Why vital signs observations are delayed and interrupted on acute hospital wards: A multisite observational study

Background: Vital signs monitoring is key to identifying deteriorating hospital patients. However, adherence to monitoring protocols is limited, with observations frequently missed or delayed. Previous studies of interruptions and delays to vital signs observations have been descriptive, with none attempting to conceptualise the types of tasks that are prioritised over vital signs observations. Objective: This paper aims to explore how nursing teams perform vital sign observations on acute hospital wards and conceptualises which types of work delay or interrupt them. Design: Non-participant observational study. Setting(s): Four hospitals in the south of England. Methods: Eligible adult wards (surgical and medical) within each hospital were randomly sampled for inclusion. Four sets of two-hour daytime observation sessions were undertaken on each ward. Two observers recorded structured and unstructured observations (open comments, field notes) on a tablet with adapted QI Tool software. We collected data over 128 h, including 715 sets of vital signs observations and 1127 interruptions. We undertook a qualitative content analysis of interruptions and delays to planned vital signs observations using both structured and unstructured observations. Results: We identified eight reasons why vital signs were delayed or interrupted: fixed routines, staff availability, bundled care, proximity-related activities, collaborative care, patient inaccessible or unavailable, requests for or responses to time-critical activities, or limited context available. We propose a new concept of 'temporal status.' Flexible care (vital signs observations, 'bundled care' and 'proximity-related care') has a low temporal status so is delayed in favour of higher temporal status activities (fixed routines and time-critical care). Conclusions: Our findings could explain why vital signs taken early in the morning and evening are least likely to be postponed, as there may be fewer competing tasks with a higher temporal status at these times. Our work also challenges binary conceptualisations of interruptions as 'beneficial' or 'detrimental', recognising the complexity of nursing care decisions on a moment-by-moment basis. Our new framework suggests the lower temporal status of vital signs observations (and other flexible care) means they are delayed by higher temporal status tasks during daytime shifts in acute hospitals, regardless of their clinical priority. Registration: 10863045, ISRCTN (6/8/2019).