'Document and go' : a critical realist descriptive explanation of how nurses use vital signs in acute care

Nurses play a key role in averting adverse outcomes from patient deterioration in hospital wards by responding to changes in vital signs. In Australia, these measurable cues of a patient's health status form the basis of hospital emergency response systems. Serious consequences, such as death or prolonged hospital stays, can result from poor vital sign measurement and recording practices. Missed deterioration remains a problem despite initiatives such as the Adult Deterioration Detection System (ADDS), which ensures that experts other than members of ward staff can be alerted and respond to deteriorations in patients' vital signs. Using a critical realist framework, this study examined factors which influenced nurses' use of vital signs in two busy hospital wards. A descriptive explanatory design, using sequential qualitative ethnographic methods, was used to collect data from nurses with different levels of experience working in medical and surgical wards. In phase one, fifty hours of observation in the context of hospital wards provided insights into nurses' vital sign practice. In phase two, interviews with twenty registered and enrolled nurses provided in-depth explanations of their vital sign practices. A critical realist explanatory process of abduction and retroduction revealed causal mechanisms which either enhanced or constrained nurses vital sign practices. This study found that organisational processes, culture and history act upon nurses vital sign practices in two main ways. Firstly, cultural barriers to and enablers of nurses' agency resulted in them circumventing rules. The ADDS was difficult for the nurses to operationalise if it conflicted with their experience and knowledge of a patient. Participants' reflective deliberations about vital sign practices revealed how they struggled to align the individual complexity of patients with the set parameters of the ADDS. Instead, nurses often privileged other cues when assessing patients, drawing upon clinical experience and their knowledge of usual patient treatment trajectories to navigate organisational and cultural barriers in order to advocate for medical attention. Secondly, nurses had greater agency if they were confident in their assessment, or had specialist education or experience outside of the clinical ward. When rituals and routines dominated in the presence of strongly hierarchical organisational structures, nurses had diminished agency and exhibited poorer vital sign practices, which often resulted in inaction or devolved care. This thesis shows that vital signs offer an imperfect account of a patient's health status, with vital sign practices, patient variability and organisational structures conflicting with the purely objective measure that ADDS relies on. Though vital signs are recognised as a means of communicating change, their use is dominated by ritual and routine practices. They are used as a tool to navigate cultural practices, which are in turn informed by power dynamics and organisational processes. Structural barriers which have an impact on nurses' assessment of patients and on their resulting actions are a new subject for investigation to develop strategies to address missed patient deterioration. The results have significance for health care organisations, for providers of health professional education and for individuals.