The Impact of Early Warning Sign (EWS): Perception of Nursing Staff at Aster Sanad Hospital, Riyadh City, Kingdom of Saudi Arabia Volume 55- Issue 1

Ihab Alawour*, Huda Bokhari, Essam Alghamdi, Nitha John, Noor Saba and Jonel Agagon

• Aster Sanad Hospital, Kingdom of Saudi Arabia

Received: February 02, 2024; Published: February 15, 2024

*Corresponding author: Ihab Alawour, Aster Sanad Hospital, Riyadh, Kingdom of Saudi Arabia

DOI: 10.26717/BJSTR.2024.55.008646

Abstract PDF

Background: Early Warning Sign (EWS) is a tool made up of vital signs chart and scoring to identify clinical decline and early detection of abnormal condition in regard with patients at hospital. However, it is still unclear how the tool impacts nurses' perception and reaction.

Aim: To explore hospital nurses’ perceptions and reactions to EWS

Methods: A descriptive cross-sectional study with convenience sampling enrolled 88 nurses in Aster Sanad Hospital during the period from November 2021 until February 2022. Electronic-based questionnaires were distributed to the nurses in English language. The questionnaire consisted of nurse’s characteristics and their perceptions about EWS. Data analysis was interpreted in descriptive and inferential analysis by using Statistical Package for the Social Sciences (SPSS) version 21.0.

Results: The overall perception gained by study participants was encouraging since the vast majority of them (n=82; 93.2%) answered positively toward EWS. The majority of respondents agreed with the statement that they are aware, confident and competent regarding EWS criteria. Most of the nurses mentioned that EWS is meaningful in identifying patient deterioration in different ways as increasing patient safety (n=50; 56.8%), reducing unplanned ICU transfer (n=50; 56.8%), preventing deterioration to code blue (n=46; 52.3%), and further deterioration to death (n=44; 50%). Also, most of the nurses stated they received enough training and education about EWS criteria and were capable of training and teaching it. Moreover, the highest perception scores towards EWS were encountered among supervisors as well as obstetric and gynecological wards nurses (P. value= 0.008), master’s degrees (P. value = 0.025) and more than 5 years experienced nurses (P. value = 0.045).

Conclusion: The vast majority of our nurses showed a positive perception of EWS criteria, and agreed with EWS criteria are meaningful and significant in identifying patients’ deterioration, as well as they recommend other hospital to implement it.

Keywords: Early Warning Sign; Perception; Nurse; Patient Deterioration

Abbreviations: EWS: Early Warning Signs; SAE: Serious Adverse Event; SDs: Standard Deviations

Early Warning Signs (EWS) Score systems are based on seven parameters using an assessment of the patient's physiological response. The seven parameters include respiration, systolic blood pressure, temperature, pulse, oxygen saturation, additional oxygen, and the level of patient awareness [1]. Patient safety relies on nurses’ timely assessment and actions. Thus, EWS has been recommended and implemented to enhance patient safety by ensuring that patient deterioration is recognized and addressed in health care [2,3]. Deterioration is a risk to all in‐hospital patients and includes the risk of suffering a Serious Adverse Event (SAE) such as cardiac arrest, unplanned admission for intensive care, and unexpected death. The majority (84%) of patients have abnormal vital signs prior to SAE, suggesting that some can be prevented if abnormal vital signs are detected and acted upon by nurses and clinicians [4]. Kruisselbrink et al in Uganda found that after using the EWS, the mortality rate of patients’ critical illness in 7 days was only 5.5% and 41.4% of the patients could be discharged. This also showed that EWS contributes greatly to improving the quality of health services [5]. A previous study conducted by Janwar O et al recruited 48 nurses at a private hospital in Eastern part of Indonesia, revealed that nurses’ knowledge about EWS significantly influenced their actions. In this case, related to patients’ management [6].

Despite the use of the EWS, there are still problems in nurses’ detection of patient deterioration and of errors in the EWS and non-adherence to referral protocols has been highlighted.

It is argued that the effectiveness of the EWS is dependent on its users [3]. Factors influencing the use of the EWS have been highlighted, such as motivation, clinical relevance, meaningfulness [7], recording of vital signs, communication, practitioner engagement [8], ward culture, staffing, skills and knowledge [9]. Although there are some studies of the EWS implementation process [7,10,11], little is known about how hospital nurses perceive and react to the EWS in clinical practice and how the working context. By exploring the introduction of the EWS to nursing practice, with a focus on nurses’ perceptions and reactions as potential factors that affect the use of such a system, gaps in knowledge of the implementing of the EWS system will be illuminated. Therefore, the aim of this study was to assess hospital nurses’ perceptions to EWS at Aster Sanad Hospital in Riyadh, KSA.

Sample and Participants

The study was carried out using a quantitative approach, involving a cross sectional study from November 2021 until February 2022. There were 88 nurses involved from Aster Sanad Hospital in Riyadh, KSA. The convenient sampling method is used in this study with inclusion criteria of the nurses that include work in the wards that utilize EW.

Data Collection

Data collection was conducted through electronic-based questionnaires consisting of two parts. Part A involves socio-demographic data on years of experience, area of practice and educational level. Part B of the questionnaire contained queries regarding statements related to EWS. The answers on self-perceived 21 perception items were reported in 5-choices categories such as “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree” and scaled from 0 to 5. Then, perception assessments were performed by using Likert’s scaling system as follow: positive perceptive (promoter) (scores: 71-105), neutral perceptive (passive) (scores: 36-70) and negative perceptive (detractor) (scores ≤ 35)

Ethical Considerations

The study was approved by Committee from Aster Sanad Hospital. Participant’s anonymity and guaranteed confidentiality of any delivered information were emphasized as well as insurance about declining participation would not have managerial consequences.

Data Analysis

Data was analyzed by using a computer program called Statistical Package for Social Sciences (SPSS V. 21.0). The analyzed data presented in tables and figures designed by Microsoft Excel 2010. Frequencies with proportions (percentages) were reported for categorical variables and means with Standard Deviations (SDs) were reported for continuous variables. One-way ANOVA was used to compare the perception score’s mean values between more than two independent categorical variables. All P. value considered as significant if less than 0.05.

In total this study recruited 88 nurses and their working units were detailed in Figure 1. Figure 2 revealed that, 54(61%) were registered nurses, 20(23%) were head/administrative nurses and 14(16%) were charge nurses as shown in Table 1, the majority of the nurses had diploma degrees (n= 53; 60.2%) and more than 5 years working experience (n= 56; 63.3%) Table 2 showed the nurse’s perceptions toward EWS, in technical aspects the majority of the participants mentioned they aware about EWS policy and procedure (n=44; 50%) and the action for each EWS score (n=46; 52.3%), able to interpret EWS criteria (n=55; 62.5%), confident enough to utilize EWS criteria (n=45; 51.1%), fully engaged with EWS criteria (n= 53; 60.2%), competent to complete EWS documentation (n=54; 61.4%), competent enough to escalate EWS score if met its criteria (n=5; 64.8%) and competent enough to follow each intervention based on EWS criteria (n=57; 64.8%). Concerning to patient’s related aspects, the majority of the respondents agreed with that EWS criteria increase patient safety (n=50; 56.8%), reduce unplanned ICU transfer (n=50; 56.8%), prevent deterioration to code blue (n=46; 52.3%), prevent further deterioration to death (n=44; 50%), and not prefer follow patients vital sign records without EWS (n=37; 30.7%). According to the training and educational aspects, the most of the nurses stated they were received enough training of EWS criteria (n=56; 63.6%), interested to share their experience in EWS criteria (n=48; 54.5%), capable to training EWS as a speaker (n=36; 40.9%), confident to teach EWS to new staff (n=48; 54.5%), recommend other hospital to implement EWS (n=51; 58%), and nursing quality provide them with the appropriate feedback with the knowledge and skills during the audit (n=53; 60.2%) As demonstrated in Table 3, by using Likert’s scaling system, the average perception scores of our study group was 86 points (range= 61-105 points), and the vast majority of them 82(93.2%) were positively perceptive toward EWS criteria (Table 3).

Figure 1

Figure 2

Table 1: The education degrees and experience years of nurses (N=88).

Table 2: The nurses’ perceptions to Early Warring Sings statements (N=88).

Table 3: The nurse’s perception scores by Likert’s scaling system (N=88).

Table 4: The correlation between perception scores and nurse’s characteristics.

Note: a By ANOVA test.

The correlation between nurse’s characteristics and perception scores illustrated in Table 4, in which the highest scores were significantly associated with supervisors as well as obstetric and gynecological wards nurses (P. value= 0.008), master’s degrees (P. value = 0.025) and more than 5 years’ experience (P. value = 0.045).

This study explored hospital nurses’ perceptions and reactions to EWS in the working context among 88 respondents. In general, the overall perception gained by study participants was encouraging since the vast majority of them (93.2%) answered positively toward EWS, which indicates EWS showed to be important to the nurses in different traits. This is in line with findings of recent Swedish study of Spångfors M et al who also reported that the nurses positively perceptive toward EWS criteria in their hospitals [12]. The effectiveness of EWS is dependent on user engagement with the tool and compliance [3]. Technical wise, the majority of our study respondents agreed with the statements of that they are aware, confident and competent regarding EWS policies, utilization, documentation, interpretation, engagement and also escalating, this condition is probably caused by the nurses’ initiative to participate in internal training. Therefore, training is needed to improve the level of knowledge of the nurses which eventually generates good quality professional nurses. This is a huge concern as the nurses are part of healthcare delivery team, so they need to become knowledgeable and aware about EWS to prevent medical malpractice or promote better care for patients. Although, Ludin S identified that the nurses in her study were lacked knowledge in EWS scoring and consequently detecting the risk of deterioration by patient’s condition. The researcher suggested that nurses must improve their skills and awareness of EWS criteria [13].

On the other hand, it is important to note that more than one-half of the nurses (51.1%) stated EWS consume the nursing care time, and this could be attributed to their busy schedule or presumably maybe due to the lack of understanding EWS criteria as reported in the study of Anati L and Salizar M in Malaysia [14], and this issue should be considered by nursing staff administration. EWS has been recommended and implemented to enhance patient safety by ensuring that patient deterioration is recognized and addressed in health care [2,3]. This fact was confirmed in this study since most of the nurses stated that EWS is meaningful and significant in identifying patient deterioration in different scopes such as increasing patient safety, reducing unplanned ICU transfer, preventing deterioration to code blue and even the death. Consistently, Jørghild K et al found that the overall perception gave by the nurses was they have a strong commitment to EWS criteria and scores to achieve optimal patient safety and thus prevent deteriorations [3]. Also, nurses in the study of Caroline S et al mentioned that the EWS criteria are expressive and important in identifying patient deterioration [15]. In systematic review of Saab M, et al. who analyzed 10 studies, the perception of nurses is that EWS scoring is important to detect patients’ health problems, then, to identify the intervention needed to reduce the incidences of medical emergency and serious adverse events of patients [16].

For no doubt, training and education are cornerstones for any medical management and intervention. Therefore, it is important to improve the practice of EWS among nurses through training or further information/ education provided by institutions or hospitals. Most of the nurses in our study stated they were received enough training and education about EWS criteria and they capable of training and teach this criterion. Also, they underlined the particular utility value of EWS for new and inexperienced nurses by sharing their experiences and described it as a tool that could enable them to more readily identify patient’s condition. These observations were consistent with the findings of Jørghild K, et al. study [3] Significantly, the present study showed that, the highest perception scores towards EWS were encountered among supervisors, advanced educational degree (master’s degree), and more than 5 years experienced nurses (P. value< 0.05). These findings were in agreement with the studies of Peter G, et al. [17] Mackintosh, et al. [18] in United Kingdom those reported that the senior/supervisor nurses more tend to have positive attitude and perceptions towards EWS. In same line, Janwar O, et al. reported good knowledge and perceptions to EWS was associated with longer experience years above 2 years [6]. When categorizing nurses according to their workplaces and units, this study showed positive EWS perceptions were associated with obstetric and gynecological wards nurses (P. value< 0.05).

However, Spångfors M et al reported the good adherence and positive perceptions to EWS were highest in surgery and orthopedics and lowest in the cardiac high dependency unit [12]. The limitations of this study could be summarized in a single-center study design that could not permit us to generalize these findings. Also, we did not examine the direct influence of EWS practicing on patients’ outcomes, therefore further studies are needed to examine the actual effects of this criteria on patients by measuring incidences of death and adverse side effects among them.

The presents study concluded that, the vast majority of our nurses were positively perceptive toward EWS criteria, and agreed with EWS criteria are meaningful and significant in identifying patients’ deterioration, as well as they recommend other hospital to implement it. Moreover, the highest perception scores towards EWS were encountered among supervisors, obstetric and gynecological wards nurses, advanced educational degree (master’s degree), long experience years above 5 years. Furthermore, sustainable nurses training of modified and updated EWS criteria are recommended to ensure knowledgeable, aware and professional nursing staff.

No conflict of interest has been declared by the authors.

Nil.

The authors wish to thank all nursing staff and administration of Aster Sanad Hospital for their contributions in this work.

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