title: Understanding the process of nurses’ recognition and response to patient deterioration
Creators: name: Dalton, M
Publisher: name: Liverpool John Moores University
Year: 2023

description: Background: nurses play a crucial role in the early recognition and management of the deteriorating patient, as they are responsible for the care they provide to their patients (Hogan et al., 2019; Connor et al., 2020; Burdeu et al., 2021). A part of this care is the monitoring of the patient’s vital signs, such as blood pressure, pulse, respiratory rate, and temperature, which are fundamental in the surveillance of health deterioration. The aim of this study was to understand the process of nurses’ recognition and response to patient deterioration in more detail. Methods: a generic, qualitative approach was adopted (interpretive description), guided by the work of Thorne et al., (1997) and used as the methodological framework. The theoretical perspectives used to underpin this study were Benner’s (1984) work from “novice to expert”, which focuses on intuitive perception and clinical reasoning in nursing, and the Cognitive Continuum Theory, developed by Hamm (1988) and revised by Standing (2008) to enhance the understanding of how nurses formulate their decisions to escalate the patient’s care. Data collection: data were collected using semi-structured interviews, a simulation exercise, and four focus groups. The total number of participants recruited was 46. Phase One in-depth interviews (n=10) Phase Two simulation exercise (n=20) Phase Three focus groups (n=16) The participants were nurses working within an acute NHS Trust and were equally represented from inpatient medical and surgical wards. They were recruited based on their experience of nursing the deteriorating patient. Results: numerous themes emerged in Phase One, which were as follows: main themes (1) Collegial relationships; (2) Intuition; and (3) Interpretation of the NEWS system (National Early Warning Score). Several subthemes included clinical credibility, confidence, competence, knowledge, decision-making and organisational culture. The main themes constructed within Phase One, also emerged within the two other phases, providing a consistent theoretical link between all three phases of the study. A simulation exercise, which replicated the five stages of an actual Medical Emergency call, was developed to aid data collection in Phase Two. This exercise identified the importance of experiential and theoretical knowledge when used in combination to recognise early warning cues of health deterioration. Barriers to this process were acknowledged, which included difficulties faced by the participants when attempting to escalate the patient’s care. Finally, their deficiency of theoretical knowledge was emphasised by the participants, which exposed their own self confidence in their ability to challenge the requested medical review process of patients. Phase Three yielded some fresh insights and revealed a widespread acceptance in terms of the content and delivery of this unique simulation. Conclusion: This study provides a meaningful understanding of the process of nurses’ recognition and response to patient deterioration, by facilitating an insight into the hidden narrative surrounding this practice. Unlike other studies within this field of inquiry, this study focuses on the importance of this narrative to explain why this practice prevails, in addition to highlighting the potential remodelling of some aspects of this care to improve patient outcomes. Moreover, this study questions the literature in terms of whether nurses are missing cues of patient deterioration as reported, suggesting their voice is simply lost within this convoluted process, offering a different focus to direct future research within this field of inquiry.