Why might nurses miss people’s ‘danger signs’ at night? – Dr Jo Hope

We know that nurses miss or delay taking patients’ vital signs (such as pulse, temperature and blood pressure) at night. Until now, no one knew why.

The NHS expects hospitals to use ‘Early Warning Scores’ to measure how ill someone is. These are based on the observation of ‘vital signs’ – measurements of things like pulse, temperature, blood pressure and breathing speed. The higher the score, the more often someone’s vital signs should be checked. This is so staff can spot the early danger signs of someone becoming very unwell, in time to help them.


Your local hospital will probably have an ‘early warning protocol’ that says how often people should be checked according to their early warning score. At higher levels observations will need to be done in the middle of the night. Despite this, we know that nurses are much less likely to do the observations that are expected to be done at night.

Our research set out to ask nurses about why they might skip or delay taking vital signs at night. We spoke to nurses and health care assistants from wards who took observations mostly on time, sometimes on time or who often missed them at night.

Staff told us it was hard to keep patients safe while making sure they got a decent amount of uninterrupted sleep. They agreed that the most unwell patients should be checked most often. However instead of taking observations according to the early warning protocol, they used their clinical judgement, juggled timings around other ward expectations or skipped observations to avoid waking other patients.

Fully qualified Registered Nurses said they used clinical judgement to decide if a patient should be woken – but healthcare assistants, who have no formal training, also said they did this. People with some long term lung diseases always have a high early warning score, so staff found it hard to justify waking them to take observations. The hospital did not expect patients at the very end of their lives to be observed at night. But patients who were not expected to recover were supposed to be woken at night, which staff felt was unfair.


Some wards had their own rules about how often patients should be checked, or knew doctors wanted ‘a fresh set of observations’ at the end of the night shift. This could lead to observations expected by the protocol to be delayed or missed to allow longer blocks of uninterrupted sleep.

Nursing teams would sometimes miss observations on one patient if they might wake others around them. Some staff members told us that people with dementia – who could become distressed when woken – might have their danger signs missed at night. This was concerning as this very vulnerable group might be left at greater risk of becoming very unwell overnight without anyone realising. However some wards took great care to make sure this did not happen.

Our work highlighted some important issues. We thought nursing teams need to document clearly why they miss taking some observations at night. Hospital teams need to check that people with dementia and lung disease are not having their ‘danger signs’ missed during the night. Early warning scores and hospital plans might need to be changed so they make sense for people with lung disease and others whose early warning scores are not expected to improve.

Read Jo and her colleagues’ paper here (it’s open access so everyone can read it): http://onlinelibrary.wiley.com/doi/10.1111/jocn.14234/full

2 thoughts on “Why might nurses miss people’s ‘danger signs’ at night? – Dr Jo Hope”

  1. These are such good reasons for not taking observations at night. We must resist a protocol to insist on people being disturbed at night in order to take observations. Disturbing people’s sleep is likely to hinder recovery. The answer should be in finding new ways to make these observations in a less intrusive manner!

    Liked by 1 person

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