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Clinical user experiences of observation and response charts: focus group findings of using a new format chart incorporating a track and trigger system
  1. Doug Elliott1,
  2. Emily Allen1,
  3. Lin Perry1,2,
  4. Margaret Fry1,3,
  5. Christine Duffield1,
  6. Robyn Gallagher4,
  7. Rick Iedema5,
  8. Sharon McKinley6,
  9. Michael Roche1
  1. 1Faculty of Health, University of Technology, Sydney, New South Wales, Australia
  2. 2South East Sydney Local Health District, Sydney, New South Wales, Australia
  3. 3Northern Sydney Local Health District, Sydney, New South Wales, Australia
  4. 4Charles Perkins Centre & Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
  5. 5Agency for Clinical Innovation, NSW Health, Sydney, New South Wales, Australia
  6. 6Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
  1. Correspondence to Professor Doug Elliott, Faculty of Health, University of Technology, Sydney, New South Wales 2007, Australia; doug.elliott{at}uts.edu.au

Abstract

Background Optimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger ‘Observation and Response Charts’ were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards.

Methods Across eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2–6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach.

Findings In this exploration of initial user experiences, key emergent themes were: tensions between vital sign ‘ranges versus precision’ to support decision making; using a standardised ‘generalist chart in a range of specialist practice’ areas; issues of ‘clinical credibility’, ‘professional autonomy’ and ‘influences of doctors’ when communicating abnormal signs; and ‘permission and autonomy’ when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of ‘increased activity/uncertain benefit’ was uncovered.

Conclusions Findings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed.

  • Human factors
  • Attitudes
  • Decision support, clinical
  • Qualitative research
  • Nurses

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