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https://doi.org/10.1186/s12912-022-00837-x
RESEARCH
Nurses’ experiences withcontinuous vital
sign monitoring onthegeneral surgical ward:
aqualitative study based ontheBehaviour
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.
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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
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Page 2 of 11
Leenenetal. 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 [1–3]. 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 [5–8]. 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 [12–17]. 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]
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Leenenetal. 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 andparticipants
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 37.5min (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]
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Leenenetal. 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 andcoaching onthejob
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).
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Leenenetal. 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 ofvital 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:
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Leenenetal. 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 fornursing 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 ofalarms
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
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Leenenetal. 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 andcompatibility withclinical workow
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 inrelation totheCOM‑B
e five generated themes were mapped onto the
COM-B model (Table1). 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
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Leenenetal. 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’ [32–34]. 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
Leenenetal. 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 le1.
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
Leenenetal. 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
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