A total of 30 participants: 10 medical officers (M = 8; F = 2) and 20 nurses (M = 2; F = 18) participated in the study. Participants’ professional post-graduation experience ranged from 1 to 40 years and were located across rural/remote (n = 8; 4 medical officers, 4 nurses), regional (n = 16; 4 medical officers, 12 nurses), and metro (n = 6; 2 medical officers, 4 nurses) hospital sites.
Two major themes were identified: (1) the use of EWS for patient monitoring; and (2) the use of EWS for the escalation of patient care. The sociocultural framework for EWS compliance, presented as Fig. 1, illustrates the individual and team factors that facilitate or inhibit compliance with EWS during monitoring and escalation. Compliance is enacted at an individual and a team level and is impacted by intra and inter-professional factors, and overarchingly, by the organisational context’s quality improvement and administrative protocols.
Theme 1: The use of EWS for Patient Monitoring
The Individual Clinician and the Complacent, Reactive or Proactive Approach
We identified that the use of EWS for patient monitoring involves nurses collecting and charting patients’ vital signs and medical officers modifying the EWS parameters to avoid unnecessary escalations. Three individual-level approaches to using EWS for patient monitoring emerged: complacent, reactive, and proactive. These approaches highlight the differences among the individual clinicians in how they engage with the tool.
The complacent approach emerged based on clinicians’ reflections related to their perceptions of their colleagues’ behaviours rather than their own. Incomplete documentation of EWS charts suggestive of incomplete patient observations were common sources of frustration. Participants typically attributed time constraints as reasons for their peers’ non-compliance, especially when increased frequency of observations were required for deteriorating patients. Participants also identified some nurses’ negative attitudes towards EWS. P16_RN observed: “they (junior staff) fill it out but aren’t paying attention, they don’t understand what they’ve ticked”. Complacency among the senior nurse clinicians was also raised. P10_RN reports: “there is some open hostility to the form from staff who’ve been around for 20–30 years. They’ll tell you day in and day out that the form’s a load of sh.t and takes away from clinical judgement”. Complacency among medical officers was evident when they verbalised the modifications but did not chart the articulated changes, or in extreme cases, did not attend the patient when summoned. P15_MO explained that “some people maybe can’t be bothered to respond because it can be quite tedious, even though you are seeing the numbers there, sometimes it (the EWS Score) is just a guesstimate of the patient’s actual acuity”.
The prevalence of a reactive approach among junior clinicians emerged. The “reactive approach” denotes the use of EWS in concrete and prescriptive ways, and “reacting” to EWS scores without further investigation. P04_MO observed that “junior nurses might react rather than do it (escalate care) proactively”. P14_RN commented: “the more junior nurses say I have a 5, this is what I need to be doing”. P08_RN pointed out the usefulness of a score: “it gives them (junior nurse clinicians) a concise idea of how sick their patient is”. P15_MO elaborates on how the reactive approach from medical officers’ impacts compliance: “because it’s a number, it’s been triggered, everyone gets called for no reason just to modify a number. Which can be a waste of everyone’s time...”.
In contrast, the proactive approach was prevalent among some nurses and medical officers. P22_RN reported using EWS score as ‘a very rough guide’. As a nurse with 28 years of experience, P22_RN asserted: “this is a blunt tool, I know how to deal with this patient and get the help that I need when I need it”. Another experienced nurse P41_RN similarly expressed: “I know personally what I can do with that form and what I can’t do. Or what I should and shouldn’t”. The proactive approach was evident among medical officers when they acknowledged their hesitancy to just write in modifications that would essentially ‘turn off the tool’. P19_MO stated that clinical reviews should not be driven by the pressure to “modify obs to get a number out of there to stop mediating about that patient”. The individual level approaches contribute to the team dynamics or processes in both the intra-professional (nursing team or medical team) and inter-professional teams (comprising of nurses and medical officers) which are considered next.
The Team
Intra-Professional Factors
Nurse participants, both nurse managers and clinicians, identified reinforcement, understanding importance and staff monitoring, as intra-professional team factors contributing to compliance. According to the nurse manager, P32_RN, the reinforcement can be as simple as: “constantly telling people… [that] if there’s a number then you have to write an intervention”. P14_RN emphasized that the junior nurse clinicians “can be influenced by the area or the people they’re working with”, hence reinforcing good practices on the team level is important. From the nurse manager’s perspective: “once there’s a proper understanding of the form, we rarely come across the same problems from individual nurses” (P24_RN). This comment highlights that differences exist in understanding importance of using the form among the nurse clinicians, and that understanding importance can be learnt.
Awareness of being monitored fosters compliance. P39_RN reflected: “one of our grads, she escalated but she didn’t document any interventions. We actually pulled her in about it and had a big chat. I know for a fact that she’s then spoken to other people about that talk and so now people are on alert”. It seems that by being monitored, the complacent approach can be changed with a trickle-down effect onto other team members.
Inter-Professional Factors
Nurse participants identified inter-professional double standards in expectations pertaining to EWS compliance. The expectation that EWS documentation is the domain of the nurses, and not the medical officers is apparent. P08_RN reported: “unless the doctors are prompted by the nurse, they normally don’t write the modifications”. P17_MO acknowledged: “we’re often prompted multiple times before we get around to doing it”.
Nurse participants expressed concern about medical officers’ complacent attitudes and behaviours towards EWS documentation. P37_RN elaborated: “even if the doctors say yeah, its ok, they need to write yeah that’s ok and they need to follow that up regularly. They don’t do that.” From the nursing perspective, the inter-professional communication can be characterised by ambiguity, potentially jeopardising the nurse’s EWS compliance. P37_RN emphasised that ultimately the nurse clinicians, rather than medical officers, are held accountable for inconsistent documentation: “the audit gets done and they’re going, your EWS tool has no modifications on it…there is never an audit into whether the doctor modified the tool correctly”.
While the nurse clinicians identified medical officers’ non-compliance with documenting modifications as disrupting the workflow, narratives from the medical officers suggest that their non-compliance is more complex than deliberate defiance. P15_MO explained that making modifications requires appropriate expertise: “my background training is in the ICU so we are a lot more comfortable with modifying physiology parameters... In other departments, say the surgical department, maybe because they are less knowledgeable with medical physiology, they will be more reluctant to modify”. Other medical participants also indicated that the senior consultants are not readily available to advise junior medical officers regarding modifications.
At times, medical officers encounter tensions between patient safety and EWS compliance. P01_MO elaborated: “the teams aren’t comfortable with modifying the EWS parameters until the person’s had enough time to be observed...”. P19_MO further cautioned that clinical reviews should not be driven by the pressure to “modify obs [observations] to get a number out of there to stop mediating about that patient”. Ultimately, patients’ safety must precede EWS procedural compliance.
Theme 2: The use of EWS for the Escalation of patient care
The Individual Clinician
Escalation processes can be either stressful or empowering. Nurse participants commonly described the initiation of escalation of patient care as a stressful event in which the nurse clinician can be undermined. P37_RN reported that medical officers commonly react with “why are you doing that, stop calling me”, particularly when being contacted at night from a regional hospital. According to P34_RN, EWS is an empowering tool for the nurse clinician: “it gives you the confidence to say, ‘you need to come review this patient immediately, because they’re scoring a 5’”. Escalations can be stressful from the medical officers’ perspective. According to P01_MO: “… the risk is if you modify too many parameters too early, there’s not really any room left and you end up having a real acute deterioration that requires urgent escalation… “.
The Inter-Professional Team Factors
Inter-disciplinary dynamics are activated during the escalation of patient care. When a patient’s EWS score reaches a predetermined threshold, the nurse is mandated to notify the medical officer. At that stage, additional support and skills are required that fall outside the nursing scope of practice. Escalation processes can either be poorly or well managed, depending on factors such as quality of communication, instructions, level of support and response time.
In a poorly managed escalation of care, the nurse participants identified that professional hierarchies hinder communication and timely responses. P10_RN reflected: “when they (medical officers) do respond it’s quite often with an eye roll and sometimes a begrudging modification is put in place... And often we’re going off verbal orders, which when it gets to coroner’s court, it doesn’t hold up”. The ambiguity of medical officers’ instructions can present a professional dilemma for the nurses. P16_RN explained: “I’ve rung the doctor, they didn’t do the mods (did not write modifications on the EWS chart) that they’d written on the chart (patient notes within the chart) that they would do. I could do a MET call, but they’ve written in the chart (patient notes) that this is their mods”. P16_RN further reported that “nurses have to cherry-pick doctors” to make escalation processes less stressful and more efficient.
The act of making the MET call further exposes the tensions related to the escalation of patient care. P16_RN viewed MET calls as “behaviour modification” for the medical officers. P16_RN explained: “doctors are very bad at including MET call in either the do or don’t section.” Upon MET’s arrival, “they [medical officers] have to answer to a MET team as to why they hadn’t reviewed the patient in a more timely manner” (P16_RN). Based on own experience of working in MET, P1_MO elaborated: “often the nurses have contacted the home team and they haven’t come and done it... If they are not getting anywhere, it can sometimes stimulate it [stimulate escalation to the MET team] to action”. Yet, P1_MO emphasized the value of second opinion: “sometimes it is good to have someone else who doesn’t know the patient who hasn’t been sitting on it for days”.
With the MET involvement, a negative feedback loop can ensue related to updating EWS documentation. P16_RN explained: “the medical teams are aware that the patient’s deteriorating, but they often leave without writing any modification for EWS and then in the next set of observations they [patient] score the same thing. If we’re going by the form, we then should be going through the whole process of a MET call again, but verbally, it’s very clear that it’s been seen (the patient) and there’s no acute change”. Here, P16_RN reiterated the challenges of working in an environment which does not strictly comply with the EWS documentation requirements. P16_RN noted that poor communication can extend to the extreme cases: “they’ll [medical officers from MET] write that the patient is dying and not think to tell anyone to stop charting on the EWS”.
In contrast to poorly managed escalation processes, the well managed approach is characterised by good communication. On-going communication is a feature of positive inter-disciplinary team practice. P40_RN expressed: “we’ve got great communication with our doctors… we’ll contact them if we think mods need to change”. P01_MO also elaborated on the interdisciplinary collegiality: “I am pretty much very compliant with it [EWS] and the nurses are very good at notifying teams when patients need review or if there’s something abnormal”. Interdisciplinary collegiality fosters a team climate of crises prevention. P42_MO commented: “even though I don’t technically have to review the patient until the score’s a 4, the nurses are comfortable to come and tell me it’s rising for whatever reason, so it gives me a chance to get on top of it before it is an issue”.
In the well managed process, the medical officers quickly respond to escalations. P34_RN elaborated: “before we hit that staff alarm, if we can escalate straight to a senior doctor in ED…my experience is that 99.99% of the time, they will come immediately”. Another feature of a well-managed escalation of patient care is that junior nurse clinicians are actively supported. P32_RN stated: “I teach people… ‘you have got a form here that will back you up, it is policy and protocol that you use the EWS form’”. P05_MO agreed that EWS fosters communication: “You call up an MO or registrar and ask them to review the patient that has a score of 6 and if any particular parameter is elevated. It makes this communication easier. Less experienced staff might go through the whole story and don’t give the right information. The language becomes easier. ‘A score of 6, you need to see this patient’”. This comment suggests acceptance and a non-judgemental approach toward the junior nurse clinicians who initiates escalation processes and focuses on the patient’s EWS score rather than their clinical assessment of the patient.
The Organisational Context
The importance of organisational context in shaping EWS compliance or non-compliance emerged. The organisational factors impact on how clinicians engage with and follow EWS protocols. Participants identified training, resources and staffing as the key organisational context factors. P24_RN reflected: “only when it [EWS training] was actually delivered to us did we understand what we’re trying to achieve with it [EWS]”. P09_MO observed: “… we had a big advertising/education campaign directed at the nurses to say you must call a MET call, and directed at the doctors to say you must not criticise the nurses when they call a MET call”. However, training can create unintended consequences. P09_MO reported: “our MET call numbers went from 2 or 3 a day, to 10 a day and some of them are totally ridiculous”. Provision of organisational training without the back up support creates additional challenges in responding to patients’ deterioration.
Tension arises between EWS compliance as a labour-intensive process and the availability of resources. P09_MO identified the problem of insufficient staffing: “you’ll have rural hospitals where there’s one doctor for the whole town who can’t review the patient every two hours”. Similarly, P16_RN based in a large regional hospital comments: “they haven’t had stable management in our ED for many years”. Staffing shortages and the associated instability are a significant challenge. Staffing allocations are also driven by established operational processes rather than the patients’ needs. P34_RN reported: “we don’t use trends (electronic patient movement software) to estimate nursing hours... whether we end up with 7 or 17 patients, we have the same amount of staffing”.
Participants in senior positions emphasized the availability of additional resources to support the clinicians’ EWS compliance. Yet, the distribution of these resources varies across locations. P09_MO indicated that: “a lot of these rural and remote areas you have the benefit of ringing TEMSU (Telehealth Emergency Management Support Unit) with video conferencing and you can ask to speak to a RN if you don’t want to speak to a doctor …” However the availability of resources varied geographically, with P01_ MO referring to a “dedicated MET team”, and P05_MO stating that “escalations are addressed by the most senior doctor on staff at the time and failing that, the most senior nurse”. Overall, insufficient resources and staffing were seen as barriers to attaining EWS compliance.