How do healthcare workers understand and manage their work in relation to the use of an Early Warning Scoring System?

Greaves, Jane (2017) How do healthcare workers understand and manage their work in relation to the use of an Early Warning Scoring System? Doctoral thesis, Northumbria University.

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Abstract

Background:
Retrospective review of the care of patients who have suffered unanticipated clinical deterioration often reveals that there have been errors in their management. Many of these patients show minor changes in their physiology as premonitory evidence of catastrophe. This can be used as an Early Warning Score to secure earlier involvement of clinicians experienced in managing critical illness. Such systems have not been consistently associated with improved patient outcomes and audit has revealed that in as many as 60% of cases, where the trigger score is exceeded, junior doctors do not review the patient in person as required by the protocol.

Aim:
To investigate how issues between professions, issues between disciplines, and authority patterns affect the medical and nursing team’s responses to critical events in the context of formalised protocols for the management of adult patient deterioration. It was hoped that this would help explain why clinical staff do not follow the protocol.

Method:
The sample included doctors, nurses and healthcare assistants (n=40) who used an Early Warning Score. Sampling was initially purposive and restricted to clinical staff but was extended to include ward and trust managers in response to the early interviews. Data was collected by semi-structured interviews over a nine-month period starting in January 2015. The methodology was qualitative, using constructivist grounded theory. It was characterised by iterative development of interview questions, simultaneous data collection and analysis and theoretical sampling. Data was held in NVivo for Mac version 11.4 and analysed for themes, from which core concepts emerged, allowing the construction of theory.

Findings:
A number of major categories emerged. Prominent amongst these was the theme of conflict between the requirements of the rapid response system and other aspects of the first-responder doctors’ work. Another concept emerging was a disjunction between the medical and nursing teams in their understanding of the Early Warning Score. The doctors use the score as an indicator of the severity of disease, in order to help them manage their overwhelming workload, whereas the nurses and healthcare assistants use trigger events to secure the assistance of the medical team in resolving uncertainty. If the outcome of a call is an unchanged management plan the doctors consider this to be a wasted effort whilst the nurses see it as a positive contribution to care.

Conclusion:
Discussion includes consideration of the idea that this dichotomy comes from the medical and nursing teams having different mental models of practice, and epistemologies of patient care. The importance of dissimilar mental models and philosophical paradigms in the context of teamwork is discussed. Such disjunctions may occur in other situations where different professions cooperate in clinical teams. Models of practice may differ between professions and reflect their different roles in patient care.

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