Neurological Soft Signs (NSS) have been used since the early 20th century to help Neuropsychologists identify subtle abnormalities in sensory-perceptual, motor, or other central nervous system functions as nonspecific indicators of impairment.
Early signs of physical “unwellness” can be recognised intuitively by physical healthcare practitioners as evidenced by staff saying “I know something is wrong, I just don’t know what”. Even people without training, but who are familiar with someone’s usual behaviour and habits, can often sense a problem resulting in them reporting that the relative, resident or child in their care “just isn’t themselves”.
There is some evidence to suggest that it is possible to identify physical deterioration before hard physiological signs are present with one study by Boockark et al finding that “Nursing assistants' documentation of signs of illness preceded chart documentation by an average of 5 days.”
Other studies highlighting the role of care assistants in identifying deterioration early include Tingström et al’s "he seems to be ill - a reason for nurses to take action”, Allemann and Sund-Levander’s “Nurses' actions in response to nursing assistants' observations of signs and symptoms of infections among nursing home residents” and Sund-Levander and Tingström’s “Clinical decision-making process for early nonspecific signs of infection in institutionalised elderly persons: experience of nursing assistants”.
The discussion below includes extracts from a white paper in which Geoff Cooper, Wessex PSC Programme Lead for Deterioration, explores the understanding of Soft Signs in the Literature, their application to Health Care in general, and Physical Deterioration in particular, and describes three Wessex based examples of their use in Care Home settings.
The full white paper,including citations referred to on this webpage, can be downloaded from the resources zone on the right hand side of this webpage.
Recognising “unwellness” early
Although recent clinical studies have called into question the time honoured concept of a “golden hour” as a fixed period of time during which prompt medical and surgical treatment will be most effective, the importance of rapid intervention is well recognised in many healthcare settings.
Wessex organisations working to improve the recognition and response to deterioration in all care settings, including Care Homes, adopted the term “Soft Signs” to refer to the early signs, flags or indicators of physical deterioration as distinct from the “Hard Signs” that could be measured such as heart rate, blood pressure or temperature.
As Interserve’s Andy Cook explains “‘soft signs’ work as proxy measures for deterioration and include observed changes in patients’ normal behaviour, such as sleep, eating, drinking and mood. These observations avoid the need for complex measurement equipment, whilst proving to be good indicators of early negative changes in the patient’s well-being.”
The concept of “Soft Signs” also reflected the desire of the teams to promote a qualitative, holistic or intuitive model alongside the more scientific or physiologically focussed approaches.
Equally a medical model may not be considered appropriate for all care settings, in residential care homes for example.
Using Soft Signs to recognise and communicate Nurse or Carer Concerns
Soft Signs also support another difficult to define concept namely “Carer Concern” which, when taken together with a structured communication tool such as SBAR(D) can be used to support the communication of safety critical information between individuals.
Soft Signs in Practice - Three Wessex Projects
A Taxonomy of Soft Sign Indicators of Physical Deterioration - Interserve Healthcare & Wessex PSC
The Interserve Healthcare team reviewed cases where clients had been admitted to hospital and identified a range of ‘events’ that indicated developing health concerns which could have triggered an earlier review of the client. These were developed into a list of around 120 ‘soft signs’ or proxy measures for deterioration.
These 120 measures were grouped into a Taxonomy against what they described as systems of life dimensions and activities of daily living, essentially all things that are just ‘observed’ or ‘noticed’.
Between 5 and 10 of the most relevant Soft Signs are then placed into a personalised care plan for each client and the Soft Signs Taxonomy has also been incorporated into the organisations electronic incident and concern reporting system.
The full Soft Signs Taxonomy can be downloaded from the resources zone on the right hand side of this webpage.
An Integrated Physical Deterioration and Escalation tool incorporating Soft Signs, NEWS2, SBARD & TEP/ACPs - West Hampshire CCG & Wessex PSC
RESTORE2TM is a physical deterioration and escalation tool for care homes wanting to use a "Soft Signs" approach as a pre-diagnostic indicator of concern" to facilitate earlier treatment and avoid unnecessary transfers to hospital.
RESTORE2TM includes Soft Signs for early identification of deterioration, a physiological assessment and escalation process based on the National Early Warning Score (NEWS2), the use of structured communication processes to communicate concerns (SBARD) and also references any Treatment Escalation Plans (TEPs) / Advance Care Plans (ACPs).
West Hampshire CCG have also released a standalone "Soft Signs" only module entitled “RESTORE2 MiniTM”.
Full information about RESTORE2TM and RESTORE2 MiniTM including training videos and links to the West Hampshire CCGs downloadable resources can be found on our RESTORE2 webpage
Recognising and Responding to Soft Signs of Deterioration in out of hospital settings - Southampton CCG & Wessex PSC
The Wessex PSC REACT (REcognise and Act) cards are based on a project by Southampton City CCG which prompted Care Home staff to look out for, and respond to, 'Soft Signs' of Deterioration in their residents. Using a deceptively simple question 'Is my resident well today?' the card includes a series of prompts to support staff to consider possible 'soft signs' of deterioration and to suggest actions to take if any triggers are present.
Possible triggers include (amongst others): Breathing difficulties; changes in appetite, mobility, consciousness or confusional state; bowel or urinary tract problems. Suggested actions include (amongst others): Raising the alert, recording observations (using NEWS2/RESTORE2) and communicating concerns by using the SBARD communication process.
Staff are also prompted to ensure that residents personal End of Life care preferences are considered as part of the response process.
A pdf copy of the REACT cards can be downloaded from the resources zone on the right hand side of this webpage.
Benefits of Soft Signs
The NHSE Patient Safety Alert issued in April 2018 highlighted the importance of early recognition of, and response to, Physical Deterioration across the NHS. The use of the National Early Warning Score (NEWS2) is intended to improve the care delivered to patients by responding promptly and effectively to physiological indicators of deterioration.
Using Soft Signs to identify signs of deterioration in out of hospital settings, and before they can be seen in physiological monitoring, raises the potential for significant benefits to the individual being cared for and to the health care system in general.
A report by the Health Foundation found that up to 41% of emergency admissions from care homes may be avoidable as being for conditions that are potentially manageable, treatable or preventable outside of a hospital setting.
Earlier recognition and treatment arising from the use of Soft Signs and NEWS2 suggests there is potential for improvements in the treatment and management of Care Homes residents conditions as well as for reductions in GP call outs, ambulance conveyances, emergency department attendances, hospital admissions and length of stay.
In qualitative terms Interserve staff also reported greater staff confidence not just in relation to escalating their concerns but also in terms of managing clients locally and avoiding unnecessary or inappropriate transfers or treatment.
As well as helping with early detection of unwellness the concept of Soft Signs provides the basis of a language to help verbalise the intuitive feelings of staff when “something just doesn’t feel right” and possibly also the intuitive knowledge that Bennet and others have ascribed to expert practitioners. As such they can help carers or nurses to raise their concerns to others.
Deterioration outcomes, whether attributed to Sepsis or other causes, are known to improve as a result of earlier recognition and response. A National Early Warning Score (NEWS2) has been implemented across the NHS in England but this may not be practical or appropriate, in patients own homes or Residential Care settings.
Equally even where NEWS2 is used, in Nursing Homes for example, the question remains as to what motivated staff to take that first set of observations that confirmed physiological evidence of deterioration? And then following on from that question, could that deterioration have been identified earlier?
The case studies emerging from the literature suggest that Soft Signs provide an approach which might assist carers to recognise deterioration earlier, potentially even days before physiological signs are present. Soft Signs also provide a language for explaining and communicating pre-physiological changes between healthcare staff, for raising carer and nurse concerns and for teaching purposes.
As well as improving residents outcomes, the use of Soft Signs has the potential to help staff care for residents in their preferred locations by preventing inappropriate emergency department attendances and hospital admissions as well as freeing up resources such as GP visits, ambulance conveyances and hospital beds.
Hopefully this discussion will stimulate further thinking around the value of Soft Signs in areas of direct care in general, the identification and prevention of physical deterioration in particular and their role in communicating concerns, professional development and reflective practice.
Geoff Cooper MSc ILM RGN. Programme Manager, Improvement Coach & Q. Wessex Patient Safety Collaborative. March 2020.
Soft Signs Video
Other Soft Signs Resources
Links to other Wessex AHSN Care Home Workstreams
Soft Signs image at top of webpage taken from West Hampshire RESTORE2TM
Further information on this workstream can be obtained from Geoff Cooper (Programme Lead) via email or via the contact link at the bottom of this page.