The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review

Aim: Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking. 

Design: A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021). 

Data Sources: CINAHL, Medline, Embase, PyscInfo. 

Review Methods: Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data. 

Results: Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool. 

Conclusion: EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms. 

Impact: This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care. 

No Patient or Public Contribution: This is a systematic review, and therefore, comprises no contribution from patients or the public.