Implementation of an early warning score system and associated factors in a hospital in Bali, Indonesia: a mixed-methods study 10.55131/jphd/2026/240117
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Abstract
Hospitalized patients are at risk of worsening clinical conditions. This requires the implementation of an early warning score (EWS) for monitoring and standardizing patient safety. This study aimed to explore the implementation of an EWS and its associated factors in a hospital in Bali. This mixed-methods study (exploratory sequential design) began with descriptive qualitative research and continued with a cross-sectional component. The qualitative study involved 14 participants (nurses), and the quantitative study involved 302 respondents (nurses). The qualitative data collection used focus group discussions, and the quantitative study used a questionnaire. The qualitative data were analyzed using thematic analysis. The quantitative data were analyzed using univariate (frequency and proportion), bivariate (chi-square test), and multivariate analysis (binary logistic regression). The qualitative analysis identified three themes: adequate EWS knowledge, poor EWS implementation, and perceived barriers. Quantitative analysis revealed that of the 302 respondents, 74.5% showed good EWS implementation. The factors associated with EWS implementation were knowledge (AOR: 2.26; 95% CI: 1.25–4.08; p=0.007), attitude (AOR: 4.32; CI: 2.39–7.80; p<0.001), and leadership support (AOR: 4.12; CI: 2.28–7.43; p<0.001). Therefore, EWS implementation needs to be improved by conducting seminars and training to gain knowledge and attitude, as well as regular supervision to increase leadership support and minimize implementation barriers.
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