- •Children often present subtle signs and symptoms of clinical deterioration.
- •Identifying pediatric patients at risk of deterioration requires more than relying on a score.
- •Non-measurable signs and symptoms are important to nurses when observing inpatient pediatric patients at the bedside.
While the use of Pediatric Track and Trigger Tools as a standard to discriminate high level of urgency in pediatric care has received considerable attention, less focus has been given to other important factors such as nurses' clinical observations and judgement. The purpose of this study was to explore nurses' observational practice and focus on which non-measurable signs and symptoms nurses find important when identifying inpatient pediatric patients at risk of clinical deterioration.
Design and methods
This was an inductive qualitative study based on an interpretive description methodology. Data were obtained through participant observation of experienced nurses working in a Danish pediatric unit and focus group interviews with pediatric nurses. Field notes were taken, and focus group interviews were audio taped and transcribed. A thematic text condensation method was used to analyse data.
Findings revealed the following four main themes of non-measurable signs and symptoms that nurses find important when identifying children at risk of clinical deterioration: Colour and skin tone; sounds; movement patterns; behavioural signs.
This study suggest that pediatric patients show signs and symptoms that go beyond the objective measurements integrated in Pediatric Track and Trigger Tools and they should not be ignored as they are highly valuable to nurses who are responsible for observing inpatient pediatric patients at risk of clinical deterioration.
More empirical research on nurses' observational practice is recommended, especially research to identify the signs and symptoms - both measurable and non-measurable – that are significant to nurses at the bedside.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of Pediatric Nursing: Nursing Care of Children and Families
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Implementation of pediatric early warning score; adherence to guidelines and influence of context.Journal of Pediatric Nursing. 2018; 38: 33-39
- Packaging: A grounded theory of how to report physiological deterioration effectively [article].Journal of Advanced Nursing. 2005; 52: 473-481
- Clinical judgment: How expert nurses use intuition [article].The American Journal of Nursing. 1987; 87: 23-31
- Beyond statistical prediction: Qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety.Journal of Hospital Medicine. 2013; 8: 248-253
- The transition to clinical expert: Enhanced decision making for children aged less than 5years attending the paediatric ED with acute respiratory conditions.Emergency Medicine Journal. 2017; 34: 76-81
Brady, P. W., & Goldenhar, L. M. (n.d.). A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. https://doi.org/10.1136/bmjqs
- Mandatory early warning scoring—Implementation evaluated with a mixed-methods approach [article].Applied Nursing Research. 2016; 29: 168-176
- If you see something, say something’: Reducing the incidence of deterioration in children.Journal of Child Health Care. 2015; 19 (SAGE publications Inc): 133-135
- Barriers and enablers to implementing the children’s hospital early warning score: A pre- and post-implementation qualitative descriptive study.Journal of Pediatric Nursing. 2019; 46: 39-47
- Systematic review of paediatric track and trigger systems for hospitalised children.Resuscitation. 2016; 109 (Elsevier Ireland Ltd): 87-109
- Nurses’ experiences of making decisions to call emergency assistance to their patients [article].Journal of Advanced Nursing. 2000; 32: 108-114
- Nurses’ ‘worry’ as predictor of deteriorating surgical ward patients: A prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-score [article].International Journal of Nursing Studies. 2016; 59: 134-140
- Capturing early signs of deterioration: The dutch-early-nurse-worry-indicator-score and its value in the Rapid Response System.Journal of Clinical Nursing. 2017; 26: 2605-2613
- Surgical ward nurses’ responses to worry: An observational descriptive study.International Journal of Nursing Studies. 2018; 85: 90-95
- Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: A systematic review.Critical Care. 2015; 19
- Embodied practice: Rediscovering the “heart” of nursing.Journal of Advanced Nursing. 2014; 70: 2235-2244
- Toward a theory of situation awareness in dynamic systems [article].Human Factors. 1995; 37: 32-64
- Qualitative study exploring factors influencing escalation of care of deteriorating children in a children’s hospital.BMJ Paediatrics Open. 2018; 2
- A gut feeling? Intuition and critical care nursing.Intensive & Critical Care Nursing. 2000; 16: 310-318
- The danish regions pediatric triage model has a limited ability to detect both critically ill children as well as children to be sent home without treatment - a study of diagnostic accuracy.Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2017; 25
- Implementation of a checklist to assist in the rapid identification of seriously ill children in the emergency department: An observational study.Journal of Paediatrics and Child Health. 2009; 45: 274-278
- Signs and symptoms that trigger nurses’ concerns about deteriorating conditions in hospitalized pediatric patients: A scoping review protocol.JBI Evidence Synthesis. 2020; 18: 1594-1601
- Signs and symptoms, apart from vital signs, that trigger nurses’ concerns about deteriorating conditions in hospitalized paediatric patients: A scoping review.Nursing Open. 2021; : 1-9
- Pediatric early warning score systems, nurses perspective – A focus group study.Journal of Pediatric Nursing. 2018; 41: e16-e22
- Comparison of two pediatric early warning systems: A randomized trial.Journal of Pediatric Nursing. 2019; 44: e58-e65
- Implementation of the bedside paediatric early warning system (BedsidePEWS) for nurse identification of deteriorating patients.Journal for Specialists in Pediatric Nursing. 2014; 19: 339-349
- Paediatric early warning systems for detecting and responding to clinical deterioration in children: A systematic review.BMJ Open. 2017; 7: 14497
- A systematic review of intuition—A way of knowing in clinical nursing?.Open Journal of Nursing. 2016; 06: 412-425
- Systematic text condensation: A strategy for qualitative analysis [article].Scandinavian Journal of Public Health. 2012; 40: 795-805
- What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature [article].Nursing Open. 2017; 4: 6-23
- Early recognition and treatment of shock in the pediatric patient.Journal of Trauma Nursing. 2006; 13: 17-21
- Pediatric emergencies.in: Howard P.K. Steinmann R.A. Sheehy’s emergency nursing. 6th ed. 2003: 630-651
- Clinical intuition in the nursing process and decision-making—A mixed-studies review.Journal of Clinical Nursing. 2017; 26 (Blackwell Publishing Ltd): 3936-3949
- Detecting and managing detoriation in children.Pediatric Nursing. 2005; 17
- Morgan D.L. Focus groups as qualitative research. 2. edition. Vol. 16. 1997 ([Book]. Sage)
- An integrative review of pediatric early warning system scores [article].Pediatric Nursing. 2015; 41: 165-174
- Nurses’ role in detecting deterioration in ward patients: Systematic literature review.Journal of Advanced Nursing. 2009; 65: 1992-2006
- Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients: The epoch randomized clinical trial.JAMA: The Journal of the American Medical Association. 2018; 319: 1002-1012
- 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. 2011; 15
- Why children die: Avoidable factors associated with child deaths.Archives of Disease in Childhood. 2011; 96: 927-931
- The meaning of ‘worried’ in MET call activations: A regional hospital examination of the clinical indicator.Collegian. 2019; 26: 378-382
- Comparison of three acute care pediatric early warning scoring tools.Journal of Pediatric Nursing. 2013; 28
- Paediatric early warning scores: Holy grail and Achilles’ heel.Postgraduate Medical Journal. 2013; 89: 358-365
- “So why didn’t you think this baby was ill?” decision-making in acute paediatrics.Archives of Disease in Childhood. Education and Practice Edition. 2019; 104: 43-48
- The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours [article].JAMIA Open. 2019; 2: 465-470
- Sage, 2000 Ethnography in nursing research. 1st ed.
- Nursing surveillance for deterioration in pediatric patients: An integrative review.Journal of Pediatric Nursing. 2020; 50 (W.B. Saunders): 59-74
- Risk stratification to improve pediatric early warning systems: It is all about the context.European Journal of Pediatrics. 2019; 178: 1589-1596
- Interpretive description.Vol. 2. Routledge, 2016
- Keywords: Research method; qualitative research; interpretive description research in nursing & health.in: Inc. Res Nurs Health. Vol. 20. John Wiley & Sons, 1997
- The analytic challenge in interpretive description.International Journal of Qualitative Methods. 2004; 3: 1-11
- Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: A systematic review.BMJ Open. 2019; 9 (BMJ Publishing Group)
- Inpatient nursing care and early warning scores: A workflow mismatch.Journal of Nursing Care Quality. 2014; 29: 215-222
- Why children die: Death in infants, children, and young people in the UK Part A.2014
- JAMA: The Journal of the American Medical Association. 2013; 310: 2191-2194
- The role of nurses’ clinical impression in the first assessment of children at the emergency department.Archives of Disease in Childhood. 2017; 102: 1052-1056
Published online: June 13, 2022
Accepted: May 22, 2022
Received in revised form: May 15, 2022
Received: November 23, 2021
© 2022 Elsevier Inc. All rights reserved.