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In total, 16 interviews were conducted with nurses from three teaching hospitals. Their characteristics are presented in Table .
Table 1 Characteristics of the 16 participating nurses
Full size table
InterventionAll three hospitals used continuous monitoring on the nursing ward, though for different patient groups. Hospital 1 used continuous monitoring for bariatric patients after surgery, Hospital 2 for patients who had undergone heart- or heart valve surgery, for clinically unstable patients, and for vulnerable elderly patients, and Hospital 3 used it for patients with pulmonary, neurological, gastrointestinal, and liver diseases. Two out of three hospitals used the Philips Biosensor [] to measure heart rate and respiratory rate. The third hospital used a sensor from SensiumPatch [] to measure heart rate, respiratory rate and temperature. The Philips Biosensor has a battery life of 4 days, while that of the Sensium Patch is 4–5 days.
Experiences with continuous monitoring on the nursing ward and in the home settingIn total, we selected 1068 quotes covering 27 CFIR constructs and 1 UTAUT construct. A total overview of the rating of all quotes from all respondents can be found in Additional files (nursing ward) and Additional file (home setting). We quantified the findings, and present the most prevailing results below.
On the nursing ward, 19 CFIR constructs and 1 UTAUT construct were identified by at least 8 nurses. Of these, 10 constructs had a positive influence, 5 were mixed, and 5 had a negative influence on implementation of continuous monitoring on the nursing ward. In the home setting, seven constructs were identified by at least 8 nurses, 2 of which were projected to have a positive influence, 2 a negative influence, while 3 were mixed. Constructs that were mentioned by at least 8 (out of 16) nurses are described below and presented in Table .
Table 2 Continuous monitoring on the nursing ward and expectations for use in the home setting (N = 16)
Full size table
Intervention characteristicsEvidence strength and quality Experience on the nursing wardThis domain refers to respondents’ practical experiences on the nursing ward and perceptions of the available evidence (e.g. from use in practice) for continuous monitoring. Statements about the importance of evidence strength and quality of continuous monitoring on the nursing ward were made by almost all respondents (14/16, 88%), with a strong negative influence on implementation. Respondents referred especially to the lack of available evidence to substantiate the use of continuous monitoring with a limited number of vital signs, e.g. only heart-rate and respiratory rate, in their patient population. Gathered evidence based on practical experiences was also found to be a negative influence, especially because measurements of vital signs by the sensor often did not correspond with measurements by another monitoring device used in daily practice. Technical issues (e.g., system was not working or not reliable) were also mentioned. Despite a negative sentiment, two nurses mentioned positive experiences with regards to early detection of deterioration (see Additional file ).
“We need to gain trust in the idea that heart rate and respiratory rate together provides sufficient information to conduct interventions. That is still difficult for me.”
Expectations for continuous monitoring in the home settingHalf of the nurses (8/16, 50%) were not convinced that there is enough available evidence for continuous monitoring in the home setting. This was caused by predominantly negative experiences based on use on the nursing ward. Additionally, they still need to gain trust in the system and the new way of working (see Additional file ).
“We are not even close to monitoring patients at home. Even here [on the nursing ward] it has not worked 100% of the time.”
Relative advantage Experience on the nursing wardA score of advantages for continuous monitoring were mentioned by almost all nurses (15/16, 94%). Advantages included data availability, patient safety, early discharge, higher turnover, higher quality of measurements, and support of the clinical view. Early detection of deterioration (12/16, 75%) as well as time and efficiency (10/16, 63%) were also seen as advantages. They stated the intervention saves them time as it eliminated the need for measuring vital signs manually during routine rounds.
“You have a continuous view on the patient. I think that is most important, you can detect early deterioration”
Expectations for continuous monitoring in the home settingNurses (9/16, 56%) foresee a number of advantages for the use of continuous monitoring in the home setting including data availability, early discharge, higher turnover or lower cost, early deterioration, time or efficiency benefits, and patient safety.
“The advantage is that people don’t need to spend the night here in the hospital. I think this also saves healthcare costs.”
Trialability Experience on the nursing wardThis domain includes statements on the ability to pilot the intervention. On the one hand, conducting a pilot was perceived positively (3/16, 19%), because the pilot made it possible to gain experience with continuous monitoring. On the other hand, it was perceived negatively (3/16, 19%), because the pilot setting led to additional tasks and duplications in registration due to the use of multiple systems.
“We conducted a pilot on the nursing ward…I think for a certain number of patients. Based on that pilot we wanted to see if it would be meaningful.”
Complexity Experience on the nursing wardComplexity refers to the perceived difficulty of the intervention. All nurses (16/16, 100%) brought up aspects related to the high degree of complexity of the intervention, and overall complexity was seen as a (strong) negative influence on implementation. The negative rating was especially due to the duration of the intervention (13/16, 81%), perceived difficulty (8/16, 50%), and the number of procedural steps (8/16, 50%). The duration of the intervention relates to the additional time involved with using it, for example to attach and activate the sensor.
“First, we had to open the system, search for the patient in the system. That will already take approximately 5 minutes, so it takes extra time.”
Design quality and packaging Experience on the nursing wardThe design quality and packaging includes statements regarding the quality of the sensor (e.g, flexibility and attachment to the body), the system (e.g. scanning and connection with sensor) and data availability (e.g. gaps in data availability). The majority of the nurses (13/16, 81%) was not satisfied with the quality of the sensor, for example because of detachment of the sensor from the patient’s body. They were also not satisfied with the quality of the system (3/16, 19%), and data availability (3/16, 19%). Positive elements about the quality of the sensor were only mentioned by a small number of nurses (5/16, 31%). Examples of such positive elements include good attachment of the sensor to the body and flexibility of the sensor.
“Our target population was sweating a lot after surgery, and we noticed the sensor would come off…”
Outer settingPatient needs and resources Experience on the nursing wardThis construct includes factors affecting patients as a result of continuous monitoring in the nursing ward. This was seen as having a positive influence on implementation. One third of the nurses (5/16, 31%) perceived that patients on the nursing ward felt safer when they were monitored continuously, and that they were not burdened by the sensor (5/16, 31%). A minority (3/16, 19%) mentioned that the sensor may be inconvenient for some patients, for example due to skin irritation.
“There were also patients that felt safe: ‘so you monitor my values 24 hours per day. So even if you are not in my room, you monitor me’. That gave patients a feeling of safety.”
Expectations for continuous monitoring in the home settingThe majority of the nurses (10/16, 63%) mentioned that the intervention can be beneficial for patients because they can recover in their own home. Although 31% (5/16) of the nurses expect that continuous monitoring will make patients feel safe at home, the majority (10/16, 63%) think that early discharge with continuous monitoring might also cause patients to feel insecure or anxious. Adequate patient information is considered an important facilitator (2/16, 13%).
“I think that people will recover better at home. I also think they will sleep better in their own bed, because that is more pleasant.”
Inner settingNetworks and communication Experience on the nursing wardThis domain includes nurse preferences for and experiences with communication about the implementation of the intervention. Most nurses (10/16, 63%) were positive about executing a task together with a colleague. They perceived this as a facilitating factor to practice the use of the sensor. Nurses were also positive about both formal communication (8/16, 50%), such as planned information meetings, and informal communication (5/16, 31%) with colleagues.
“During the planned meetings we could get together and share experiences, we also had frequent mail contact but the moments together were the most pleasant.”
Tension for change Experience on the nursing wardTension for change encompasses statements on the need to change the current situation of monitoring on the nursing ward, such as the current practice of using MEWS to detect patient deterioration. Although according to 31% (5/16) changing the current situation would be beneficial e.g. the respiratory rate can be measured by a device instead of manually by nurses, 50% (8/16) did not feel the need to change the current situation. They were satisfied with the current monitoring and especially the use of the Modified Early Warning Score (MEWS).
“These check-ups, the MEWS, are really useful during acute situations. You can really compare with other check-ups or with deteriorating patients, so I am used to working with the MEWS and I think it is quite nice.”
Compatibility Experience on the nursing wardThis domain relates to the extent to which the intervention is compatible with existing work processes and systems []. Multiple (sub)categories were distinguished including compatibility with work processes and the use of systems, change in work, and perceived risks. Compatibility with work processes was rated negatively by most nurses (12/16, 75%). This can be explained by increased workload (4/16, 25%). For example, in case of deteriorating vital signs, nurses needed to check the patients and perform extra check-ups. Some sensor limitations were also not compatible with work processes, according to 6 nurses (6/16, 38%). For instance, the sensor could not measure blood pressure. Also, the sensor could not be used for patients with a pacemaker, when diagnostic tools such as a CT scan were used, or while the patient was taking a shower. Almost half of the nurses (7/16, 44%) thought that with continuous monitoring their work would not change and would not be affected, especially because they think their clinical view is still needed in addition to continuous monitoring. Six nurses (6/16, 38%) reported risks of continuous monitoring including a lack of the clinical view (4/16, 25%).
“So at some point you could see a deviation in a patient, which you couldn't see with your clinical view alone, but to really be sure how the patient was doing you still had to go and take the measurements. So that was an additional task…”
Expectations for continuous monitoring in the home settingCompatibility was perceived as a negative influence on implementation of continuous monitoring in the home setting. Half of the nurses (8/16, 50%) thinks that continuous monitoring in the home setting will negatively change their work. According to 44% (7/16) of nurses, the intervention will have a negative effect on their relation and contact with patients, because there will be less personal contact due to patients’ shorter stay in the hospital. In total, 50% (8/16) is negative about compatibility with work processes. Nurses expect workload to increase (5/16, 31%) if they have to monitor patients in the home setting in addition to taking care of patients on the nursing ward. Nearly all nurses (15/16, 94%) think that continuous monitoring in the home setting involves risks including a lack of the clinical view, occurrence of complications in the home setting, when complications remain unnoticed (for too long) and technical issues (e.g., Wi-Fi connection or defective sensor). Nurses also perceive using the sensor for patients with low health literacy or poor coping mechanisms as a risk.
“There are definitely risks in the home setting. There must always be somebody who can take action if a patient calls or when you receive an alarm with the measurements of this patient. These are the measurements of this patient, who is responsible for taking action? There are quite a number of challenges [regarding monitoring in the home setting].”
Relative priority Experience on the nursing wardThis is defined as the degree to which nurses perceived continuous monitoring to be a priority in the organization and their department. Although the responses varied, most nurses (11/16, 69%) thought that the implementation of continuous monitoring would be a priority for the hospital. However, the priority on the nursing ward itself varied during implementation; 19% (3/16) considered it a priority during implementation, 19% (3/16, 19%) thought it was not a priority. All three hospitals conducted a pilot; 19% (3/16, 19%) mentioned that the priority decreased due to the unsuccessful pilot, and that there was a lack of priority (6/16, 38%) on the nursing ward after the pilot had ended.
“I think priority is high, because a lot of manpower and money is dedicated to it.”
Goals and feedback Experience on the nursing wardAll respondents (16/16, 100%) could explain the aim of the intervention i.e. early detection of deterioration and the prospect of early discharge with continuous monitoring in the home setting.
“Eventually, the goal is to discharge a patient early and to monitor them at home”
Learning climate Experience on the nursing wardLearning climate refers to the degree to which nurses feel it was possible to give input, whether their input was valued, sufficient opportunity was given to try out the new intervention, sufficient time was available for learning, and how they felt about making mistakes. It was possible to give input (9/16, 56%) and the input was valued (12/16, 75%). Almost all nurses (12/16, 75%) had enough time for training. However, their perceptions about the possibility to test the intervention and whether they felt safe to try the intervention and make mistakes varied.
“It was a pilot and it was no direct risk for the patient. We also performed the normal checks, so you had a good view of the patient and patient safety was not at risk”.
Available resources Experience on the nursing wardThis domain refers to the available resources and time for implementation. Nurses’ experiences varied, 81% (13/16) thought there were sufficient additional resources such as a dedicated project team and technical support. The majority (11/16, 69%) did not receive extra time for the intervention and 37% (6/16) reported that there were not enough human resources available during implementation. In particular, there was a lack of dedicated nurses.
“There was a project team with supervisors and researchers and somebody from the technical department.”
Expectations for continuous monitoring in the home settingIn total, 38% (6/16) thought that the current staffing is insufficient to handle the additional tasks for continuous monitoring in the home setting, and that extra human resources (4/16, 25%) would be beneficial for implementation.
“If you also have patients here, you don’t have time for the patients at home. You need an extra person per shift, responsible for monitoring [in the home setting]”
Access to information and knowledge Experiences on the nursing wardAccess to information and knowledge included access to a manual and training on how to execute tasks associated with the intervention. Overall, this was rated positively by almost all nurses (15/16, 94%), especially a manual was perceived to be helpful. In total, 63% (10/16) was positive about the training. However, four nurses (4/16, 25%) were less satisfied, reasons being that a lot of information was given at once and they felt that there was insufficient opportunity to practice during the training.
“The manual was changed frequently, with new tips and things. That was very useful!”
Expectations for continuous monitoring in the home settingIn total, 75% (12/16) of the nurses think that information, for example a decision tree, or training would be beneficial for continuous monitoring in the home setting.
“I think we need a manual on what to do with which complaints. It needs to be unequivocal.”
Characteristics of individualsKnowledge and beliefs Experiences on the nursing wardThis domain included statements on nurses’ beliefs about and attitudes towards continuous monitoring. Nurses were predominantly positive (7/16, 44%) about continuous monitoring on the nursing ward. In total, 25% (4/16) was not positive about the intervention.
“I think it is a very nice development. When I see it in practice, I think it could be possible…there are a lot of patients that could just go home.”
Expectations for continuous monitoring in the home settingNurses’ beliefs regarding continuous monitoring in the home setting varied; 56% (9/16) was positive about continuous monitoring in the home setting and they think it is a positive development, though 38% (6/16) was less enthusiastic about the development, especially because of the change in providing care.
“I think this is a logical development in the sense that you always keep considering how care can be organized differently; you evolve with the time, technology develops rapidly, and I can understand that you start thinking about how you can monitor people at home, does that result in early discharge, and what can be done safely.”
Other personal attributes Experience from use on the nursing wardThis domain includes personal characteristics affecting implementation such as competence, age, employment, and experience with the intervention. In total, 75% (12/16) mentioned personal characteristics that will contribute to the implementation, for example (younger) age (2/16, 13%). Also, according to 63% (10/16) of nurses, experience with the new intervention tasks will be beneficial, for example to execute tasks correctly and at a more rapid pace.
“The more often you do it, the easier it will become and you will get into a routine.”
ProcessFormally appointed internal implementation leaders Experience from use on the nursing wardSix nurses from all three hospitals mentioned that a formally appointed internal implementation leader, often a project leader, was appointed to coordinate the intervention project. This was seen as positive by 44% (7/16) of the nurses because of the support and motivation they received.
“The project leader was accessible, and visible on the nursing ward….I think that is important especially at the start, that somebody is always available to answer your questions”
Champions Experience from use on the nursing wardChampions were mostly referred to as “key users”, a group of nurses with specific involvement and focus on this project. Champions were reported to be present in all three hospitals and their presence was appreciated by more than half (10/16, 63%) of all nurses, for example for practical support.
“We had key-users who helped us attaching and connecting the sensor.”
Reflecting and evaluation Experience from use on the nursing wardOver half of the nurses (9/16, 56%) were positive about the evaluation of the intervention’s implementation. They reported that evaluations, conducted during or after the implementation period, were completed in (team) meetings or that evaluation forms were used. This provided them with insights into the status of the implementation project. Almost 40% (6/16) was not involved in an evaluation or would have preferred an evaluation.
“We discussed it each day in the daily evaluation. How is it going, is the connection working, are the check-ups good, do you notice differences, do you feel positively or negatively about it. A lot of attention was paid to it.”
Facilitating conditions (UTAUT) Experience from use on the nursing wardFacilitating conditions concern the extent to which nurses perceive that technical infrastructure is adequate to support the intervention. This was considered negatively by half of the nurses (8/16, 50%). This was mainly due to a bad Wi-Fi connection (7/16, 44%), which was the main reason for discontinuing the pilot in two hospitals. Lack of interoperability with already existing systems, for example with the Electronic Medical Record (EMR), was also seen as a negative aspect by 25% (4/16).
“The Wi-Fi was a problem. Sometimes the sensor did not connect and we had to restart the whole system. So that was the reason it did not work out.”
Suggestions and technical conditions for further development of continuous monitoring on the nursing ward and in the home settingSuggestions for further developmentIn total, 12 nurses (12/16, 75%) provided suggestions for further development of continuous monitoring in the hospital and the home setting. Seven nurses (7/16, 44%) mentioned that they need additional parameters for continuous monitoring inside and outside the hospital, for example blood pressure or oxygen saturation. Other suggestions for improvement of continuous monitoring in the home setting include: agreements upon responsibilities for continuous monitoring in the home setting (3/16, 19%), personalized target values of vital parameters to prevent false alarms (2/16, 13%), and a dedicated contact person (2/16, 13%).
Conditions for continuous monitoringTo ensure successful intervention, interoperability with already existing systems (e.g. EMR) is perceived as important by nurses (8/16, 50%). This could contribute to (future) implementation and reduce nurses’ workload at the same time, by eliminating the need to manually register the sensor measurements in the EMR. Other conditions for continuous monitoring include properly working and reliable technology (network, sensor, etc.) (6/16, 38%), which will also lead to (extra) added value of this intervention. In addition, patients’ home situation should be ready (1/16, 6%), and patients should have the necessary skills (2/16, 13%) to use the sensor, before continuous monitoring can be implemented at home.