Patient Deterioration In Nursing

One of the pivotal roles of a nurse is the ability to recognise patient deterioration. The skill of identifying crucial elements of deterioration and acting appropriately is fundamental for positive patient outcome. A vital skill performed primarily by nurses is the act of respiratory rate measurement. This skill is performed in addition to five other physiological parameters, which form a basis for a scoring system. The scoring systems commonly used are known as NEWS (National Early Warning Score) and EWS (Early Warning Score). As many adverse events are preceded by a period of time where by the patient exhibits physiological dysfunction, there is often time to correct abnormalities. This has significance for nurses, as they are responsible

for preserving physiological safety by accurately observing and preventing further deterioration.
The presence of an abnormal respiratory rate is usually the first symptom of impending ill health. A retrospective case study completed between May 1989 and December 1990 compared 72 hours of pre arrest vital sign measurements, with those who did not suffer cardiopulmonary arrest. Results found that the occurrence of one or more respiratory rate of >27 breaths per minute over a 72 hour period was predictive of arrest (Fieselmann et al 1993). It was also identified that there is usually an extended period between the first elevated rates and the need for CPR, making it possible to potentially correct measures. The presence of Tachypnoea can indicate certain disease states with the potential to lead to cardiopulmonary arrest, such as hypoxeamia, acidosis, sepsis and hypotension. The performance of an accurate respiratory rate measurement is therefore necessary in the identification of deteriorating patients.
Sadly, this essential vital sign is often the most neglected.

An audit of patient records completed in 2005, revealed a low incidence of respiratory rate recording. An initial audit completed revealed that only 7% of 341 patients had a respiratory rate recording (Butler-Williams 2005). Due to this worrying outcome, the priority was to implement appropriate training to raise respiratory rate significance. Due to the audit being completed hospital wide and with no prior warning, it is an accurate indicator of an overall attitude of practice towards the recording of respiratory rate. Various studies have been conducted in order to gain an understanding as to why this precious sign is so often ignored. Jacqueline Hogan explored the paucity of patient monitoring on acute wards, completing qualitative research using focus groups in 2004. Four major themes were identified, firstly the issue of the nursing workload. Many participants acknowledged the expansion of the nurse’s role and with this added responsibility, the need for delegation of activities such as patient observations. Observations are often delegated to junior staff members such as healthcare assistants and student nurses. Although many nurses admitted to delegating this vital activity, 73% of nurses did not consider healthcare assistants possessed the required knowledge to interpret observational results. With this lack of knowledge comes the absence of appreciation for the completion of such vital signs, and

therefore a reduction in accurate results. Most acknowledged routine ritualistic practice being employed; this may be due to working around meal times or feeling that such organisation can only accommodate the workload. The development of ritualistic practice has implications, as the reasoning behind ones actions can become lost. The skill being performed loses its reasoning and worth and develops into a repetitive task. By having an understanding and knowledge behind why a skill is performed in such a way, it takes it from a ritualistic act and into a skill. A skill can only be performed when reasoning and knowledge is present.
Respiratory rate was recognised as being poorly monitored. Staff displayed a lack of knowledge on how to complete respiratory rate measurement correctly. Many participants acknowledged that if they were not carrying a watch they could not physically complete this vital sign. As all additional vital signs are completed with the use of electronic equipment, a reliance on machinery was also emphasised. Dependence on machinery can weaken basic nursing observational skills and cause additional clues to go unnoticed, which can only be recognised by looking, listening and feeling. An issue with this study is that it was undertaken in one hospital and used focus groups. When using focus groups there is a concern that results may be generalised and participants may not feel comfortable to voice their actual beliefs. Contrary to this, various studies have also identified similar issues.
The NPSA launched its fifth Patient Safety Observatory report in July of 2007 where by deterioration was identified as a key theme.

The aim of the report was to illustrate why deterioration incidents happen. Focus groups and semi-structured interviews were conducted with nurses and doctors from acute trusts across England and Wales. Concerns were found within written communication on patient observation charts. Rather than results being plotted, users were writing in numbers creating information in a disjointed manner. This has implications for identifying trends and makes it difficult to notice deviation. Issues involving prioritisation due to nursing workload were also emphasised. Many nurses felt that patient comfort was often prioritised as oppose to completing observations. Although comfort is a fundamental attribute to patient satisfaction, the need for appreciation and respect for vital sign monitoring should be promoted over all tasks in order to identify deterioration promptly. A general lack of confidence and respect was held for all patient observations, being viewed as merely a task that needs to be

completed.
The developed attitude of a skill becoming a task results in compromised action. The use of ‘spot’ assessments and estimations are often employed rather than performing a formal respiratory assessment. ‘Spot’ assessments are defined as observing a respiratory rate for approximately 15 seconds and multiplying by four. Formal respiratory assessment is where by the respiration is counted for a full minute.