Registered Nurses’ use of a National Early Warning Score: An interpretative hermeneutic phenomenological study

Background: The National Early Warning Score (NEWS) was introduced in the U.K. to address the patient safety risk of failing to recognise and act on patient deterioration promptly. However, patients still deteriorate unnoticed. Registered Nurses are responsible for patient monitoring and are the main users of NEWS. Aim: To explore Registered Nurses’ experiences and perceptions of using NEWS in the U.K. as part of the recognition and management of acute adult patient deterioration. Methodology: Sixteen Registered Nurses from a U.K. NHS Trust were interviewed using an interpretative hermeneutic phenomenological approach, guided by Gadamerian philosophy. In-depth interviews formed part of a Gadamerian spiral, interpreted to gain new understanding through a fusion of horizons to reveal the story of using NEWS in clinical practice and the meaning for nurses. Findings: The story revealed three pinch points of risk in clinical practice: delegation of vital sign monitoring to healthcare assistants with uncertainty and delayed escalation; over-reliance on NEWS and a culture-based deference to expertise by Junior Nurses; and Senior Nurses' potential over-confidence in selfmanaging deteriorating patients. Workplace culture surrounding NEWS revealed constant compromises and lack of learning opportunities with a potential consequence of future skills gaps in the nursing workforce. Conclusions: When using NEWS, failure to recognise the risks associated with the three pinch points threatens patient safety. Wrong decisions at these points may lead to missed chances in preventing deterioration. Incorrect judgments may lead to unrecognised patient deterioration or inappropriate management leading to preventable adverse events. Recommendations for practice: The nursing profession and health service need to: • address education gaps in the registered/unregistered nursing workforce relating to the recognition and management of deteriorating patients, to ensure safe use of NEWS; • foster a culture that supports, values and develops nurses' clinical judgment to enhance patient safety