Intensive and Critical Care Nursing (2016) 34, 3341

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ORIGINAL ARTICLE

The experiences of nurses implementing

the Modied Early Warning Score and a
24-hour on-call Mobile Intensive Care
Nurse: An exploratory study
Siv K. Stafseth a,b,c,1, Sturle Grnbeck a,2, Tine Lien d,3,
Irene Randen d,3, Anners Lerdal e,f,

a
Division of Emergencies and Critical Care, Oslo University Hospital-Rikshospitalet, P.O. Box 4950 Nydalen,
NO-0424 Oslo, Norway
b
Department of Research and Development, Oslo University Hospital-Rikshospitalet,
P.O. Box 4950 Nydalen, NO-0424 Oslo, Norway
c
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
d
Department of Master and Continuing Education in Nursing, Lovisenberg Diaconal University College,
Lovisenberggt. 15, NO-0456 Oslo, Norway
e
Department for Patient Safety and Development, Lovisenberg Diaconal Hospital, Lovisenberggt. 17,
NO-0440 Oslo, Norway
f
Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo,
P.O. Box 1130 Blindern, NO-0318 Oslo, Norway

Accepted 31 July 2015

KEYWORDS
Clinical deterioration;
Critical care;
Qualitative research;
Vital sign monitoring
Summary
Aims and objectives: To explore experiences of nurses implementing and using the Modied
Early Warning Score (MEWS) and a Mobile Intensive Care Nurse (MICN) providing 24-hour on-call
nursing support.
Background: To secure patient safety in hospital wards, nurses may increase the quality of care
using a tool to detect the failure of vital functions. Possibilities for support can be provided
through on-call supervision from a qualied team or nurse.

Corresponding author at: Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, P.O. Box 1130 Blindern,

NO-0318 Oslo, Norway. Tel.: +47 22850550.

E-mail addresses: sistaf@ous-hf.no (S.K. Stafseth), stugro@ous-hf.no (S. Grnbeck), tine.lien@ldh.no (T. Lien), irene.randen@ldh.no
(I. Randen), anners.lerdal@medisin.uio.no (A. Lerdal).
1 Tel.: +47 23070726.
2 Tel.: +47 23073711.
3 Tel.: +47 22358200.

http://dx.doi.org/10.1016/j.iccn.2015.07.008
0964-3397/ 2015 Elsevier Ltd. All rights reserved.
34 S.K. Stafseth et al.

Design: This exploratory qualitative investigation used focus group interviews with nurses from
two wards of a university hospital in Norway.
Methods: A purposive sample of seven registered nurses was interviewed in focus groups. A
semi-structured guide and an inductive thematic analysis were used to identify interview themes.
Results: Three themes emerged: (1) experiences with the early recognition of deterioration
using the MEWS, (2) supportive collaboration and knowledge transfer between nurses and (3) a
new precise language using the score for communicating with physicians. The use of scores
and support were perceived as improving care for deteriorating patients and for supporting the
collaboration of nurses with other professionals.
Conclusion: In our study, nurses described increased condence in the recognition of deterio-
rating patients and in the management of such situations. The non-critical attitude, supportive
communication and interactive learning according to the MICN were essential elements for suc-
cess.
2015 Elsevier Ltd. All rights reserved.

Early Warning Score (MEWS) and an on-call nurse support

Box 1 Implication for Clinical Practice
Systematic use of MEWS and Mobile Intensive Care
Nurse supports nurse-to-nurse collaboration.
It provides standardised language for describing
patients status and thus facilitates nurse-physician
communication.
Learning in practice is highly recommended for
educational purposes, and the MICN provides on-
going learning opportunities for RNs caring for
patients at risk for deterioration.
Introduction
service (not a team), as implemented at a university hospital
in Norway.
Background
Clinical judgment and clinical bedside decision support
are essential for the early identication of deterio-
rating patients in hospital wards. The effectiveness of
track-and-trigger systems is dependent on appropriate
implementation, compliance and clinical response (Smith
et al., 2013). EWS has been developed, and according to
Smith et al. (2013), there are currently 33 different scoring
tools in use.

Technological and scientic advances have contributed
to the escalating costs of healthcare and thus to cost-
effectiveness pressures on healthcare delivery systems with
limited resources. Adverse events in hospitals can be trau-
matic for patients, lead to prolonged hospitalisation, have
life-threatening consequences and be costly. Serious adverse
events may be prevented by the early recognition and
response to clinical and physiological deterioration. Deteri-
oration symptoms can be detected at the bedside by nurses
and physicians (in this paper medical staff, doctors and sur-
geons). To better manage both patient safety and costs,
track-and-trigger systems have been introduced to facili-
tate the early identication of patients who are at-risk for,
or are deteriorating clinically (Bokhari et al., 2010). Various
track-and-trigger and support systems are currently in use
in hospitals, e.g., rapid response systems have been devel-
oped and implemented in Australia, the UK, Canada and
the USA (Gao et al., 2007). In a review of the impact of
in-hospital mortality, patterns of intensive care unit admis-
sion and usage, length of hospital stay, cardiac arrest and
other serious adverse events were evaluated (Alam et al.,
2014). The review concluded that a hospital-wide Early War-
ning Score (EWS) was useful and showed a positive trend
towards better clinical outcomes whether it was coupled
with an outreach team or not (Alam et al., 2014). The focus
of the present study is to gain more knowledge regarding
the experiences of ward nurses using a EWS, the Modied
Early Warning Score (EWS)
Historically, most EWSs include data on the pulse, blood
pressure, respiratory rate, temperature and central nervous
system function. Each parameter is scored and summed,
with higher scores indicating a more abnormal reading.
Subbe et al. (2001) demonstrated a system, MEWS, for
identifying at-risk medical patients, which included urine
output and deviation from normal blood pressure. The
results from the study indicated that the MEWS was feasibly
applied in acute medical units and was valid for identify-
ing patients requiring increased levels of care. Green and
Edmonds (2004) included MEWS in the ICU Liaison Nurse
standard assessment tool that was especially made for dis-
charge criteria from ICUs. The MEWS could also be used as
an effective prediction of outcomes in oncology patients
(Cooksley et al., 2012). An EWS can be used to predict when
it is necessary to transfer patients to ICUs in addition to
guiding the management of patients on the ward (Churpek
et al., 2012). There is no single validated EWS that can
be used for all diagnoses and there is a paucity of data
on the implementation and evaluation of its use in general
wards (Kyriacos et al., 2011). Researchers concluded that a
MEWS tool includes too few vital signs and includes subjec-
tive and intuitive signs of the patients condition (Kyriacos
et al., 2011). In the United Kingdom, the National Early
Warning Score (NEWS) was presented in the Royal College
Experiences of nurses implementing the MEWS and a 24-hour on-call MICN
of Physicians report (2012). The NEWS scores were settled
by consensus and differed in several areas; they include a
single, physiological measured extreme value in addition to
the aggregate score to initiate interventions, whereas other
EWSs commonly rely on one aggregated score. Urine output
is not included as a criterion. The clinical response to the
NEWS triggers a graded response protocol.
In addition, the cost of ICU care is high and admission to
the ICU can cause major distress for the patient. Sometimes
patients do not actually need to be transferred to the ICU
if they can receive the same or even more cost-effective
treatment on the ward by nurses with adequate competence
or competent support.
Critical Care Outreach Services
Outreach teams that are on call can range widely from
the support of one nurse for a few hours a week to a
consultant physician-led, multidisciplinary team providing
coverage 24 hours a day, seven days a week. The different
team structures make it difcult to compare the results
of implementing the EWS across studies (Baker-McClearn
and Carmel, 2008). Athifa et al. (2011) investigated the
Critical Care Nursing Outreach Service (CCOS) in Australia
for avoiding adverse events after ICU discharge and found
that the CCOS improved communication and enhanced the
transition process. Similarly, Baker-McClearn and Carmel
(2008) found that outreach services reduced ICU referrals,
contributed to smoother ICU discharges and improved col-
laboration between ward nurses and physicians. Green and
Edmonds (2004) described the development and introduc-
tion of an advanced practice nursing position from 1998
until 2004 in Australia and found that the ICU Liaison Nurse
bridged the gap between ICU and ward-based care. They
were also involved in the care of deteriorating patients
when transfer to the ICU was necessary, but only in the
daytime.
A meta-analysis (Chan et al., 2010) evaluating the effect
of rapid response teams on hospital mortality found a lack
of robust evidence. The comprehensive review from Massey
et al. (2010) showed inconclusive evidence of whether the
rapid response team reduced major events in ward patients,
although this may have been due to the system being under-
activated or underused by nursing staff. In contrast, Kyriacos
et al. (2011) found evidence of reduced mortality in observa-
tional studies of the use of MEWS. McNeill and Bryden (2013)
concluded in a review that a track-and-trigger system with a
sum score is preferred to a single parameter system, and the
team appears to be most effective when a clinician with crit-
ical care skills is in the lead. Ludikhuize et al. (2014) found
that an assessment of the use of the MEWS three times daily
resulted in a better detection of patients deterioration and
more reliably activated the Mobile Emergency Team (MET).
Clinical decision-making and assistance seeking by
nurses
In the hospital ward, clinical judgment and the recogni-
tion of vital signs are important skills for nurses and are
required for making good clinical decisions. How do ward
nurses obtain such skills? Tanner (2006) and McGaughey
35
(2009) address the need for nurses to discover, interpret
and respond to clinical situations rapidly. The experiences
of nurses with clinical decision-making have been explored,
with a focus on the uncertainty associated with calling
for assistance, being able to identify at-risk situations and
recognising changes in patients conditions (Odell et al.,
2009). A review of qualitative studies showed that ward
nurses frequently detected patient deterioration through a
process of intuitive knowledge. Nurses described difculty
articulating the patients critical condition to other profes-
sionals and obtaining support from a team or physician for
interventions (Ciof, 2000). The experiences of ward nurses
have been studied and showed that nurses often checked
with peers before calling the MET, and they articulated
a gut feeling associated with knowing when they needed
to call for assistance (Ciof, 2000; Young et al., 2008).
A general feeling of being worried about a patients
condition has been described as one of the most common
reasons for nurse referrals to the MET, rather than specic
clinical signs (Pattison and Eastham, 2012; Young et al.,
2008). Rattray et al. (2011) found that patients may receive
care too late if deterioration is not detected. Their study
showed that nurses used a combination of cues, the EWS and
clinical information, to make decisions. Cox et al. (2006)
found that more experienced nurses recognised the need
to obtain support, while inexperienced nurses tended to
wait for assistance. In a Canadian survey, 77% of the nurses
(N = 275) agreed that the MET was helpful in managing their
ill patients (Bagshaw et al., 2010). Simultaneously, 15% of
the nurses acknowledged a feeling of reluctance associ-
ated with calling the MET due to a fear of criticism. Making
valid clinical assessments and decisions about a patients
health status is important, and in practice, the process
can be quite complicated. In computer-presented clinical
scenarios, Thompson et al. (2007) conducted an analysis
of how nurses assess the risk of a critical event and how
nurses would intervene. They found large variations in the
nurses assessments. In their survey, Scherr et al. (2012)
found that only 10% of nurses had received education or
collaborated in patient situations with MET. In-depth inter-
views showed that both nurses and physicians had negative
feelings towards or were afraid of hostile reactions from col-
leagues when calling for MET (Shearer et al., 2012). Mattew
(2010) even described the necessity of a statement of MET
to not criticise nurses who call for assistance. McGaughey
(2009) and Randen et al. (2013) found that learning activities
must focus on attaining a deeper understanding of symptoms
and signs to help nurses recognise patients early problems.
Tanner (2006, p. 204) dened clinical judgment as an inter-
pretation or conclusion about a patients needs, concerns, or
health problems and/or the decision to take action (or not),
use or modify standard approaches, or improvise new ones
as deemed appropriate by the patients response. Pattison
and Eastham (2012) found that both practical critical care
experience and theoretical knowledge from teaching ses-
sions were benecial for making decisions. Mitchell et al.
(2010) showed the effect of educational sessions resulting
in a better understanding of when to call MET. It is there-
fore of interest to determine whether the implementation
of a track-and-trigger system can be useful for enhancing
nurses clinical judgments to identify and provide care for
at-risk patients.
36
Implementation of a track-and-trigger system
In the present study, the MEWS and a Mobile Intensive Care
Nurse (MICN) were introduced as the track-and-trigger sys-
tem. The system was implemented for a period of six months
from 2011 to 2012 in two general wards at Oslo Univer-
sity Hospital in Norway. The wards have acutely ill patients
with potential for deterioration, including those with sev-
eral transfers to the ICU; adverse events, such as cardiac
arrest; or requiring acute surgery. During the study, one
ward expanded from 16 to 28 beds and had patients with
haematological disorders requiring a haematopoietic stem
cell transplant or other treatments. The other ward with
25 beds had patients treated for gastro-surgical and urol-
ogy problems. During the study, this second ward included
patients with diagnoses of severe pancreatitis, who are at
risk for deterioration and have a high risk for admission to
ICU.
All MICN nurses were registered nurses (RNs) with two
years of postgraduate education in critical care nursing and
extensive experience in acute and critical care. The MICN
can, at any time, take a call and quickly respond with a
ward visit because they do not have patient responsibili-
ties when they are serving such an assisting function. If the
MICN, for any reason could not provide the service the ward
nurse should call the physicians directly. The costs for MICN
are in the ICU budget, and no extra nurses were employed.
The MICN is designed to be an easy line for collaboration ward, in 2012. The RNs, six women and one man, were
between nurses from the ICU and RNs on the general wards.
The hospital already has a specially trained team for car-
diac arrest, team for pain treatment, and our aim was to
enable RNs to use the track-and-trigger system for their
patients and thereby avoid situations of cardiac arrest and
other adverse events.
In a collaborative effort between Lovisenberg Diaconal
University College and the ICU at Oslo University Hospital, an
educational programme was developed for 120 RNs, 80 bach-
elor students in nursing and 40 post-bachelor students in a
critical care nursing training programme. A half-day course
was conducted by the MICN and focused on the MEWS assess-
ment and the availability of 24-hour on-call support. The
MICN could be contacted if the MEWS was >4 points or if the
RN was worried about a patient, for example, due to pain,
as measured with a numeric rating scale. According to the
study protocol, all patients at risk or patients in the acute
postoperative period should be assessed using the MEWS at
least every 8 hours until recovery. During the study, 37 calls
for MICN were registered in a book. Of the calls, approxi-
mately 70% reported a severe failure in vital signs, with a
MEWS >6 points. The main problem was respiratory failure or
cardiac/haemodynamic instability, resulting in several visits
to the ward. Treatment, including oxygen, suction and pain
relief, was handled in addition to contact with physicians on
the ward. Pain by itself can cause many symptoms and can
increase the scores in MEWS.
The current study was designed to build on the knowledge
obtained in prior studies and to expand our understanding
of nurses experiences in this area. Training sessions and
nursing observation and practice can be understood within
the context of the MEWS and the MICN, and it is of interest
for improving patient outcomes. The program was evaluated
using mixed methods for gathering evidence: a survey of RNs
S.K. Stafseth et al.
and students and focus group interviews with RNs from the
two wards.
Aims
The aims of the study were to: (a) explore RNs experiences
with the early detection and recognition of vital function
failures and (b) explore their experiences with the use of
the MEWS and the MICN.
Methods
Design
An exploratory qualitative study using semi-structured focus
group interviews to explore the experiences of nurses after
implementing the MEWS and the MICN, as well as an edu-
cational program focused on their use. To obtain a deeper
understanding of their perceptions and to allow discussion
regarding the decision-making process, we chose to conduct
interviews in focus groups (Polit and Beck, 2012).
Participants
A purposive sample of seven RNs was interviewed in two
focus groups of three and four nurses, one group from each
recruited by nursing unit managers to voluntarily participate
in the group interview on a specied day. Coincidence ren-
dered the selection of a mix of newly educated and expert
RNs. The ward operated on a rotation system, so variations
in nightday experience were automatically included. Two
of the participants had not been through the educational
program; they learned the MEWS from experienced nurses
at the bedside.
Data collection
The interviews were conducted after the study period at the
hospital in a secluded room while the RNs were on duty. The
duration of the interviews was approximately 60 minutes.
The theme for the interviews was not sensitive, and it
was assumed that the experiences of nurses would lead to
meaningful and deep discussions. Participants were asked
to describe their experience with the implementation of
the MEWS and the MICN on the ward and with the educa-
tional program. The thematic interview guide is presented
in Table 1. To increase validity, the moderator ensured that
the answers were correctly understood by summarising the
participants comments or asking: Did I understand you
correctly, you said . . .? At each interview, two intensive
care students were present as observers, taking notes and
asking clarifying questions at the end of the interview. The
interviews were audio taped and transcribed verbatim by a
professional secretary.
Ethics
The study was conducted in accordance with the Declara-
tion of Helsinki (World Medical Association, 2008). The local
Experiences of nurses implementing the MEWS and a 24-hour on-call MICN 37

audiotapes. All authors read the interviews. initial codes

Table 1 Thematic interview guide.
(Braun and Clarke, 2006) and themes were identied (see
Topic guide Table 3 for an example). The themes were reviewed, orga-
nised and named according to overarching themes before
How do you perform your observations of patients and their the report was produced. Of particular interest were themes
clinical/vital signs? about using the MEWS with at-risk patients and the outreach
Intuition team led by the trained MICN. Because no study has inves-
Equipment tigated RNs satisfaction with the MEWS and the 24-hour
Systematic routines on-call MICN, we used an inductive approach concerning this
Other theme. The authors discussed the analysis of the themes
What are your feelings in situation with patients at until agreement was obtained. Three themes emerged:
deterioration or at risk for deterioration?
Clinical competence
Anxiety or condence a) experiences with the early recognition of deterioration
Physicians not available and the MEWS,
How and when do you make contact for help or assistance? b) collaboration and transfer of knowledge between RNs
Colleagues or other health professionals and the MICN and
Waiting or action c) a new precise language using the MEWS for communi-
Where and how do you make notes regarding observations cating with the physicians.
in the medical report?
Can you describe your experiences after the
implementation of the MEWS and MICN?
The participants citations were translated to English and
Education, learning
numbered according to who was being cited. We used cita-
Changes
tions P1P7 to preserve anonymity.
Support, collaboration
Communication
Ultimately: are there other aspects related to the use of Results
MEWS that you nd important?
Not discussed today Experiences with early recognition of deterioration
and the MEWS

Patients at risk for deterioration will always be a concern

Table 2 Six phases of thematic analysis from Braun and
Clarke (2006).
1. Familiarising yourself with data
2. Generating initial codes
3. Searching for themes
4. Reviewing themes
5. Dening and naming themes
6. Producing the report
Ethics Committee for Medical Research approved the study
(PV 2011/15561). Information regarding the anonymity and
condentiality of the collected data was provided to partic-
ipants as well as the option of withdrawing from the study at
any time. Written informed consent was collected from all
participants. Both the audiotapes and transcriptions were
secured in a locker in the moderators ofce, and electronic
data were stored in the research server, in accordance with
hospital policy.
Analyses
The interviews were analysed thematically in six phases
(Table 2), as recommended by Braun and Clarke (2006).
Familiarity with the data was achieved through repeated
reading and listening to ensure that the right person was
matched to the right voice and to note when there were
pauses, interruptions or silence. To increase reliability,
the transcriptions were compared for accuracy against the
for nurses, but the nurses who attended the educational
programme generally found MEWS to be helpful for recog-
nising clinical deterioration. All participants could explain
the MEWS, and one (P1) described it as easy to learn,
self-instructive and actually pretty easy to use. One par-
ticipant (P5) was now more aware of respiration patterns,
the importance of both the frequency and movement of the
thorax, and no longer relied only on blood pressure. The
on-call physicians mostly asked for the pulse and blood pres-
sure but seldom the respiratory rate. One participant (P2)
mentioned the assessment of pain, indicating that she pre-
ferred to ask the at-risk patient about pain rst and, if that
was not a problem, then she used the MEWS. For each at-risk
patient, the nurses registered the MEWS and could see the
deterioration from one assessment to the next. One nurse
(P1) explained: before the education programme I was
afraid of calling for help from the ICU . . . maybe they did
not see the problem or I was not sure when to call or should
I wait? . . . Now I just explain the score and situation and get
advice from the MICN or they come for a visit. The moder-
ator asked her what she did before the study. The participant
answered: I talked to my good colleagues and they could
sometimes help me out and . . . sometimes the physician on
call was contacted. But it is not easy for them because they
seldom see or dont know the patients or they dont have
time to come and see the patient. Nowadays we have more
patients at risk and they are really critically ill. The feel-
ing of being worried about the patient was mentioned as
an opportunity to call regardless of the score obtained using
the MEWS.
38 S.K. Stafseth et al.

Table 3 Two examples of data extraction with applied codes.

Data extract Applied code

This project is both for learning and to obtain more facts/competence, such as Transferring knowledge
the MEWS, a tool that gives a number to explain vital signs and how to Collaboration
understand what is going on with the patient. Not only my feeling . . . I have Better words and easier to
better words and it is easier to explain what is going on. I called the MICN explain
and . . . I can also use my knowledge for my patients after transfer to ICU.
When the MICN came and conrmed my worries, we talked and I got some advice Communication with MICN
on what to do, and we had several conversations and follow ups during the
evening. For that situation, we felt safe and comfort . . . support from new
eyes from the MICN and someone to collaborate with.

Collaboration and transfer of knowledge between
the RNs and the MICN
The opportunity to make a call and obtain support from
experienced critical care nurses triggered the collabora-
tion. Patients being transferred from the ICU to the ward
require a close follow up, and the RNs explained that they
called the MICN without hesitation regarding patients who
were recently transferred from the ICU. One participant
(P7) said: I was happy for the MICN visit; he conrmed
what I saw and scored! He called for the doctor, and he
came immediately. Another participant (P1) had partic-
ipated in the educational session and used the MICN to
conrm the MEWS and for observations over time with sev-
eral scores (hourly). Were the scores correct? Together with
the MICN, they had a meeting and considered the whole
patient situation. The MICN did not take over the situa-
tion, he only conrmed and asked for collaboration by using
skills in communication and support and gave us treatment
suggestions. We learned and listened; hopefully I can use
this knowledge in other situations too. The approachable
style and non-critical attitude of the MICN and their prompt
responses in giving advice over the phone or reviewing the
situation in person were recurrent comments throughout the
interviews.
One participant (P4) had called the MICN about a criti-
cal situation with a patient whose MEWS was getting worse.
Together, they handled the situation, and after it was
resolved and the patient had recovered, the MICN stayed
with the RNs a little longer, offering additional support. The
RNs appreciated not being left alone in that situation. The
participants noted their need for the MICN as a supportive
colleague, commenting that they did not feel nervous or
uncertain seeking guidance from another nurse. Participants
saw particular need for support during the evening and night
shifts when there are few RNs who are sometimes under
a considerable workload pressure. The moderator asked,
What does the MICN do for the patient if you call them?
One (P3) RN who had called the MICN said: they listen
and ask for more information and go to see the patient
with me . . . once, he (the MICN) just adjusted the position
in bed and intervened with oxygen treatment . . . we waited
and the patient got better. We called the physicians for a
decision about an ICU transfer or not. The participants
also reported on experiences that were not so positive (P1):
I called the MICN, but did not reach anyone, so I had to
call the physician. Another (P2) said: The scores were
above 4 all the time, so we couldnt call the MICN every
time . . . our patients are really sick. One surprising result
was that some of the participants had never called the MICN
during the six months of the study.
The RNs from one ward made visits to the ICU if their
patients were under treatment and supported the ICU
nurses. RNs from the ward may have knowledge about and
a relation to their patients and families from earlier stays.
One nurse (P5) said: it is of interest to us and also for
learning purposes. We knew the patient and their family,
we have hope for them and can support the ICU! The RNs
explained, again, that they often found it easy to contact
and collaborate with ICU nurses. The participants were not
sure if they would have called for additional help if the team
consisted of both physicians and nurses, as they might have
waited longer to be sure of their observations and their deci-
sion to call. The participants asked for more education and
repeated training in the future.
A new precise language using the MEWS for
communication with physicians
The RNs were eager to tell us about the new precise
language they used. One participant (P3) said: before the
study I had difculty communicating the situation of deterio-
ration in patients; I told the physicians I felt something was
wrong . . . or I couldnt get exact words for the situation.
The RNs explained: it is easier now, pulse, and rate of res-
piration and so on . . . and the doctors understand the critical
setting and come faster to attend. In the study, vital signs
and the MEWS were recorded in a chart, showing the time
and trends for the scores. One RN did not use the MEWS in
the medical report, but she wrote the blood pressure and
pulse as she used to do before the study. She thought it was
a waste of time doing it twice.
In communicating with the MICN, the RNs reported the
MEWS and asked for help in making decisions. The partici-
pants said that the MICN on call only needed a short time
after the score was reported to understand the situation
and to know what was wrong with the patient. The RNs
described the MEWS as a useful tool for health care profes-
sionals and students. They wanted the MICN to be continued
and hopefully expanded to the entire hospital after the study
was nished.
Experiences of nurses implementing the MEWS and a 24-hour on-call MICN
Discussion
We found a common agreement among the RNs that using
the MEWS tool assisted them in their role as nurses and
that the collaboration with the MICN helped them to make
better decisions for their patients. Nurses should be proac-
tive in identifying patients at risk for failure according to
vital signs and thus avoiding situations of patient deteriora-
tion or cardiac arrest. Furthermore, the early identication
of patients who have critical care needs should enhance
clinical decision-making and thus might improve patient out-
comes (Alam et al., 2014). Bleyer et al. (2011) explored vital
signs from many observations and found that the MEWS was
not only valid but also a good predictor of mortality dur-
ing hospitalisation. Their results supported our decision to
include the MEWS in the current project. Recently published
results from Ludikhuize et al. (2014) supported the use of
the MEWS, despite others who reported that the NEWS had
a greater ability to discriminate patients at risk compared
to 33 other EWS tools (Smith et al., 2013). The participants
in our study considered it important to systematically mea-
sure vital signs, often using charts to more easily identify
trends before taking action. The RNs in this study could
choose to use the MEWS if they wanted and used it to reduce
their workload and to obtain assistance from the MICN. Hav-
ing clear criteria for when to use the MEWS would likely
have resulted in more systematic use. Reasons for giving RNs
this choice included their perception of increased workload
when few nurses were on duty and who had several ongoing
projects. These reasons could also be a barrier for the early
detection of vital failures.
All vital signs are important in the early detection of
patient deterioration. As stated in the interview, the physi-
cians most frequently asked for pulse and blood pressure,
but seldom requested the respiratory rate. This may lead to
an unreported respiratory status by nurses. Data from the
present study showed that deterioration of respiratory sta-
tus was the main problem in more than half of the cases.
Findings by Ludikhuize et al. (2012) showed a lack of docu-
menting respiratory problems in hospital wards. In having a
systematic approach for the observation of vital signs, our
nurses found the MEWS to be helpful. It will be difcult to
compare the newer NEWS tools that have different targets
and areas for the clinical setting (Badriyah et al., 2014).
Does this indicate a need for another reference or target for
calling? Or is a specialised unit for intermediary care a good
solution? One of the wards in our study established such a
unit one year after the project.
At our hospital, we chose to have a trained intensive care
nurse on call, the MICN. The MICN is observed as a low cost
and easy line of support and collaboration between nurses,
rather than a physician or an emergency outreach team. We
might prevent admissions in ICUs and save days and costs.
With the focus on patient safety, the opportunity to consult,
seek advice and obtain support in making clinical decisions
is critical in nursing. The RNs on the wards must be com-
fortable contacting the MICN, and the non-critical attitude
and style of the MICN were evident throughout the interview
data. The strength of the training program was that the MICN
was teaching about how and why to use the MEWS, so when
RNs called the MICN, they occasionally recognised the per-
son. Another strength was the follow up after a call or visit
39
on the ward and that the MICN never criticised the RNs for
their attempts to assess vital signs indicating patient deteri-
oration. Having experienced critical care nurses in the MICN
role was crucial to the programs effectiveness. The themes
derived from the interviews in this study are consistent with
those of Pattison and Eastham (2012), emphasising the sup-
portive role that the outreach team played throughout their
interactions and in varied situations. Reviews (Alam et al.,
2014; Kyriacos et al., 2011; Odell et al. 2009; Rowe and
Fletcher, 2010) have reported positive ndings of support
from outreach teams or the MET, but they also noted that
some nurses worried about calling the whole team. This non-
supportive attitude was conrmed in the studies by Scherr
et al. (2012) and Shearer et al. (2012). That was the main
reason for using a single, highly qualied nurse in the cur-
rent study, which also resulted in lower costs for the hospital
compared to a multidisciplinary team. The 24-hour support
from the MICN was a must, especially during evening and
night shifts, and nurses cited the wards lower stafng lev-
els as a primary reason for seeking support. In the study
by Athifa et al. (2011), the outreach team only functioned
during the daytime, even though hospitalised patients often
have critical needs after ofce hours. Nowadays outreach
team can function for 24 hours a day and seven days a week.
The RNs in our study perceived the reection-in-action
with the MICN as important, which is a dynamic way of learn-
ing. The MEWS gave a new precise language for the nurses
in communicating with both the MICN and the physicians.
Their contact with physicians was made easier by the pre-
cise language for vital signs, but it could also be benecial to
provide more information about the MEWS to the physicians
on call. The system for the MEWS and the MICN needs to be
implemented for all health care professionals on the wards,
not only for nurses, as performed in the present study.
RNs in our study reported that the MEWS tool improved
their ability to distinguish changes in a patients condition
and helped them in their clinical decision-making. These
ndings are consistent with those of a review by Kyriacos
et al. (2011), which concluded that: Recording vital signs
is not enough. Patient safety continues to depend on nurses
clinical judgment of deterioration (p. 311). The impor-
tance of clinical judgment was also supported by Pattison
and Eastham (2012), who found that intuition was the rea-
son for referral to the outreach team when the MEWS was
normal. Therefore, it is necessary for nurses to have the
option of calling for assistance whenever they are worried
about a patient.
Implementation studies often show an improvement of
nursing care and collaboration with physicians, although
hierarchical barriers are present (Shearer et al., 2012).
The teaching sessions in the present study focusing on
observations, assessments and management of the patient
contributed to nurses self-consciousness and condence.
For learning several techniques, as reported by Hammond
et al. (2012), the RNs had a CD and online quiz for train-
ing purposes. Simulation sessions are also recommended
to increase reection, condence and competence issues
(McGaughey, 2009; McGaughey et al., 2010; Rattray et al.,
2011). The university college in the present study now
includes the MEWS for the assessment of patients vital
statuses in simulation sessions for bachelors students and
intensive care nurse students in the Masters programme
40
to prepare them for clinical practice. Reection requires
the nurses understanding of the relationship between nurs-
ing assessments and interventions and patient outcomes
(McGaughey, 2009; Tanner, 2006). In the current study,
reection was performed in nurse-to-nurse collaboration in
the clinical eld during and after the situation and might be
as effective as a simulation session. The university hospital
decided in 2015 to implement the NEWS and have continued
the MICN service for several departments.
Limitations and strengths
The results of this study should be considered in light of its
limitations and strengths. Although the number of partic-
ipants included in the study was small, they had a diverse
range of nursing experience and represented diverse experi-
ences from the two wards serving different types of patients.
It is unclear whether the participants had more positive
views about the MEWS and the MICN than non-participants,
although the interviews did contain negative comments in
some areas. There are only a few studies that have been
published using a qualitative approach with a focus on the
contribution of knowledge to the organisational processes
that have an impact on how to identify, respond and manage
deteriorating patients in the hospital setting. The strengths
of our study were that two authors performed the initial
analysis and all of the authors participated in the nal stages
of the analysis, which enhanced the rigor and trustworthi-
ness of the study. Six out of seven participants were cited
in the results. Our results from two wards have led to other
hospitals using the MEWS and the MICN or MET.
Conclusion
In our study, the nurses described increased condence
in the recognition of deteriorating patients and in the
management of such situations. The non-critical attitude,
supportive communication and interactive learning by the
MICN were essential for success. The use of the standardised
MEWS and the MICN supported RNs in their clinical deci-
sions. The result suggests that on-call support by one critical
care nurse should be available 24 hours a day and may be
especially important during evening and night shifts.
Conict of interest
The authors have no conict of interest to declare.
Acknowledgements
The study was funded by Lovisenberg Diaconal University
College and Oslo University Hospital.
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