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Patient safety is fundamental to nursing and remains a central goal of the NHS. The breakdown in communication and the inability to detect deterioration, which were found in the Francis Report (2013), show that safety cannot be reduced to the work of individual nurses but requires tools, teamwork, and facilitating systems (NHS, 2019). This essay is devoted to two significant factors that affect the safety in acute care: risk assessment tools and communication. Structured monitoring of deterioration is done with the help of tools like NEWS2, yet their effectiveness relies on efficient escalation and collaboration (RCP, 2017; NMC, 2018). Theoretical views, such as Maslow’s Hierarchy of Needs (1987) and Peplau’s Interpersonal Relations Theory (1997), enhance the appreciation of the role of communication in reassuring patients and therapeutic communication. These domains are also positioned in the integrative review by Redley et al. (2022) within the framework of more global harm-prevention measures, relating to personal practice and the safety culture in general. The main point that is being made here is that patient safety is a result of a combination of structured tools, interpersonal skills, and organisational support.
Risk assessment is the core of safe nursing practice, which guarantees timely identification and intervention of patient deterioration. The National Early Warning Score 2 (NEWS2) is the standardised acute illness monitoring tool used in the NHS to minimise unnecessary variation and enhance escalation of care. It needs to be critically examined in its rationale, clinical application, population implications, and systemic limitations to determine its implications on safe practice.
NEWS was initially implemented to correct the discrepancy in the identification of deterioration amongst NHS Trusts. Before its creation, local tools were inconsistent, e.g., the Modified Early Warning Score (MEWS), in that a septic patient could be escalated in one Trust and ignored in another (RCP, 2017). Although authoritative, the RCP (2017) guideline was mostly expert-opinion-based and not founded on empirical trial evidence (CASP appraisal). Standardisation produced a common language of risk, though standardisation does not mean safety is assured- degradation depends on many factors, such as communication and context.
NEWS2 was created to fill the gaps that were noted in the original NEWS. Changes were made to the oxygen saturation levels of patients with COPD, and the introduction of a new parameter of confusion (RCP, 2017). Although these changes were a response to emergent evidence, uptake has been patchy across Trusts, and there has been a failure to interpret COPD baselines adequately.
NEWS2 allocates scores to six parameters: the respiratory rate, oxygen saturation, blood pressure, pulse, temperature, and level of consciousness (RCP, 2017). Although systematic, this physiological orientation does not pay attention to behavioural signs of agitation, pain, or distress, which can be paramount in patients with learning disabilities. Nurses, therefore, have to supplement quantitative scoring with a holistic assessment. There are thresholds of escalation (020): the higher the score, the sooner the review should be conducted.
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NEWS2 is deployed in both acute hospital settings and community care, and in small proportions of mental health and care home settings. This consistency facilitates the process of communication with one another during the transfer (RCP, 2017; Redley et al., 2022). Nonetheless, it is possible that universal application is not appropriate; e.g., mental health populations tend to express deterioration differently.
It has been shown that NEWS2 helps to detect and escalate earlier and has better outcomes in the form of fewer cardiac arrests and better recognition of sepsis. It is strong in terms of standardising communication among the services. Nevertheless, the overuse may lead to alarm fatigue and mechanical use (Alhmoud et al., 2021).
In patients with COPD, the NEWS2 SpO 2 thresholds decreased inappropriate escalation (RCP, 2017). Nevertheless, the mistakes continue to exist even when the baselines of individuals are not known (Mehdipour et al., 2021). Nurses should thus encourage the recording of individualised parameters. In racially diverse populations, pulse oximetry is less accurate in dark skin, and it may result in missed hypoxia. Nurses need to be able to put readings into context and escalate when presentation is contrary to device data. Automatic escalation on scores may conflict with palliative goals in end-of-life care (Redley et al., 2022).
The success of the NEWS2 relies on the competence of staff. An example of parameters that are often misinterpreted and compromise safety is the COPD parameters. Thus, lifelong learning is a professional requirement (RCP, 2017). On the same note, strict reliance can prevail over the autonomy of nurses. Escalation is to merge the scores and situation analysis (Redley et al., 2022).
The lack of staff and pressure on the system restricts the effectiveness of NEWS2. When there is much work to do, missed or delayed observations are the order of the day. When NEWS2 is incorporated into the framework of the structured communication tool, SBAR, communication is enhanced, but it is only effective when there is enough workforce capacity (Swanwick & Vaux, 2020). Nurses are expected to promote safe staffing and make sure that escalation pathways are operational.
Clinical errors are a consequence of multiple minor failures that are brought together as shown by the Swiss Cheese Model. With NEWS2, there is a risk that deterioration will be missed due to delayed observation or handover failure. In this way, the tool must be integrated into a broader safety culture that predicts human error and reinforces communication systems.
In comparison to the alternatives like MEWS, Waterlow, or MUST, NEWS2 is more inclusive of systemic illness (RCP, 2017). However, no tool is adequate in itself. Nurses need to incorporate NEWS2 with additional risk assessments to present a more comprehensive patient assessment.
Redley et al. (2022) claim that harm prevention should be implemented at the system level and not risk tools. NEWS2 is best applied within the context of organisational safety cultures that favour communication, teamwork, and nurse autonomy. Nurses are integrators, employing NEWS2 in a critical and not mechanical way, and placing it in the context of holistic patient safety.
Patient safety in nursing is based on communication. It is not only an interpersonal competency, but a safety-sensitive competency that aids deterioration recognition, decision-making, and therapeutic relationships. The Francis Report (2013) revealed failures in communication at Mid Staffordshire as the causes of avoidable harm, and the NMC Code (2018) clearly states that effective communication is the key to safe, evidence-based practice. Nonetheless, the clinical cultures that value measurable outputs rather than relational care tend to undervalue communication. Importantly, unlike technical work, communication is contextual and therefore more challenging to measure but no less critical. Nurses thus need to regard communication not as a soft skill, but as a safety-critical intervention on par with physiological monitoring (Francis, 2013; NMC, 2018).
In the case of newly qualified nurses (NQNs), transition into practice exacerbates the communication problems. The concept of transition shock by Duchscher (2009) emphasises the loss of confidence and role uncertainty in new practitioners, and the novice-to-expert model by Benner (2001) indicates that NQNs might not be able to challenge the senior colleagues. This is unlike the requirement in the NMC Code (2018) that nurses should speak up when patient safety is compromised. The theoretical models, like Duchscher and Benner, are conceptual and not empirical. Importantly, they expose communication as an opportunity to grow professionally as well as a barrier caused by fear, hierarchy, and inexperience. To transition safely, support systems should enable NQNs to raise concerns without fear and fill the gap between idealised professional standards and the reality of hierarchical healthcare practice (Duchscher, 2009; Benner, 2001; NMC, 2018).
The human factors theory upholds the value of communication to patient safety. The Swiss Cheese Model explains that even minor failures, such as unclear handovers or the failure to use the opportunity to apply SBAR, can combine with the systemic pressures to cause harm. Escalation may not occur even when structured tools such as NEWS2 detect deterioration because concerns are not communicated effectively. Structured tools can reduce risk but cannot entirely overcome such cultural barriers as hierarchy or fear of reprisal. In the case of nurses, integrating human factors awareness into training will help to underline the fact that safe communication is influenced as much by organisational culture and team dynamics as it is by individual skill.
A major communication model is SBAR (Situation, Background, Assessment, Recommendation), which is meant to standardise high-stakes communication. A systematic review conducted by Muller et al. (2018) discovered that SBAR led to fewer adverse events and greater clarity during handovers. Systematic reviews have a strong methodology, but the studies included in them were uneven in their design and quality. Significantly, SBAR minimises ambiguity and, when used without listening and contextual thinking, can be formulaic. SBAR is safer than unstructured dialogue, but the complex patient does not always suit a rigid structure. Therefore, nurses should be flexible with SBAR, and it should not be used to substitute clinical judgement (Muller et al., 2018).
Theoretical views also enhance communication. As Maslow’s Hierarchy of Needs (1987) shows, effective communication fulfills the basic psychological needs of the patients to be safe and reassured. However, the model has been criticised as linear and culturally limited. The Interpersonal Relations Theory by Peplau (1997) places communication as a core of therapeutic nurse-patient relationships, but is too narrow in its application to the broader organisational obstacles. When juxtaposed, Maslow describes the importance of communication, whereas Peplau describes how it is implemented in the practice of therapy. Collectively, they demonstrate that communication is a right of patients and a professional means. Nurses need to combine these views by making patients feel safe and heard (Maslow) and using therapeutic skills (Peplau) in daily practice (Maslow, 1987; Neher, 1991; Peplau, 1997).
Communication barriers do not only occur between the nurse and the patient. The language differences and cultural diversity are vulnerable to the risk of misunderstanding, and cultural competence is a key to safety (Papadopoulos, 2018). The hierarchy is a constant obstacle; Sutton et al. (2020) revealed that NQNs are reluctant to confront doctors. Handovers are also reduced due to the workload pressures, and this results in missing information and a greater possibility of harm (Kane et al., 2021). Further difficulties emerge when the patients have hearing impairment, neurodiversity, or remote consultations. Despite the fact that Papadopoulos (2018) provides a conceptual framework, Sutton et al. (2020) and Kane et al. (2021) provide empirical studies, which are limited. Importantly, these results help to visualise that communication equity is not a given and that structural and cultural barriers increase risks. Nurses should thus be inclusive and advocate to support equal communication in various settings (Papadopoulos, 2018; Sutton et al., 2020; Kane et al., 2021).
The remedies entail organised support systems. Health Education England (2019) asserts that preceptorship enhances confidence, communication, and retention among NQNs; nevertheless, Cousins et al. (2022) point to the inconsistency of implementation in the NHS Trusts. Although preceptorship can result in safer communication, it cannot solve system-wide problems such as workload or hierarchy. Therefore, nurses have to promote the regularity of preceptorship programmes but acknowledge that a wider cultural change is necessary.
Selected paper: Nursing guidelines for comprehensive harm prevention strategies for adult patients in acute hospitals: An integrative review and synthesis by Redley et al. (2022).
An accurate understanding of the methods of research is essential to the nursing practice because it helps clinicians question, instead of simply explaining, evidence. The following critical appraisal is devoted to Redley et al. (2022), who conducted an integrative review on the topic of how the strategies of harm prevention can be implemented into practice. The review synthesised evidence in a variety of areas, including risk assessment, nutrition, falls prevention, skin integrity, and communication, to develop accessible nursing guidelines. But, as the Critical Appraisal Skills Programme (CASP, 2025) reminds us, reviews cannot be accepted as credible evidence until they are interrogated in terms of clarity of aims, transparency of methods, and robustness of findings. Nurses should thus not only be concerned with what the recommendations say, but also how they were put together.
By using an integrative review design, Redley et al. (2022) were able to combine quantitative and qualitative research. This breadth is beneficial since the prevention of harm is physiological, behavioural, and organisational. Integrative reviews are most appropriate when examining such complexity because they enable different types of evidence to be synthesised into practical frameworks. CASP (2025) warns, though, that transparency is a key aspect where credibility is concerned. Redley et al. (2022) do not give much information about the depth of analysis of their synthesis, which poses a question of whether the integration was rigorous enough. According to Mancin et al. (2024), in some cases, systematic reviews can be more reproducible and more transparent in terms of evidence weighting. In the case of nursing, that implies integrative reviews can be helpful in breadth mapping. Still, the conclusions of such reviews must be used with an understanding of possible depth limitations.
The review exhibited great strengths in methodological clarity. Redley et al. (2022) described databases searched, inclusion and exclusion criteria, and explained why ethical approval was not sought due to the secondary nature of the study. This openness enhances validity and goes in line with the advice by CASP (2025) on clarity of purposes and systematic method. Aguinis et al. (2025) point out that replicability is based on transparency, especially in secondary research. The lack of complete reporting of search string sensitivity, however, begs the question whether all relevant studies were retrieved. In the case of nurses, this implies that the results are based on a peer-reviewed foundation, but the fact that there may be unidentified studies should prevent excessive use of conclusions.
These are strengths, but there are also severe limitations in the study. The limitation of including only published guidelines and peer-reviewed literature led Redley et al. (2022) to the risk of publishing bias. CASP (2025) makes us question the inclusion of all the relevant evidence, and Babarczy et al. (2025) warn that by not including grey literature, local policies, and experiential nursing knowledge, one limits the applicability. This limitation is relevant to the nursing field since the patient safety strategies have to be localised and fit in the workforce conditions and cultural practices that could not be represented in peer-reviewed products. In turn, although the results can serve as a reasonable basis, nurses should complement them with their experience and local policy data to make them contextually relevant.
The review summarised a wide variety of harm-prevention interventions, such as falls management, skin care, nutrition, medication safety, and structured interventions, such as NEWS2, MUST, and Waterlow. These are in line with NHS patient safety priorities. Nevertheless, CASP (2025) poses the question of whether the results are meaningful and can be applied to the practice. Redley et al. (2022) did not examine the implementation issues properly, such as staff shortage, organisational culture, and workload requirements. Swanwick and Vaux (2020) state that these are the systemic factors that are important in the success of evidence-based strategies in practice. Such a lack of transferability diminishes the value of evidence and reminds nurses that evidence should be critically interpreted in the context of practice environments.
Redley et al. (2022) conclude that the implementation of risk-assessment tools on a system-wide basis is the key to harm prevention. The standardised instruments like NEWS2 can improve consistency and reliability of monitoring deterioration. However, Papadopoulos (2018) warns that overuse of these tools can undermine professional judgement, especially among NQNs who are yet to be comfortable in making decisions. CASP (2025) also encourages the reader to consider feasibility in a variety of practice settings. In the case of nurses, it underlines the necessity to strike a balance between following the guidelines and critical thinking and patient-centred care, so that the tools should provide information rather than clinical skills.
In comparison with other scholarship, Redley et al. (2022) focus on structural and guideline-based safety measures, but they ignore relational and cultural aspects. Swanwick and Vaux (2020) emphasise the role of organisational culture in making safety a part of the culture, whereas Papadopoulos (2018) notes that cultural competence is crucial in making the process of ensuring equity and inclusivity. Conversely, the emphasis on formalised frameworks by Redley et al. is at risk of ignoring such bottom-up realities. Transferability is one of the appraisal criteria emphasised by CASP (2025), and in this case, the review seems limited. The implication is evident in the case of nursing practice: guidelines are not enough unless they become a part of supportive, inclusive, and learning-based cultures.
In general, Redley et al. (2022) present a valid contribution to evidence-based nursing, as they use a systematic synthesis to present the strategies that can be used to prevent harm in adult acute care. The review is methodologically rigorous in terms of scope, clarity, and systematic searching. Nevertheless, it suffers due to a lack of inclusivity, inadequate contextualisation, and a lack of implementation barrier analysis. CASP (2025) states that these are the factors that limit the transferability of findings. To practice, this implies that the review must be used as a guide and not a guide. Its suggestions need to be combined with professional judgement, situational awareness, and participation in local systems to support nurses in providing safe and person-centred care.
The essay was a critical discussion of the role of NEWS2 and communication in patient safety among newly qualified nurses. Safety is a product of interaction between structured tools, interpersonal skills and system factors. Although the NEWS2 standardises the identification of deterioration, it needs contextual judgment to be used safely, especially in vulnerable populations. Communication, which is facilitated by such a framework as SBAR, is safety-critical but influenced by hierarchy, confidence, and workload. The review of Redley et al. emphasised that tools or dialogue are not enough to guarantee safety in the absence of supporting systems. Finally, high-quality nursing combines bioscience, communication and system awareness into logical, person-centred care that avoids harm.
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