title: Validation of a modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool: A mixed methods study.
abstract: OBJECTIVE
  To develop and validate a modified Situation-Background-Assessment-Recommendation communication tool incorporating components of the Cape Town modified early warning score vital signs chart for reporting early signs of clinical deterioration.
  
  
  BACKGROUND
  Reporting early signs of physiological and clinical deterioration could prevent "failure to rescue" or unexpected intensive care admission, cardiac arrest or death. A structured communication tool incorporating physiological and clinical parameters allows nurses to provide pertinent information about a deteriorating patient in a logical order.
  
  
  METHODS
  Mixed methods instrument development and validation.
  
  
  METHODS
  We used a sequential three-phase method: cognitive interviews, content validation and inter-rater reliability testing to validate a self-designed communication tool. Participants were purposively selected expert nurses and doctors in government sector hospitals in Cape Town.
  
  
  RESULTS
  Cognitive interviews with five experts prompted most changes to the communication tool: 15/42 (35.71%) items were modified. Content validation of a revised tool was high by a predetermined ≥70% of 18 experts: 4/49 (8.2%) items were modified. Inter-rater reliability testing by two nurses indicated substantial to full agreement (Cohen's kappa .61-1) on 37/45 (82%) items. The one item achieving slight agreement (Cohen's kappa .20) indicated a difference in clinical judgement. The high overall percentage agreement (82%) suggests that the modified items are sound. Overall, 45 items remained on the validated tool.
  
  
  CONCLUSIONS
  The first modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool developed in South Africa was found to be valid and reliable in a local context.
  
  
  CONCLUSIONS
  Nurses in South Africa can use the validated tool to provide doctors with pertinent information about a deteriorating patient in a logical order to prevent a serious adverse event. Our findings provide a reference for other African countries to develop and validate communication tools for reporting early signs of clinical deterioration.
authors.affiliation: Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Debora
authors.initials: D
authors.lastname: Burger
authors.affiliation: School of Human and Health Sciences, Swansea University, Wales, UK.
authors.forename: Sue
authors.initials: S
authors.lastname: Jordan
authors.affiliation: Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Una
authors.identifier: http://orcid.org/0000-0003-1611-8014
authors.initials: U
authors.lastname: Kyriacos
mesh_terms: D003142:Communication; D003422:Critical Care / Q000379:methods; D018450:Disease Progression; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods* / Q000451:nursing; D015203:Reproducibility of Results; D063189:Symptom Assessment / Q000295:instrumentation / Q000379:methods*; D055986:Vital Signs
keywords: Situation-Background-Assessment-Recommendation; deterioration; failure to rescue; modified early warning score; reliability; validity