Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

YJPDN-01737; No of Pages 7 Journal of Pediatric Nursing xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study Claus Sixtus Jensen, PhD student, MHSc (Nurs), RN a,b,c,⁎, Pia Bonde Nielsen, MHH, RN, Staff Development Nurse d, Hanne Vebert Olesen, PhD, MD d, Hans Kirkegaard, Professor, PhD, MD a, Hanne Aagaard, PhD, SEANS, MScN, RN e,f Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, 8200 Aarhus N, Denmark Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark Department of Paediatrics and Adolescent Medicine, Herlev Gentofte Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark Department of Child and Adolescent Health, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark Lovisenberg Diaconal University College, Norway Section for Nursing, Department of Public Health, Aarhus University, Denmark

a r t i c l e

i n f o

Article history: Received 3 December 2017 Revised 30 January 2018 Accepted 5 February 2018 Available online xxxx Keywords: Pediatric Early Warning System Clinical deterioration Vital sign monitoring Qualitative research

a b s t r a c t Purpose: Pediatric early warning score (PEWS) systems are used to monitor pediatric patients' vital signs and facilitate the treatment of patients at risk of deteriorating. The aim of this study was to gain knowledge about nurses' experiences with PEWS and to highlight factors facilitating and impeding the use of PEWS tools in clinical practice. Design and Methods: An exploratory qualitative design was chosen using focus group interviews to gain a deeper understanding of nurses' experiences with PEWS. A total of five focus group interviews were conducted at three hospitals, and a qualitative meaning condensation analysis as described by Kvale and Brinkmann was performed. Results: Seven themes were identified, including i) lack of interdisciplinary awareness, ii) clinical judgment and PEWS—a multi-faceted approach, iii) PEWS supports a professional language, iv) monitoring the patient's – a challenge, v) PEWS helps to visualize the need for escalating care, vi) an inflexible and challenging tool, and vii) supportive tools enhance the nurses' experiences of PEWS positively. Conclusions: Our findings suggest that attention should be given to nurses' perceptions of how both clinical judgment and PEWS should be seen as essential in providing nurses with information about the patients' conditions. If not, the risk of failing to recognize patients' deteriorating conditions will remain as this can have an impeding influence on nurses' use of PEWS. From the nurses' perspective, medical doctors seemed unaware of their role in using PEWS. © 2018 Elsevier Inc. All rights reserved.

Background Children often present symptoms of deterioration in the 24 h preceding cardiac arrest (McLellan, Gauvreau, & Connor, 2017; Robson, Cooper, Medicus, Quinyero, & Zuniga, 2013), and many pediatric deaths have been described as either avoidable or potentially avoidable (Pearson, 2008). Pediatric early warning score (PEWS) systems serve to alert staff to children's deteriorating conditions. The majority of PEWS systems are based on vital signs, where each vital sign is valued according to its variance from normal and combined with other vital signs to produce an overall score. A high score indicates a risk of critical ⁎ Corresponding author at: Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, 8200 Aarhus N, Denmark. E-mail address: [email protected] (C.S. Jensen).

illness and prompts an escalating series of actions (Jensen, Aagaard, Olesen, & Kirkegaard, 2017). Hence, there are solid grounds for increased attention to the recognition of clinical deterioration through the implementation of PEWS. Surprisingly few studies have explored healthcare professionals' perceptions of using the systems in a clinical setting (Bonafide et al., 2013; Fox & Elliott, 2015; Lydon, Byrne, Offiah, Gleeson, & O'Connor, 2016; Stafseth, Grønbeck, Lien, Randen, & Lerdal, 2016). Experiences from early warning score systems for adult patients indicate that a variety of factors influence the degree to which the systems can be implemented successfully (Niegsch, Fabritius, & Anhøj, 2013; Patterson et al., 2011). Patterson et al. (2011) suggest that implementation problems are rooted in the absence of a standardized national early warning score system that provides an observation chart, staff training program, and review mechanism. Other authors suggest that the problems are staff-related—for example, lack of awareness

https://doi.org/10.1016/j.pedn.2018.02.004 0882-5963/© 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

2

from physicians' and that ward nurses lack confidence in calling for help whenever they think patients are unwell but cannot provide quantifiable information to substantiate their suspicion and therefore are reluctant to activate medical teams (Fox & Elliott, 2015; Stafseth et al., 2016). PEWS systems are mostly simple in design, yet Pearson (2008) reveals problems such as staff failure to recognize deteriorating patients and delayed responses to the systems, which suggests the suboptimal implementation of such systems may signify shortcomings in healthcare delivery. Studies considering issues related to PEWS' implementation and the healthcare professionals' experiences with PEWS systems are therefore warranted. Nurses play a central role in implementing PEWS systems, and it is therefore important to capture their “voice” when evaluating the effectiveness and use of this tool. The present study is part of a larger ongoing randomized clinical trial evaluating two PEWS models (reference absent due to the anonymity of the manuscript), and the current study was initiated when PEWS had been implemented for a minimum period of one year to ensure that the staff had gained some experience using the PEWS systems. The two PEWS tools investigated were the bedside PEWS (Parshuram, 2009; Parshuram, 2011; Parshuram, Bayliss, Reimer, Middaugh, & Blanchard, 2010) and a modified version called the Central Denmark Region PEWS model (Jensen et al., 2017) (Table 1). Teaching sessions were performed for both nurses and medical doctors, separately. The included children were monitored using one of the two different PEWS tools. PEWS scores were obtained upon admission; re-scoring and actions according to the severity of the child's illness would then follow the PEWS algorithm which were identical for both PEWS tools (Supplementary material). An electronic patient chart was developed providing age-specific sub-scores for each of the seven parameters and an aggregated PEWS score. The age specific sub-scores are not presented in this paper but can be found in Jensen et al. (2017). A mini pamphlet was developed for the project containing: Decision algorithm for both PEWS; clinical decision support; Identify, Situation, Background, Assessment and Recommendation (ISBAR) communication tool; cardiopulmonary resuscitation (CPR) guidelines; content of the two PEWS and assessment tool for respiration effort assessment. Aim The aim of this study was to gain knowledge about nurses' experiences with PEWS and to highlight the factors facilitating and impeding the use of PEWS tools in clinical practice. Methods Design An exploratory qualitative design was chosen using focus group interview to gain a deeper understanding of nurses' experiences with PEWS (Polit & Beck, 2010). Focus group interviews were chosen because this method allowed us to monitor dynamic and interactive discussions to gain insight into nurses' perceptions and experiences and because the method is especially useful for revealing shared understandings and practices (Halkier, 2014; Krueger & Casey, 2009; Puchta & Potter, 2004). The aim guided the research process. As we wanted

to interpret and understand the participants' experiences, a hermeneutic analytic approach was chosen. The hermeneutic interpretation follows the hermeneutical spiral, searching for the basic meaning of a text as a whole through an investigation of its parts (Kvale & Brinkmann, 2015). The three researchers' (CSJ, PBN and HA) preunderstanding was based on various experiences from clinical practice within the field of acute pediatric nursing, adolescent and diabetic nursing, and neonatal care as well as on their experiences as researchers. In an attempt to move beyond preconceptions and understand the participants' experiences of PEWS, a reflective attitude was maintained throughout the process. Setting The study was conducted in five pediatric units at three hospitals, including two regional hospitals and a university hospital with pediatric patients ranging from 0 to 19 years of age. Participants and Recruitment Nurses who had had direct experience with the use of PEWS tools were invited to participate. Five focus group discussions (counting three to seven participants) were conducted. The head nurses distributed information about the study and recruited participants to the focus group discussions. Participants were recruited from participating centers in the Central Denmark Region and purposively sampled to achieve maximum diversity of experiences from work with pediatric patients (Table 2). Focus group discussions were conducted in different departments and settings to capture a breadth of opinion from November 2016 to February 2017. Data Collection The principal investigator (CSJ) moderated the focus group discussions, which included keeping the discussion on track and ensuring that everyone participated actively. A project nurse (PB) served as a co-moderator and was present as an observer responsible for ensuring that all questions were discussed (Halkier, 2014; Krueger & Casey, 2009). Both researchers had prior experience conducting research interviews. The focus group discussions lasted between 43 and 82 min (mean 66 min). They were conducted close to the clinical setting to ensure a high participation rate from the nurses. All discussions were audiotaped and transcribed verbatim, and the co-moderator described the contextual details of the discussion. To facilitate the discussion, a semistructured interview guide based on relevant literature was developed (Kvale & Brinkmann, 2015). The interview guide is presented in Table 3. To get the discussion started, the moderators were allowed to use different artifacts, such as screen prints from the electronic patient charts or different measurement instruments such as blood pressure measurement tools. Each focus group discussion began with a short, structured introduction by the moderator. The transcribed interviews were conducted in Danish and analysed in Danish and the central quotation were translated to English. Ethical Considerations

Table 1 Description of the contents of the two PEWS models. Bedside PEWS model

Central Denmark Region model

Heart rate Respiratory rate Respiratory effort Systolic blood pressure Pulse oximetry Oxygen therapy Capillary refill time

Heart rate Respiratory rate Respiratory effort Level of consciousness Pulse oximetry Oxygen therapy Capillary refill time

The ethical principles highlighted in the Declaration of Helsinki were followed (World Medical Association, 2013). The participants were informed that participation was voluntary and oral and written informed consent was obtained. According to Danish law, this type of research does not need approval from an official research ethics committee. At the beginning of each focus group discussion, the participants were informed of the aim of the study, the voluntary and confidential nature of their participation, and their right to withdraw at any time without consequences.

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

3

Table 2 Characteristics of participants and setting.

Focus Group 1 Focus Group 2 Focus Group 3 Focus Group 4 Focus Group 5

No. of participants (N = 23)

Setting

Years of pediatric experience Range (mean)

Years since nurse education Range (mean)

Age Range (mean)

Gender

3

University Hospital Specialty: Pediatric oncology and hematology

0.5–18 (9)

1–17 (12)

26–43 (37)

All female

6

University Hospital Specialty: Pediatric, cardiology, nephrology, gastroenterology, and urology

1.5–30 (7,25)

3–35 (13)

27–58 (39)

All female

6

Regional Hospital Specialty: General pediatric medicine, general orthopedic and abdominal surgery

1–30 (12)

9–36 (17)

35–59 (43)

All female

4

University Hospital Specialty: General pediatric medicine, neuropediatric, social pediatrics, endocrinology, diabetes, cystic fibrosis, pulmonology, allergology, asthma, and infectious diseases Regional Hospital Specialty: General pediatric medicine, general orthopedic and abdominal surgery

1–24 (15)

10–36 (18)

38–61 (47)

All female

9–42 (19)

12–42 (22)

36–64 (47)

All female

4

Analysis

Findings

The analysis was based upon qualitative meaning condensation analysis described by Kvale and Brinkmann (2015). The analysis process consisted of three steps: self-understanding, common-sense understanding, and theoretical understanding (see Table 4 for an example). The transcribed texts were structured using NVivo 12 (QSR International, 2014). To acquire an overview of the empirical material, the transcripts were read through several times by the first, the second, and the last authors in the first step. The transcripts were then searched for natural meaning units expressed by the participants, keeping the purpose of the study in mind. The meaning units were condensed, and self-understanding emerged when the researchers condensed the participants' statements according to the research teams' understanding. In the second step, the transcripts were re-read, focusing on the content of the meaning units. To achieve a common-sense understanding, interpretations were discussed. The research group searched for patterns and variations in the participants' experiences. The first and second steps are integrated in the “Findings” section. The third step consisted of forming a theoretical understanding. In this part of the analysis, relevant theoretical perspectives are included. This level is presented in the “Discussion” section (Kvale & Brinkmann, 2015).

The data analysis revealed the following seven themes: Lack of interdisciplinary awareness; clinical judgment and PEWS—a multi-faceted approach; PEWS supports a professional language; monitoring the patient's – a challenge; PEWS helps to visualize the need for escalating care; an inflexible and challenging tool; supportive tools enhance the nurses experiences of PEWS positively.

Table 3 Focus group interview guide. Welcome and introduction • The patient case is read aloud… o “Please talk about PEWS in relation to this particular case” • I am going to ask you some general questions about PEWS. Feel free to use examples from situations you may have experienced • since your unit started using the PEWS • How are things going with PEWS on your unit? • Supportive questions: What works… What doesn't work… • Is there anything about the PEWS that you would want to change or modify? • What do you see as the role of the PEWS? • Do you feel PEWS makes you more or less able to recognize deterioration? • PEWS, does it help the communication with pediatricians • Since going live with PEWS scoring, has the atmosphere changed on your unit? Summary of the discussions by the co-moderator, followed by the question: How well does this capture what has been discussed? “Have we forgotten anything?” Artefact to boost discussion: • • • •

Blood pressure cuffs O2 saturation probe Screen dumps from electronic patient system PEWS mini pamphlet

Lack of Interdisciplinary Awareness The nurses experienced lack of involvement from the medical doctors (MDs). As a consequence the nurses experienced PEWS as a nursing tool. Besides experiencing a lack of involvement, the nurses also felt that the MDs were unaware of the information offered by PEWS and of its underlying rationale. One participant noted: “when you call and say that they have a PEWS score of 5, then they don't know what 5 means” (FG2 P1). The lack of involvement on the part of the MDs had implications for the nursing staff and their experiences with PEWS. The lack of awareness was especially obvious during evening and night shifts when they engaged in dialogue with the MDs about the PEWS scores and the level of observation required. It was clear from the MDs' responses that they did not wish to commit themselves to using PEWS; for example a nurse related to a response she received when asking a MD which action she should take having a patient with a high PEWS score: “… a fine question, for rounds tomorrow …” (FG2 P3) the MD responded. Such responses made the nurses feel less respected due to being rejected when addressing the MDs with a clinical problem. The nurses expressed that dialogue about the patients' PEWS scores should be part of the daily rounds. The discussions also revealed how some the younger MDs engaged in dialogue about the PEWS scores at the time of the children's admission. They would ask the nurses to contact them if there were any changes in the children's condition and would be more disposed to make changes to the level of observation. Some of the nurses had been working with early warning score (EWS) in adult patients, and they expressed how EWS was an integrated part of caring and treating the adult patients, for example: “you would EWS score from the morning in order to be ready for ward rounds” (FG4 P3). They highlighted that it was unthinkable not to do EWS measurements and that you could not call an MD to discuss a patient without having the EWS score. This was not the case in the participating pediatric departments where PEWS did not seem to be an integrated part of practice. The nurses expressed that they were concerned about and felt some resistance toward the initial introduction of PEWS but that PEWS was now beginning to be an integrated part of their care. It could be frustrating for them if colleagues were not using PEWS, as illustrated in the

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

4

Table 4 Example illustrating the analysis process with self-understanding, common-sense understanding and theoretical understanding. Theme: Lack of interdisciplinary awareness

“I tried that, when I called and asked for having changes made in relation to the PEWS score… yes that's a fine question, for rounds tomorrow… they always says that in the nightshift” (FG2 P3)

Self-understanding The researcher tries to formulate what the participant seems to perceive as the meaning of his own statements. I tried to get the medical doctor to change the PEWS score but he did not find that it was a task for him.

following: “In the beginning, I thought it was troublesome, but now it's an integrated part of my work … if the children are not PEWS scored, I get irritated” (FG3 P3). When discussing the resistance toward PEWS, several participants stressed that it was important to keep in mind that the goal for PEWS was to alert nurses and MDs to changes and prompt them to think critically about the possibility of deterioration and that misunderstanding the goal could lead to resistance. The participants experienced the MDs' reluctance to modify the PEWS score for children with chronic conditions. The reluctance to modify the score would apply to patients with cystic fibrosis, for example, resulting in high PEWS scores that would not necessarily indicate a clinical deterioration. Consequently, the nurses deviated from the decision algorithms: “… if I'm not worried myself, then I don't necessarily contact an MD” (FG1 P1). Clinical Judgment and PEWS—A Multi-faceted Approach Some of the nurses saw PEWS and clinical judgment as supplementary or equal in relation to patient care, as one nurse stated: “… they should supplement each other, the clinical judgment and the vital signs we measure” (FG2 P6). Furthermore, some nurses perceived their clinical judgment to be superior to PEWS. This meant that the nurses would be guided by their clinical judgment and not by PEWS. They would not follow the recommended guidelines, as one nurse pointed out: “… to me, clinical judgment is the most important … my clinical judgment has a strong presence in my assessment … and no children have died during my shift because I forgot to call the MD in time” (FG1 P2). For some nurses PEWS was perceived as enhancing their role in clinical decision-making and as a supplement to rather than a replacement for clinical judgment. Several examples of patients where PEWS was believed to have helped detecting patients deterioration was highlighted during the discussions. The nurses used their clinical judgment to assess patients and did not rely solely on PEWS. It seemed as if the nurses' clinical judgment and not the PEWS observation algorithm was the basis for the nurses' justification for PEWS measurements during the night. The implication of this was that the nurses rarely carried out PEWS observations during nightshifts, and thus no PEWS observations were made for a period of approximately 10 h. The nurses had experienced “false” negative PEWS scores: “I have often had a patient with a PEWS score of zero but where I was very concerned … this patient can deteriorate any time” (FG4 P2). Using their clinical judgment seemed to be an essential part of their care for the patients. They did, however, have difficulties in describing what would trigger them in the “false” negative cases. When asked to explain what the clinical judgment was based on, the participants talked about how their clinical judgment was rooted in observations that could not be measured, as one nurse said: “It's a kind of an assessment of a child that is not only based upon vital signs but also based upon what you see, feel, and smell” (FG2 P6). Inexperienced and new nurses in the department used PEWS more often, as illustrated by on nurse: “The new [nurses] … they are actually very aware of PEWS … you can see that they've used it in other places” (FG5 P1). It was a shared concern that inexperienced pediatric nurses would miss something if they relied too much on the PEWS scores. In line with this discussion, the nurses also talked about how an experienced pediatric

Common sense understanding The meaning may be a broader frame of understanding leading to a critical view about what has been told regarding the content. The collaboration with the medical doctors plays an important role when working with PEWS.

Theoretical understanding A theoretical framework is used when interpreting statements

Inter-professional collaboration perspective would likely inform aspect of collaboration between groups of healthcare professionals (Kvarnström, 2008; Sheehan, Robertson, & Ormond, 2007; Suter et al., 2009; Zwarenstein & Reeves, 2009).

nurse could deviate from the PEWS algorithm owing to her experience. The nurse would then use her clinical judgment to decide if she should do a PEWS assessment.

PEWS Supports a Professional Language When communicating with the MD's about a child's condition PEWS provided nurses with a common language. Thus, the PEWS tool had an impact on and promoted the nurses' technical terminology, both when documenting their observations in the electronic patient record and when communicating with the MDs, as one nurse said: “PEWS supports us in getting … a professional language concerning what we describe” (FG3 P4). However, PEWS was not always used as a tool to communicate the patients' clinical conditions. In cases of handovers and transfers, the nurses had experienced how staff seemed not to adequately inform each other regarding the patients' PEWS scores. PEWS was used as a communication tool not only between nurses and MDs but also among nurses, parents, and the children. Nurses used the PEWS scores to address parents' concerns or as a medium for talking about the children's conditions. From the nurses' perspective, it seemed as if the parents and their children found it valuable to be informed about the clinical status using the PEWS tool.

Monitoring the Patient's – A Challenge A lack of equipment was identified as a barrier to performing PEWS as it is essential to have relevant equipment, such as devices for the monitoring of saturation and blood pressure, to perform PEWS measurements. The discussion concerned the availability and accuracy of the monitoring equipment. The lack of appropriate blood pressure monitors was mentioned as an important element hindering the successful use of PEWS. The staff needed equipment to function effectively—even in busy periods as it supported working with PEWS. The measurement of blood pressure was highlighted as an important issue, and difficulties performing such measurements were identified as a cause of frustration not only for the nurses who needed to provide results reflecting the patients' clinical situations but also for the patients and their parents: “the thing that is not good about PEWS is the blood pressure. I hope that we do not have to do it systematically …” (FG4 P3). The nurses felt that many children would not cooperate when having their blood pressure measured, and this would have an impact on the results. The nurses reflected on how they used different strategies to help the patients cope with having their blood pressure measured. This could be distraction, such as playing with teddy bears, or telling a story—all procedures they found time-consuming. They used different strategies for documenting in the patients' charts the children's unwillingness to have their blood pressure measured or if the result seemed to be affected by the patients' inability to cope with the procedure, as illustrated in the following quotation: “… I have to admit that I very often just estimate the blood pressure” (FG4 P3).

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

PEWS Helps to Visualize the Need for Escalating Care PEWS played an important role in informing the nurses about the level of observation required. PEWS also informed nurses' about the intervals at which the MDs should assess the child and which level of education the MDs should have, as illustrated in this quote: “When the PEWS score is 6 then you get an algorithm for how often you should make observations … and whether the MD should assess [the child] and the level of the MD …that is very good, I think” (FG4 P4). Likewise, PEWS was used as a tool for prioritizing between the children for whom the nurses were responsible so that they would attend the children at risk of clinical deterioration first at the beginning of a shift. The nurses' discussed how PEWS also was used as a way to address and assess the need for nursing care and the need for escalation to a higher level of care. An Inflexible and Challenging Tool Even though the nurses did find that the PEWS models were an important tool, they also noted that they did not use them as intended, for example because they did not see how it made sense making PEWS observations for some patients: “… children with asthma you give them Ventoline, and they have a heart rate of 180–200 … then you need to wake them up every 15 minutes, knowing it's the medication; that's why I don't think PEWS is relevant there” (FG3 P3). The nurses noted that the parents could get frustrated when the nurses were to take measurements during the night, as illustrated here: “We have frustrated parents because we wake the children up” (FG3 P6). Furthermore, it was not only the parents who found the PEWS measurements during the night to be a source of frustration. The nurses also mentioned that from their own perspective, as pediatric nurses, waking patients up seemed to run counter to their role as pediatric nurses, as expressed by one nurse: “I can't bring myself to do it; you know sleep also means something for the children's health and also for the parents' rest, and the parents' rest means something for the children's health” (FG4 P1). This issue was, however, also seen from another perspective as some nurses did not have any problems with obtaining PEWS observations during the night. Supportive Tools Enhance the Nurses Experiences of PEWS Positively In the present study, PEWS was documented in an electronic patient system, which provided an overview of time and trends for the PEWS scores. This element was debated during the focus group discussions: “I think it's great when you use the graph; you can see the PEWS measurements and how they correlate with each other” (FG1 P2). The participants addressed the functionality of the electronic patient records. They requested the possibility to do the PEWS registrations in real-time at the bedside as registrations could be done only on a computer in the office. The inability to make real-time PEWS registrations was influenced by several elements. Time pressure influenced the ability to make realtime registrations especially during nightshifts: “In a night watch, especially during the winter, you can go for a round, and when you return [to the office] and register … it can take an hour and a half” (FG4 P2). Realtime documentation was hindered by interruptions from other patients or colleagues, meaning that not all seven PEWS parameters were obtained at the same time. Being under time pressure resulted in nurses having to prioritize which patients to make PEWS observations on. However, the nurses did find the form in which they documented the PEWS measurements manageable and informative as it provided the aggregated PEWS score as well as the score for each of the seven measurements. The PEWS mini-pamphlet developed for this project seemed to have worked as intended—that is, as a support for the clinicians: “It's our new bible” (FG4 P3). The mini-pamphlet was used in different ways. It provided nurses with helpful age-based reference ranges for vital signs. Experienced as well as inexperienced nurses used this frequently. The

5

mini-pamphlet was not only used in relation to PEWS; it was also integrated as part of daily practice and simulation training: “… that ABCD is also part of our simulation training, and we are now very aware of what the different parts consist of” (FG3 P7). Discussion The findings of the present study reveal several factors both impeding and facilitating the improvement of healthcare via the use of PEWS tools. We identified positive attitudes toward the PEWS tool, but the findings also highlighted several important considerations that need to be addressed before implementing a PEWS tool in order to reap its full potential for improving the quality of care and enhancing patient safety. The two PEWS tools in the randomized control trial (RCT) study (reference absent due to the anonymity of the manuscript) were introduced together with a regional guideline. The introduction was accompanied by the education of the staff—nurses and MDs separately—and a standardized documentation tool was provided in the electronic patient chart. However, the success of the implementation of the two PEWS tools also seemed to depend on the MDs' responses and attitudes. If healthcare professionals do not collaborate, this can affect the care and treatment of patients and thus have adverse effects on patient care (Zwarenstein & Reeves, 2009). In line herewith, problems with collaboration between nurses and MDs have also been reported in other studies (Fox & Elliott, 2015; Lydon et al., 2016). Studying PEWS in an inter-professional collaboration perspective would likely inform the challenges addressed by the participants in the present study. Specifically, studies focusing on inter-professional collaboration have highlighted different aspects that seem to challenge the collaboration between groups of healthcare professionals, including unfavorable communication patterns, problematic team dynamics, and unclear roles (Kvarnström, 2008; Sheehan et al., 2007; Suter et al., 2009; Zwarenstein & Reeves, 2009). Kvarnström (2008) described how members of a professional team felt their contributions and knowledge were not valued by other members of the team, much like in the present study where the nurses experienced the MDs ignoring them when they reported PEWS observations. Interestingly, this was especially obvious during evening and night shifts. The MD's on evening and night duty had participated in the PEWS education program and were thus informed about their role. It is possible that implementing PEWS had prompted more calls from nurses influencing the MD's workload negatively. Being able to speak freely and have your statements valued is an important element in a collaborative team approach, as stated by Sheehan et al. (2007). Even though the nurses in the present study were clear about their role and function, they gave examples where their contributions to patient care were not valued. In the present study the MD's reluctance to modify the PEWS score for children with chronic conditions had the consequence that nurses' deviated from decision algorithm and would not necessarily contact a MD. Interdisciplinary teams have been described by D'Amour and Oandasan (2005) as groups of professionals working collaboratively for the patients in contrast to multidisciplinary teams where the staff members work independently and then share information. Looking at the findings in the present study, we may argue that nurses and MDs are working as multidisciplinary teams and not as interdisciplinary teams; hence, they do not work in parallel together and do assign value to the other professionals' expertise and contributions to patient care (D'Amour & Oandasan, 2005; Zwarenstein & Reeves, 2009). The problems experienced with inter-professional collaboration in the present study have also been reported in other studies (Bunkenborg, Poulsen, Samuelson, Ladelund, & Åkeson, 2016; Fox & Elliott, 2015; Lydon et al., 2016). Having separate PEWS training sessions for MDs and nurses may have contributed to this lack of collaboration, which is supported by Bunkenborg et al. (2016) who found that interprofessional training and teaching sessions had promoted the implementation of a EWS. The participants also

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

6

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

talked about other challenges related to their cooperation with MDs. It is possible for the MD to deviate from the PEWS escalation protocol, but this requires an explanatory entry in the patient's electronic record. Likewise, if a patient is known to have abnormal vital signs, such as due to a chronic disease, it is possible to adjust the acceptable intervals in the electronic patient record. However, as documented by Fox and Elliott (2015) and by Lydon et al. (2016) in studies on EWS for adults, it is difficult to get the MDs to comply with this procedure having the consequence that the nurses did not find the EWS system meaningful in those situations. Clinical judgment plays an important role when nurses assess patients' risk of clinical deterioration (Benner, Tanner, & Chesla, 2009; Stafseth et al., 2016). Since PEWS models are an element in the detection of the deteriorating condition, and clinical judgment is another important element, it is hardly surprising that all focus group discussions touched upon the nurses' clinical judgment and how such judgment was linked to PEWS. Interestingly, it was the clinical judgment and not the PEWS algorithm for observation that formed the basis of the nurses' argumentation related to PEWS measurements, especially during the night. The participants in the present study discussed clinical judgment and PEWS as two ways of assessing patients, and they seemed to weigh them against each other. According to Lydon et al. (2016), models like PEWS have been criticized for making nurses reluctant to use their clinical judgment. However, this was not seen in our study, where the nurses' clinical judgment would guide the observation level and any ensuing actions. Benner et al. (2009) argued that not all can be captured within theory or diagnosis treatment models and that expert nurses respond to caring situations based upon extensive practical knowledge from years of experience. Furthermore, expert nurses are to provide high-quality care; however, Benner, Hughes, and Sutphen (2008) state that expert nurses and patients' outcomes are not consistently reported. Some studies have even shown that the length of professional experience is not positively related to patient outcomes; in fact, it is negatively related (Benner et al., 2008). The nurses were challenged by having to make routine measurements of vital signs. This may possibly be related to the fact that some vital signs were seen as a supplement to or support for their clinical judgment. Thus, it has been shown that nurses are challenged when they have to follow checklists or guidelines or have to use standardized documentation forms (such as PEWS), which do not leave room for intuition or when they feel that their intuition is not valued (Benner et al., 2009; Odell, Victor, & Oliver, 2009). Benner et al. (2008) describe how all nurses used their intuition as a trigger for taking action in patient care. In the present study, the nurses also addressed this issue when talking about patients with a low PEWS score, indicating less severity, but where they were, nevertheless, worried about the patient. In the current study, the use of intuition also came into play in relation to the measurement of the different vital signs included in the PEWS tools. The nurses used their clinical judgment and intuition to reflect on the PEWS observations and used their knowledge to evaluate whether a measurement adequately reflected a patient's clinical condition. The participants in the present study found it important to systematically measure vital signs and to have baseline data for the patients. Indeed, some got frustrated when colleagues had failed to make PEWS observations. Similar findings were shown by Bunkenborg et al. (2016), who demonstrated that their implementation of EWS reached the point where nurses could see the benefits for their patients. Working with PEWS also provides the nurses with a professional language and helps them voice their concern for children when using the PEWS system. These findings are supported by Bonafide et al. (2013) and Stafseth et al. (2016) who found that the EWS offered a “new” and precise language in the communication between the nurses and MD's. The nurses experienced challenges related to technology and the availability and accuracy of the monitoring equipment. The measurement of blood pressure challenged the nurses considerably as it can be

especially difficult to make children cooperate when obtaining this measurement. This led the nurses to record normal values for blood pressure even though a measurement had not been obtained. However, they also found the new technologies to be helpful. The PEWS system and its incorporation into the electronic patient chart gave the nurses more information, and such information was gathered and presented systematically, providing them with a better overview of the patients and also affording them the possibility to see changes developing over a longer time frame. The graphic display in the electronic patient chart and the mini PEWS pamphlet developed for the project thus facilitated the use of the two PEWS models. This finding is supported by Görges and Staggers (2008), who showed significant improvements in decision-making in a review of computerized physiological monitoring displays. When we introduced the PEWS tools, a multi-faceted educational program was launched. The mini pamphlet was one of many different elements in the educational program. This is in line with the recommendations from the Cochrane Effective Practice and Organisation of Care Group, which reported that successful guideline implementation strategies should be multi-faceted and actively engage clinicians throughout the process (Cochrane Effective Practice and Organisation of Care Group, 2017). Limitations This study has some limitations that need to be considered. The findings reflect only the experiences of nurses. MDs' and patients' views and experiences are important and warrant investigation in future studies. Several steps were taken to ensure trustworthiness. In regular meetings the analytical process and the theoretical understanding were discussed to strengthen methodological coherence. To heighten the validity, constant back-and-forth between text extracts and the whole text was upheld, and the participation of three researchers throughout the whole analysis process also served to strengthen the validity. The use of triangulation, by combining the focus group interviews with field observations, could have increased the content validity. Although the number of focus group interviews was limited, the groups were composed of nurses with different levels of clinical experience and from different hospitals and who worked with different patient groups. The principal researcher had a dual role as he had planned, developed and taught in the PEWS educational program and also moderated the focus group discussions. This dual role could be both an advantage and a potential impediment to the participants. The participants in the focus group discussions did, however, voice both positive and negative issues related to the PEWS project and the principle researcher's role. Thus, the dual role seemingly did not have substantial impact. Although the findings of this study cannot be generalized because of the small size of the sample and the method adopted, we did conduct focus group discussions at three different hospitals, and we believe that the themes identified are worthy of further investigation to establish their generalizability. We were also aware that the backgrounds, positions, and preconceptions of the researchers could potentially affect the focus and perspectives of the study, and the research group (authors of this article) voiced this as an important consideration. Despite the potential limitations, we believe that this study provides useful information regarding nurses' experiences with PEWS. Conclusion Our findings suggest that attention should be given to nurses' perceptions of how both clinical judgment and PEWS should be seen as essential in providing nurses with information about the patients' conditions. If the nurses' perceptions are not represented, the risk of failing to recognize deteriorating patients will remain as this can have an impeding influence on nurses' use of PEWS. From the nurses' perspective, the MDs seemed unaware of their role in using PEWS. We also identified several aspects facilitating the positive view of the use of

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004

Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study

PEWS. The small pocket-sized PEWS mini-pamphlet developed for this project was mentioned as a supportive feature that facilitated working with PEWS and in some departments now forms part of the simulation training. Furthermore, the electronic patient system which provided an overview of time and trends for the PEWS scores was assessed as helpful. Supplementary data to this article can be found online at https://doi. org/10.1016/j.pedn.2018.02.004. Conflict of Interest None. Acknowledgments We would like to thank the participating nurses. The PEWS study is supported by grants from the Maria Dorthea and Holger From Foundation, the Novo Nordisk Foundation (NFF150C0016756 and NNF130C0006135), the Aase og Ejnar Danielsens Foundation, the Central Denmark Region Emergency Research Programme, Aarhus University Hospital, ‘The Acute Patient’ research program, the Department of Child and Adolescent Health at Aarhus University Hospital and the A.P. Møller Foundation for the Advancement of Medical Science 15-161. None of the funding bodies had any role in the design of the study, collection, analysis or interpretation of data or in writing the manuscript. References Benner, P., Hughes, R. G., & Sutphen, M. (2008). Clinical reasoning, decisionmaking, and action: Thinking critically and clinically. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): AHRQ Publication NBK2643 [bookaccession]). Benner, P., Tanner, C. A., & Chesla, A. C. (2009). Clinical judgment. Expertise in nursing practice: Caring, clinical judgment & ethics (pp. 199–232) (2nd ed.). Springer. Bonafide, C. P., Roberts, K. E., Weirich, C. M., Paciotti, B., Tibbetts, K. M., Keren, R., ... Holmes, J. H. (2013). (2013). Beyond statistical prediction: Qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety. Journal of Hospital Medicine, 8(5), 248–253. Bunkenborg, G., Poulsen, I., Samuelson, K., Ladelund, S., & Åkeson, J. (2016). Mandatory early warning scoring—Implementation evaluated with a mixed-methods approach. Applied Nursing Research, 29, 168–176. Cochrane Effective Practice and Organisation of Care Group (2017). EPOC 2013 EPOC: Cochrane effective practice and organisation of care group. Retrieved from http:// epoc.cochrane.org/our-reviews. D'Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 1, 8–20. Fox, A., & Elliott, N. (2015). Early warning scores: A sign of deterioration in patients and systems (- Early warning score; - decision making; - evaluation; - healthcare systems; - implementation; - training EDAT- 2015/03/26 06:00 MHDA- 2015/10/10 06:00 CRDT- 2015/03/26 06:00 AID - https://doi.org/10.7748/nm.22.1.26.e1337 [doi] PST – ppublish). Görges, M., & Staggers, N. (2008). Evaluations of physiological monitoring displays: A systematic review. Journal of Clinical Monitoring and Computing, 22, 45–66.

7

Halkier, B. (2014). Fokusgrupper (2nd ed.). Frederiksberg C: Samfundslitteratur. Jensen, C. S., Aagaard, H., Olesen, H. V., & Kirkegaard, H. (2017). A multicentre, randomised intervention study of the paediatric early warning score: Study protocol for a randomised controlled trial. Trials, 18(1), 267. Krueger, R. A., & Casey, M. A. (2009). Focus groups: A practical guide for applied research (4th ed.). Calif: Sage. Kvale, S., & Brinkmann, S. (2015). InterViews: Learning the craft of qualitative research interviewing. Los Angeles: SAGE. Kvarnström, S. (2008). Difficulties in collaboration: A critical incident study of interprofessional healthcare teamwork. Journal of Interprofessional Care, 22(2), 191–203. Lydon, S., Byrne, D., Offiah, G., Gleeson, L., & O'Connor, P. (2016). A mixed-methods investigation of health professionals' perceptions of a physiological track and trigger system. BMJ Quality and Safety, 25(9), 688–695. https://doi.org/10.1136/bmjqs-2015004261. McLellan, M. C., Gauvreau, K., & Connor, A. J. (2017). Validation of the children's hospital early warning system for critical deterioration recognition. Journal of Pediatric Nursing, 32, 52–58. Niegsch, M., Fabritius, M. L., & Anhøj, J. (2013). Imperfect implementation of an early warning scoring system in a danish teaching hospital: A cross-sectional study. PLoS One, 8(7), e70068. Odell, M., Victor, C., & Oliver, D. (2009). Nurses' role in detecting deterioration in ward patients: Systematic literature review. Journal of Advanced Nursing, 65(10), 1992–2006. Parshuram, C. (2009). Development and initial validation of the bedside paediatric early warning system score. Critical Care (London, England), 13(4), R135. Parshuram, C. (2011). Multicentre validation of the bedside paediatric early warning system score: A severity of illness score to detect evolving critical illness in hospitalised children. Critical Care (London, England), 15(4), R184. Parshuram, C. S., Bayliss, A., Reimer, J., Middaugh, K., & Blanchard, N. (2010). Implementing the bedside paediatric early warning system in a community hospital: A prospective observational study. Paediatrics & Child Health, 16(3), e18–e22. Patterson, C., Maclean, F., Cameron, B., Mukherjee, E., Bryan, L., Woodcock, T., & Bell, D. (2011). Early warning systems in the UK: Variation in content and implementation strategy has implications for a NHS early warning system. Clinical Medicine (London, England), 11(5), 427. Pearson, G. A. (2008). Why children die: A pilot study 2006; England (south west, north east and west midlands), Wales and Northern Ireland. London: CEMACH. Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research: Appraising evidence for nursing practice (7th ed.). Philadelphia PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Puchta, C., & Potter, J. (2004). Focus group practice (1st ed.). London: SAGE Publications. QSR International (2014). NVivo, version 12. Robson, J. M., Cooper, L. C., Medicus, A. L., Quinyero, J. M., & Zuniga, A. S. (2013). Comparison of three acute care pediatric early warning scoring tools. Journal of Pediatric Nursing, 28(6), 33–41. Sheehan, D., Robertson, L., & Ormond, T. (2007). Comparison of language used and patterns of communication in interprofessional and multidisciplinary teams. Journal of Interprofessional Care, 21(1), 17–30. Stafseth, S. K., Grønbeck, S., Lien, T., Randen, I., & Lerdal, A. (2016). The experiences of nurses implementing the modified early warning score and a 24-hour on-call mobile intensive care nurse: An exploratory study. Intensive & Critical Care Nursing, 34, 33–41. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23(1), 41–51. World Medical Association (2013). World medical association declaration of helsinki: Ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053. Zwarenstein, M., & Reeves, S. J. (2009). Interprofessional collaboration: Effects of practicebased interventions on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, art. no.: CD000072(3).

Please cite this article as: Jensen, C.S., et al., Pediatric Early Warning Score Systems, Nurses Perspective – A Focus Group Study, Journal of Pediatric Nursing (2018), https://doi.org/10.1016/j.pedn.2018.02.004