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Nurses face ‘dilemma’ between safety and fewer obs at night to avoid disturbing patients


Nurses are deviating from early warning scoring systems and taking fewer vital signs at night so they do not disrupt patients’ sleep, which could be posing a risk to patient safety, according to a new study involving a hospital in England.

Researchers from the universities of Southampton, Portsmouth and Bournemouth, highlighted that completing observations was key to reducing avoidable deterioration and that early warning scores were often used to decide how frequently this should be done.

“Efforts were made to support the longest possible period of uninterrupted sleep”

Study authors

But their study, based on interviews with 17 nursing staff at a district general hospital in England, found staff varied this routine at night to allow patients to sleep for longer.

While the frequency of night-time observations was mostly determined by clinical judgement, some nurses suggested they would also take fewer vital signs for non-clinical reasons, such as if patients had dementia and were more likely to disturb others when woken.

The researchers also found unqualified staff were sometimes making such judgements, which they described as concerning.

Many nursing staff told researchers the number of observations they recorded at night took into account the patient’s appearance, other physiological signs, what was considered normal for them, and knowledge about the condition.

“Higher acuity scores were used… but vital signs observations were not as frequent as the protocol required”

Study authors

Those taking part in the study – 13 registered nurses, two healthcare support workers and two student nurses who also worked as support staff – said it meant there could be more or fewer vital signs taken compared with the number required by the early warning score protocols.

“Higher acuity scores produced by the protocol calculation were used as part of this decision but vital signs observations were not necessarily taken as frequently as the protocol required,” said the researchers.

“Instead efforts were made to support the longest possible period of uninterrupted sleep,” they stated in the Journal of Clinical Nursing.

All of the nursing staff – who worked on general medical and surgical wards – said supporting patients to sleep was a core part of their job, with some noting its importance for recovery. But they also said taking vital signs was key to their role, meaning they faced a dilemma.

Only one study participant claimed she had never woken someone at night to take vital signs observations – but noted that she would if they had interrupted breathing due to sleep apnoea.

Another participant, who was based on a medical ward, said a nurse in charge of a shift had asked her not to wake patients to do vital signs observations.

“[For patients with COPD] one predictable abnormality…could trigger a greater number of observations”

Study authors

Meanwhile, the research revealed that patients with chronic obstructive pulmonary disease or dementia were more likely to be at risk of under-monitoring, compared with the early warning score requirements.

For patients with COPD, “one predictable vital sign abnormality (such as oxygen saturation) could trigger a greater number of vital signs observations,” said the study authors, suggesting it affected how often they were checked.

Patients with dementia were more likely to disturb others on the ward if woken, which meant some nurses may deliberately avoid taking vital signs, they noted.

In addition, among patients whom staff judged to be nearing the end of their life – but were not yet formally receiving care in line with this diagnosis – regular monitoring was felt to be too intrusive by some “given that halting deterioration was not the clinical aim”.

The academics behind the study said it was concerning that “unqualified personnel” were taking vital signs and sometimes making clinical judgements to inform the frequency of observations.

They said more research was needed to find out if this was common practice and how it was affecting patient safety.

It was also “most concerning” that patients with dementia – who may be less able to verbalise concerns about deterioration – may have fewer observations taken at night, said the researchers.

Some nurses prioritise patients rest at night over monitoring their vital signs

Some nurses prioritise patients rest at night over monitoring their vital signs

This was because the reasons given by staff were not clinical and either related to not wanting to wake other patients, fear of causing distress, or increasing workload, said the study paper.

The researchers acknowledged that the evidence for the frequency of observations set by early warning scores was still developing.

But they warned that widespread belief that scores could be deviated from may threaten patient safety.

This was because unwarranted changes to the number of observations may became “socially acceptable” at ward level, which risked “delegitimising the whole system” of early warning scores.

It may also lead to staff being told they should adhere to targets, meaning they end up taking vital signs unnecessarily – such as with patients nearing the end of life, said the study paper.

While the evidence is developing, academics recommended nurses involve other professionals when making clinical judgements about whether to adjust the frequency of observations – and recording their reasons for doing so.


Readers' comments (3)

  • (1) - I have concerns about: NHS NATIONAL EARLY WARNING SCORES (NEWS) (ONE SIZE FITS ALL) especially in relation to Care of the Elderly which costs the NHS millions and my reasons are as follows:

    (a) - TEMPERATURE: NEWS allege that temperatures between 36.1-38C is normal and scores = 0........ No trained professional would ever think that any elderly patient with a temperature of over 36.9C-37.2C is normal.

    (b) - PULSE: NEWS allege that a pulse rate between 51-90 is normal and scores = 0....... No trained professional would ever think that any elderly patient with a pulse rate of 51 is normal.

    (c) - BLOOD PRESSURE (BP): NEWS allege that a systolic BP rate between 111 - 219 is normal and scores = 0....... No trained professional would ever think that any elderly patient with a systolic BP over 160 is normal. - I am unable to determine what the NEWS allege is normal for the diastolic reading?

    (2) - NHS expenditure has amounted to millions on admissions over the age of 65 years, but NHS abide by the NEWS (implemented by Royal College of Physicians) which seems to be completely disproportionate to NURSE TRAINING. I am unable to comprehend such NEWS (scores) of = 0.


    (3) - September 2016 - Lecturers at Plymouth University have disagreed with the Royal College of Physicians findings with the NEWS and have informed all student nurses that they have a duty of care to act expediently for their patients and just because the baseline clinical observations may equate to a score of “0”, this does not mean that the patient is fine…… Nurses must act in accordance to how they have been trained re: clinical observations and the normal range.

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  • I think the main point around obs at night is communication. Where they are necessary at night - I try to explain to my patients in advance what the nightly schedule will be. If they are a patient who is unlikely to deteriorate and they have capacity and give me an indication that they would prefer not to be woken - then I explain the risks and benefits - respect their decision and document.

    For patients with dementia or who lack capacity but are stable and have been for some time (and again are unlikely to suddenly deteriorate) - I would err on the side of allowing them to sleep due of its therapeutic effects - and because of the role that disturbed sleep plays in exacerbating delirium.

    There has to be an element of professional judgement.

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  • A study of 17 nurses is very limited. Can you really draw conclusions from such a small number? Also it took 3 universities for such a small number.

    From my experience patients obs are often taken far more often than NEWS indicates. There seems to be a blanket ‘every 4 hours’ rule.

    I feel patients need to be given better food and an environment that is more conducive to sleep. Patients seem to always be tired as they never seem to be left in peace for more that 3 or 4 hours.

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