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Keywords:

  • adverse event;
  • deteriorating patient;
  • graduate nurses;
  • literature review;
  • novice nurses;
  • prearrest

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

Aims and objectives

To explore the research literature that provided data on factors that influence new graduate nurse's preparedness for recognition and response to patient deterioration in the acute care setting.

Background

Nurses have a significant role in recognising subtle signs of patient deterioration and responding appropriately to prevent adverse events and improve patient outcomes. This pivotal position has often fallen to the new graduate who must be prepared to make high-consequence decisions in relation to a suspected decline in their patient's condition.

Design and methods

An integrative review was undertaken. A comprehensive literature search was conducted using online databases, reference lists of key articles and expert advice. Multiple keyword combinations were used. All relevant studies were subsequently appraised for rigour and quality. Seventeen primary research studies drawn from novice and experienced registered nurse experiences emerged as relevant to the review.

Results

Thematic analysis of the studies provided six major themes related to the aim of the review. Emergent themes were as follows: clinical staff support, lack of nurse experience, overwhelming workload, holistic patient assessment, past experiences and lack of available resources.

Conclusions

This review highlighted the importance of positive staff support and subsequent confidence building. Graduates then felt able to present effective assessments and less fearful of reprimand when escalating an intervention call. The need for further research to investigate graduate nurses' experiences of recognising and responding to the deteriorating patient emerged.

Relevance to clinical practice

Realistic workloads and access to supportive experienced staff would allow graduates time to focus on grouping clinical information to understand the ‘total picture’ of the patient. Results indicated undergraduate and hospital in-service education programmes needed to offer the opportunity to practice reasoning. Complex clinical situations involving patient deterioration through simulation and clinical placement opportunities appeared most useful.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

Nurses have a significant role in recognising subtle signs of patient deterioration and responding appropriately to prevent adverse events and improve patient outcomes (Cioffi 2000, Jones et al. 2009, Odell et al. 2009, Liaw et al. 2011). However, past studies found ward nurses provided suboptimal care at times because of the inability to detect deterioration and seek rapid assistance for deteriorating patients (McQuillan et al. 1998, Buist et al. 2002, Hillman et al. 2002).

Graduates (first-year registered nurses following completion of undergraduate degree programme) can be required to respond to patient deterioration just as frequently as other nurses with expectations they will be competent to do so. Graduates become rapidly immersed in the complexity of care associated with contemporary nursing, with high-consequence decision-making a part of clinical practice (Ebright et al. 2004, Valdez 2008, Burger et al. 2010). This transition can feel overwhelming for graduates and a major role challenge (Goh & Watt 2003, Burger et al. 2010), while limited experience and basic-level knowledge make care of deteriorating patients difficult.

The differences in practice between graduate (often referred to as novice or advanced beginner) and expert nurses have been extensively outlined previously (Benner 1982, 1984, Benner et al. 1996). It has also been well recognised that nurses' knowledge, skills and cognitive processes develop over time with experience (Benner 1982, King & Macleod Clark 2002, Ebright et al. 2004, Cioffi et al. 2006, Burger et al. 2010). Expert nurses possess vast experience and skill which enable them to instinctively understand the total picture and to rapidly respond to individual patient situations (Benner 1982, King & Macleod Clark 2002, Valdez 2008, Levett-Jones et al. 2010). In contrast, graduates have been found to have insufficient exposure to clinical situations to process and sort relevant information or use discretionary judgment at the same level (Benner 1982, King & Macleod Clark 2002, Ebright et al. 2004, Valdez 2008, Burger et al. 2010). Similarly, some graduates displayed poor clinical reasoning skills and an unsafe level of practice in Levett-Jones et al. (2010) study, while Del Bueno (2005) found only 35% of a graduate group met entry expectations in clinical judgement. These findings are particularly important because clinical judgment is an imperative, not only in the collection of cues and recognition of changes in the patient, but also in processing information, initiating medical intervention and evaluating outcomes (Levett-Jones et al. 2010).

Additionally, contemporary acute care has increasing numbers of patients with complex health problems and the accompanying risk of serious deterioration (Levett-Jones et al. 2010). New graduates therefore care for sicker patients with multiple illnesses more frequently than in the past. As a result, the graduates' need to recognise and respond to patient deterioration has been increasingly acknowledged in transition programmes and national competency standards in many countries including Australia.

The National Institute for Health and Clinical Excellence (NICE 2007) and the National Patient Safety Agency (NPSA 2007) have developed guidelines and consensus statements outlining recommendations to assist nurses, doctors and other healthcare professionals improve patient safety in acute care facilities in Australia. The Australian Commission on Safety and Quality in Health Care (ACSQHC 2010) has also provided guidance for transition nursing programme curricula on the topic of recognising and responding to clinical deterioration (for example, SA Health Transition to Professional Programs, Government of South Australia 2011).

Similarly, clear guidelines direct the preparation of nursing students through university educational programmes to comply with national competency standards such as those set by the Australian Nursing and Midwifery Council (ANMC 2005). These standards require new graduates to be proficient in responding effectively to unexpected or rapidly changing patient situations (ANMC 2005).

In response to recognised patient complexity met by registered nurses and graduates, initiatives such as rapid response (RRT) and medical emergency teams (MET) have been implemented in hospitals. All nurses can now gain rapid assistance for deteriorating patients who meet the call activation criteria (Jones et al. 2009, Liaw et al. 2011). Yet, literature available on registered nurses' involvement in recognising and responding to clinical deterioration appears to offer little on graduates' preparedness for this role.

Aim

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

The aim of this review was to explore research literature to establish factors that influence graduate nurse preparedness for recognition and response to patient deterioration in the acute care setting.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

An integrative review methodology was chosen, which involved ‘identification, analysis and synthesis of research findings from independent…studies to determine the current knowledge (what is known and not known) in a particular area' (Burns et al. 2011, p. 24).

This review was undertaken using a systematic search of all relevant research literature. The retrieved studies were critically appraised against recognised criteria to identify relevant and robust primary research. Relevant themes were identified through thematic analysis of the studies' findings (Taylor 2006).

A comprehensive literature search was conducted using online databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, Informit and Google Scholar. A combination of various keywords included patient deterioration, deterioration, pre-arrest period, emergency assistance, resuscitation, vital signs, clinical decision-making, novice nurses, new graduate nurses, expert nurses, adverse event and complexity. Searching of reference lists of key articles and expert advice assisted in the location of relevant studies. The inclusion and exclusion criteria for the studies have been presented in Table 1.

Table 1. Inclusion and exclusion criteria
Inclusion criteriaExclusion criteria
Published between 2000–2011Published prior to 2000
Published in English languagePublished in language other than English
Primary research article or thesisArticles other than primary research article or thesis
Related to acute care settingDid not relate to acute care setting
Related to graduate nurses and registered nursesRelated to student nurses
Related to perceptions of real experiencesPerceptions of simulated experiences
Related to complexity of patient careDid not relate to complexity of patient care
Related to recognising and responding to deteriorating or at-risk acutely ill patientsRelated to involvement in treatments or interventions required to stabilise patients

An illustration of the search trail has been presented (Fig. 1), and the steps undertaken have been detailed later. Initially, only research studies that related to the experiences of nurse graduates in recognising and responding to the deteriorating patient were sought. However, no published studies that specifically addressed all aspects of this topic in isolation were located. Hence, studies of graduates' experiences of caring for at-risk acutely ill patients in complex acute care environments were included. Also, the inclusion criteria were expanded to include studies of registered nurses' (beyond graduate level) experiences in recognising and responding to patient deterioration. General registered nurses' experiences of the deteriorating patient provided insights from their memories and observations of others that provided rich information pertaining to the experience of the new graduate.

image

Figure 1. Flow chart of literature search.

Download figure to PowerPoint

The initial implementation of the online search was restricted to primary research studies, published between 2000 and 2011 in English language. A total of 84 studies were retrieved, exclusions in accordance with the criteria left 24 articles for further in-depth assessment. A further fifteen were eliminated, leaving nine studies highly relevant and focused primarily on nurses' perceptions of experiences in acute, complex patient situations. Two were also identified by an expert resource, and a further 19 were identified from reference lists; 13 were deemed irrelevant, leaving another six studies to be included. Overall, 17 studies were found to meet the inclusion criteria (see Table 1). Four studies were deemed to be specific to graduate nurses (G), three explored nurse transition from beginner to expert (T). The final ten studies explored the experiences of general registered nurses (R). A summary of the 17 research studies, with the above-mentioned codes in use, has been presented in Table 2.

Table 2. Summary of reviewed articles
StudyAimSampleMethodMajor findingsStrengths & limitations
  1. AVS, abnormal vital signs; Drs, doctors; ED, emergency department; HCA, healthcare assistants; MO, medical officer; MET, medical emergency team; Obs, observations; pt, patient; RN, registered nurse; Uni, university; Grads, graduates; Info, information; vs., versus; NSW, New South Wales; Rcd, received; RRT, rapid response team; Tech, technology.

Andrews and Waterman (2005)

UK (R)

Explore how staff use vital signs and warning signs to package deterioration and respond appropriately

44 participants (30 RNs, 7 Drs, 7 HCAs)

Purposive/theoretical sampling

Uni teaching hospital

Qualitative

Grounded theory

Interviews & participant observation

RNs feared being ridiculed & questioned their knowledge base. RNs recognised need for quantifiable evidence when articulating pt changes to Drs, which required confidence, experience & education.1 hospital, 2 wards. Self-reported bias. Investigator bias not considered. Recruitment strategy inadequately explained. Mixed methods.

Burger et al. (2010)

USA (T)

Explore the differences in how advanced beginners, competent, and expert nurses respond to complexity

23 female nurses (8 advanced beginner, 8 competent & 7 expert)

Purposive sampling 5 Midwestern acute care hospitals on cardiac units.

Qualitative

Descriptive, comparative design

Survey, priority list, field obs & semi-structured interviews.

New nurses relied on experienced RNs to guide their actions. Time pressures meant they could only complete the required care. Actions were in response to a situation/event, with lack of anticipation.

Reactive and investigator effects. Observer bias.

Multiple sites & data collection methods – increased applicability. Data validation.

Cioffi (2000)

Australia (R)

Describe the experiences of nurses calling emergency assistance to their pts

32 female RNs

Purposive sampling 4 wards/units in a teaching hospital and 3 wards in a peripheral hospital within an Aust area health service

Qualitative Exploratory, descriptive study

Unstructured interviews

RNs valued a collaborative team decision. They questioned themselves, worried what others might think. Used past experiences with specific/similar pts to identify change. Recognised the need to call a MET when there was a lack of staff.Self-reported bias. Investigator bias not considered. 2 different healthcare settings & various units. Moderate sample size.

Cioffi et al. (2006)

Australia (R)

Explore doctors and nurses responses to abnormal vital signs in a busy emergency department

11 RNs and 7 MOs volunteered to participate.

Purposive sampling

ED of a health service in Western Sydney

Qualitative

Descriptive approach

Focus group interviews

Junior RNs faced possible reprimand. Inexperience led to non-recognition of AVS. Workload /distractions a concern. Ability to gain action from a MO comes with experience. Pts history affected interpretation/action of AVS. Delays when RNs couldn't find senior staff.1 hospital ED. Small sample size. Domination of participants may occur in focus groups. Investigator bias not considered.

Cox et al. (2006)

UK (R)

Explore the influential factors surrounding the experiences of trained nurses caring for critically ill patients on the general ward.

7 female nurses with range of experience

Purposive sampling 1 medical ward in a district general hospital

Qualitative

Exploratory, descriptive study

Interview & questionnaire

RNs valued clinical support. Less experienced RNs gained assistance before action. RNs felt time pressures - ill pt vs. care of others. Vital signs to verify RNs intuitive suspicions. Knowing pt important. Lack of access to equipment a barrier.

1 hospital. Small sample size. Self-reported bias.

Mixed methods. Validation of themes.

Ebright et al. (2004)

USA (G)

Identify human performance factors that are connected to novice nurse adverse event situations

8 novice RN's <12 months experience aged 23–38

Purposive sampling 6 different units within 3 different facilities, although 1 Midwest healthcare system

Qualitative

Descriptive, longitudinal, phenomenological study

Retrospective interviews

Grads requested assistance from experienced RNs. Decisions influenced by staff, worried what others think. Grads unfamiliar with new procedures/ different situations. Time pressures surrounding adverse events. Unable to sort/synthesise information, lack total picture.1 healthcare system. Small sample size. Self-reported bias. Investigator bias not considered. Inadequate description of data analysis process.

Endacott et al. (2007)

Australia (R)

Identify how nurses and doctors recognise and communicate patient deterioration

11 nurses & 14 doctors

Purposive sampling

Australian 220 bed regional hospital

Qualitative

Case study design

Semi-structured interviews, chart audit & ward focus group interview (6 RNs)

Nursing expertise influenced quality of assessment. Lack of time led to incomplete assessment. RNs relied heavily on vital signs rather than holistic assessment. Pts symptoms & conditions aided assessment. Staffing concerns - shortages, casual staff & medical rotations

1 hospital. Small sample size. Self-reported bias.

Investigator bias not considered. Mixed methods. Validation of themes

Etheridge (2007)

USA (G)

Examine the perceptions of recent nursing graduates about learning to make clinical judgments.

Female graduates aged 22–26

Purposive sampling Acute care institutions in West Michigan

Qualitative Semi-structured interviewsGrads used a person of authority to validate their decisions. Found new level of responsibility overwhelming & unexpected. Had trouble putting info together & knowing what it meant.Sample size & institutions not recorded. Nil ethical considerations. Investigator bias not considered. Inadequate description of data analysis.

Gazarian et al. (2010)

USA (R)

Describe the factors that influence nurses decision-making in the pre-arrest period

13 female RNs aged 22–52

Purposive sampling 4 medical units in a 747-bed academic medical centre in Northern USA

Qualitative

Descriptive study

Interviews, field notes, review medical records

RNs valued help from staff they trusted, avoided inexperienced team members. Time pressures limited cue processing. RNs acknowledged responsibility for assigned pts vs. deteriorating pt. Knowing pt/pts baseline important. Previous rapid response experience guided actions.

1 hospital. Small sample size. Self-reported bias.

Investigator bias not considered. Reliance on retrospective reports.

Four medical units. Multiple data collection methods.

Kenward and Hodgetts (2002) (R)Identify the factors that may lead nurses to become concerned and predict patient deterioration

1 specialist senior nurse in acute medicine

Convenience sampling

Qualitative Phenomenological approach

In-depth interview

Possibility of damaging credibility if RNs concerns poorly articulated to Drs. Experience plays role in interpreting signs & unease. Senior RNS better able to articulate concerns about a pt than juniors. Knowing pt/family useful in detecting change.1 participant. Location not reported. Self-reported bias. Investigator bias not considered.

Kielpikowska (2006)

Australia (R)

Nurses experiences and needs before, during and after difficult MET call situations

6 RN's

Purposive & nominated sampling

Hospital setting - medical, cardiac and surgical wards

Qualitative

Case study, interpretive approach

Semi-structured, in-depth individual interviews

Teamwork, communication & collaboration important. RNs worried about feeling inadequate during MET, concerns sometimes disregarded. Unmanageable workload put pt & RN in jeopardy. Experience of MET a positive learning strategy.

1 hospital. Small sample size. Self-reported bias.

Reactive and investigator effects. Investigator bias & preconceptions. Validation of results.

King and Macleod Clark (2002)

UK (T)

Explore and identify nurses clinical expertise and use of intuition in surgical and intensive care settings

61 RN's (advanced beginner, competent, proficient and expert)

Purposive sampling 3 hospitals in England

Qualitative

Constructivist approach

Observation and semi-structured interviews

Grads sought clarification, anxious about being considered silly. Relied on reportable vital signs rather than intuitive feelings. They had feelings of uneasiness but lacked confidence. Limited knowledge & experience affected ability to identify/interpret clinical signs.Limited to time and place in which use of intuition and decision-making took place. Investigator bias not considered. Multiple sites and large sample size.

Lea and Cruickshank (2007)

Australia (G)

Explore new graduate nurses' experiences of transition within rural settings.

10 new graduate nurses in 1st year transition programme in rural setting

Purposive sampling 8 rural healthcare facilities of northern NSW

Qualitative

Hermeneutic phenomenological design

Individual in-depth interviews

Grads felt intimidated & rebuked if unable to make clinical decisions. Some colleagues more supportive than others. Grads felt lack of experience, knowledge & confidence, especially in rural nursing. Overwhelming workload a concern.Small sample size. Self-reported bias. Multiple healthcare settings.

Minick and Harvey (2003)

USA (R)

Describe the early recognition skills of medical surgical nurses

14 medical surgical RN's

Purposive sampling

Urban hospital in South-Eastern USA

Qualitative

In-depth group interviews

RNs apprehensive about calling MO & sought further data to confirm/explain suspicions. Caring for pts with similar conditions helpful. Knowing pt directly/through family was important in early recognition of pt problems.1 hospital. Small sample size. Domination of participants may occur in focus groups. Investigator bias not considered.

Ranse and Arbon (2008) Australia

(G)

Explore the lived experience of the graduate nurse who had participated in an in-hospital resuscitation event

6 graduate nurses with < 12 months experience

Convenience sampling

Australian tertiary teaching hospital

Qualitative

Hermeneutic phenomenological design

Focus group narrative

Grads desired a collaborative team approach, sought clarification from experienced RNs. Rcd negative comments from peers. Talked about being a ‘learner’, didn't feel they had the knowledge/skill.1 healthcare system. Small sample size. Self-reported bias. Focus group - reactive and investigator effects. Convenience sampling.

Wheatley (2006)

UK (T)

Discover the practice of basic nursing observations and assessment of the physical state of the general ward patient

4 RNs & 4 unregistered nurses

Purposive sampling

Acute medical/surgical ward

Qualitative Ethnographic approach

Observation and semi-structured interviews

RNs don't spend enough time with pts, inexperienced HCAs take obs. Lack of time/workload a barrier. Assessment lacked overall physical state, reliance on tech. Equipment is lacking/doesn't work.

1 hospital. Small sample size. Self-reported bias.

Reactive and investigator effects. Observer bias. Mixed methods.

Williams et al. (2011)

USA (R)

Investigate nurses feelings surrounding experiences of rapid response team use

13 nurses (6 staff nurses, 2 nurse clinician and 6 supervisors/educators)

Convenience sampling

Medical & cardiac care units, 156-bed community hospital

Qualitative

Focus group methodology

Valued collaborative problem solving. RNs rcd negative reactions, made them question their ability. Intuition based on life experience of nursing. Lack of assistance a barrier to action, the RRT a measure of relief. RRT a positive learning experience.1 hospital. Small sample size. Domination of participants may occur in focus groups. Investigator bias. Convenience sampling.

Critical appraisal

A rigorous critical appraisal of all reviewed studies was undertaken using 10 questions from the Critical Appraisal Skills Programme (CASP 2006) evaluation tool (Table 3). The chosen studies were evaluated to determine rigour and reliability and justification for inclusion in the review. A summary of the critical appraisal showed different strengths and weaknesses when the reviewed studies were assessed using the appraisal tool (Table 4).

Table 3. Critical appraisal skills programme (CASP) appraisal tool for qualitative research
Screening questions
1. Was there a clear statement of the aims of the research?
2. Is a qualitative methodology appropriate?
3. Was the research design appropriate to address the aims of the research?
4. Was the recruitment strategy appropriate to the aims of the research?
5. Were the data collected in a way that addressed the research issue?
6. Has the relationship between researcher and participants been adequately considered?
7. Have ethical issues been taken into account?
8. Was the data analysis sufficiently rigorous?
9. Is there a clear statement of the findings?
10. How valuable is the research?
Table 4. Summary of critical appraisal
 Q1: AimsQ2: MethodQ3: DesignQ4: SamplingQ5: Data collectionQ6: ReflexivityQ7: EthicsQ8: Data analysisQ9: FindingsQ10: Value
Andrews and Waterman (2005)Minimal descriptionX
Burger et al. (2010)ModerateModerate
Cioffi (2000)X
Cioffi et al. (2006)X
Cox et al. (2006)
Ebright et al. (2004)XLimited
Endacott et al. (2007)Minimal descriptionX
Etheridge (2007)XXLimitedXLimited
Gazarian et al. (2010)X
Kenward and Hodgetts (2002)Minimal descriptionMinimal descriptionXXLimitedLimited
Kielpikowska (2006)
King and Macleod Clark (2002)X
Lea and Cruickshank (2007)Limited
Minick and Harvey (2003)XLimited
Ranse and Arbon (2008)Minimal description
Wheatley (2006)
Williams et al. (2011)

All of the 17 reviewed studies used qualitative methodologies assessed to be appropriate to meet the aims of the research question. The strength of these qualitative studies was found in the exploration of the attitudes, beliefs and subjective decision-making of the nurses in critical situations.

Six of the reviewed studies were conducted in Australia, six in the USA, four in the UK, while one study did not establish the location. The findings of the appraisal indicate that four studies met all of the appraisal tool criteria (Cox et al. 2006, Kielpikowska 2006, Wheatley 2006, Ranse & Arbon 2008, Williams et al. 2011). A number of studies (Cox et al. 2006, Endacott et al. 2007, Burger et al. 2010) used methodological triangulation through mixed data collection methods and/or validation of themes to further strengthen and enrich their findings. King and Macleod Clark (2002) ensured rigour by using multiple settings, observation and interview methods and a very large sample size (n = 61), which allowed a broad range of perceptions. Gazarian et al. (2010) and Williams et al. (2011) described how participants were recruited until data saturation was reached, demonstrating that the established concepts had been well defined and explained (Corbin & Strauss 2008).

In contrast, the main limitations were lack of recognition of researcher bias and small sample size. All but five studies failed to sufficiently identify and examine the role of the researcher and recognise potential bias. Eight of the studies had a sample size of 10 or less. One study failed to identify the sample size (pseudonym use suggested six participants) and where the study was conducted (Etheridge 2007). Another was conducted with just one participant and had minimal discussion surrounding data collection, ethics and data analysis (Kenward & Hodgetts 2002). Although the latter reduced the rigour, they were both recognised to be phenomenological studies which generally have few participants. Pope et al. (2000) recognise that single case study may be the most successful way to explore a phenomenon of interest and should not be discounted. The findings were particularly informative and in keeping with the other reviewed studies, and therefore, these studies were included in the review.

Thematic analysis

A manual thematic analysis was used to identify themes across the reviewed studies. Taylor's (2006) steps, incorporating a colour coding method, were used to aid this process and to highlight similar findings across the literature. Similar findings were extracted and merged into respective groups. Each of the themes and subthemes represent a unique connection to addressing the review aim.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

Six major themes were identified being ‘clinical support’, ‘lack of nurse experience’, ‘overwhelming workload’, ‘holistic patient assessment’, ‘past experiences’ and ‘lack of available resources’. The identified themes included some subthemes and along with their supporting studies have been presented (Table 5).

Table 5. Themes and subthemes identified from the findings of the studies
Themes and subthemes identified from the findings of the studies
Themes by title (=number of studies per theme)SubthemesNo. of studies per subthemeEmpirical sources
1. Clinical support (=14)1a) Positive experiences9Cioffi (2000), Ebright et al. (2004), Cox et al. (2006), Kielpikowska (2006), Etheridge (2007), Ranse and Arbon (2008), Burger et al. (2010), Gazarian et al.(2010), Williams et al. (2011)
1b) Negative experiences10Cioffi (2000), Kenward and Hodgetts (2002), King and Macleod Clark (2002), Ebright et al. (2004), Andrews and Waterman (2005), Cioffi et al. (2006), Kielpikowska (2006), Lea and Cruickshank (2007), Ranse and Arbon (2008), Williams et al. (2011)
2. Lack of nurse experience (=11)  Kenward and Hodgetts (2002), King and Macleod Clark (2002), Ebright et al. (2004), Cioffi et al. (2006), Cox et al. (2006), Wheatley (2006), Endacott et al. (2007), Lea and Cruickshank (2007), Ranse and Arbon (2008), Gazarian et al. (2010), Williams et al. (2011)
3. Overwhelming workload (=10)  Ebright et al. (2004), Cioffi et al. (2006), Cox et al. (2006), Kielpikowska (2006), Wheatley (2006), Endacott et al. (2007), Etheridge (2007), Lea and Cruickshank (2007), Burger et al. (2010), Gazarian et al. (2010)
4. Holistic patient assessment (=10)4a) Using objective data to support nurse's concerns 5Minick and Harvey (2003), Andrews and Waterman (2005), Cioffi et al. (2006), Cox et al. (2006), Endacott et al. (2007)
4b) Lack of a holistic approach 3Cox et al.(2006), Wheatley (2006), Endacott et al. (2007)
4c) Graduate's lack of the total picture 4King and Macleod Clark (2002), Ebright et al. (2004), Etheridge (2007), Burger et al. (2010)
5. Past experiences (=7)5a) Specific patient 6Cioffi (2000), Kenward and Hodgetts (2002), Minick and Harvey (2003), Cioffi et al. (2006), Cox et al. (2006), Gazarian et al. (2010)
5b) Similar patients 4Cioffi (2000), Minick and Harvey (2003), Endacott et al. (2007), Gazarian et al.(2010)
5c) Rapid response situation 3Kielpikowska (2006), Gazarian et al.(2010), Williams et al. (2011)
6. Lack of available resources (=7)6a) Staff resources 5Cioffi (2000), Cioffi et al. (2006), Endacott et al. (2007), Gazarian et al. (2010), Williams et al. (2011)
6b) Insufficient/faulty equipment 3Cox et al. (2006), Wheatley (2006), Gazarian et al. (2010)

The results have been segregated within each theme first presenting the broader registered nurse literature, followed by findings specific to graduates.

Theme 1 – clinical support

Fourteen of the studies recognised the importance of clinical support from nursing colleagues and medical officers in decision-making to escalate care. Nurses frequently requested assistance from their peers when uncertain; however, not all experiences were positive. The need for support for the new nurse was recognised within eight of the studies focusing on registered nurses and all six of the graduate-focused studies. This theme was divided into two subthemes, being positive and negative experiences.

Positive experiences

Registered nurses highlighted the importance of a combined effort between nurses, nurse managers and doctors in successfully managing a MET situation (Kielpikowska 2006). Cox et al.'s (2006) participants recognised the intensive care unit staff as a particularly valuable source of support. Collaborative problem solving expedited the assessment process, improved the patient's condition and reinforced nurses' use of the rapid response team (Williams et al. 2011). Nurses preferred consultation with more experienced and trusted peers owing to a sense of mutual respect (Gazarian et al. 2010).

Similarly, less experienced nurses sought opinions from more experienced nurses when unsure about calling a MET (Cioffi 2000), in the case of an adverse event (Ebright et al. 2004) or to validate their decisions when uncertain (Etheridge 2007). Graduates desired a supportive team environment, with experienced and knowledgeable nurses being their first line of support (Ranse & Arbon 2008, Burger et al. 2010). New graduates relied on people with authority; however, with confidence and experience began to trust themselves and feel more comfortable with their abilities (Etheridge 2007).

Negative experiences

Registered nurses acknowledged the negativity of experiences where they feared looking ‘stupid’ and being ridiculed when articulating their concerns to medicos or calling the MET (Cioffi 2000, Andrews & Waterman 2005). It was felt that professional credibility could be damaged if nurse concern for a patient was poorly communicated to the doctor (Kenward & Hodgetts 2002). Nurses also described how at times the medical officers either disregarded or did not respond to their concerns about a patient which delayed their decision to call the MET, leaving them unsupported and distressed (Kielpikowska 2006).

Fear of reprimand was perceived to be particularly important to new nurses and delayed the reporting of abnormal vital signs (Cioffi et al. 2006). Negative responses made nurses question their ability and reluctant to call for assistance subsequently (Andrews & Waterman 2005, Williams et al. 2011). Similarly, ‘advanced beginner’ nurses had an overriding fear of being considered silly and were reluctant to seek support (King & Macleod Clark 2002). Such feelings were compounded if negative comments were received from more experienced staff members considered role models (Ranse & Arbon 2008). New graduates felt the need to prove themselves and fit in by adapting socially acceptable behaviour (Ebright et al. 2004). Lea and Cruickshank's (2007) study of new graduates in rural NSW practice found that socialisation was especially sought as graduates could otherwise be faced with workplace hostility or bullying.

Theme 2 – lack of nurse experience

Eleven studies identified lack of nurse experience as a barrier to interpreting signs of deterioration and gaining action for their patient (seven registered nurse and four graduate studies). Registered nurses highlighted how the quality and quantity of patient assessment was influenced by nurse expertise (Kenward & Hodgetts 2002, Endacott et al. 2007). Cioffi et al. (2006) found non-recognition of abnormal vital signs related to inexperience in nurses unable to appreciate the significance of such measurements and take action. Others acknowledged less experienced nurses tended to wait for assistance instead of seeking action, delaying treatment (Cox et al. 2006, Gazarian et al. 2010, Williams et al. 2011). An interesting parallel was found in healthcare assistants who lacked experience taking patient observations, sometimes missing clues to patient status leading to inadequate overall physical assessments (Wheatley 2006).

Graduate nurses recognised their inadequate knowledge and skill and lack of clinical experience associated with being new and a learner (Ranse & Arbon 2008). Lack of exposure led graduates to feeling inadequate in the identification and interpretation of deterioration, making them fearful and anxious (King & Macleod Clark 2002). Ebright et al.'s (2004) participants particularly recognised that first-time experience was a factor common to adverse events, where graduates were unfamiliar with a new procedure or situation. Graduates within the rural environment felt particularly vulnerable because of additional responsibilities and expectations beyond their level of experience (Lea & Cruickshank 2007).

Theme 3 – overwhelming workload

Ten studies identified overwhelming workload as a barrier to adequate assessment and recognition of the deteriorating patient (six registered nurse and four graduate nurse studies). Registered nurses recognised that an overwhelming workload, constant interruptions and time pressures impacted powerfully on patient care and detection of deterioration (Cioffi et al. 2006, Kielpikowska 2006, Wheatley 2006, Endacott et al. 2007). An overwhelming workload was described as emotionally and physically exhausting placing nurses and patients in jeopardy (Kielpikowska 2006). When one deteriorated, nurses often worried about providing high-quality patient care to other allocated patients owing to the increased workload (Cox et al. 2006, Kielpikowska 2006, Gazarian et al. 2010).

Graduates highlighted how a stressful workload was common to ‘advanced beginners’, and interruptions significantly affected their organisation (Burger et al. 2010). Graduates often described feeling time limited, only able to complete the required tasks (Burger et al. 2010). Ebright et al. (2004) illuminated graduates' feelings on time pressures and constraints surrounding an adverse event. These feelings were accompanied by a sense of overwhelming responsibility and unrealistic expectations quite different to those experienced as students (Etheridge 2007, Lea & Cruickshank 2007).

Theme 4 – holistic patient assessment

The need to go beyond vital signs and gain a full picture in the patient assessment was recognised in ten studies. Registered nurse studies (n = 6) informed the subthemes of ‘using objective data to support nurses’ concerns’ and ‘lack of a holistic approach’ and graduate nurse studies (n = 4) informed the third subtheme of ‘graduate's lack of the total picture’.

Using objective data to support nurse's concerns

Registered nurses recognised the need to use vital signs or other objective data to support their suspicions in five studies. This ability was often associated with experience and confidence possibly explaining why this subtheme was not found in the graduate studies. Minick and Harvey (2003) found that nurses gathered quantifiable information to explain and confirm their original suspicions of patient deterioration, with vital signs being a succinct method. The nurses acknowledged that ability was needed to present that information succinctly to convince medical staff and gain action (Andrews & Waterman 2005, Cioffi et al. 2006, Cox et al. 2006, Endacott et al. 2007). Andrews and Waterman (2005) highlighted how hard it was to get action from a doctor if no quantifiable evidence was provided as measurable information could lead to a probable diagnosis and interventions.

Lack of a holistic approach

Registered nurses acknowledged a reliance on vital signs in the assessment process to the detriment of a holistic approach (Cox et al. 2006, Wheatley 2006, Endacott et al. 2007). This was closely connected to a dependence on equipment and the notion that observations were a routine task to be undertaken. Wheatley (2006) alluded to the impact of a lack of education and experience in how to effectively assess the overall physical state of the patient potentially leading to missed clues in the detection of patient deterioration.

Graduate's lack of the total picture

Four graduate studies found new nurses often lacked a grasp of the ‘total picture’ of what would be deemed satisfactory for a patient's situation (Ebright et al. 2004). This subtheme was particular to graduates appearing to indicate limited clinical reasoning skills through insufficient preparation for practice. King and Macleod Clark (2002) and Etheridge (2007) highlighted how beginner nurses had a feeling of uneasiness about the status of their patient but were unable to put the information together to determine what it meant. Similarly, a lack of anticipation was noted in graduates with most actions being in response to a clear situation or event (Ebright et al. 2004, Burger et al. 2010).

Theme 5 – past experiences

Seven registered nurse studies found that a variety of past experiences influenced the nurse's ability to recognise and respond to the deteriorating patient. No graduate studies indicated the importance of experience, possibly because of limited clinical exposure and lack of awareness of how much they would learn from ‘past’ experiences. Three subthemes follow, being the ‘specific patient’, ‘similar patients’ and ‘rapid response situation’.

Specific patient

After caring for a patient, understanding their history and interacting with family members, nurses were better able to use cues in decision-making and identify variations from the patient's baseline data (Cioffi 2000, Kenward & Hodgetts 2002, Cioffi et al. 2006, Cox et al. 2006, Gazarian et al. 2010). Further, nurses recognised that previous contact with a patient enabled them to detect very subtle changes that were not yet measurable, leading to early recognition of rising problems (Minick & Harvey 2003).

Similar patients

Nurses also valued past experiences with patients who had similar conditions and symptoms. Illness trajectories and patterns were better understood after exposure to similar patients, comparing situations during assessment and decision-making (Cioffi 2000, Minick & Harvey 2003, Gazarian et al. 2010). Endacott et al. (2007) found that assessment practices were determined by the patient's medical condition and the signs and symptoms that were expected in that situation.

Rapid response situation

Previous experience in a rapid response situation was found to inform nurses' decisions to escalate care for a patient (Gazarian et al. 2010). Other studies discussed using such experiences as a learning strategy and even a teaching tool, especially for new graduates (Kielpikowska 2006, Williams et al. 2011).

Theme 6 – lack of available resources

Seven registered nurse studies found a lack of adequate or accessible resources was a major barrier to recognising and responding to the deteriorating patient yet no graduate studies indicated awareness. Two subthemes emerged ‘insufficient/faulty equipment’ and ‘staff resources’.

Staff resources

A lack of available staff resources was perceived as a major barrier in receiving help for a patient of concern. Primarily nights or weekends, when there was reduced staff numbers and support, as well as ‘covering’ doctors unfamiliar with the patients, were highlighted (Cioffi 2000, Endacott et al. 2007). The lack of assistance from an appropriate senior person caused delays in patient treatment and was seen as a ‘critical’ factor in an adverse event (Cioffi et al. 2006, Gazarian et al.2010). Interestingly, one registered nurse described how the rapid response team was used to gain action when there was a lack of availability of co-workers to provide guidance (Williams et al. 2011).

Insufficient/faulty equipment

A lack of accessible or functioning equipment emerged as another concern in detecting the deteriorating patient. For example, faulty machinery affected the quality and accuracy of the patient assessment and resultant decisions (Wheatley 2006) and unfamiliar replacement equipment hindered (Cox et al. 2006) the process. Similarly, Gazarian et al. (2010) found equipment issues impacted strongly on nurses' ability to provide safe care.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

Clearly, nurses of all levels of expertise valued clinical support from a range of sources in complex patient situations. However, positive support from experienced colleagues emerged as critical to the graduate unfamiliar with the hospital environment, policies and emergency situations (Ebright et al. 2004, Etheridge 2007, Ranse & Arbon 2008, Burger et al. 2010). Graduates worried about what others might think and feared negative comments from peers on their actions (King & Macleod Clark 2002, Ebright et al. 2004, Lea & Cruickshank 2007, Ranse & Arbon 2008). Studies highlighted how negative experiences could lead new nurses to refrain from seeking help and consequently trying to solve problems on their own. Graduates were perceived to lack confidence and experience to present effective assessments to gain action for patients (Kenward & Hodgetts 2002, Andrews & Waterman 2005, Cioffi et al. 2006, Lea & Cruickshank 2007). Findings of graduates' fear of other staff members and their reprimands along with limited assessment capacity could potentially lead to delay in early medical intervention for the deteriorating patient. Such fear in graduates could also lead to breakdown in team communication, subsequent errors around adverse events and preventable patient mortality (O'Daniel & Rosenstein 2008).

An overwhelming workload emerged as a major barrier for graduates in recognition of a deteriorating patient. Time pressures were especially problematic for graduates, who were less able to prioritise and organise, a finding consistent with other literature (Duchscher 2008, Fink et al. 2008, Olson 2009). Ongoing discussion and debate has long surrounded preparation for transition to clinical practice with concerns particularly surrounding graduates' clinical and patient management skills (Levett-Jones & Fitzgerald 2005). Linear thinking and limited capacity for multi-tasking has also been recognised in graduates previously (Burger et al. 2010). A demanding workload may result in less one-on-one time and compromise ongoing patient assessment through limited examination and information collection (Wheatley 2006). Lack of time and expertise may thus cause graduates to focus on tasks and technology, rather than physical assessment of essential clinical signs such as respiration and neurological status.

A clinical reasoning educational model proposed for students by Levett-Jones et al. (2010) could be useful for graduates with importance placed on specific physiological measurements as significant early warning signs in identification of deterioration. Emphasis has also been placed on recognition that failure to rescue can occur when signs and symptoms go unrecognised, not acted upon, or when medical interventions are started too late (Levett-Jones et al. 2010).

The graduates overall lack of experience was also identified as an issue. Graduates were recognised as particularly vulnerable because of their lack of exposure, knowledge and skill, all barriers to interpreting clinical signs of deterioration and taking appropriate action (King & Macleod Clark 2002, Ebright et al. 2004, Ranse & Arbon 2008). Furthermore, new nurses struggled with their ability to group together clinical information and understand the ‘total picture’ (King & Macleod Clark 2002, Ebright et al. 2004, Etheridge 2007, Burger et al. 2010). The graduates noted situations where they felt uneasy about the status of their patient but were unsure how to respond appropriately (King & Macleod Clark 2002, Etheridge 2007). They often associated such difficulties with ‘being a learner’ and recognised the need to increase their skills with further experience and exposure (Etheridge 2007, Lea & Cruickshank 2007, Ranse & Arbon 2008).

Experienced nurses in this review recognised the benefit of prior experiences with similar patients and rapid response situations in subsequent episodes where early recognition of patient deterioration was noted, a finding not established in the graduate studies. This result would suggest graduates had yet to become aware of how much past experience could potentially inform their future practice. Effective clinical decision-making has long been recognised as dependant on a combination of knowledge and experience rather than sole application of theoretical knowledge by significant researchers (Luker & Kenrick 1992, Cioffi et al. 2006). Hence, scenario-based programmes have been deemed more effective than just delivery of theory (Cox et al. 2006) and should be encouraged. Such experiences act to increase the cognitive resources required to interpret and understand the patient situation (Cioffi et al. 2006). Clearly, graduate education programmes need to adequately prepare for the clinical reality of nursing practice that will involve care of the deteriorating patient.

Strengths and limitations

Results of the review indicated that while a number of qualitative studies inform, an absence of studies specifically focused on graduates' experiences of recognising and responding to the deteriorating patient became apparent. The reviewed qualitative studies were robust and demonstrated minor weaknesses only (limited recognition of researcher bias and small sample sizes). These studies provided in-depth understanding of nurses' experiences in complex patient care that inform graduates' preparedness to recognise and respond to the deteriorating patient.

Relevance to clinical practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

Research

The absence of studies specific to graduate nurse's preparedness for recognising and responding to patient deterioration indicates the need for further research. Qualitative or mixed method studies appear most likely to provide in-depth understanding of graduates' views on this critical aspect of nursing practice.

Future evaluative research of educational programmes could provide best practice preparation of graduates in this field. Findings from this review indicate critical factors in transitional educational programmes would include patient assessment, communication and knowledge sharing within the healthcare team and decision-making around escalation of care. Past experiences and expertise emerged as significant in identifying subtle changes and gaining action for the deteriorating patient. Future research that investigates how graduates can assist their development of expertise in this field is also recommended.

Implications for practice

Results of the review indicate that it is vital to promote a work environment in which all nurses can express their concerns. Organisations can encourage shared decision-making, team dynamics and open communication across health disciplines through generic educational programmes.

Shared structured communication tools such as introduction/identify-situation-background-assessment-recommendation (ISBAR) can be particularly effective when urgent action is necessary, helping to develop critical thinking essential for effective information transfer and teamwork.

Graduates also learn through positive mentoring by carefully selected, prepared and educated preceptors. To improve patient management and safety, graduates need a realistic workload allocation with preceptor input. A gradual increase in workload over time increases confidence and facilitates independence in graduates. A prolonged orientation and supernumerary period would allow graduates to perform a range of clinical skills under expert clinical supervision, promoting a cohesive team environment. These factors appear particularly significant for graduates in rural and remote areas where resources, time and staff support are limited or unavailable. Transitional programmes in rural health facilities need to address the high expectations made of graduates entering the workforce. In particular, how graduates can be provided with opportunities to consult with more experienced registered nurses in times of uncertainty.

Education

Students and graduates need the opportunity to recognise relevant clinical cues, understand contextual issues and practice clinical reasoning, as well as the chance to reflect on their assumptions. Simulation is increasingly included in educational programmes and would provide graduates with the opportunity to identify and problem-solve complex clinical situations of patient deterioration in a safe and controlled environment (Shepherd et al. 2007). Preparation for graduate transition flows back to undergraduate students who need effective simulations and actual clinical placements to learn how to recognise and respond to signs of patient deterioration.

In conjunction with simulation, graduates along with other healthcare staff require education on precise communication tools, ‘track and trigger’ charts and clinical escalation policies so they identify patient deterioration and act appropriately. Strong preceptor guidance also assists graduates to feel confident to follow the correct escalation of care procedures without fear of reprimand (one of the most influential factors on graduates in patient deterioration situations).

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

The importance of timely and appropriate management of patient deterioration has become increasingly recognised; however, there is a significant deficit in the existing literature regarding graduates' levels of preparation for this responsibility. This literature review has revealed the critical importance of adequate preparation of graduates for caring for the deteriorating patient and the likely factors impacting upon it.

The findings suggest that graduates require considerable support and guidance from colleagues and preceptors in decision-making and gaining appropriate action for deteriorating patients. In contrast, negative peer support, an overwhelming workload and lack of experience are recognised as substantial barriers to this pivotal aspect of care. Lack of experience means graduates can struggle to gain the ‘total picture’ of a patient's situation, potentially compromising care and safety. Educational strategies are needed to prepare graduates for managing the acute and complex patient situations found in the contemporary healthcare setting. Clearly, further research is needed in this field.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

The first author would like to sincerely thank and recognise Flinders University School of Nursing & Midwifery for their educational support for this project.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References

The first author acknowledges the financial assistance of the Flinders University School of Nursing & Midwifery through the 2011 Undergraduate Student Publishing Incentive Award.

References

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  2. Abstract
  3. Introduction
  4. Aim
  5. Methods
  6. Results
  7. Discussion
  8. Relevance to clinical practice
  9. Conclusion
  10. Acknowledgements
  11. Contributions
  12. Funding
  13. Conflict of interests
  14. References
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