Abstract
Failure to recognize the deterioration of hospital patients has led to the implementation of a system known as the Rapid Response System. The aim was to explore nurses’ use of the afferent limb of the Rapid Response System to recognize and respond to deteriorating patients. Data were collected via video recordings with observations of 20 registered nurses (RNs) from general wards performing scenarios in a simulation laboratory with focus group interviews. Data were analyzed using systematic text condensation. COREQ were followed. In the first scenario, nurses did not apply ABCDE or ISBAR, and the use of NEWS was insufficient. Completing an education program led to evident improvement in the use of the tools during the second scenario. Nurses initially viewed their new competency as useful, but it was not sustained a year later. Customized education programs and fidelity-scale simulations are suited but not sufficient to change clinical competency without management anchoring.
Keywords
Introduction
Reports from health authorities in Norway, such as the Norwegian Patient Safety Program 1 and Norwegian Ministry of Health Care Services, 2 identified patient safety as a key dimension of healthcare services. These reports emphasized the need for healthcare professionals to have competence in the systematic use of clinical observation, clinical assessment, and communication tools. Delays or failure to recognize the deterioration of patients in the general ward have led to the implementation of systems known as rapid response systems (RRSs). 3 An RRS is defined as ‘a whole system for providing a safety net for patients who suddenly become critically ill and have a mismatch of needs and resources’. There are four components of an RRS: an afferent limb to identify deterioration of patients includes order to escalate care, notify, and activate professional assistance as the rapid response team (RRT) efferent limb; a process improvement arm; and a governance/administrative structure.3–6 The early warning score (EWS) is one of several scoring systems with different terms and is a part of the afferent limb in the RRS. The EWS defines the physiological parameters to be measured and the frequency of observations, and it includes a point score that should trigger a response, the afferent limb.6,7 In this study, the National Early Warning Score (NEWS) was used. The NEWS has six physiological parameters: respiration rate; temperature; oxygen saturation; systolic blood pressure; pulse rate; and level of consciousness. Nurses in the general ward manually assess the NEWS parameters, and it is important that nurses use tools such as the NEWS in combination with their professional judgment to assess the patient’s deterioration.7–9 If a score is abnormal considering the patient’s expected condition, it is vital to call for a physician or an intensive care nurse, who is part of an RRT, the efferent limb. 10 The clinical tool airway, breathing, circulation, disability, and exposure (ABCDE) 6 was also included. This is because the ABCDE approach is used as a systematic method to assess all deteriorating or critically ill patients.1,4,5,9,11 The structured communication tool identifies situation, background, assessment, and recommendation (ISBAR), in the context of RRT, which is recommended by Norwegian studies. The ABCDE approach is used as a systematic method to assess all deteriorating or critically ill patients.1,4,5,9,11 ISBAR is a structured communication tool and is used as an aid for the management of information between healthcare personnel. This tool gives a clear picture of the patient’s clinical issues so that incorrect or omitted information becomes clear when the RRT is consulted. 12
Several international systematic reviews addressing the competence and performance of nurses worldwide regarding RRS state that the activation process is complex and multifactorial.4,13,14 The findings from these studies showed work pressure as one of the reasons for incorrect measurement among the nurses in general wards. The use of the afferent limb gave nurses in the general ward more self-confidence, and they experienced greater safety in communication with the RRT. The findings also showed that some nurses do not have sufficient knowledge, skills, and competence to manage patient deterioration to secure patient safety.13,15,16 A review by Lee et al. 17 shows that registered nurses (RNs) in the general ward are increasingly given responsibility for patients with complex and serious diseases and at high risk of clinical deterioration. Failure to recognize and respond to deterioration has led to an increased risk of adverse events in hospitalized patients and unexpected death. 18 Unplanned admissions to intensive care units (ICUs) from wards are often related to healthcare professionals’ failures in monitoring patients. 19 Another reason may be that nurses underestimate the pathophysiology underlying clinical abnormal vital signs.20,21 The early warning signs of deterioration often manifest as suboptimal vital signs, such as increased respiratory rate. 22 Studies show that effective communication skills, medical language, and clinical information sharing between healthcare professionals can result in a relevant response to patient deterioration. 15 Studies have also highlighted nurses’ competence in ensuring patient safety in relation to deteriorating conditions.16,23
There is a lack of research in general ward nurses’ clinical competence in using the afferent limb in Norwegian hospitals after implementation of the RRS.
This project was initiated after a head of the ICU at the hospital received complaints from members of the RRT that nurses in the general wards provide insufficient clinical information during interaction with the RRT when needing help with deteriorated patients. In the context of a planning meeting between hospital managers and university researchers and in previous research, we developed goals and methods to improve the use of the afferent limb of the RRS in the general ward. The aim of this study was to explore nurses’ use of the afferent limb of the Rapid Response System to recognize and respond to deteriorating patients.
Methods and design
An action research design was chosen for this study. The focus was on current practice to explore nurses’ use of the RRS afferent limb and possibilities to improve, change, and develop nurses’ competence. The data collection was conducted from March 2018 to January 2019. The focus in action research is to develop new knowledge and skills in practice, with close collaboration between practitioners and researchers. 24 The methods, observations, and focus interviews were used to obtain a better understanding of the phenomenon than using a singular approach. 25 This study adhered to the consolidated criteria for reporting qualitative research (COREQ). 26
Action research is performed as a cyclic learning-based interaction process that may include stages such as planning, acting and observing, reflecting, recognizing, and revising planning. 27 Hart and Bond present action research as a professionalizing strategy in nursing and a development process that involves nurses in an iterative approach. This process unfolded in five stages 27 : stage 1 was a planning meeting with practice; stage 2 was observation and mapping the nurses’ actions in a simulation laboratory; stage 3 had the nurses complete an education program; stage 4 involved a new observation and mapping of the nurses’ actions; and stage 5 mapped the nurses’ experiences using the NEWS, ABCDE, and ISBAR one year later. We present the cyclic stages of this action research process and the data collection methods in Figure 1.
The nurses’ competence to recognize and respond to patient deterioration cyclic action of the research stages during a one-year period (left side) combined with the data collection methods (right side).
Setting
The participants were RNs from the general wards of a 100-bed hospital, divided into surgical, medical, emergency, and ICUs in Norway, where approximately 200 nurses worked.
Recruitment/sample
The researchers provided project information personally to the lead nurses in each of the general wards and invited all RNs to participate. The researchers received the contact information of possible participants and provided written and oral information about the study. The inclusion criteria were being an RN and employed in general wards. A total of 20 participants were chosen by a purposive sampling procedure, working in two surgical and three medical wards, comprising four nurses from each ward. Their ages were in the range of 23–50 years, and they had work experience in the range of 0.5–20 years, all females.
The project started with 20 participants; eight participants dropped out during the project, and 12 participants completed the entire project. The reasons why participants dropped out were sick leave, received leave to take further education, relocation, and understaffing in practice.
Data collection
All nurses in the project received training in the use of high-fidelity simulations in the simulation laboratory before the actual scenarios 1 and 2 started.
Scenarios 1 and 2 took place at the university’s simulation laboratory where the nurses’ actions were observed to explore the implicit assumptions in their professional practice. The use of a simulation laboratory was based on a review by Massey et al. 28 and the Norwegian Ministry of Health Care Services, 1 which recommended simulations and courses to improve nurses’ clinical ability to recognize and respond to patient deterioration. Efforts were made to ensure that the simulated situations were as authentic as possible.
Scenario 1. The leader from the ICU and the researchers together developed a scenario of an actual situation of patient deterioration. The nurses, who were divided into random groups, four groups with two participants, and four groups with three participants, for a total of 20 participants, performed the scenario with use of the ABCDE, NEWS, and ISBAR. The researchers videotaped with sound and observed the nurses’ actions in a total of eight videos.
Scenario 2. The second scenario was simulated with new and different clinical issues after the nurses completed the clinical educational program. The nurses, who were divided into random groups, four groups with two participants and two groups with three participants, for a total of 14 participants, performed the scenario with the use of the ABCDE, NEWS, and ISBAR. The researchers videotaped with sound and observed the nurses’ actions in a total of six videos.
Observations
An observation research method is a technique in which participants are observed in their natural environment. This enables researchers to see how they interact, make choices, and respond to situations in their natural environment. 28 The focus of the observations was on how the nurses identified and assessed the signs and symptoms, their decision-making, and interventions with the use of the ABCDE and NEWS, and how they used the ISBAR communication. Each of the four researchers took notes during observations based on checklists prepared from the systematics of ABCDE structure, vital measurement in NEWS, and the structure of the ISBAR communication. Then, the researchers compared notes and compiled a joint summary of their observations. In addition, the researchers watched the videos for the second time, discussed the observations, and wrote a final summary.
Customized education program
After the first scenario, the nurses received a specific clinical education program that lasted four days. It was developed together with nurses and based on identified weaknesses during observations and the findings from the first focus group interviews. The lectures and training took place at the university and the hospital. University lectures, physicians, and specially trained nurses from the hospital conducted the lectures. The subjects consisted of the RRS, theory lectures, and skills training on the ABCDE approach, NEWS, and ISBAR, and how to collaborate in detecting and responding to patient deterioration. The learning perspective was based on a holistic approach.
Focus group interviews
According to Malterud, 29 focus group interviews are a suitable method when the purpose of the study is to produce data that reflect a diversity of attitudes, opinions, and experiences on a specific topic. In addition, data are generated from a group dynamic interaction process in focus group interviews that would not have emerged during in-depth interviews. 29
To understand the nurses’ intent of action in the first and second scenarios in stages 2 and 4, the researchers captured the nurses’ perspectives and experiences through the interviews held after the sessions in the simulation laboratory. The focus groups consisted of participants from different general wards. In stage 2, the focus groups were divided into two groups with five participants, one with six participants, and one with four participants. In stage 4, the focus groups were divided into two groups with four participants and two groups with three participants. Three of the researchers alternated between being the moderator and assistant moderator in the first, second, and third interview sessions. A semi-structured interview guide with open questions was developed to identify nurses’ attitudes towards and experiences with their clinical competence. Open questions were asked such as, ‘Please tell me about your experiences regarding how you identify and assess early warning signs?’, ‘How do you interpret clinical observations?’, ‘How do you act during clinical patient deterioration?’, and ‘How do you make decisions regarding the implementation of treatment strategies?’ More details were elicited by asking, ‘Can you provide an example?’ The interviews involved listening to the nurses’ experiences, soliciting more detailed descriptions, and asking additional open-ended questions when expected responses were omitted.
The third interview session (stage 5) focused on nurses’ experiences with applying their new competencies in the general wards. The nurses reflected on whether their new competencies had changed their practice. In stage 5, the focus group interviews took place in one group with nine participants and one group with three participants.
Each focus group interview from stages 2, 4, and 5 was audio recorded and lasted approximately 1 hour. The interviews were transcribed verbatim shortly after the interviews were conducted. After the data analysis was conducted, the researchers agreed that the data were saturated.
Data analysis
The data were analyzed from the researchers’ summaries and the focus group interviews via systematic text condensation based on Malterud. 30 The method consists of four stages. First, all of the material was read several times individually by four of the researchers to obtain an overall impression and identify preliminary themes. Second, meaning units connected with the preliminary themes representing different aspects of the nurses’ clinical competence in the use of the RRS were identified and coded. Third, subgroups were formed, followed by content reduction by condensing ‘from code to meaning’. Fourth, the condensates were summarized by generalizing the descriptions and concepts to fulfil the aim of the study and were organized into categories. 30 Below is an example of systematic text condensation (Table 1).
Systematic text condensation.
Note. NEWS: National Early Warning Score.
Ethical considerations
The Norwegian Social Science Data Services (NSD) 31 approved the project (no. 59402) and the regional health authorities’ research board. The project was conducted according to the current ethical guidelines of the World Medical Association. 32 All data were handled confidentially by storing audio material and transcriptions on an external hard drive in a locked cabinet 33 and deleting data in accordance with NSD guidelines. Participants voluntarily signed a consent form and were assured confidentiality and freedom to withdraw at any time without stating a reason.
Findings
The learning loops in action research are designed for the development and change of practice through experiences that may reinforce learning. We present findings on how learning and changes occurred in various action cycles.
No use of the ABCDE approach in the first scenario
The observations of the first scenario revealed no collective systematic application of the ABCDE approach upon the detection of early signs of patient deterioration. The nurses’ descriptions indicated an integrated and unconscious clinical practice developed through experience. All the nurses acted in a vague and sporadic way in their clinical approach, and insufficiencies in their patient observations caused delays in responding to the patients’ symptoms and limited the nurses’ intervention strategies.
In the focus group interviews, the participants agreed that there had been a shift to more complex and challenging clinical practices. A nurse from a medical ward stated, ‘There are more clinically unstable patients in the general ward now; it’s noticeable’ (FG2-P3). The nurses stated that they had not adapted the systematic ABCDE approach when detecting early warning signs and revealed that the systematic ABCDE approach was needed in emergency units. A nurse said, ‘I think there are very few of us where I work that use ABCDE, but in emergency units, ABCDE is needed to get a quick overview’ (FG1-P2)
Insufficient use of NEWS in the first scenario
In the first scenario, it was observed that some of the groups did not use the NEWS mapping tool. The groups that used the NEWS started mapping the measurements very late, and they documented few measurements. When they consulted the physicians, no one discussed the NEWS results or used them as clinical information. One of the nurses wrote the NEWS on a note and then put it in her pocket without using the score. However, in the interviews, the nurses expressed familiarity with the NEWS approach. They stated that it was a reliable assessment tool to detect deteriorating patients and helped them assess changes in a patient’s condition. A nurse stated, ‘NEWS is a good tool to get an overview and to identify more parameters to observe changes, it is a useful tool’ (FG3-P2).
Insufficient use of ISBAR in the first scenario
In the first scenario, observations showed that communication with physicians about the patient’s condition was insufficient and unstructured. Few groups followed the ISBAR structure. They contacted the physician before completing an examination of the patient and generating a mutual understanding that they had obtained enough clinical information. The physician had to ask almost all the nurses about what they had observed and assessed. During the dialogue with the physician, they showed some lack of professional terminology. In the interviews, they also revealed that they did not use the ISBAR when they had an experienced physician on call. They explained that the physicians filtered out the essence of the clinical information they reported. As a nurse from a medical ward expressed, ‘Generally, the physicians are knowledgeable about the patients’ conditions and ask the questions, and therefore, it is not necessary to use ISBAR’ (FG4-P1). The nurses disclosed that they intended to use ISBAR. As a nurse from a surgical ward explained, ‘I try to remind myself to use ISBAR because the communication will then be more systematic, particularly when the physicians are inexperienced’ (FG2-P2).
Common use of ABCDE in the second scenario
In the second scenario, after the nurses completed the education program, it was observed that all the nurses showed changes in their skills when using the systematic ABCDE approach. Almost all the nurses collaborated in the same systematic way when observing the patients, and the assessment approach had a more exploratory character. The observations in the simulation lab clearly showed that all the nurses in the groups had an increased consciousness of being hands-on with the patients; for example, they counted the respiratory rate and used a stethoscope during clinical observations. In this scenario, almost all the groups made adequate interventions with fewer delays. In the interviews, the nurses indicated that it was important to have a common holistic systematic approach in the general ward. Several admitted that when some of the symptoms were abnormal, it was difficult to be systematic during the performance of the action. One nurse stated, ‘Had we been more aware of the ABCDE approach from the start, we would probably have improved the structure and systematics of how to use it’ (FG1-P2). In some of the groups, the nurses considered the consequence to be like missing the clinical information provided by vital signs. The nurses expressed in the interviews that they were more focused on the system and experienced a greater understanding of the importance of detecting early deterioration. One of the nurses stated, ‘It is scary with sepsis, especially in adolescents, because of the compensation mechanisms’ (FG4-P2). The nurses indicated that their understanding expanded in such a way that they were more alert to early warning signs.
Similar summary of the NEWS in the second scenario
After the second scenario, all the groups that used the NEWS tool had similar summaries of the NEWS and used the NEWS as clinical information when they had a physician on call. The nurses started to quickly map the patients’ vital signs, and they actively applied the NEWS. Almost all groups reassessed the NEWS after initiating the treatment, but detection of the patient’s level of consciousness was inadequate. In the interviews, one of the nurses said, ‘The NEWS makes us come up with evidence that is more tangible for following the deterioration of vital signs’ (FG3-P3). The nurses stated that they used clinical intuition in their daily patient monitoring and could not rely on the NEWS alone. The nurses expressed how difficult it can be to detect early warning signs and indicated the importance of a high level of knowledge and skills.
Some improvements in the use of ISBAR in the second scenario
In the second scenario, several of the groups used the ISBAR structure, provided adequate clinical information, and used professional terminology in dialogue with physicians. However, some nurses still did not take the initiative to give the doctors a complete report but waited for the physician to take the initiative and ask for more clinical information. In the interviews, other nurses in the groups said that they were not conscious of how they used ISBAR when communicating clinical information. They stated that it is vital to report the clinical measurements first and that the patient’s history is secondary. One nurse stated, ‘I thought the abnormal signs were clear enough because of how critically ill the patient was, so I did not say that the patient had been ill for three days. If I forget something, I expect that the physician will ask for more information’ (FG2-P3).
Use of ABCDE after one year in the general ward
Some nurses described increased awareness based on their use of the systematic ABCDE approach and indicated that their observations became more targeted. Others revealed that they did not use it since it is not common practice. They stated that what is most important when implementing new knowledge is that everyone has the same training to gain a common understanding. One nurse said, ‘The teamwork would have been more systematic if everyone was using the ABCDE approach in the general wards’ (FG2-P3). They indicated that increased knowledge stimulated a desire to learn more. Several nurses expressed that they were now more hands-on with patients during clinical observations.
Use of the NEWS after one year in the general ward
The nurses noted that the NEWS simplified communication with physicians. One change that was clearly expressed was that they had gained a greater understanding of why they use the NEWS and that it was now integrated into patient care as a standard procedure. They actively used the NEWS and reassessed patients based on it. One nurse stated, ‘Now we communicate with NEWS instead of telling the physician that the patient is not in shape’ (FG1-P1).
Use of ISBAR after one year in the general ward
Almost all the nurses indicated that they used ISBAR but suggested that it was not necessary when the physician knew the patient. They remarked that the logical structure of ISBAR makes sense, and it is important to report the vital signs indicative of deterioration first One nurse said, ‘I do not follow the structure slavishly, for the content will be the same, just not in chronological order’ (FG1-P4). Other nurses admitted that a lack of structure caused delays when consulting the physician.
Lack of a competence plan from the management
Several nurses noted that the management of the wards, to a small degree, facilitated the sharing of their knowledge from the project with the other nurses. One nurse said, ‘Our colleagues saw that we had developed new competencies, and they also wanted these skills’ (FG1-P4). They revealed that there was no common plan from the leaders to highlight the integration of RRS.
Discussion
The use of ABCDE, NEWS, and ISBAR in a simulation laboratory: transfer into clinical practice
The findings from the first scenario revealed that during their actions in the simulation lab, the nurses did not comply with the recommendations from the health authorities regarding the use of RRSs and afferent limbs. 1 In the second scenario, close to when they had completed the customized education program, they showed changes in attitude and improvements in knowledge and practical skills. However, after one year, the nurses explained that they used the afferent limb in clinical practice only occasionally despite their eagerness to put their new competencies into action. The discussion covers the consequences of the identified local practices, the development of nurses’ competence in the use of the ABCDE, NEWS, and ISBAR and the lack of changes initiated in the general ward one year after the development process.
Consequences of nurses’ insufficient use of the ABCDE, NEWS, and ISBAR tools in the simulation laboratory
Consistent with international studies,18,28 the findings in the present study showed an imbalance between the complex clinical challenges in the first scenario and nurses’ clinical competence in the use of the ABCDE, NEWS, and ISBAR. Although nurses focused on the patient’s condition, their data collection was limited due to unsystematic observations and a lack of use of the ABCDE approach, which resulted in incomplete use of the NEWS. The nurses’ recognition of early warning signs occurred infrequently and incompletely, and they did not appropriately respond to patient deterioration. The consequences may include the risk of not discovering early deterioration. 34 The discrepancy between the belief that the NEWS was well integrated and the performance of the actual skills corresponds with the findings of Lundin et al. 35 An additional finding was that the nurses presented unstructured use of ISBAR, exhibited poor terminology use, and had no understanding of how to mutually engage in consultations with physicians, which might lead to unnecessary time spent by the physicians in gathering data and thus to a lack of timely treatment. Nurses play a vital role in the early detection and management of deterioration, and to promote patient safety, nurses must apply the same systematic structured communication tools. 36 According to previous studies, if healthcare professionals lack the ability to articulate their concerns in an objective manner, then patients may be at risk, the desired medical response may not be achieved, and the opportunity to take action at an early stage of deterioration may be lost. 37 Patient safety is a key dimension, and developing clinical assessment tools, communication tools, and collaboration between health professionals, such as via the afferent limb, is a goal. Only recently has bachelor-level education in nursing included training in the use of clinical tools to detect early patient deterioration. It is therefore not surprising that nurses with an older bachelor’s degree cannot perform at the expected level. However, nurses working in general wards have the daily responsibility of mentoring students in their practical training, and our findings indicated that nurses who lack updated workplace training consequently had no capability to provide appropriate guidance to nurse students. The Norwegian Ministry of Education and Research 38 emphasizes that higher education has not exhibited sufficient adaptability to developments in health and care services.
Improved use of the ABCDE, NEWS, and ISBAR with an educational program
An important finding was that new and increased knowledge provided through the action research design enabled the nurses to develop and change their understanding of how to use the systematic ABCDE approach and the NEWS, the afferent limb. Thus, the nurses generated more reliable clinical observations, which might promote adequate ISBAR communication in practice. Nurses also noted that these systematic approaches, combined with intuitive knowledge, should be in general use among all nurses. According to Smith and Bowden, 5 nurses must have a common practice with respect to the use of clinical tools to generate effective ISBAR communication in clinical practice. A review supports this view and highlights that systems such as the EWS must be seen as the minimum basis for data collection and should be combined with nurses’ subjective intuition, which is valuable for recognizing early warning signs. 37 Although the systematic use of the ABCDE approach was clearly improved, several nurses seemed to need more practice to enhance these skills. According to Wilson et al., 39 it takes time to learn new skills. Increased knowledge reveals and clarifies one’s own shortcomings and stimulates critical assessment of one’s own practice and desire for more knowledge. Self-regulation is a cyclic process in which experiences are used when new learning is to be practiced. 40 According to previous studies,28,41 ongoing specific clinical education and skills training are vital factors in enabling nurses’ recognition of and responses to patient deterioration. In addition, nurses with higher education show more self-confidence in recognizing and responding to patient deterioration than nurses with a lower degree of education. 28 The findings in the present study showed some progress in the use of the ISBAR structure in the second scenario. Some of the nurses understood the structure and what information was vital to report to the physician. Despite the improvements in the collected clinical data, the nurses still expected the experienced physician to filter the information. Anecdotally, the prevailing communication pattern may reflect the traditional hierarchy in health services. However, a positive finding was that the use of professional terminology increased during consultations with physicians.
Why is new clinical competence developed in a simulation laboratory not transferred into clinical practice?
Although some of the nurses involved in this action research program saw both its utility and importance, the findings showed that the majority did not. The nurses’ experiences indicated that new competencies did not seem to be activated in real practice. A study highlighted that it is not enough for the new knowledge to be considered useful in an implementation process; it must also be implemented in daily practice. 42 According to Fonteyn and Ritter, 43 it is vital that nurses collaborate in problem resolution to achieve positive patient outcomes. In the present study, it was discovered that the nurses’ experiences were in their practice; they did not collaborate in teams to reach a consensus on the use of ABCDE, NEWS, and ISBAR. This finding calls into question whether the performance of a new practice depends on nurses’ lack of self-confidence in making changes to ineffective habits of professional practice. Moreover, tacit knowledge continued to dominate and was not reflected in the ward community. Other factors may also affect whether the new competency is used, such as workload and lack of collaboration among RRT members and nurses.4,13,14
Need for leadership to follow up on new competencies in practice
The findings indicate that nurses experienced a lack of interest and support from their managers regarding their newly acquired clinical competencies, both during the ongoing project and after its completion. This happened even when the managers were the initiators of the project. Meanwhile, their colleagues wanted to learn the new knowledge. Similar findings from an action research project by Kjerholt et al. 44 indicate that participants lacked support from management and that there was no discussion of ongoing projects in the ward. Management support for practicing new knowledge is important for successful practice development.13,14,45 According to Fuglsang and Sørensen, 42 the more people use new knowledge in the field of practice, the faster it can spread through institutional wards. However, this process depends on how management understands innovation processes and their ability to spread new knowledge.42,46
Methodological considerations
A weakness of the study was that eight out of twenty participants dropped out before the end of the project. A strength may be that all five general wards were represented throughout the project. Experienced moderators in the focus group interviews emphasized summarizing and asking clarifying questions, which helped to strengthen the validity of the study. Method triangulation may provide trustworthy data collection and integrate insights from both verbal and non-verbal experiences.25,29 The trustworthiness of the results was strengthened because the four researchers collaborated closely in all steps of data collection and analysis.
Conclusion
The action research process contributed to increasing clinical competence and generated a mutual understanding among the nurses that using tools such as the ABCDE, NEWS, and ISBAR together may improve the afferent limb for patient deterioration. A customized education program seems well suited but is not sufficient to change clinical competency among experienced nurses. We suggest that for more successful implementation, it is vital to follow up on the concrete methods developed in real practice, and hospital management must support nurses during the project to achieve a common understanding in the ward. Based on our findings, there are many indications that mandatory practical exercises and full-scale simulations are needed to promote the use of the ABCDE, NEWS, and ISBAR among nurses in general wards to increase patient safety. This study identifies important issues that future studies should address, such as establishing regular simulation training in general wards.
Footnotes
Acknowledgments
We thank the participants in the study.
Author contributions
SGJ was responsible for the drafting of the manuscript and substantial contributions to the conception and design, data collection, analysis and interpretation of data, and contributed ti the majority of the writing and analysis in this manuscript. LSR and TM were responsible for substantial contributions to the conception and design, data collection, analysis and interpretation of data, and drafting the manuscript. GR was responsible for contributing to the analysis and interpretation of data and drafting the manuscript. SV drafted the manuscript and made critical revisions in the final version.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
