiences and poor care. Organisational and service-wide commitment are needed to create the culture and context in which relational care can flourish. Tweetable abstract: Synthesis of qualitative research on older ppl's hospital experiences: hospital's physical and social environment positions older ppl as insignificant and powerless. Highly negative experiences result if impact of context not mediated by individualised relational work by nurses.

The Quality of Interactions Schedule (QuIS) and person-centred care: Concurrent validity in acute hospital settings.

BACKGROUND: There is a lack of consensus on how the practices of health care workers may be assessed and measured in relation to compassion. The Quality of Interactions Schedule (QuIS) is a promising measure that uses independent observers to assess the quality of social interactions between staff and patients in a healthcare context. Further understanding of the relationship between QuIS and constructs such as person-centred care would be helpful to guide its future use in health research. OBJECTIVE: This study aimed to assess the validity of QuIS in relation to person-centred care measured using the CARES® Observational Tool (COT™). METHODS: 168 nursing staff-patient care interactions on adult inpatient units in two acute care UK National Health Service hospitals were observed and rated using QuIS and COT™. Analyses explored the relationship between summary and individual item COT™ scores and the likelihood of a negative (lower quality) QuIS rating. RESULTS: As the degree of person-centred care improved, QuIS negative ratings generally decreased and positive social ratings increased. QuIS-rated negative interactions were associated with an absence of some behaviours, in particular staff approaching patients from the front (relative risk (RR) 3.7), introducing themselves (RR 3.1), smiling and making eye contact (RR 3.4), and involving patients in their care (RR 3.7). CONCLUSION: These findings provide further information about the validity of QuIS measurements in healthcare contexts, and the extent to which it can be used to reflect the quality of relational care even for people who are unable to self-report.