A realistic evaluation of early warning systems and acute care training for early recognition and management of deteriorating ward-based patients

  • Jennifer McGaughey

Student thesis: Doctoral ThesisDoctor of Philosophy


Rapid Response Systems (RRS) have been implemented nationally and internationally to improve patient safety in hospital. The implementation of the Early Warning Systems (EWS) and acute care training in practice is essential to the success of Rapid Response Systems but is dependent upon nurses utilising EWS protocols and applying Acute Life-threatening Events: Recognition and Treatment (ALERT) course best practice guidelines. To date there is limited evidence on the effectiveness of EWS or ALERT as research has primarily focused on measuring patient outcomes (cardiac arrests, ICU admissions) following the implementation of a Rapid Response Team. The aim of this study was to evaluate factors that enabled and constrained the implementation and service delivery of Early Warnings Systems (EWS) and acute care training in practice in order to provide direction for enabling their success and sustainability.

The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of Realist Evaluation research which allowed empirical data to be gathered to test and refine Rapid Response System programme theory. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records.

Data synthesis found similar regularities or factors enabling or constraining successful implementation across the case study sites. Findings showed that personal (confidence; clinical judgement; professional accountability; personality), social (ward leadership; communication), organisational (workload; time pressures; staffing levels and skill-mix), educational (constraints on training and experiential learning) and cultural (delegation of observations, referral hierarchy; rigid recording practices) factors influenced the impact of EWS and acute care training outcomes. There were also differences noted between medical and surgical wards across both case sites.

RRS theory refinement using realist evaluation explained what works, for whom in what circumstances. Future service provision needs to consider improved staffing levels and skill mix of qualified nurses on medical wards; flexible implementation of protocols underpinned by empowerment and clinical judgement; on-going experiential ward-based learning and interprofessional educational opportunities during acute care training to enable the success and sustainability of Rapid Response Systems.
Date of AwardJul 2013
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SponsorsQueen's University Belfast
SupervisorBronagh Blackwood (Supervisor), Peter O'Halloran (Supervisor) & Sam Porter (Supervisor)


  • Early warning systems
  • rapid responses system
  • medical emergency team
  • critically ill patients
  • adults
  • hospital

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