Table 2. Barriers and Enablers to PEWS Implementation.
| Domain | Theme | Example | |
|---|---|---|---|
| Barrier | Enabler | ||
| Inner setting | Hospital characteristics | We’re a hospital of specialties, we treat more than 80 specialties and subspecialties; it’s difficult for them to be involved in all areas and in all projects (quality director, San Luis Potosi) | The implementation process of PEWS at [our hospital]...was faster, in a more organized way, we felt the support of everyone, maybe because it was a smaller hospital with fewer staff to organize and commit (implementation leader, Cuenca) |
| And also, the extra workload, not because of the project, but we’re a center that unfortunately is having more patients each time, from last year to this year, we experienced 20% to 30% increase in the flow of patients; with the same amount of staff, it was difficult (implementation leader, Xalapa) | Since we are an oncology hospital, we’ve always considered ourselves as a special hospital. In this state, we have many general hospitals and with specialties, but we’re sure we’re different; this is why we try to be updated and have good reception for those programs that strengthen our patient’s safety (nurse director, Xalapa) | ||
| Material resources | The main barriers [were] not having enough supplies to take vital functions properly or monitors, for example (implementation leader, Lima) | Yes, I think enough resources, adapted to our reality; for example, we had snacks during trainings and educator helped with the educational materials (nurse director, Cuenca) | |
| Because it’s a hospital with multiple specialties, the ICU is not exclusive for oncology, we share it with the other specialties, so sometimes the lack of space in the ICU is still an issue (implementation leader, San Salvador) | It’s never enough when we talk about resources. We’d love to have more, maybe to have monitors, more equipment….But it was enough to start with (implementation leader, Xalapa) | ||
| Human resources | The nurse’s time at the hospital is very limited…the nurse-patient [ratio] is 6:1, and at the medical center is 9-10 patients for every nurse. It was a huge challenge to try to implement a project when the nurse-patient [ratio] is not the right one (implementation leader, San Salvador) | The human resources that we have here, doctors, nurses, [were enough] to facilitate the direct communication and continuous training for the staff (implementation leader, Cuenca) | |
| Culture | Like we say here in Mexico, the staff has many tricks. They are used to do certain things, even though we know those are not the right ways to do it, and that has generated or may generate in certain moments a barrier for new ideas (implementation leader, San Luis Potosi) | This hospital is in constant [growth]…we are constantly trying, for the sake of the patient, to find the best technologies, the best trainings; there are investigation projects that are always running here (research director, Cuenca) | |
| What we saw at the beginning was that doctors put a little bit of resistance because very often we have that culture of I'm the doctor, and I'm the one who decides so we don’t allow anyone to tell us what to do (implementation leader, San Salvador) | I think the fact that it was started in pediatrics, that is a compact team, more united. I think that might have helped. But to make it faster…I think it was because of the nurses’ participation and that pediatrics is a united team inside the hospital (implementation leader, Xalapa) | ||
| Role of hospital leaders | The chief of nursing would put barriers and if she was doing that so the rest of the nurses would never feel this was something they should do (physician director, San Luis Potosi) | Once we had the support of the chiefs, it was part of our daily work and that’s how we managed the whole team to participate...finding the support of the chiefs and the institution. I think that pushed the project forward (implementation leader, Lima) | |
| Characteristics of individuals | Stage of change | I think the biggest barrier was the change of thinking. It’s not easy for the Salvadorian who has always been walking in the right side of the road to suddenly change and say to them, now walk on the left side (quality improvement coordinator, San Salvador) | The entire staff knew what was PEWS and what PEWS implied, so it was something very beautiful they already considered PEWS a part of the institution, part of the routine, something we had to do (implementation leader, Lima) |
| I think every change generates rejection, to take something out of their comfort zone, something they already have in their nurse routine to add a change, it always generates rejection (implementation leader, San Luis Potosi) | The staff’s acceptance, the willingness to implement the project, the dedication. It was an absolute dedication, in time, in study, in training…it was a time when people got very motivated and I think that was very helpful (implementation leader, Cuenca) | ||
| Skill using PEWS | There are many mistakes and errors we can make as nurses in the evaluation of the patients, or maybe we learned once in the university and we haven’t applied it again (implementation leader, Cuenca) | We see that sometimes we don’t do the evaluations correctly, with practice, we get to see those details and as far as I can see, the staff now applies the evaluation in an objective manner, there are very few mistakes now, almost none (implementation leader, Xalapa) | |
| Other characteristics | The staff is used to do things their own way since 20 or 30 years and they are not open to new ideas to improve the service (implementation leader, San Luis Potosi) | I think [it] is a hospital characterized by having a staff with high sensitivity and empathy with patients, so, they’re always looking for challenges and improvements, so patients can receive a better attention (research director, Xalapa) | |
| When we started the implementation of PEWS it was big challenge because I was conscious that some of them never rotated in pediatrics, they were not experts in pediatrics (nurse director, Lima) | I think young people are more open minded to be able to learn and implement new things. I think it facilitates the implementation of this and other programs (physician director, San Luis Potosi) | ||
| Outer setting | Health systems | We’re a third-world country, we don’t have enough funds for health and looking for a way to save money for the hospital (implementation leader, San Salvador) | In our country Peru, the morbimortality, especially in pediatric patients, is a national problem, I think that has been the motivation, I think all of this has intervened (physician director, Lima) |
| Experience collaboration | One of the assistant doctors that works with us, a rotation she did in Boston, she took this idea and made it happen based on the experiences from other places (physician director, Lima) | ||
| PEWS characteristics | Origin | Well, at the beginning they didn’t believe in the program, they thought it was a 1-person program that would benefit 1 person [physician leader] (nurse director, San Luis Potosi) | Being a project endorsed by St Jude, directed by St Jude, has helped in the development (implementation leader, Lima) |
| Evidence | Since we demonstrated from the beginning that this was something happening in various parts of the world and that it was working and that there were studies that supported it, I think we didn’t have that much resistance (implementation leader, San Luis Potosi) | ||
| Complexity | At the beginning I think they thought we weren’t going to make it, that it was going to be difficult, that they were going [to] have work overload, that they will have too many patients, many things (nurse director, San Salvador) | I think part of its success is because it’s very simple, you can do it by just looking at the patient (implementation leader, San Luis Potosi) | |
Abbreviations: ICU, intensive care unit; PEWS, pediatric early warning systems.