The problem of recognising the deteriorating patient is a complex and multifaceted issue. The issue is conducted in five major steps, which include education, monitoring, recognition, call for help, and response (Resuscitation Council UK, 2021, p. 11). The current UK legislation and policies related to the topic are the Nursing & Midwifery Council (NMC) and National Institute for Health and Care Excellence (NICE). The latter is based on evidence-based recommendations and guidelines, which involve adapting healthcare services, improving quality of care, promoting health, and preventing illnesses (National Institute for Health and Care Excellence, 2022a). Relevant legislation from NICE is titled “Acutely ill adults in hospital: recognising and responding to deterioration” with reference number CG50 published in 2007 (National Institute for Health and Care Excellence, 2022b). The key driver behind the legislation is an aim to reduce the hospital stay for patients by ensuring quick and complete recovery (National Institute for Health and Care Excellence, 2007). The issue is important to the patient as well as the system on the basis of patient safety and avoidance of complaints. Under the legal framework of NICE, three key core quality standards apply. These include emergency and acute care in over 16s, rehabilitation after critical illness in adults, and acute kidney injury (National Institute for Health and Care Excellence, 2007).
Another major piece of national policy and legislation is NMC. The latter was designed as a critical part of the Health Act of 1999, which belongs to a category of secondary legislation complementing the core legal framework (Nursing & Midwifery Council, 2022). In the case of recognising deteriorating patients, NMC states that nurses must have an ability to interpret as well as recognise key signs of physical and mental health deterioration (Nursing & Midwifery Council, 2010, p. 8). The recognition must be promptly followed by an effective response leading to health improvement, patient safety, and patient comfort (Nursing & Midwifery Council, 2010, p. 8). Key drivers of the legislation are NMC standards, accountability, cost, safety, and quality of care in regard to the patient (Nursing & Midwifery Council, 2018). Similar to NICE, it is important for NMC to ensure a high degree of safety levels for the patients to avoid patient dissatisfaction in the form of complaints alongside the additional risks of health deterioration. In addition, longer hospital stays of patients incur massive costs on healthcare organisations, which provide more incentives to recognise and prevent health deterioration.
UK’s national quality assurance is strongly tied to new scoring systems, accountability in practice, reduction in hospital stays, and improvement of patient experience (Norton, 2019). Commissioning for Quality and Innovation (CQUINS) focuses on extra quality improvement objectives through financial incentives, where the core elements are better patient outcomes, facilitation of quality-oriented culture, continuous improvement in quality, and appraisal and reward for excellence (NHS Cambridge Community Services: NHS Trust, 2017). CQUINS is directly supported for a broader national integration and a proven standard for effective operational delivery methodological frameworks. Its core strength is the fact that CQUINS facilitates the implementation of rather non-complex solutions, such as simple and direct interventions.
One example of a quality assurance system would be an organisational audit by NHS England, and NHS Improvement is relevant to the topic due to the comprehensiveness of the document (Norton, 2019). For the quality assurance systems relevant to the chosen topic, the Framework for Quality Assurance (FQA) establishes streamlined steps to emphasise the maximisation of professional standards through regulations and appraisals (Norton, 2019). The framework allows medical professionals to understand quality assurance processes, such as risk assessment and incident reporting, to structure them within the organisation and workplace with consideration to the nursing associate roles (Nursing & Midwifery Council, 2019). More specifically, the FQA is an audit that found that an outstanding degree of medical professional engagement in health deterioration prevention, as well as patient satisfaction, improved in three consecutive years (Norton, 2019, p. 5). One of the key factors is the FQA’s emphasis on competence of prompt recognition of patient deterioration.
Another quality assurance system relevant to the topic of recognising patient deterioration is Portsmouth Hospitals NHS Trust’s clinical IT system based on risk assessment and incidence reporting (Portsmouth Hospitals NHS Trust, 2011). The system primarily focuses on detection, recognition, and response aspects of the topic (Portsmouth Hospitals NHS Trust, 2011). It utilises a more automated and doctor-independent approach by monitoring key health indicators with the use of technology. Unlike the FQA, the clinical IT system overcomes the most challenging part of the recognition of deterioration, which is human resistance to organisational change and human error (Portsmouth Hospitals NHS Trust, 2011).
However, both the FQA and clinical IT systems put a great deal of focus on early sign recognition in order to minimise the resources needed for a patient since the earliest detections lead to the most effective preventions. In other words, audits provide a more comprehensive picture of the overall situation in regards to quality assurance, but incidence reporting enables a more precise assessment of each case and patient. When it comes to risk assessments, they are predictive by design, which makes them ideal candidates for the earliest forms of detection, but such systems need to be adjusted to reduce false positive recognitions. Clinical effectiveness of evidence-based practice, as well as related procedures and policies, supports quality assurance by enabling higher validity and reliability of data. The latter follows the Pareto principle or 80:20 rule, where evidence allows to focus on 80% of patient improvements caused by 20% of input measures (NHS England and NHS Improvement, 2021). The role of a trainee nurse associate or TNA is to be accountable in regard to complaints and evidence-based practice. A TNA needs to be aware of complaint policies, identify problematic elements in patient experience, adhere to core procedures and policies, and be aware of one’s current competence levels (NHS Northern Care Alliance, no date).
When it comes to recognising patient deterioration, root cause analysis or RCA can be applied more systematically to identify the underlying problems to improve quality. It is stated that when the RCA investigations take place, the areas of focus include the care provision time and staff involvement (NHS Devon Partnership, no date, p. 3). The framework of RCA is based on determining what happened, understanding why an incident took place, and findings ways to reduce the chances of similar occurrences in the future. These efforts are conducted through five steps, which include problem definition, data collection, possible cause identification, root cause identification, and solution recommendation as well as implementation (NHS Foundation Trust, no date). For example, missing an early recognition window of patient health deterioration can be caused by infrequent staff checks or poorly operating equipment, where the root cause can be inadequate resource allocation with no focus on equipment and employees.
NHS Improvement Model is an important quality improvement and change management model based on seven key steps. These include leadership by all, spread and adoption, measurement, project and performance management, motivation and mobilisation, system drivers, and improvement tools (NHS England, no date). However, one should be aware that the quality improvement and change management model of NHS is not prescriptive, which means that some steps might not be as critical for specific cases (NHS England, 2020). When it comes to patient deterioration recognition, the core steps relevant include measurement, system drivers, and improvement tools. Detecting early signs of the issue needs precision, which can be enhanced through modern instruments for monitoring vital health indicators (ACSQHC, 2022). Measurement defines the process of recognising patient deterioration since a specific set of changes need to occur to justify the response.
Any improvement process, especially quality of care, is greatly facilitated through feedback. Both patient and public feedback are ideal measures of assessment and evaluation of the overall quality of care (Nursing Times, 2018). Patient feedback enables healthcare professionals to determine whether or not patient experience is at a satisfactory level. Public feedback provides a more systematic evaluation of the healthcare teams, facilities, and organisations. In the case of patient deterioration recognition, patient feedback can show the effectiveness of early sign detection (Patient Safety First, no date). Therefore, quality improvement and change management are similar to the patient and public feedback in regards to the search for continuous quality increase (NHS, no date). However, the difference lies in the overall approach, where feedback-based measures are reflective, whereas change-related actions are proactive.
The role of TNA in quality improvement is to be highly accountable and be able to work within team environments. In addition, they need to be competent at promptly recognising key areas of improvement from the feedback they receive from their team members and supervisors. The latter statement is critical because trainee nurse associates develop by learning from and observing others, such as role modelling (Nursing & Midwifery Council, 2018a). TNAs need to adhere to the NMC Code and core standards of care, which include accountability, promotion of health, monitoring and providing care, working in teams, care quality and safety improvement, and integrated care contribution (Nursing & Midwifery Council, 2018b).
Personal Leadership for Quality
When it comes to recognising patient deterioration, resilience is crucial. I maintain my ongoing resilience in my practice by focusing on five key areas. These include my personal style, having emotional intelligence, role modelling, being constantly resilient, and continuing my professional development and learning (Nursing & Midwifery Council, 2021). In the practical sense, I focus on self-care, de-brief, and Schwartz rounds, and the latter is particularly vital for me since they provide me with space where I can share my vulnerabilities and internal problems (The Schwartz Centre, (no date). When I need to respond to incidents, adverse events, or challenging situations, my role as well as required knowledge and behaviour as a TNA involve role modelling, reporting the incidents, and adhering to leadership. In addition, it is essential to be aware of my burnout and compassion fatigue. In addition, I attentively focus on the sphere of control primarily, but secondarily, I expend a smaller amount of my mental and physical energy on the sphere of influence (The Management Centre, 2021). However, I do not waste my time and effort in a sphere of concern where I have no control.
As someone who wants to become a leader in my field of interest, I recognise leadership implies being an experienced professional, innovator, motivating force, and role model for others. Therefore, role modelling for TNAs is critical not only to be able to perform their duties as responsibly and effectively as they can but additionally to develop leadership qualities within themselves. I always try to use expert feedback assessments in the analysis of the quality of medical care since it is important and appropriate. An effective and efficient system for monitoring the quality of services provided significantly improves the culture, level, and end result of medical care for patients.
I should state that the activities of TNAs in my field are aimed at maintaining the health of deteriorating patients on the principles of agreement and mutual responsibility. The list of medical services provided includes monitoring the development of identification deterioration factors, as well as knowledge of personal competencies and responsibilities, and carrying out preventive measures. The complex therapeutic and preventive measures allow the health worker, in most cases, to prevent the formation of complicated forms of diseases. However, the fundamental principle of the work of the healthcare professional in general practice remains the identification of key factors of deterioration.
Summary and Conclusion
In conclusion, the learning outcomes based on the topic of recognising deteriorating patients were presented. The quality issue was identified as recognition of patient deterioration. Quality assurance and improvement topics were covered in relationship with the topic of interest. The key elements of personal leadership for quality are accountability, resilience, and role modelling.
National Institute for Health and Care Excellence (2007) Acutely ill adults in hospital: recognising and responding to deterioration.
National Institute for Health and Care Excellence (2022a) NICE guidelines.
National Institute for Health and Care Excellence (2022b) Guidance, NICE advice and quality standards.
NHS (no date) Managing patient feedback.
NHS Cambridge Community Services: NHS Trust (2017) Commissioning for quality and innovation (CQUIN).
NHS Devon Partnership (no date) How do we investigate serious incidents?
NHS England (2020) The change model guide.
NHS England (no date) Change model.
NHS England and NHS Improvement (2021) Pareto.
NHS Northern Care Alliance (no date) Trainee nursing associates.
Nursing & Midwifery Council (2010) Standards for competence for registered nurses.
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Nursing & Midwifery Council (2018a) Read The Code online.
Nursing & Midwifery Council (2018b) Standards of proficiency for registered nursing associates.
Nursing & Midwifery Council (2019) Quality assurance framework for nursing, midwifery and nursing associate education.
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Nursing & Midwifery Council (2022) Our legislation.
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