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

作者：Hope Joanna^*; Recio Saucedo Alejandra; Fogg Carole; Griffiths Peter; Smith Gary B; Westwood Greta; Schmidt Paul E

来源：Journal of Clinical Nursing, 2018, 27(9-10): 1860-1871.

DOI：10.1111/jocn.14234

• adult nursing
• clinical judgement
• dementia care
• guideline adherence
• nursing care
• palliative care
• qualitative study
• sleep disturbance
• vital sign

Aims and objectivesTo explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night.
BackgroundRegular 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.
DesignA qualitative interpretative design informed this study.
MethodsSeventeen 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.
ResultsAt 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.
ConclusionIn 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 practiceNurses 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.

• 出版日期2018-5