Introduction
Methods
Selection criteria
Search strategy
Quality appraisal
Data extraction
Review process
Synthesis
Results
Search outcome
Quality assessment
First author | Year | Reference | Are objectives clearly stated? | Is the design appropriate? | Are eligibility criteria, sources and methods of selection of participants described? | Are outcomes described? | Sources of data and details about methods of measurements described appropriate? | Risk of bias taken into account? | Is the study size adequate? | Are characteristics, numbers of participants and reasons for non-participation described? | Is the statistical method adequate? | Are relevant subgroups described in results? | Are results properly described? | Overall study quality |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Bertaut | 2008 | [17] | - | - | - | - | - | - | ? | - | - | ? | + | L |
Boniatti | 2010 | [20] | + | ± | + | + | - | ± | + | + | + | ? | + | M |
Hourihan | 1995 | [21] | + | + | + | + | + | + | ± | + | + | ± | + | M |
Laurens | 2011 | [22] | ± | ± | ± | ± | ± | + | ± | + | + | + | + | M |
Offner | 2007 | [18] | + | ± | ± | + | - | - | ? | ± | + | ? | + | L |
Parr | 2001 | [23] | + | + | + | + | ± | ? | + | + | + | ? | + | M |
Santiano | 2009 | [24] | + | + | + | + | ± | + | + | + | + | + | + | H |
Thomas | 2007 | [19] | - | ? | - | ? | - | ? | ? | + | + | + | ? | L |
First author, year | Reference | Qualitative approach appropriate? | Aim/literature/theory | Study design | Data collection methods | Validity: Role researcher | Validity: Description context | Validity: Reliability methods | Validity: Rigorous+ /not rigorous - /not sure or not reported ± | Analysis: Rich+ /poor - /not sure or not reported ± | Analysis: Reliable+ /unreliable - / not sure or not reported ± | Analysis: Findings convincing | Analysis: Findings relevant to aim of study | Analysis: Conclusion adequate | Ethical considerations |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Appropriate +/inappropriate - /not sure ± | Clear +/unclear- /mixed ± | Defensible +/not defensible - /not sure ± | Appropriate+ /inappropriate - /not sure ± | Clear+ /unclear - /not described ± | Clear+ /unclear- /not sure ± | Reliable/unreliable - /not sure ± | Convincing+ /not convincing - /not sure ± | Relevant+ /irrelevant - /partially relevant ± | Adequate+ /inadequate - / not sure ± | Clear+ /unclear - /not sure or not reported ± | |||||
Andrews, 2005 | [11] | + | + | ± | - | ± | ± | ± | + | + | ± | ± | + | + | + |
Cioffi, 2009 | [26] | ± | + | ± | + | ± | + | ± | ± | ± | ± | + | + | + | + |
Cioffi, 2000 | [27] | + | + | + | + | ± | + | ± | ± | + | + | + | + | ± | ± |
Cox, 2006 | [30] | + | ± | ± | ± | + | ± | - | + | + | ± | + | + | + | + |
Donaldson, 2009 | [31] | + | + | + | ± | ± | ± | + | + | - | + | ± | + | ± | - |
Endacott, 2007 | [33] | + | ± | ± | + | ± | + | + | ± | ± | ± | + | + | ± | + |
Gazarian, 2010 | [34] | + | + | + | ± | ± | + | ± | ± | + | ± | + | + | + | ± |
Leach, 2010 | [35] | + | ± | + | ± | ± | ± | ± | + | ± | ± | - | + | + | - |
Massey, 2014 | [36] | + | + | + | + | + | + | + | + | ± | ± | + | + | ± | + |
McDonnell, 2013 | [37] | + | + | + | + | - | + | ± | ± | ± | ± | + | + | ± | + |
Minick, 2003 | [38] | + | + | + | ± | ± | + | + | + | + | ± | + | + | + | ± |
Pattison, 2011 | [39] | + | + | + | + | ± | ± | ± | + | + | ± | + | + | + | + |
Williams, 2011 | [40] | + | + | + | + | + | + | ± | + | + | ± | + | + | + | + |
Characteristics of included studies
Signs and symptoms underlying worry or concern
10 indicators | Analysis qualitative studies (exploring cues nurses use) | Analysis qualitative studies (process of recognition) | Analysis RRS worry calls |
---|---|---|---|
Change in Breathing | |||
Change in Circulation | Impaired cutaneous perfusion [26], cold feet [26], coldness [27], tachycardia [27], (new) sweating [26, 27, 39], clammy [27, 39], (quite) pale [27], new observation, just a bit paler [26], color drainage changes, dusky [27], more pale than usual, porcelain pale, just a sort of gray, loss of pink color to their skin and color draining [27] | ||
Temperature | |||
Change in Mentation | |||
Agitation | Agitation [26], not getting out of bed [26], uneasy, want to sit in chair instead of bed, cannot get right position, restless [26], not comfortable [26], not comfortable in or out of bed, sitting on the edge of the seat, unsettled, distressed, anxious, climbing about, wanting tablets [27], pulling catheters and tubes out, calling out, pressing the buzzer more often [27], activity level [33] and increase activating the bed alarm [34] | ||
Pain | (Unusual) pain [38] | ||
Unexpected Trajectory | |||
Patient indicates feeling unwell | |||
Subjective nurse observation | Reduced motivation, neglect, not getting out of bed, not acting in their normal way [38], patient looks unwell [11], changes in mood [38], does not look or seem right [35, 37, 38], something is not right [30 ,35], patient somehow looks so ill, difference in behavior, patient is quieter, patient did not open eyes [38] and patient looks really bad [31] | ||
Knowing without a rationale |
Indicator | Underlying signs and symptoms |
---|---|
Change in breathing | Noisy breathing and/or short of breath and/or no full sentences and/or accessory muscles and/or increasing supplemental O2 to maintain SaO2 and/or increase in respiratory rate |
Change in circulation | Colour and/or clammy and/or coldness and/or impaired perfusion and/or colour drainage changes and/or hypertension and/or arrhythmia |
Temperature | Rigors and/or fever and/or hypothermia |
Impaired mentation | Lethargic and/or confused and/or sensory change in level of consciousness |
Agitation | Restless and/or anxious |
Pain | New pain and/or increasing pain |
No progress | No progress and/or abdominal distension and/or nausea and/or bleeding and/or dizzy and/or fall and/or hypoglycaemia |
Patient | Not feeling well and/or feeling of impending doom |
Subjective nurse observation | Change in behaviour and/or does not look good and/or a look in the eyes, like a gaze |
Knowing without a rationale | Gut feeling and/or knowing something is wrong |
First author, year, reference | Change in breathing | Change in circulation | Temperature | Change in mentation | Agitation | Pain | Unexpected trajectory | Patient indicates feeling unwell | Subjective nurses observation | Knowing without a rationale | Number of indicators described per study | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Analysis of qualitative studies | Andrews, 2005 [11] | x | x | x | x | x | x | x | 7 | |||
Cioffi, 2009 [26] | x | x | x | x | x | x | x | x | x | 9 | ||
Cioffi, 2000 [27] | x | x | x | x | x | x | x | x | 8 | |||
Cox, 2006 [30] | x | x | 2 | |||||||||
Donaldson, 2009 [31] | x | x | x | x | 4 | |||||||
Endacott, 2007 [33] | x | x | 2 | |||||||||
Gazarian, 2010 [34] | x | x | x | x | 4 | |||||||
Leach, 2010 [35] | x | x | 2 | |||||||||
Massey, 2014 [36] | x | x | 2 | |||||||||
McDonnell, 2013 [37] | x | x | x | x | 4 | |||||||
Minick, 2003 [38] | x | x | x | x | x | x | x | 7 | ||||
Pattison, 2011 [39] | x | x | x | 3 | ||||||||
Williams, 2011 [40] | x | 1 | ||||||||||
Analysis of worry RRS calls | Boniatti, 2010 [20] | x | x | x | x | x | 5 | |||||
Hourihan, 1995 [21] | x | x | x | x | 4 | |||||||
Laurens, 2011 [22] | x | x | 2 | |||||||||
Parr, 2001 [23] | x | x | x | x | x | x | x | 7 | ||||
Santiano, 2009 [24] | x | x | x | x | x | x | 6 | |||||
Total number of studies describing an indicator | 9 | 9 | 3 | 9 | 10 | 8 | 7 | 2 | 11 | 11 |
Discussion
Signs and symptoms underlying worry or concern
Implications for practice
Limitations
Conclusions
Key messages
-
A total of 10 indicator domains describe the nature of worry or concern of nurses.
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Variable incidences and combinations of indicator domains scored are encountered among deteriorating patients in general wards.
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Nurses frequently describe worry or concern before changes in vital signs occur, suggesting potential relevance as early indicator of deterioration.
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As study designs were merely retrospective, prospective evaluations are warranted to assess the value to clinical relevance of worry or concern of nurses