ArticlePDF Available

Nurses’ experiences with continuous vital sign monitoring on the general surgical ward: a qualitative study based on the Behaviour Change Wheel

Authors:

Abstract and Figures

Background To support early recognition of clinical deterioration on a general ward continuous vital signs monitoring (CMVS) systems using wearable devices are increasingly being investigated. Although nurses play a crucial role in successful implementation, reported nurse adoption and acceptance scores vary significantly. In-depth insight into the perspectives of nurses regarding CMVS is lacking. To this end, we applied a theoretical approach for behaviour change derived from the Behaviour Change Wheel (BCW). Aim To provide insight in the capability, opportunity and motivation of nurses working with CMVS, in order to inform future implementation efforts. Methods A qualitative study was conducted, including twelve nurses of a surgical ward in a tertiary teaching hospital with previous experience of working with CMVS. Semi-structured interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis. The results were mapped onto the Capability, Opportunity, Motivation – Behaviour (COM-B) model of the BCW. Results Five key themes emerged. The theme ‘Learning and coaching on the job’ linked to Capability. Nurses favoured learning about CVSM by dealing with it in daily practice. Receiving bedside guidance and coaching was perceived as important. The theme ‘interpretation of vital sign trends’ also linked to Capability. Nurses mentioned the novelty of monitoring vital sign trends of patients on wards. The theme ‘Management of alarms’ linked to Opportunity. Nurses perceived the (false) alarms generated by the system as excessive resulting in feelings of irritation and uncertainty. The theme ‘Integration and compatibility with clinical workflow’ linked to Opportunity. CVSM was experienced as helpful and easy to use, although integration in mobile devices and the EMR was highly favoured and the management of clinical workflows would need improvement. The theme ‘Added value for nursing care’ linked to Motivation. All nurses recognized the potential added value of CVSM for postoperative care. Conclusion Our findings suggest all parts of the COM-B model should be considered when implementing CVSM on general wards. When the themes in Capability and Opportunity are not properly addressed by selecting interventions and policy categories, this may negatively influence the Motivation and may compromise successful implementation.
This content is subject to copyright. Terms and conditions apply.
Leenenetal. BMC Nursing (2022) 21:60
https://doi.org/10.1186/s12912-022-00837-x
RESEARCH
Nurses’ experiences withcontinuous vital
sign monitoring onthegeneral surgical ward:
aqualitative study based ontheBehaviour
Change Wheel
J. P. L. Leenen1,2*, E. M. Dijkman1, A. van Hout3, C. J. Kalkman4, L. Schoonhoven5,6 and G. A. Patijn1,2
Abstract
Background: To support early recognition of clinical deterioration on a general ward continuous vital signs monitor-
ing (CMVS) systems using wearable devices are increasingly being investigated. Although nurses play a crucial role in
successful implementation, reported nurse adoption and acceptance scores vary significantly. In-depth insight into
the perspectives of nurses regarding CMVS is lacking. To this end, we applied a theoretical approach for behaviour
change derived from the Behaviour Change Wheel (BCW).
Aim: To provide insight in the capability, opportunity and motivation of nurses working with CMVS, in order to
inform future implementation efforts.
Methods: A qualitative study was conducted, including twelve nurses of a surgical ward in a tertiary teaching
hospital with previous experience of working with CMVS. Semi-structured interviews were audiotaped, transcribed
verbatim, and analysed using thematic analysis. The results were mapped onto the Capability, Opportunity, Motiva-
tion – Behaviour (COM-B) model of the BCW.
Results: Five key themes emerged. The theme ‘Learning and coaching on the job’ linked to Capability. Nurses
favoured learning about CVSM by dealing with it in daily practice. Receiving bedside guidance and coaching was
perceived as important. The theme ‘interpretation of vital sign trends’ also linked to Capability. Nurses mentioned the
novelty of monitoring vital sign trends of patients on wards. The theme ‘Management of alarms’ linked to Opportunity.
Nurses perceived the (false) alarms generated by the system as excessive resulting in feelings of irritation and uncer-
tainty. The theme ‘Integration and compatibility with clinical workflow’ linked to Opportunity. CVSM was experienced
as helpful and easy to use, although integration in mobile devices and the EMR was highly favoured and the manage-
ment of clinical workflows would need improvement. The theme ‘Added value for nursing care linked to Motivation.
All nurses recognized the potential added value of CVSM for postoperative care.
Conclusion: Our findings suggest all parts of the COM-B model should be considered when implementing CVSM on
general wards. When the themes in Capability and Opportunity are not properly addressed by selecting interventions
and policy categories, this may negatively influence the Motivation and may compromise successful implementation.
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco
mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Open Access
*Correspondence: j.p.l.leenen@isala.nl
1 Department of Surgery, Isala, Dr. van Heesweg 2, 8025 AB Zwolle, The
Netherlands
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 2 of 11
Leenenetal. BMC Nursing (2022) 21:60
Background
Serious unexpected adverse events and complications
occur regularly on general surgical wards, especially
in the group of high-risk postsurgical or elderly frail
patients [13]. On general wards the current standard
of care is intermittent monitoring of vital signs with
Early Warning Scores (EWS), in which nurses play an
important role in the measurement, recognition of pos-
sible deterioration, and follow-up [4]. Common used
scores are the New EWS (NEWS) in the UK and the
Modified EWS (EWS) in Continental Europe and the
USA. However, important limitations of these scores
are their intermittent nature and the optimal measure-
ment frequency remains unknown [58]. is poten-
tially results in delayed detection of events and thereby
inferior patient outcomes [9].
Over the last few years, wearable, wireless measure-
ment devices, such as smart patches on the chest and
wrist worn devices for continuous monitoring of vital
signs (CMVS) of patients have become available for
ambulant patients on general wards [10]. A system-
atic review about these devices mostly found studies
reporting technical validation and feasibility outcomes
[11]. Several of these studies reported a broad range
of acceptability rates of nurses in working with CMVS
devices [1217]. We also found moderate rates on usa-
bility and satisfaction by nurses in our recent feasibility
study with the SensiumVitals® CMVS system on our
general surgical ward [18]. It is important to recognize
that implementation of CMVS can only be successful if
nurses are able to integrate this technology in routine
patient care work flow [19, 20]. Importantly, only when
successful implementation in nursing care has been
realized, one can reliably investigate the potential effect
on patient outcomes and value.
The Behaviour Change Wheel
To guide intervention development and implementation
of a CMVS system on the general ward a systematic evi-
dence based approach is needed, such as the Behaviour
Change Wheel (BCW) (Fig. 1) [21]. e BCW enables
selection of interventions that influence behaviour, which
needs to change to enable and support implementation.
e core layer of the BCW is the Capability, Oppor-
tunity and Motivation model (COM-B) (Fig. 2) [21].
According to the COM-B model, behaviour is part of an
interacting system of the social and physical factors. For
an individual nurse to engage in a specific behaviour (B)
there is a need for ‘capability’ (C) to do it, both psycho-
logical and physical. ere must also be the social (e.g.,
support from others) and physical (e.g., the necessary
resources) ‘opportunity’ (O) to perform the behaviour.
And finally, there must be sufficient strong ‘motivation’
(M) to undertake the desired new behaviour over other
Keywords: Telemedicine (MeSH), Monitoring, Physiological (MeSH), Vital signs (MeSH), Continuous vital sign
monitoring, Telemonitoring, Wearable devices, Nurses, Implementation, Behaviour Change Wheel
Fig. 1 The Behaviour Change Wheel [21]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 3 of 11
Leenenetal. BMC Nursing (2022) 21:60
competing behaviours. Motivation covers automatic
processes involving emotional reactions, desires and
impulses, as well as reflective processes involving self-
conscious planning and beliefs about what is good and
bad [22]. Also, Capability and Opportunity may have an
influence on Motivation in the model.
Understanding these factors helps to determine
which COM-B components needs to shift for the
desired behaviour to occur. After this behavioural diag-
nosis, the BCW identifies intervention functions and
policy categories likely to be effective in bringing about
change [22]. So, by defining the COM-B, effective inter-
ventions can be selected to address behaviour.
Published studies about CMVS monitoring so far
mainly assessed nurses’ experiences with acceptability
questionnaires [15, 16, 18]. ere is a lack of more in-
depth insight in the opinions and experiences of this
important stakeholder group for the implementation
of CMVS. erefore, the aim of this study is to provide
insight in the capability, opportunity and motivation of
nurses providing CMVS, in order to inform and sup-
port future implementations using the BCW.
Methods
Design
A qualitative study design was applied utilizing semi-
structured interviews. is study is reported in con-
cordance with the Consolidated criteria for reporting
qualitative research (COREQ) [23].
Recruitment andparticipants
All nurses (n = 35) who worked with the SensiumVitals®
CMVS system in a previous feasibility study on a general
surgical ward of Isala, a large tertiary teaching hospital in
the Netherlands, were eligible to be interviewed [18]. In
our previous study, 30 postoperative abdominal patients
were continuously monitored over a three month period
resulting in 1–4 simultaneously monitored patients of a
total of six patients per nursing shift. When passing vital
signs thresholds, alarms were sent out to the nurses on
a mobile device. ese thresholds were based upon the
conventional MEWS thresholds [3]. After receiving a
vital signs alert, the nurses were asked to measure the
patient’s vital parameters manually in accordance with
the routine hospital policy; measuring all parameters for
a MEWS score. At the end of study, nurses were asked
to complete the Usefulness, Satisfaction, and Ease of use
(USE) questionnaire.
To explore the nurses’ views and judgments about
CMVS, we subsequently interviewed a purposive sam-
pled group of nurses. Maximum variation sampling
ensured inclusion of a broad range of perspectives.
Recruitment continued until maximum variation was
met for age, work experience, the median score on the
USE questionnaire or non-response on the questionnaire
in the previous study. Sampling based on the USE ques-
tionnaire scores was divided in positive (score 4.6–7.0),
negative (score 1.0–3.4) or neutral. (3.5–4.5 score) [24].
Eventually twelve nurses were approached and agreed
to participate in the interviews with a median duration
of 37.5min (IQR 33.80-IQR 46.36). All respondents were
female with a median age of 27.5 (IQR 23–31.5) years old
and a median of 5.5 (IQR 2–8.5) of years’ work experi-
ence. A broad range of responses on the USE question-
naire of the previous study was represented, namely
positive (n = 5), neutral (n = 3), negative (n = 2) and
non-response (n = 2). e selected participants were
approached by email by JL. After explaining the goal of
the study and the voluntary participation, informed con-
sent was gained and an interview was scheduled. At the
start of the interview, the researchers were not aware of
the interviewee’s score on the USE questionnaire to pre-
vent confirmation bias. No new themes emerged after
interviewing ten participants.
Data collection
In preparation for the study, the interviewers (JL; male
and ED; female) were trained in qualitative research
methods. Both interviewers were part-time employed as
nurses at the same ward where the CMVS system was
implemented and they knew the nurses before the inter-
views. Semi-structured, face-to-face interviews were
conducted with the nurses at the hospital in a secluded
office on the ward between April 2020 and August 2020.
e 25 interview questions were divided over the three
elements of the COM-B model (see Additional File 1).
e topic guide was developed by three researchers
Fig. 2 The COM-B model [21]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 4 of 11
Leenenetal. BMC Nursing (2022) 21:60
(JL, ED and GP), pilot tested with one ward nurse, and
revised during the iterative process of data collection and
analysis. e interviewer was guided by the topic scheme,
but was allowed to change the sequence of questions
within the topics or to add questions for emerging topics.
Different probing techniques such as remaining silent,
echoing, and asking for elaboration were used to gain
further insight into experiences [25].
All interviews were audio-recorded and transcribed
verbatim. Keynotes were used to record feelings and
thoughts of the researcher [26].
Data analysis
e interviews were analysed using deductive thematic
analysis using the qualitative data analysis software
NVivo 11 (QSR International, London, UK). e raw data
was analysed using a six-stage thematic analysis as out-
lined by Braun and Clarke [27]. e stages include: (1)
immersion; (2) generating initial codes; (3) searching for
and identifying themes; (4) reviewing themes; (5) defin-
ing and naming themes; and (6) writing the report.
Stage 1 to 3 were conducted independently by two
researchers (JL and ED). During the first and second
stage, JL and ED became familiar with the data by lis-
tening to the audio recordings, checking the transcrip-
tions against the audio recording, reading, listening
sections again and re-reading the final transcripts. Dur-
ing the third stage, both researchers read the transcripts
and codes for categorizing similar statements into first
themes.
For the fourth and fifth stages, JL, ED, AvH and CK
were responsible for reviewing, defining and naming
themes, which were discussed with the other authors.
AvH is an expert in qualitative research. Eventually, in
the sixth stage the themes were mapped to the COM-B
model and discussed with all authors. During the sixth
stage, the themes were brought to the nurses for member
checking by e-mail, which did not result in any changes
to the themes.
Results
e analytical process resulted in five key themes: learn-
ing and coaching on the job, interpretation of vital sign
trends, added value for nursing care, management of
alarms and integration and compatibility with clinical
workflow.
Learning andcoaching onthejob
All of the nurses indicated that receiving training and
education is conditional to acquire adequate knowl-
edge of the system and to be able to start with CMVS.
e preferred educational methods were training ses-
sions, such as an e-learning module, but also informa-
tion by e-mail. Also, the timing of training and dosage
of the amount of information was considered important,
preferably shortly before the start of the implementation
and repeated regularly during implementation to keep
their acquired knowledge up to date. Some nurses who
were not trained expressed feelings of insecurity in using
the system. However, these feeling were also present in
nurses who had gained knowledge by the training. One
nurse stated:
‘In the beginning I had to get used to it for a while
and I still felt insecure about some aspects of contin-
uous monitoring. But it did help that we just started
doing it and having an involved project leader and
key users. ere was always an opportunity to ask
questions and she was also often present in the
department, so that you just became really confident
in working with it.’ (R15).
Several nurses believed it was important to develop
skills in CMVS by handling it in daily practice, the learn-
ing on the job. Further, supportive for learning on the job,
some nurses mentioned to prefer a printed guideline but,
more importantly, coaching by the project leader or from
key users and colleagues on the ward. During their shift,
key users provided information and instructions to the
nurses. One nurse mentioned:
‘I think that you should also give proper educa-
tion and training beforehand. But also providing
extra training for the people who find it difficult
in advance. For example, by setting up a personal
coaching plan for the nurse. So, you really have to
spend time on one-on-one guidance in the first
period, so that nurses feel heard. (…) To be able to
ask questions about your patient with continuous
monitoring to a colleague who knows the system
well, that will get you going.’ (R10).
Several nurses indicated that education before the start
of the vital signs monitoring in practice, does not work
without applying the new knowledge at the bedside. In
particular, practical skills such as pairing the patient to
the platform or attaching the patch sensor to the patient
are best taught at the bedside. One nurse stated:
‘To be honest, we had training before the start, but
that did not really take root at the time. At the start
of the implementation, I really think it would be dif-
ficult to work with continuous monitoring. Because
you really need the experience in real-life practice,
with real patients, if you want to be able to work
with this new device properly.’ (R4).
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 5 of 11
Leenenetal. BMC Nursing (2022) 21:60
Also, some nurses indicated that it required some
time to gain the practical skills and get used to the new
work process. Several nurses mentioned that only a few
patients had CMVS instead of all of them during their
shifts. As a result, working with two work processes for
vital sign monitoring was difficult, confusing and some-
times experienced as extra work. erefore, they would
prefer a higher patient volume of CMVS in the study.
One nurse stated:
‘Yes, continuous monitoring is something that if
you want to perform well, I think you really should
do it structurally. And I mean, just really work
with the system every day with every patient. Not
only with some of your patients. en you will eas-
ily learn the system during a few shifts, just in your
daily work.’ (R1).
In summary, nurses favoured learning CMVS by
actually dealing with such systems in daily practice. An
important success factor was that guidance and coaching
was available during the initial period of implementation.
Interpretation ofvital signs trends
All of the nurses mentioned their experience with inter-
preting and judging vital sign trends, but their perspec-
tives varied. On one hand they indicated they were able
to assess the trend properly, and on the other hand
some nurses experienced difficulty because of the lack
of knowledge of what normal trends should look like.
Also, the pre-specified vital signs thresholds were guid-
ing in the interpretation, but deviating or irregular trends
within the thresholds were challenging to interpret in
combination with the clinical status of the patient. Dif-
ficulty was also experienced when there were invalid
or missing measurements in the trend. One nurse said
about this:
‘I think it is quite hard in the beginning, because you
do not know what a vital sign trend should look like.
Especially when taking the patient status, activity
and missing data in the trend into account. ose
factors are important to consider when assessing the
trend.’(R6).
For interpreting the vital sign trends, several nurses
thought a clear protocol would be useful. ey espe-
cially experienced challenges in clinical decision sup-
port and follow-up of alarms, because it was unclear
what the follow-up actions should be when one vital
sign deviated. Also, they found CMVS to be a supple-
ment to current vital signs protocols, mainly because
they strongly feel that the full range of vital signs is
needed to measure an Early Warning Score. ey
indicated that measuring more vital signs, provided
a more complete insight in the clinical status of the
patient. Also they found some specific causes of clini-
cal deterioration are detected by other vital signs, such
as blood pressure or body temperature. erefore, the
more vital values are continuously measured, the more
complete and informative the scores will be for nurses
and physicians. A nurse said about this:
‘Nowadays we work with the Early Warning Scores.
ose are recognizable and guiding in our follow-up
actions, like calling a physician when a score is 5.
e trends and thresholds did not provide such clear
follow-up. Also, because continuous monitoring still
does not measure all the vital signs to generate a
proper EWS.’ (R2).
Some nurses considered the collaboration with phy-
sicians vitally important for successful interpreting
the trends and the follow-up. ey thought physicians
have more knowledge and experience in trend assess-
ment and should play a major role in the follow-up of
deviating trends. ey believed the physician has the
responsibility to determine medical policy in the event
of clinical deterioration. Also, some nurses said it was a
shared responsibility of the nurse and physician and that
close collaboration is important in vital sign monitoring.
For example, one nurse said:
‘Besides trend assessment by us as nurses, physi-
cians must be involved. ey need to know how to
act based on deviating trends. Eventually, they are
responsible for the medical policy following the
trend’ (R3)
Within their reports on the trend, the nurses placed
trends in the perspective of their clinical assessment. One
nurse stated:
‘Yes, I think I should see continuous monitoring as a
helpful tool. I don’t see it as a substitute for me as a
nurse, like: “Oh that one patient has a wireless vital
sign monitor and I can blindly rely on those meas-
urements”. But your own clinical assessment of the
patient besides vital signs remains most important.
For example, if you observe values measured by the
device, it is important that you always use your own
observations as a nurse and decide whether it fits the
patient’s condition.’ (R7).
Also, most of the interviewed nurses mentioned they
had no experience with a clinically deteriorating patient
with a continuous vital sign monitor during this study
period. ey thought this would be helpful to learn to
interpret the vital sign trends. A nurse said about this:
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 6 of 11
Leenenetal. BMC Nursing (2022) 21:60
’I think it is helpful if you cared for a patient that
had an acute clinical deterioration. en you possi-
bly have a clear picture of such a deviating vital sign
trend in combination with the clinical status of the
patient.
is statement relates to the previously mentioned
theme learning and coaching, on which several nurses
mentioned learning in practice with real patients was
important for successful use of the CMVS systems. Fur-
ther, nurses believed that CMVS could support their clin-
ical reflection and judgment during their work, although
several believed that their overall clinical assessment of
the patient was important for the evaluation of trend
monitoring, and that technology alone cannot be relied
upon for clinical decision making.
Added value fornursing care
All nurses recognized the potential added value of
CMVS for postoperative nursing care based upon their
experience in practice. ey considered vital signs as an
important element of clinical evaluation on the ward and
believed this technology may contribute to earlier detec-
tion of clinical deterioration by better insight into the
vital sign trends and thus increase the safety of care. One
nurse stated about this:
‘I think it can offer a lot for us and patients, espe-
cially if you are able to detect the complications
earlier. By the insight in trends you may detect
clinical deterioration earlier between the routine
measurements.
In addition, in the end that you also get less inten-
sive care unit (ICU) admissions or patients who
spend less time on the ICU.’ (R6)
Also, several nurses thought that CMVS may only
prove to be beneficial for patients with a high risk of
clinical deterioration, for whom the benefits of rapid rec-
ognition of acute deterioration are most obvious. ey
considered there should be a clear rationale to measure
vital signs at a high frequency. Otherwise, they consid-
ered current manual measurement intervals to be suffi-
cient. A nurse said:
‘I would not see much added value for low-complex-
ity care. ese patients already have a low risk of
complications and so clinical deterioration of vital
signs. For example, consider an appendectomy.’ (R1)
In relation to this statement, the same nurse also men-
tioned that the costs of implementation of CMVS sys-
tems should be in proportion to the benefits for patient
care. High costs for the implementation and for the pur-
chase of software or hardware should be justified by a
reduction in the cost of care through a decrease of com-
plication rate, length of stay, ICU admission or readmis-
sions. A nurse said:
‘If the wearable sensor is very expensive, it is worth
considering whether the investment is worth it for the
particular patient group. I do not think it is effective
to apply on those low-complex care patients.’ (R1)
Besides, having ability of continuous insight in the
patient vital signs, the nurses found the possibility of
remote monitoring of the patient especially useful during
night shifts because of the higher patient-to-nurse ratio.
Also, one nurse mentioned there is a desire not to unnec-
essarily wake the patient. A nurse said:
‘During the night shift you have a direct insight and
an overview whether each patient is still breathing
or showing abnormalities in vital signs. is is really
helpful when you nearly have a half ward of patients
to take care of.’ (R11).
Overall, nurses believed in the potential added value of
CMVS to increase the safety of care by earlier detection
of clinical deterioration by better insight into the vital
sign trends.
Management ofalarms
Most nurses mentioned their experience with the alarms
generated by the CMVS system. All of them experienced
that the system generated too many and too many false
alarms. is was possibly caused by the system’s set time
frame of only fifteen minutes for sending out alarms.
Besides, the false alarms were mainly caused by the sys-
tem’s strict artefact rejection algorithms for respiratory
rate and motion artefacts. ese alarms were experienced
as disruptive and caused feelings of uncertainty and lead
to irritation. One nurse said:
‘I found the number of alarms that you got on your
telephone the most inconvenient for me. ere
were really too many. is was often already with
a deviation or technical problem for a short time.
For instance, when you support in mobilization,
you don’t have time to check the notification on
your phone every time. You can’t leave the patient
at all at that moment so an alarm does not add up
to better care.(…) Sometimes I was happy when the
alarms didn’t ring for a while.’ (R1).
is quote reveals feelings of possible agitation about
the alarms, potentially related to the extra workload
caused by the need to respond to the alarms. Also, feel-
ings of uncertainty raised by alarms were caused by
having doubts about their own clinical experience
by receiving multiple and frequent alarms. ey also
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 11
Leenenetal. BMC Nursing (2022) 21:60
mentioned that many alarms and the relatively high rate
of false alarms also indirectly may have bothered the
patients because of the necessary extra checks conducted
at the bedside. Nurses suggested user-adjustable alarm
settings to decrease false alarm rate and prevent alarm
fatigue. One nurse said about this:
‘Often as a nurse you could not do anything with the
alarm because the heart rate had already dropped
again or the connection had already been restored.
en you start doubting whether you are doing
your work right or not missing any abnormalities
in the patient condition. (…) Also, adjusting values
to the specific patient could be helpful in reducing
alarms.)’ (R5).
In summary, the quantity and frequency of (false)
alarms generated by the CMVS system were experienced
as excessive. is resulted in feelings of agitation and
uncertainty, when they were unable to directly respond
to the alarms. In addition, they mentioned that the avail-
ability of continuous monitoring on the ward should not
be a reason to consider this type of vital sign monitoring
to be similar to an ICU setting.
Integration andcompatibility withclinical workow
Nurses found CMVS easy to use overall. However, work-
ing with CMVS and the integration in nursing practice
was influenced by a number of factors.
Several nurses preferred a CMVS system technically inte-
grated into their existing mobile devices without restric-
tions in the range of the wireless connection. Also, they
strongly favoured integration of vital signs trends into the
Electronic Medical Record (EMR) allowing more effective
documentation, evaluation and productivity. A nurse said:
‘It does work better for me if we can assess the trends
in the current used systems such as the EMR, but
also receiving alarms on the calling system instead
of using a separate phone. is makes everyday use
much easier’ (R7).
Further, two nurses mentioned that availability of
CMVS should not be a reason to discharge patients ear-
lier from the ICU to the ward. ey expressed certain
fears that this might result in a higher workload and
unsafe nursing care. A frequently mentioned reason
was the inability to immediately respond to alarms as
reported in the previous theme. is also highlights that
the focus on and importance of vital signs monitoring
is perceived differently by general ward nurses and ICU
nurses. One nurse said:
‘If an alarm rings from one patient and at the
moment you are bathing a patient and you also
have to care for four other patients, then responding
to the alarm can be challenging. I think that’s differ-
ent on an ICU.’(R9)
Other mentioned reasons relating to clinical workflows
were the current high workload at their ward because of
the lower nurse-patient ratio. Also, they believed not to
have the technical nursing skills and knowledge of vital
signs monitoring that ICU patients would need. One
nurse said about this:
‘Continuous monitoring should not be a reason for
patients to be discharged from the ICU to our ward
earlier. We care for many more patients per nurse
and in case of acute deterioration we do not have the
same resources. It then becomes impossible to pro-
vide good quality care. Maybe even dangerous for
patients.’ (R9)’
Several nurses also expressed the hope that in the
future CMVS devices will be able reduce the workload of
current routine manual measuring and registering vital
signs, allowing them to be more productive and have
more dedicated time for patient care. One nurse said:
‘I hope in the future wearable sensor will measure
the full spectrum of vital signs so I don’t have to col-
lect them manually several times a day. is will
save time which I can still devote to many other
tasks during a busy shift.’ (R5).
Overall, CMVS was experienced helpful and easy to
use, although several improvements were mentioned
such as integration in mobile devices and EMR and the
need to securely manage clinical workflows and protocols
when transferring high-risk patients from the ICU.
Themes inrelation totheCOM‑B
e five generated themes were mapped onto the
COM-B model (Table1). Two themes related to Capa-
bility and two themes were related to Opportunity. All
themes had a relation to Motivation. One theme was
linked to Motivation.
Table 1 Themes mapped onto the COM-B model
Theme COM‑B component
Learning and coaching on the job Capability, Motivation
Interpretation of vital signs trends Capability, Motivation
Management of alarms Opportunity, Motivation
Integration and compatibility with clinical
workflow Opportunity, Motivation
Added value for nursing care Motivation
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 11
Leenenetal. BMC Nursing (2022) 21:60
Discussion
To our knowledge, this is the first study providing an
overview of nurses’ perceptions of behavioural fac-
tors that influence implementation of a CMVS system
on general surgical wards. Application of the COM-B
model provides a theoretical framework for understand-
ing nurses’ views and behaviour in CMVS systems on
the ward and may guide in selecting the relevant inter-
ventions and policy categories of the BCW. Using semi-
structured interviews five relevant themes were identified
a related to nurses’ capability, opportunity, and motiva-
tion, which were mapped onto the COM-B model. As
expected, themes within Capability and Opportunity
were also potentially influencing Motivation.
Considering Capability, it was evident that nurses
must be adequately trained before starting to work
with the CMVS system. However, for successful imple-
mentation, bedside learning and coaching to enhance
their knowledge and skills in clinical practice, seem to
be important for nurses. e desire of developing skills
and training with support and coaching during imple-
mentation of CMVS was also reported in other stud-
ies [12, 15]. Although it seems that this type of learning
may be most appropriate, it is also advised to offer other
types of learning methods to match the various learning
style preferences as well as take into account the varia-
tion in attitudes towards innovation [28, 29]. Related to
this, nurses perceived that a certain minimum volume
of patients with CMVS on the ward is needed to build
routine. Nurses consider this essential, especially in the
initial phase of the implementation which is in line with
previous findings that eHealth acceptance requires suf-
ficient time and exposure by a high patient volume [30].
e capability of nurses to interpret vital signs’ trends
was also important. Nurses mentioned assessing trends
instead of the standard absolute EWS values was chal-
lenging. is is in line with statements of physicians
about nurses not having adequate training to interpret
continuous data in an earlier study [31]. Besides train-
ing, developing adequate trend interpretation skills is
expected to take a high patient volume and specific
exposure to clinically deteriorating patients with CMVS,
which was limited in this study.
Moreover, nurses’ overall clinical assessment, obtained
by direct patient contact and based on their professional
experience, should be incorporated into the evaluation
of vital sign trends. Obviously, nurses’ observations on
the patient status and possible clinical deterioration is
much more than just monitoring vital signs. Current sen-
sors and vital sign trends still do not include factors such
as the nurse worry factor and the critical EWS compo-
nent ‘level of consciousness’ [3234]. In line with other
studies, the value of the nurse’s clinical observations in
detection of deterioration was also with respect to reser-
vations about a potential decrease in the bedside nurse-
patient contacts by using CMVS which may limit the
value of their clinical judgement [15, 35, 36].
Also, nurses strongly valued the role of the physician
in trend assessment because of their expertise with vital
sign trends interpretation as part of their clinical judge-
ment. Besides, they thought physicians should play a role
in the follow-up of the trends. is may also be a relevant
factor for implementation of such systems, which was
mentioned in a previous study, in the context that CMVS
may support interdisciplinary communication between
nurses and doctors [12].
Considering Opportunity, nurses generally believed
that CMVS may fit well into their clinical workflow,
which was also recognized in other studies [31, 37].
Although, we found that smooth integration in IT sys-
tems and clinical workflows as well as selective alarm
management are important factors to support success-
ful CMVS implementation. Specifically, this includes the
need for CMVS data integration into the EMR and in
mobile devices and an adequate connectivity and range of
the sensor, which was also mentioned in previous studies
[11, 36]. Also, integration in clinical workflows should be
optimized. Especially, clear criteria to prevent premature
transfers of patients from ICU to the general ward with
CMVS are needed, which was also was mentioned as a
potential worry in another study [32].
Importantly, the multitude of (false) alarms in our
study was perceived as excessive, which may cause alarm
fatigue and may be a major barrier for successful imple-
mentation. In several other studies, nurses also reported
frequent (false) alarms to be the biggest disruptive fac-
tor for their work processes [31, 38], although in one
study nurses found alarms were generally appropriate
[16]. Currently, alarm strategies used by CMVS systems
are mostly based on conventional high or medium care
unit protocols, using pre-set thresholds values. However,
this does not consider other factors such as the delta
of trends over time, the mobilization of the ambulant
patient on general wards, and circadian rhythm of the
patient. erefore, for general wards more sophisticated
alarm strategies would be desirable, but these are still
under development [39]. Alternatively, strategies relying
on routine trend assessments only (e.g. several times per
day) rather than using pre-set alarms may be a solution to
deal with excessive alarms and support implementation
and compliance on general wards.
Considering Motivation, nurses seem to be clearly moti-
vated to use this innovation because they believe in the
potential for improving the quality and safety of patient
care. e potential benefit for patients was also recog-
nized by nurses in several other studies with a CMVS
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 11
Leenenetal. BMC Nursing (2022) 21:60
systems, specifically for earlier detection of clinical dete-
rioration in certain high risk patient groups and provid-
ing remote insight in the patients vital signs during night
shifts [14, 31, 32, 36]. Unfortunately, contrary to common
belief among nurses strong evidence for clinical benefit
and cost-effectiveness is still lacking due to the various
study designs, low study quality and various outcome
measures used in available published reports [11, 40].
However, providing nursing care according to the princi-
ples of Evidence-Based Practice is more than just the fol-
lowing the evidence, but also consists the preferences of
the patient and clinical expertise of the nurses [41].
Taken all together, based on the five themes identified
and subsequent mapping onto the COM-B model, sev-
eral intervention functions of the BCW may be applied
to allow successful implementation (Fig.1) [22]. Bedside
training and education could enhance the Capability
of nurses about CMVS. Enablement and environmen-
tal structuring may address the themes mapped onto
Opportunity as described above. Lastly, modelling may
strengthen the Motivation of nurses. Supporting to the
intervention functions, the possible policy categories of
the BCW could be guidelines, environmental planning
and legislation.
Limitations
e findings in this study need to be interpreted in
light of several limitations. First, our study was per-
formed on a Dutch general surgical ward which may
affect transferability to other countries and specialisms.
Also, the experience of nurses was with one particular
CMVS platform (SensiumVitals®), while many other
systems are available [11, 42]. However, we emphasized
beforehand to respondents that we wished them to give
us their opinion on the concept rather than the par-
ticular system we used. Furthermore, we only included
female nurses in our study so results may not be trans-
ferable for male nurses. However, a previous study did
not show a significant effect on technology acceptance
between genders [43]. Moreover, respondents’ experi-
ence with CMVS was based on a relatively short period
of working with the new system and a limited number
of patients per nursing shift, whereas sufficient expo-
sure is a known condition for successful implementa-
tion of innovations. Also, the extensive interview guide
gave a broad overview of the nurses’ perceptions but
limited in-depth insights. Moreover, framing of the
themes to the COM-B and BCW model may have lim-
ited the openness of the interviews as other frameworks
such as the Technology Acceptance model are not con-
sidered [44, 45]. However, the COM-B model does
take the challenging context factors on the ward into
account. Finally, JL and ED were part-time employed
as nurses at the same ward where the CMVS system
was implemented. Although it was explicitly stated that
answers had to be given honestly, this may have influ-
enced the social desirability of the answers. On the
other hand, the interviewers had a broad experience
in clinical nursing, qualitative research methods as
well as the technical aspects of CMVS. is supported
the understanding of the context and quality of the
study design. Another strength of this study was that
the application of analyst triangulation by coding and
forming and framing themes was done independently
by several authors (JL and ED).
Conclusion
CMVS using wearable wireless devices may support
the timely detection of clinical deterioration. Success-
ful implementation of such novel technology is impor-
tant but challenging. is study provides an overview
of the nurse experiences regarding the implementation
of CMVS on a general surgical ward. Our findings sug-
gest all parts of the COM-B should be considered when
implementing CVSM on general wards, with particular
attention to the complexity of interaction of the elements
of the model. When the themes in Capability and Oppor-
tunity are not properly addressed in the selection of
interventions and policy categories, this may negatively
influence the Motivation and may compromise successful
implementation.
Collectively, our findings related to the COM-B model
may guide implementation strategies of CMVS systems
on general wards when using the intervention functions
and policy categories of the BCW. Further studies should
focus on evaluation of implementation strategies of such
systems in daily practice.
Abbreviations
BCW: Behaviour Change Wheel; COM-B: Capability Opportunity Motivation –
Behaviour; EMR: Electronic Medical Record; IT: Information Technology; USE:
Usefulness, Satisfaction, and Ease of use questionnaire.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12912- 022- 00837-x.
Additional le1.
Acknowledgements
The authors would like to thank Robert Orsel and Renate Jansen in their
assistance with conducting and transcribing the interviews and all nurses for
participating in the study.
Authors’ contributions
JL contributed to the conceptualisation of the study, collected the data,
analysis of the data, drafted the manuscript and final compilation of the
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Leenenetal. BMC Nursing (2022) 21:60
manuscript. ED contributed to the conceptualisation of the study, collected
the data, analysis of the data and final compilation of the manuscript. AvH
analysis of the data, drafted and final compilation of the manuscript. CK
analysis of the data, contributed to the conceptualisation of the study. LS con-
tributed to the conceptualisation of the study, analysis of the data and final
compilation of the manuscript. GP contributed to the conceptualisation of the
study, final compilation of the manuscript. All the authors read and approved
the final manuscript.
Funding
This work was supported by Isala Innovation and Science Fund (grant number
INNO1937).
Availability of data and materials
All data generated or analysed during the current study are available from the
corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The Daily Board of the Medical Ethics Committee of Isala Zwolle, the Nether-
lands, reviewed the protocol and waived the need for formal ethical approval
of the study (protocol no. 200329). The study was conducted in accordance
with the Declaration of Helsinki. Written informed consent was obtained from
each nurse to participate in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Surgery, Isala, Dr. van Heesweg 2, 8025 AB Zwolle, The Neth-
erlands. 2 Connected Care Centre, Isala, Dr. van Heesweg 2, 8025 AB Zwolle,
The Netherlands. 3 Research Group IT Innovations in Health Care, Windesheim
University of Applied Sciences, Campus 2-6, Zwolle 8017CA, The Netherlands.
4 Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht
University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. 5 Julius Cen-
tre for Health Sciences and Primary Care, University Medical Centre Utrecht,
Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
6 School of Health Sciences, Faculty of Environmental and Life Sciences, Univer-
sity of Southampton, University Rd, Southampton SO17 1BJ, UK.
Received: 12 April 2021 Accepted: 2 March 2022
References
1. Perman SM, Stanton E, Soar J, Berg RA, Donnino MW, Mikkelsen ME, et al.
Location of In-Hospital Cardiac Arrest in the United States-Variability in
Event Rate and Outcomes. J Am Heart Assoc. 2016;5(10):e003638.
2. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and
Prevention. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2021.
PMID: 29763131.
3. Zanetti ACB, Gabriel CS, Dias BM, Bernardes A, de Moura AA, Gabriel AB,
et al. Assessment of the incidence and preventability of adverse events in
hospitals an integrative review. Rev Gauch Enferm. 2020;41:e20190364.
4. Gerry S, Bonnici T, Birks J, Kirtley S, Virdee PS, Watkinson PJ, et al.
Early warning scores for detecting deterioration in adult hospital
patients systematic review and critical appraisal of methodology. BMJ.
2020;369:m1501.
5. Downey CL, Tahir W, Randell R, Brown JM, Jayne DG. Strengths and limita-
tions of early warning scores: A systematic review and narrative synthesis.
Int J Nurs Stud. 2017;76:106–19.
6. Clifton L, Clifton DA, Pimentel MAF, Watkinson PJ, Tarassenko L. Predic-
tive monitoring of mobile patients by combining clinical observations
with data from wearable sensors. IEEE J Biomed Heal informatics.
2014;18(3):722–30.
7. Lockwood C, Conroy-Hiller T, Page T. Vital signs. JBI Libr Syst Rev.
2004;2(6):1–38.
8. Evans D, Hodgkinson B, Berry J. Vital signs in hospital patients: a system-
atic review. Int J Nurs Stud. 2001;38(6):643–50.
9. Beckett D, Gordon C, Paterson R, Chalkley S, Macleod D, Bell D. Assess-
ment of clinical risk in the out of hours hospital prior to the introduction
of Hospital at Night. Acute Med. 2009;8(1):33–8.
10. Michard F, Gan TJ, Kehlet H. Digital innovations and emerging technolo-
gies for enhanced recovery programmes. Br J Anaesth. 2017;119(1):31–9.
11. Leenen JPL, Leerentveld C, van Dijk J, van Westreenen H, Schoonhoven L,
Patijn G. Current Evidence for Continuous Vital Signs Monitoring by Wear-
able Wireless Devices in Hospitalized Adults Systematic Review. J Med
Internet Res. 2020;22(6):e18636.
12. Prgomet M, Cardona-Morrell M, Nicholson M, Lake R, Long J, Westbrook J,
et al. Vital signs monitoring on general wards: Clinical staff perceptions of
current practices and the planned introduction of continuous monitor-
ing technology. Int J Qual Heal Care. 2016;28(4):515–21.
13. Verrillo SC, Cvach M, Hudson KW, Winters BD. Using Continuous Vital
Sign Monitoring to Detect Early Deterioration in Adult Postoperative
Inpatients. J Nurs Care Qual. 2019;34(2):107–13.
14. Weenk M, van Goor H, Frietman B, Engelen LJ, van Laarhoven CJ, Smit J,
et al. Continuous Monitoring of Vital Signs Using Wearable Devices on
the General Ward Pilot Study. JMIR mHealth uHealth. 2017;5(7):e91.
15. Izmailova ES, McLean IL, Bhatia G, Hather G, Cantor M, Merberg D, et al.
Evaluation of Wearable Digital Devices in a Phase I Clinical Trial. Clin Transl
Sci. 2019;12(3):247–56.
16. Watkins T, Whisman L, Booker P. Nursing assessment of continuous vital
sign surveillance to improve patient safety on the medical/surgical unit. J
Clin Nurs. 2016;25(1–2):278–81.
17. Weller RS, Foard KL, Harwood TN. Evaluation of a wireless, portable, wear-
able multi-parameter vital signs monitor in hospitalized neurological and
neurosurgical patients. J Clin Monit Comput. 2018;32(5):945–51.
18. Leenen JPL, Dijkman EM, van Dijk JD, van Westreenen HL, Kalkman C,
Schoonhoven L, et al. Feasibility of continuous monitoring of vital signs
in surgical patients on a general ward an observational cohort study. BMJ
Open. 2021;11(2):e042735.
19. Booth RG. Educating the future eHealth professional nurse. Int J Nurs
Educ Scholarsh. 2006;3:Article 13. https:// doi. org/ 10. 2202/ 1548- 923X.
1187.
20. Brown J, Pope N, Bosco AM, Mason J, Morgan A. Issues affecting nurses’
capability to use digital technology at work: An integrative review. J Clin
Nurs. 2020;29(15–16):2801–19.
21. Michie S, Atkins L, West R. The behaviour change wheel - a guide to
designing interventions. Surrey, UK: Silverback Publishing; 2014.
22. Michie S, van Stralen MM, West R. The behaviour change wheel: a new
method for characterising and designing behaviour change interven-
tions. Implement Sci. 2011;6:42.
23. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups. Int
J Qual Heal care J Int Soc Qual Heal Care. 2007;19(6):349–57.
24. Lund A. Measuring Usability with the USE Questionnaire. Usability User
Exp Newslett. 2001;8(2):3–6.
25. Whiting LS. Semi-structured interviews: guidance for novice researchers.
Nurs Stand. 2008;22(23):35–40.
26. Chesney M. Interaction and understanding. Nurse Res. 2000;7(3):58–9.
27. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
2006;3(2):77–101.
28. Mangold K, Kunze KL, Quinonez MM, Taylor LM, Tenison AJ. Learning Style
Preferences of Practicing Nurses. J Nurses Prof Dev. 2018;34(4):212–8.
29. Lee T-T. Nurses’ adoption of technology: application of Rogers’ innova-
tion-diffusion model. Appl Nurs Res. 2004;17(4):231–8.
30. Li J, Talaei-Khoei A, Seale H, Ray P, Macintyre CR. Health Care Provider
Adoption of eHealth Systematic Literature Review. Interact J Med Res.
2013;2(1):e7.
31. Weenk M, Bredie S, Koeneman M, Hesselink G, van Goor H, vande Belt
T. Continuous Monitoring of Vital Signs in the General Ward Using
Wearable Devices Randomized Controlled Trial. J Med Internet Res.
2020;22(6):e15471.
32. van Rossum M, Leenen J, Kingma F, Breteler M, van Hillegersberg R,
Ruurda J, et al. Expectations of Continuous Vital Signs Monitoring for
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 11
Leenenetal. BMC Nursing (2022) 21:60
fast, convenient online submission
thorough peer review by experienced researchers in your field
rapid publication on acceptance
support for research data, including large and complex data types
gold Open Access which fosters wider collaboration and increased citations
maximum visibility for your research: over 100M website views per year
At BMC, research is always in progress.
Learn more biomedcentral.com/submissions
Ready to submit your research
Ready to submit your research
? Choose BMC and benefit from:
? Choose BMC and benefit from:
Recognizing Complications After Esophagectomy Interview Study
Among Nurses and Surgeons. JMIR Perioper Med. 2021;4(1):e22387.
33. Douw G, Schoonhoven L, Holwerda T, Huisman-de Waal G, van Zanten
ARH, van Achterberg T, et al. Nurses’ worry or concern and early recogni-
tion of deteriorating patients on general wards in acute care hospitals: a
systematic review. Crit Care. 2015;19(1):230.
34. Mok WQ, Wang W, Liaw SY. Vital signs monitoring to detect patient dete-
rioration: An integrative literature review. Int J Nurs Pract. 2015;21(Suppl
2):91–8.
35. Downey C, Brown J, Jayne D, Randell R. Patient attitudes towards remote
continuous vital signs monitoring on general surgery wards: An interview
study. Int J Med Inform. 2018;114:52–6.
36. Areia C, King E, Ede J, Young L, Tarassenko L, Watkinson P, et al. Experi-
ences of current vital signs monitoring practices and views of wear-
able monitoring: A qualitative study in patients and nurs. J Adv Nurs.
2021;00:1–13.
37. Cardona-Morrell M, Prgomet M, Turner RM, Nicholson M, Hillman K.
Effectiveness of continuous or intermittent vital signs monitoring in
preventing adverse events on general wards: a systematic review and
meta-analysis. Int J Clin Pract. 2016;70(10):806–24.
38. Downey C, Randell R, Brown J, Jayne DG. Continuous Versus Intermittent
Vital Signs Monitoring Using a Wearable, Wireless Patch in Patients Admit-
ted to Surgical Wards Pilot Cluster Randomized Controlled Trial. J Med
Internet Res. 2018;20(12):e10802.
39. van Rossum MC, Vlaskamp LB, Posthuma LM, Visscher MJ, Breteler MJM,
Hermens HJ, Kalkman CJ, Preckel B. Adaptive threshold-based alarm
strategies for continuous vital signs monitoring. J Clin Monit Comput.
2021. https:// doi. org/ 10. 1007/ s10877- 021- 00666-4. Epub ahead of print.
40. Areia C, Biggs C, Santos M, Thurley N, Gerry S, Tarassenko L, et al. The
impact of wearable continuous vital sign monitoring on deterioration
detection and clinical outcomes in hospitalised patients: a systematic
review and meta-analysis. Crit Care. 2021;25(1):351.
41. Chien LY. Evidence-Based Practice and Nursing Research. J Nurs Res.
2019;27(4):e29.
42. Joshi M, Ashrafian H, Aufegger L, Khan S, Arora S, Cooke G, et al. Wearable
sensors to improve detection of patient deterioration. Expert Rev Med
Devices. 2019;16(2):145–54.
43. Wilkowska W, Kowalewski S, Ziefle M. A Small but Significant Difference
– The Role of Gender on Acceptance of Medical Assistive Technologies.
2010. p. 82–100. https:// doi. org/ 10. 1007/ 978-3- 642- 16607-5_6.
44. Ogden J. Celebrating variability and a call to limit systematisation: the
example of the Behaviour Change Technique Taxonomy and the Behav-
iour Change Wheel. Health Psychol Rev. 2016;10(3):245–50.
45 Lee K, Kozar K, Larsen K. The Technology Acceptance Model: Past, Present,
and Future. Commun Assoc Inf Syst. 2003;12(50):50.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
... The findings of our study regarding nurses' opinions on MCs are consistent with other studies that emphasise the critical role of training and technical support in the successful implementation of new medical technologies. Research by Curtis and Brooks [13], Dahm and Wadensten [14], and others [15][16] has demonstrated that nurses require continuous support and access to information to effectively utilise new tools. Regular training and practical support not only improve the quality of patient care but also enhance both the safety and efficiency of healthcare staff, ultimately leading to better clinical outcomes and increased job satisfaction. ...
... Our study identified that 41.9% of nurses expressed a need for additional training in MCs handling, underscoring the necessity for systematic training and ongoing support. The introduction of new medical technologies and devices often presents challenges related to staff adaptation; however, regular training sessions significantly enhance staff competence and contribute to improved patient safety [13][14][15][16][17][18]. ...
... Wyniki naszego badania dotyczące opinii pielęgniarek na temat MC zestawiono z innymi badaniami, które podkreślają znaczenie szkoleń i wsparcia technicznego w skutecznym wdrażaniu nowych technologii medycznych. Badania Curtis i Brooks [13] oraz Dahm i Wadensten [14], a także innych autorów [15][16], wykazały, że pielęgniarki potrzebują ciągłego wsparcia i dostępu do informacji, aby efektywnie korzystać z nowych narzędzi. Regularne szkolenia i praktyczne wsparcie poprawiają jakość opieki nad pacjentem, zwiększając zarówno bezpieczeństwo, jak i efektywność personelu, co prowadzi do lepszych wyników klinicznych i większej satysfakcji zawodowej. ...
Article
Full-text available
Aim. The aim of this study is to assess nurses’ opinions on the usability, effectiveness, and benefits of midline catheters (MC) in nursing practice. Additionally, the study identifies nurses’ subjective knowledge levels and training needs related to these catheters. Material and methods. A cross-sectional correlational study was conducted from 15th October to 15th November 2023, involving 127 nurses from various departments. Data were collected through an anonymous survey with 13 questions about opinions on MC, subjective knowledge, and sociodemographic metrics. Statistical analysis was performed using IBM SPSS Statistics. Results. Most nurses had experience with patients using midline catheters, and the average rating of opinions on MC was 4.44 on a Likert scale (1-5). The average subjective knowledge about MC was 4.26. A total of 88% of respondents desired future training on MC, and 72% wanted to learn how to insert these catheters. Nurses who attended training rated their preparedness to handle MCs higher. Conclusions. Midline catheters are well-regarded by nurses and integral to their practice. Regular training and support are essential for effectively implementing new medical technologies. Investing in medical staff education is crucial for improving healthcare quality and patient safety.
... They highlight its benefits, including detecting patients who are deteriorating early on and saving time, which is especially beneficial during evening and night duties. A qualitative study by Leenen et al. [23] using the Behavior Change Wheel framework emphasized the significance of clinical assessment by nurses in conjunction with device measurements and the novelty of monitoring vital sign trends onwards. ...
Article
Full-text available
Technical and accessibility issues in hospitals often prevent patients from receiving optimal mental and physical health care, which is essential for independent living, especially as societies age and chronic diseases like diabetes and cardiovascular disease become more common. Recent advances in the Internet of Things (IoT)-enabled wearable devices offer potential solutions for remote health monitoring and everyday activity recognition, gaining significant attention in personalized healthcare. This paper comprehensively reviews wearable healthcare technology integrated with the IoT for continuous vital sign monitoring. Relevant papers were extracted and analyzed using a systematic numerical review method, covering various aspects such as sports monitoring, disease detection, patient monitoring, and medical diagnosis. The review highlights the transformative impact of IoT-enabled wearable devices in healthcare, facilitating real-time monitoring of vital signs, including blood pressure, temperature, oxygen levels, and heart rate. Results from the reviewed papers demonstrate high accuracy and efficiency in predicting health conditions, improving sports performance, enhancing patient care, and diagnosing diseases. The integration of IoT in wearable healthcare devices enables remote patient monitoring, personalized care, and efficient data transmission, ultimately transcending traditional boundaries of healthcare and leading to better patient outcomes.
... Churpek et al. [56] noted that trends in vital signs improve the accuracy of models designed to detect critical illness on hospital wards compared to models containing only instantaneous measurements of vital signs. Leenen et al. [57] found that continuous vital sign monitoring (CVSM) was perceived as helpful and easy to use by nurses, highlighting the potential added value of CVSM. Stawicki [58] identified key indicators, such as the stochastic oscillator, moving average convergence-divergence tool, price envelope analysis, and moving average, in trend analysis to describe and interpret vital sign data. ...
Article
Full-text available
Multiple studies and review papers have concluded that early warning systems have a positive effect on clinical outcomes, patient safety and clinical performances. Despite the substantial evidence affirming the efficacy of EWS applications, persistent barriers hinder their seamless integration into clinical practice. Notably, EWS, such as the National Early Warning Score, simplify multifaceted clinical conditions into singular numerical indices, thereby risking the oversight of critical clinical indicators and nuanced fluctuations in patients’ health status. Furthermore, the optimal deployment of EWS within clinical contexts remains elusive. Manual assessment of EWS parameters exacts a significant temporal toll on healthcare personnel. Addressing these impediments necessitates innovative approaches. In this regard, wearable medical technologies emerge as promising solutions capable of continual monitoring of hospitalized patients’ vital signs. To overcome the barriers of the use of early warning scores, wearable medical technology has the potential to continuously monitor vital signs of hospitalised patients. However, a fundamental inquiry arises regarding the comparability of their reliability to the current used golden standards. This inquiry underscores the imperative for rigorous evaluation and validation of wearable medical technologies to ascertain their efficacy in augmenting extant clinical practices. This prospective, single-center study aimed to evaluate the accuracy of heart rate and respiratory rate measurements obtained from the Vivalink Cardiac patch in comparison to the ECG-based monitoring system utilized at AZ Maria Middelares Hospital in Ghent. Specifically, the study focused on assessing the concordance between the data obtained from the Vivalink Cardiac patch and the established ECG-based monitoring system among a cohort of ten post-surgical intensive care unit (ICU) patients. Of these patients, five were undergoing mechanical ventilation post-surgery, while the remaining five were not. The study proceeded by initially comparing the data recorded by the Vivalink Cardiac patch with that of the ECG-based monitoring system. Subsequently, the data obtained from both the Vivalink Cardiac patch and the ECG-based monitoring system were juxtaposed with the information derived from the ventilation machine, thereby providing a comprehensive analysis of the patch’s performance in monitoring vital signs within the ICU setting. For heart rate, the Vivalink Cardiac patch was on average within a 5% error range of the ECG-based monitoring system during 85.11±10.81% of the measured time. For respiratory rate this was during 40.55±17.28% of the measured time. Spearman’s correlation coefficient showed a very high correlation of ρ=0.9\rho = 0.98 for heart rate and a moderate correlation of ρ=0.66\rho = 0.66 for respiratory rate. In comparison with the ventilated respiratory rate (ventilation machine) the Vivalink and ECG-based monitoring system both had a moderate correlation of ρ=0.68.\rho = 0.68. A very high correlation was found between the heart rate measured by the Vivalink Cardiac patch and that of the ECG-based monitoring system of the hospital. Concerning respiratory rate the correlation between the data from the Vivalink Cardiac patch, the ECG-based monitoring system and the ventilation machine was found to be moderate.
... The difficulties in measuring RR are a hurdle that many manufacturers and researchers face. Based on the literature [61,68], expertise and cooperation with different intensive care units in hospitals, and the practical implementations of monitoring devices and telemonitoring critically ill patients, the key message is that trends in vital signs are more important than absolute values and momentary measurements. The mean difference of 2 BrPM in our best combination algorithm remained high, but Spearman's correlation of 0.82 shows that the device is capable of correlating with the medical-grade device and able to represent trends in respiration measurements. ...
Article
Full-text available
The remote monitoring of vital signs via wearable devices holds significant potential for alleviating the strain on hospital resources and elder-care facilities. Among the various techniques available, photoplethysmography stands out as particularly promising for assessing vital signs such as heart rate, respiratory rate, oxygen saturation, and blood pressure. Despite the efficacy of this method, many commercially available wearables, bearing Conformité Européenne marks and the approval of the Food and Drug Administration, are often integrated within proprietary, closed data ecosystems and are very expensive. In an effort to democratize access to affordable wearable devices, our research endeavored to develop an open-source photoplethysmographic sensor utilizing off-the-shelf hardware and open-source software components. The primary aim of this investigation was to ascertain whether the combination of off-the-shelf hardware components and open-source software yielded vital-sign measurements (specifically heart rate and respiratory rate) comparable to those obtained from more expensive, commercially endorsed medical devices. Conducted as a prospective, single-center study, the research involved the assessment of fifteen participants for three minutes in four distinct positions, supine, seated, standing, and walking in place. The sensor consisted of four PulseSensors measuring photoplethysmographic signals with green light in reflection mode. Subsequent signal processing utilized various open-source Python packages. The heart rate assessment involved the comparison of three distinct methodologies, while the respiratory rate analysis entailed the evaluation of fifteen different algorithmic combinations. For one-minute average heart rates’ determination, the Neurokit process pipeline achieved the best results in a seated position with a Spearman’s coefficient of 0.9 and a mean difference of 0.59 BPM. For the respiratory rate, the combined utilization of Neurokit and Charlton algorithms yielded the most favorable outcomes with a Spearman’s coefficient of 0.82 and a mean difference of 1.90 BrPM. This research found that off-the-shelf components are able to produce comparable results for heart and respiratory rates to those of commercial and approved medical wearables.
... HCPs surveyed have consistently recognized this feature as the most significant benefit of RPMS, underscoring its role in proactive patient care. These findings align with literature where HCPs emphasize the benefits of continuous vital sign monitoring in detecting clinical deterioration earlier [20][21][22][23]. ...
Article
Full-text available
Introduction: Remote patient monitoring systems (RPMS) are increasingly integrated into hospital wards to improve patient safety and reduce the workload on healthcare professionals (HCPs). This study evaluates the efficacy of RPMS in general wards, focusing on their impact on nursing efficiency, patient care, HCPs, and patient satisfaction. Methods: A comprehensive time-motion study was conducted along with surveys targeting HCPs and patients in M.S. Ramaiah Memorial Hospital, Bangalore, India, which has implemented RPMS in general wards. The study involved observing and comparing nursing activities in RPMS-equipped wards versus control wards without RPMS across various shifts. In addition, feedback on the system's impact on patient safety, overall care quality, and usability was gathered through a survey form. Results: RPMS decreases the amount of time nurses spend on routine monitoring, communication, and coordination, enabling a 43.11% increase in time available for patient care. More than 89% of HCPs noted improvements in the level of care and overall patient safety. More than 80% of the HCPs also noted improvement in the patient’s experience. More than 50% of HCPs find RPMS easy to use and user-friendly. More than 60% of the patients noted an overall improvement in care quality. Conclusion: RPMS has proven to be a valuable asset in hospital wards, enhancing patient monitoring and safety while reducing the workload on staff. In addition, significant time savings on routine tasks and high satisfaction levels from both staff and patients underscore the system's benefits.
... In recent studies, most systems have only limited integration into the hospital electronic Health Record (EHR) and other hospital information systems, such as the wireless connectivity and mobile applications for nurses. Interoperability standards for CVSM systems are necessary and a prerequisite for adequate usability by nurses [69]. Once in place, this could dramatically increase their successful implementation in clinical practice. ...
Article
Purpose of review Wearable wireless sensors for continuous vital signs monitoring (CVSM) offer the potential for early identification of patient deterioration, especially in low-intensity care settings like general wards. This study aims to review advances in wearable CVSM – with a focus on the general ward – highlighting the technological characteristics of CVSM systems, user perspectives and impact on patient outcomes by exploring recent evidence. Recent findings The accuracy of wearable sensors measuring vital signs exhibits variability, especially notable in ambulatory patients within hospital settings, and standard validation protocols are lacking. Usability of CMVS systems is critical for nurses and patients, highlighting the need for easy-to-use wearable sensors, and expansion of the number of measured vital signs. Current software systems lack integration with hospital IT infrastructures and workflow automation. Imperative enhancements involve nurse-friendly, less intrusive alarm strategies, and advanced decision support systems. Despite observed reductions in ICU admissions and Rapid Response Team calls, the impact on patient outcomes lacks robust statistical significance. Summary Widespread implementation of CVSM systems on the general ward and potentially outside the hospital seems inevitable. Despite the theoretical benefits of CVSM systems in improving clinical outcomes, and supporting nursing care by optimizing clinical workflow efficiency, the demonstrated effects in clinical practice are mixed. This review highlights the existing challenges related to data quality, usability, implementation, integration, interpretation, and user perspectives, as well as the need for robust evidence to support their impact on patient outcomes, workflow and cost-effectiveness.
... Finally, we used Gagnon's list for data analysis, because previous interviews regarding the use of the Visi Mobile were also analysed with this list [20]. Another study in this field used the Behaviour Change Wheel as the theoretical basis of the analysis [44]. Our model enabled the analysis of the sustainable updating of the technology, while their aim was to assess nurses' behaviours regarding wireless monitoring. ...
Article
Full-text available
Continuous monitoring of vital signs using a wireless wearable device was implemented in 2018 at a surgical care unit of an academic hospital. This study aimed at gaining insight into nurses’ and patients’ perspectives regarding the use and innovation of a continuous vital signs monitoring system, three years after its introduction. This qualitative study was performed in a surgical, non-intensive care unit of an academic hospital in 2021. Key-user nurses (nurses with additional training and expertise with the device) and patients were selected for semi-structured interviews, and nurses from the ward were selected for a focus group interview using a topic list. Transcripts of the audio tapes were deductively analysed using four dimensions for adoptions of information and communication technologies (ICT) devices in healthcare. The device provided feelings of safety for nurses and patients. Nurses and patients had a few issues with the device, including the size and the battery life. Nurses gained knowledge and skills in using the system for measurement and interpretations. They perceived the system as a tool to improve the recognition of clinical decline. The use of the system could be further developed regarding the technical device’s characteristics, nurses’ interpretation of the data and the of type of alarms, the information needs of patients, and clarification of the definition and standardization of continuous monitoring. Three years after the introduction, wireless continuous vital signs monitoring is the new standard of care according to the end-users at the general surgical ward.
Thesis
Patients on general wards are at risk of complications, often associated with deviations in vital signs. Unfortunately, the currently used manual method of intermittently measuring vital signs is not optimal, potentially leading to late recognition and treatment of complications, and sometimes with serious consequences such as intensive care admissions and even death. A possible solution may be wearable, wireless sensors that can continuously monitor vital signs (CMVS), but large-scale evaluation and successful implementation have not yet been described. This thesis aimed to gain a deeper understanding of the essential elements of CMVS, the crucial aspects of the implementation process, and the potential benefits of such systems for patient care, all with an emphasis on the nurse's perspective, as a prelude to further development and future implementations. The findings highlight the complexity of implementing CMVS on general wards and underline the need for further development and studies to assess actual clinical value and cost-effectiveness. Due to the current early stage of technology development, implementation remains a serious challenge. Nurses have an essential role in the successful deployment of CMVS on regular wards and are key to their success. Wearable continuous vital signs monitoring technology is expected to mature further in the coming years, enabling continuous monitoring of all relevant vital signs, enabling software to integrate seamlessly with hospital IT systems and providing personalised clinical decision support. If properly implemented, such evolving systems promise to significantly improve the future quality, safety and efficiency of patient care, both inside and also outside the hospital.
Article
Full-text available
Aims To understand current experiences of vital signs monitoring of patients and clinical staff on a surgical ward, and views on the introduction of wearable ambulatory monitoring into the general ward environment. Design Qualitative study. Methods Semi-structured interviews using topic guides were conducted with 15 patients and 15 nurses on a surgical ward between July 2018 and August 2019. The concept of ambulatory wearable devices for clinical monitoring was introduced at the end of the interview. Results Three interconnected themes were identified. Vital sign data as evidence for escalation, examined nurses' use of data to support escalation of care and the implications for patients perceived to be deteriorating who have not reached the threshold for escalation. The second theme, Trustworthiness of vital sign data, described nurses’ practice of using manual measurements to recheck or confirm automated vital signs readings when concerned. The final theme, finding a balance between continuous and intermittent monitoring, both patients and nurses agreed that although continuous monitoring may improve safety and reassurance, these needed to be balanced with multiple limitations. Factors to be considered included noise pollution, comfort, and impact on patient mobility and independence. Introduction of the concept of ambulatory wearable devices was viewed positively by both groups as offering solutions to some of the issues identified with traditional monitoring. However, most agreed that this would not be suitable for all patients and should not replace direct nurse/patient contact. Conclusion Both patients and staff identified the benefits of continuous monitoring to improve patient safety but, due to limitations, use should be carefully considered and patient-centred. Impact Feedback from nurses and patients suggests there is scope for ambulatory monitoring systems to be integrated into the hospital environment; however, both groups emphasized these should not add more noise to the ward nor replace direct nursing contact.
Article
Full-text available
Background Timely recognition of the deteriorating inpatient remains challenging. Wearable monitoring systems (WMS) may augment current monitoring practices. However, there are many barriers to implementation in the hospital environment, and evidence describing the clinical impact of WMS on deterioration detection and patient outcome remains unclear. Objective To assess the impact of vital-sign monitoring on detection of deterioration and related clinical outcomes in hospitalised patients using WMS, in comparison with standard care. Methods A systematic search was conducted in August 2020 using MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL, Health Technology Assessment databases and grey literature. Studies comparing the use of WMS against standard care for deterioration detection and related clinical outcomes in hospitalised patients were included. Deterioration related outcomes (primary) included unplanned intensive care admissions, rapid response team or cardiac arrest activation, total and major complications rate. Other clinical outcomes (secondary) included in-hospital mortality and hospital length of stay. Exploratory outcomes included alerting system parameters and clinical trial registry information. Results Of 8706 citations, 10 studies with different designs met the inclusion criteria, of which 7 were included in the meta-analyses. Overall study quality was moderate. The meta-analysis indicated that the WMS, when compared with standard care, was not associated with significant reductions in intensive care transfers (risk ratio, RR 0.87; 95% confidence interval, CI 0.66–1.15), rapid response or cardiac arrest team activation (RR 0.84; 95% CI 0.69–1.01), total (RR 0.77; 95% CI 0.44–1.32) and major (RR 0.55; 95% CI 0.24–1.30) complications prevalence. There was also no statistically significant association with reduced mortality (RR 0.48; 95% CI 0.18–1.29) and hospital length of stay (mean difference, MD − 0.09; 95% CI − 0.43 to 0.44). Conclusion This systematic review indicates that there is no current evidence that implementation of WMS impacts early deterioration detection and associated clinical outcomes, as differing design/quality of available studies and diversity of outcome measures make it difficult to reach a definite conclusion. Our narrative findings suggested that alarms should be adjusted to minimise false alarms and promote rapid clinical action in response to deterioration. PROSPERO Registration number : CRD42020188633 .
Article
Full-text available
Objective To determine feasibility, in terms of acceptability and system fidelity, of continuous vital signs monitoring in abdominal surgery patients on a general ward. Design Observational cohort study. Setting Tertiary teaching hospital. Participants Postoperative abdominal surgical patients (n=30) and nurses (n=23). Interventions Patients were continuously monitored with the SensiumVitals wearable device until discharge in addition to usual care, which is intermittent Modified Early Warning Score measurements. Heart rate, respiratory rate and axillary temperature were monitored every 2 min. Values and trends were visualised and alerts sent to the nurses. Outcomes System fidelity was measured by analysis of the monitoring data. Acceptability by patients and nurses was assessed using questionnaires. Results Thirty patients were monitored for a median duration of 81 hours (IQR 47–143) per patient, resulting in 115 217 measurements per parameter. In total, 19% (n=21 311) of heart rate, 51% (n=59 184) of respiratory rate and 9% of temperature measurements showed artefacts (n=10 269). The system algorithm sent 972 alerts (median alert rate of 4.5 per patient per day), of which 90.3% (n=878) were system alerts and 9.7% (n=94) were vital sign alerts. 35% (n=33) of vital sign alerts were true positives. 93% (n=25) of patients rated the patch as comfortable, 67% (n=18) felt safer and 89% (n=24) would like to wear it next time in the hospital. Nurses were neutral about usefulness, with a median score of 3.5 (IQR 3.1–4) on a 7-point Likert scale, ease of use 3.7 (IQR 3.2–4.8) and satisfaction 3.7 (IQR 3.2–4.8), but agreed on ease of learning at 5.0 (IQR 4.0–5.8). Neutral scores were mostly related to the perceived limited fidelity of the system. Conclusions Continuous monitoring of vital signs with a wearable device was well accepted by patients. Nurses’ ratings were highly variable, resulting in on average neutral attitude towards remote monitoring. Our results suggest it is feasible to monitor vital signs continuously on general wards, although acceptability of the device among nurses needs further improvement.
Article
Full-text available
Background Patients undergoing esophagectomy are at serious risk of developing postoperative complications. To support early recognition of clinical deterioration, wireless sensor technologies that enable continuous vital signs monitoring in a ward setting are emerging. Objective This study explored nurses’ and surgeons’ expectations of the potential effectiveness and impact of continuous wireless vital signs monitoring in patients admitted to the ward after esophagectomy. Methods Semistructured interviews were conducted at 3 esophageal cancer centers in the Netherlands. In each center, 2 nurses and 2 surgeons were interviewed regarding their expectations of continuous vital signs monitoring for early recognition of complications after esophagectomy. Historical data of patient characteristics and clinical outcomes were collected in each center and presented to the local participants to support estimations on clinical outcome. Results The majority of nurses and surgeons expected that continuous vital signs monitoring could contribute to the earlier recognition of deterioration and result in earlier treatment for postoperative complications, although the effective time gain would depend on patient and situational factors. Their expectations regarding the impact of potential earlier diagnosis on clinical outcomes varied. Nevertheless, most caregivers would consider implementing continuous monitoring in the surgical ward to support patient monitoring after esophagectomy. Conclusions Caregivers expected that wireless vital signs monitoring would provide opportunities for early detection of postoperative complications in patients undergoing esophagectomy admitted to the ward and prevent sequelae under certain circumstances. As the technology matures, clinical outcome studies will be necessary to objectify these expectations and further investigate overall effects on patient outcome.
Article
Full-text available
Continuous vital signs monitoring in post-surgical ward patients may support early detection of clinical deterioration, but novel alarm approaches are required to ensure timely notification of abnormalities and prevent alarm-fatigue. The current study explored the performance of classical and various adaptive threshold-based alarm strategies to warn for vital sign abnormalities observed during development of an adverse event. A classical threshold-based alarm strategy used for continuous vital signs monitoring in surgical ward patients was evaluated retrospectively. Next, (combinations of) six methods to adapt alarm thresholds to personal or situational factors were simulated in the same dataset. Alarm performance was assessed using the overall alarm rate and sensitivity to detect adverse events. Using a wireless patch-based monitoring system, 3999 h of vital signs data was obtained in 39 patients. The clinically used classical alarm system produced 0.49 alarms/patient/day, and alarms were generated for 11 out of 18 observed adverse events. Each of the tested adaptive strategies either increased sensitivity to detect adverse events or reduced overall alarm rate. Combining specific strategies improved overall performance most and resulted in earlier presentation of alarms in case of adverse events. Strategies that adapt vital sign alarm thresholds to personal or situational factors may improve early detection of adverse events or reduce alarm rates as compared to classical alarm strategies. Accordingly, further investigation of the potential of adaptive alarms for continuous vital signs monitoring in ward patients is warranted.
Article
Full-text available
Objective: To highlight the scientific production related to the use of the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals. Method: An integrative review in the MEDLINE, LILACS, SCOPUS, Web of Science and EMBASE databases conducted in May 2019 with the following guiding question: What is known about the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals? Subsequently, the categorization, synthesis, and classification of the evidence levels of the included publications were performed. Results: In the 13 selected studies, the instruments adopted to assess the occurrence of adverse events were the Harvard Medical Practice Study, the Canadian Adverse Event Study, the Quality in Australian Health Care Study, and the Global Trigger Tool. Incidence ranged from 5.7 to 14.2%, while preventability ranged from 31 to 83%. Conclusion: Differences in incidence and preventability were found, showing different results in the quality of care provided, the information registered in medical records, the screening criteria used, and the assessments of the reviewers.
Article
Full-text available
Background: Continuous monitoring of vital signs using wearable, wireless devices may allow for timely detection of clinical deterioration in patients on general wards in comparison to the standard intermittent vital signs measurements. A large number of studies with many different wearable devices have been reported in recent years, but a systematic review is not available to date. Objective: The aim of this study was to provide a systematic review for healthcare professionals of the current evidence about validation, feasibility, clinical and cost outcomes of wireless wearable devices for continuous vital signs monitoring. Methods: A systematic and comprehensive search was performed using PubMed/MEDLINE, EMBASE, and CENTRAL from 2009 to September 2019 for studies that evaluated wearable, wireless, devices for continuous monitoring of vital signs in adults. Outcomes were structured by validation, feasibility, clinical and costs. Risk of bias was determined by Mixed Methods Appraisal Tool, QUADAS-2 or Quality of Health Economic Studies tool. Results: Twenty-seven studies were included which evaluated thirteen different wearable devices. Studies predominantly evaluated validation or feasibility outcomes of these devices. Only a few studies reported clinical outcomes and they did not report a significant effect. Cost outcomes were not reported in any study. The quality of included studies was predominantly rated as low or moderate. Conclusions: Wireless wearable continuous monitoring devices are mostly still in the clinical validation and feasibility testing phases. As yet there are no high quality large well controlled studies of wireless wearable devices available that show a significant clinical benefit or cost-effectiveness. Such studies are needed to help healthcare professionals and administrators in their decision-making regarding implementation of these devices on a larger scale in clinical practice or in-home monitoring. Clinicaltrial:
Article
Full-text available
Objective To provide an overview and critical appraisal of early warning scores for adult hospital patients. Design Systematic review. Data sources Medline, CINAHL, PsycInfo, and Embase until June 2019. Eligibility criteria for study selection Studies describing the development or external validation of an early warning score for adult hospital inpatients. Results 13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias. Conclusions Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice. Systematic review registration PROSPERO CRD42017053324.
Article
Full-text available
Background Digital capability, that is the ability to live, work, participate and thrive in a digital world, is imperative for nurses because increasingly nurses’ work and patient outcomes are influenced by technology. Aim To evaluate and synthesise the evidence regarding the development of digital capability in nurses and the strategies that support effective integration of digital skills into the workplace. Design Whittemore and Knafl’s methodology, following the preferred reporting items for systematic reviews (PRISMA) guidelines. Data sources CINAHL, Embase, PsychINFO, Medline (Ovid) and Pubmed databases were searched for articles published in English from 2008‐2019. Search terms included; digital capabil*, digital literacy, informatics, nursing informatics, health informatics, nurs*, knowledge, knowledge integration, competency, continuing education, nursing skills, workplace, work environment. Review methods A total of 35 studies were retrieved for quality assessment by two reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI‐MAStARI and JBI‐QARI). Minimum essential criteria and scores were agreed prior to appraisal. Results The 17 studies included comprised quantitative (n=7), qualitative (n=8) and mixed methods (n=2). Integration of digital capability in nurses’ workplaces is dependent on user proficiency and competence (theme 1). Nurses use technology to access data at the point of care, specifically accessing evidence to guide care (theme 2a) as well as accessing the medical records (theme 2b). Nurses have several concerns related to the use of technology at point of care (theme 3), some of which can be resolved through investment for implementation (theme 4). Conclusions There are key attributes of digitally proficient nurses. Nurses with these attributes are more inclined to use digital technology in their work. Involvement of the nurses as end users in the development of digital systems to ensure they are fit for purpose, alongside investment in professional development opportunities for nurses to develop digital capability, should be prioritised.
Article
Full-text available