Provider Emotions Surrounding Clinical Deterioration Events and the Associated Impact of Pediatric Early Warning Systems in Hospitalized Pediatric Oncology Patients Open Access

Abstract

INTRODUCTION: Pediatric oncology patients have a high rate of clinical deterioration and often require critical care. Patient deterioration events are distressing for providers, and little is known about how Pediatric Early Warning Systems (PEWS) impact provider emotional responses to deterioration events. The aim of this sub-analysis was to examine provider emotions around clinical deterioration events and assess PEWS impact on emotions.

METHODS: Semi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care providers who had recently participated in a patient clinical deterioration event at St. Jude Research Hospital (N=42 participants) in Memphis, Tennessee or at Unidad Nacional de Oncología Pediátrica (N=41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants’ native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content using MAXQDA software.

RESULTS: Emotions around patient deterioration, including concern, fear, and frustration, were reported across all disciplines at both hospitals. Three themes emerged from data analysis including topics regarding provider emotions around deterioration and care escalation, impact of PEWS on emotions, and confidence and clinical judgment. Elevated PEWS were concerning for intensive care providers, floor providers, and nurses. The concern resulted in increased provider alertness and attention. Persistently elevated PEWS scores resulted in various emotions, including a misleading sense of comfort. PEWS scores were linked to increased confidence in clinical judgment among nurses from both institutions. However, nursing judgment did not transcend objective evidence at UNOP. While most of the emotions expressed by providers were negative, some positive emotions, including comfort and understanding, manifested. Emotions expressed did not differ based on hospital resource-level.

CONCLUSIONS: Providers experience a range of emotions when faced with clinical deterioration. Elevated PEWS scores can exacerbate concern among providers by indicating that a patient is sick, but PEWS also instill an autonomy among nurses to escalate care. Studying provider emotions can enhance provider’s course of treatment and patient care around clinical deterioration events.

Table of Contents

Table of Contents

CHAPTER 1: INTRODUCTION...........................................................................1

1.1      Introduction and Rationale......................................................................1

1.2      Problem Statement..................................................................................3

1.3      Purpose Statement...................................................................................5

1.4      Research Objectives.................................................................................5

1.5      Significance Statement............................................................................5

1.6      Definition of Terms..................................................................................6

CHAPTER 2: LITERATURE REVIEW...................................................................8

2.1      Pediatric Oncology and PEWS..................................................................8

2.2      The Role of PEWS in Early Identification.................................................9

2.3      PEWS and Clinical Judgment...................................................................10

2.4      Emotional Influences on Provider Judgment...........................................11

CHAPTER 3: MANUSCRIPT...............................................................................14

ABSTRACT.........................................................................................................16

INTRODUCTION................................................................................................16

Setting................................................................................................................17

Population..........................................................................................................18

Study Design and Analysis.................................................................................18

Ethical Considerations.......................................................................................19

RESULTS.............................................................................................................20

Provider Emotions Around Patient Deterioration and Care Escalation..............21

Impact of PEWS on Emotions.............................................................................23

Confidence and Clinical Judgment.....................................................................27

DISCUSSION.......................................................................................................28

CONCLUSIONS...................................................................................................31

CHAPTER 4: RECOMMENDATIONS....................................................................33

REFERENCES.......................................................................................................36

APPENDIX 1: PEWS MATERIAL...........................................................................40

Supplemental Figure 1: Escala de Valoración de Alerta Temprana (EVAT) PEWS Reference Tool................40

Supplemental Figure 2: Escala de Valoración de Alerta Temprana (EVAT) PEWS Escalation Algorithm......41

Supplemental Figure 3: St. Jude Advanced Warning Score (SJAW) PEWS Reference Tool............................42

Supplemental Figure 4: St. Jude Advanced Warning Score (SJAW) PEWS Escalation Algorithm..................43

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Oncology Health Sciences, Public Health
Keyword	PEWS early warning systems pediatric emotions qualitative research oncology
Committee Chair / Thesis Advisor	Karen Andes, Emory University
Committee Members	Asya Agulnik, St. Jude Children's Research Hospital Dylan Graetz, St. Jude Children's Research Hospital

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