Running head: CLINICAL DETERIORATION 1

Clinical Deterioration

Hannah Thatcher

Brigham Young University-Idaho

Nursing 420 Section 01

Sister Erin Bennion

July 12, 2017

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Background

There are many points in a patients hospital stay in which they are at risk for clinical

deterioration. This is especially true of patients who are admitted with numerous complicated

health issues. Nurses interact with patients frequently, and their observations and assessments of

the patients condition is crucial. Often times nurses are the first health care professionals with

the opportunity to notice these changes in patient conditionnoting them as signs of clinical

deteriorationand initiating life-saving measures (Hart et al., 2014). In a constantly changing

patient-care environment, recognizing early warning signs of deterioration and intervening

appropriately requires perceptive patient assessments and critical thinking skills.

Unfortunately nursing staff are not consistently recognizing declining patient status. Too

often signs of clinical deterioration go unnoticed by nurses (McDonnell et al., 2013). For

example, alarms alerting nurses of abnormal vital signs may be silenced, a patient reporting

shortness of breath may not be taken seriously, or the gravity of new onset of agitation may not

be considered.

Hart et al. (2014) conducted a simulated study examining nurses and their ability to

manage patient deterioration. The study specifically addressed the assessment skills of nurses,

their clinical knowledge of deterioration, and their ability to intervene and perform the necessary

skills. The results showed nurses missing key information. The assessment findings that went

unaddressed most often include abnormal vital signs, pallor, patients reporting not feeling

right, and changes in patient temperament. Considering nurses engage in such frequent

interaction with the patient, there is a definite disconnect in patient care. Current research

recognizes this as a significant problem, whereas the cause is still being explored.
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It is possible that failure to recognize these changes could be a result of lack of

knowledgethat nurses are unsure of criteria that should warrant concern and involvement of

other members of the health care team (Tait, 2010). Or, if the physiological changes are

recognized, nurses may be reluctant to initiate the needed interventions. The failure to recognize

and act on a change in patient conditions has a negative impact on patient outcome (McDonnell

et al., 2013). Adverse effects of delayed interventions include increased admission to critical care

units and increased mortality.

Significance

Many acute deterioration events, including unplanned admission to critical care, cardiac

arrest, and unexpected death are often preceded by early warning signs (Hart et al., 2014). These

warning signs can be as straight forward as recognizing abnormal vital signs, and other

observable indicators of decline. A change in neurological status, a sudden drop in blood

pressure, increased work of breathing, or complaints of new onset pain are some examples of

assessment findings the nurse should further investigate. Performing basic assessments, and

critically thinking about findings in some situations can be the difference in life or death for a

patient.

A favorable outcome to an acute event seems most likely in a hospital setting; with many

resources available, and surrounded by health care professionals. Unfortunately, this is not the

case. This has been recognized, and has spurred many studies investigating the cause of this

problem and portraying its significance.

One such study, done in Australia (Mullany, Ziegenfuss, Goleby, & Ward., 2016) tracked

their reported hospital deaths from July 2008 to December 2012. Throughout this period, early

notification of patient deterioration was enhanced by the implementation of rapid response teams
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and education of nurses regarding calling MET codes. The results showed a significant decrease

in hospital deaths and an increase in the number of MET calls.

Another study (Elder, L. 2017) found that of the 715,000 reported hospital deaths in

2010, 576 were potentially avoidable, and 64 were associated with a worsening in patient

condition without nurse recognition and intervention. This suggests that delayed response to an

acute illness is directly related to more negative outcomes, including lower rates of survival.

Patient outcome is being effected, and lives are being lost over failure to recognize early signs of

decline. Ultimately, there is need for improvement in nurses ability to recognize and respond to

early signs of clinical deterioration, as it often precedes life-threatening events.

Ida Jean Orlandos Nursing Process Discipline Theory

Ida Jean Orlandos theory focuses on the dynamic quality of the patient-nurse interaction.

Orlando noted that each interaction with a client is unique, and because of that, the process of

assessing, diagnosing, planning, implementing, and evaluating should also be individualized

(Rosenthal, 2006). By keenly observing and completing thorough patient assessments, the nurse

can accurately identify the patients needs, which leads to an appropriate intervention by the

nurse and ultimately an improvement in the patients health.

Orlando believed that the function of the professional nurse is to identify the patients

specific, and immediate needs. This is achieved by monitoring and interpreting both verbal and

nonverbal behaviors from the patient (Abdoli & Safavi, 2010). These behaviors should be seen

as a request. However, Orlando suggests looking deeper than the most obvious needs. Nurses can

begin the process of determining how to help by utilizing their perception of the client and

exploring all meanings of their behavior. When the clients behavior is viewed in this light, the

nurse is in a mindset of problem solving in ways directly applicable to the client.

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In these nurse-patient situations, the nursing process discipline theory concentrates on the

concept of inquiry and observance to get to the root of the problem. When reacting to this

problem, Orlando emphasized that nurses should be cautious of automatic, prescribed responses

(Rosenthal, 2006). She suggested that a routine intervention, neglecting to consider the meaning

of the clients behavior, decreases the quality of nursing care given and can actually cause the

client distress (Abdoli & Safavi, 2010). Simply going through the motions to perform the

interventions needed to fulfill required hospital standards can result in less personalized care.

Patients may recognize this, and in times of ailment, an insincere approach can have a negative

impact.

Link Between the Nursing Process Discipline Theory and Clinical Deterioration

A patients condition is constantly fluctuating. These changes in their condition may be

manifest through their behaviorverbally, or in non-verbal ways, such as a change in vital signs.

Orlandos theory suggests viewing these changes as problematic situations, ones which deserve

the nurses immediate response (Abdoli & Safavi, 2010). This approach requires nurses to think

critically and problem solve in a variety of situations in order to intervene in possibly life-saving

ways. For example: is this patient experiencing shortness of breath because there is more serious,

underlying issue? Deviation from a patients baseline status should raise concern in a nurse, a

prompt follow-up.

Often emergent situations, such as cardiac arrest, are preceded by these more subtle types

of changes. Nurses are continually assessing their patients and watching for changes, but they

may be missing key information, or failing to get beyond the initial prescribed interpretation and

intervention. These unnoticed or misinterpreted signs of changes in patient status are a source of

avoidable harm for patients (Patrick et al., 2013). Responding rapidly to a patients drop in blood
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pressure and rise in temperature could prevent the downward spiral of a patient experiencing

septic shock. Correctly identifying a change in patient condition, and critically examining

assessment findings in the context of the unique patient may prevent acute events.

Utilizing Orlandos theory can decrease patient distress and improve the nurse client

relationship (Abdoli & Safavi, 2010). Nurses that are more sincerely aware of patients behaviors

and immediate needs will provide better quality care. By critically thinking through each

patients signs and symptoms the nurse can individualize interventions. Because early signs of

clinical deterioration, if left untreated can lead to serious clinical issues, prompt recognition is

key. Orlandos nursing process discipline theory proposes identifying these immediate patient

needs and taking action in hopes of improving the patients situation, or avoiding further

deterioration.

Research Methods

It is predicted that experienced, confident nurses are more apt to accurately recognize and

respond to acute patient deterioration. Vigilant assessments and the ability to monitor changes in

hospitalized patients takes skill. Identifying immediate patient needs and intervening

appropriately is the basis of Orlandos nursing process discipline theory. With a vast array of

information coming in from the patients verbal and nonverbal cues, a novice nurse could lose

direction. The more experienced nurse has the ability to make sense of the patients behaviors

and prioritize their immediate needs.

Research Design

Quantitative research will be conducted. Using the descriptive study method, this

research will describe the perceived self-confidence level of nurses regarding their ability to

recognize and respond to acute patient deterioration. The relationship between these variables
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will be examined. In addition, number of years experience as a nurse will be described in

relation to perceived ability to react to a change in patient behavior and respond in an appropriate

way. These variables will be examined and measured allowing an interpretation of findings and

an explanation of any relationship found. More information will be gained about the role clinical

experience and nurses confidence level plays in recognizing clinical deterioration. These

variables will not be manipulated, instead any existing trends will be described.

Research Population

Bachelors degree of science (BSN) level nurses will be included in this study, while

nurses with additional schooling or training will be excluded. In this way, variations in formal

education will be eliminated from the research. A minimum sample size of 300 nurses with any

amount years working experience will be included. Both genders will be invited to participate, as

well as all age brackets above age 18. Nurses from all adult care floors of the hospital will be

invited to participate in the study. This excludes nurses specializing in pediatrics neonates.

Additional inclusion criteria for nurses includes: hospitals within the continental United States,

and willingness to complete the study. It is anticipated that this research population will provide

diversity in both years of nursing experience and confidence in ability to promptly intervene

when noting patient deterioration.

Methods and Measurements

Cluster sampling will be used to first randomly select five states to be sampled.

Following this, a hospital within each of these states will be selected at random. The BSN

population meeting the aforementioned criteria at each selected hospital will be invited to

participate in this study via a survey, which will be sent to them. A private research software
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company will be used to input the research questions, and to document the participants

response.

Initially, a section disclosing this researchs purpose and asking the participants for their

consent will be presented. The demographic portion of the survey will follow. Close-ended

questions will then be asked to each participant. Information to be gathered includes the

participants age, the current department they work in, and years of working BSN experience.

Following this section, different patient scenarios will be described. Scenarios will

include patient situations such as new onset shortness of breath, chest pain, abnormalities in vital

signs, and change in level consciousness. For each scenario, participants will choose a nursing

action from four multiple-choice responses. Through the information gathered in these questions,

the nurses ability to recognize, andthrough critical thinkingderive a response to clinical

deterioration will be identified. Finally, the nurses will be asked to rate, on a scale of one to ten,

their level of confidence in completing the selected answer should it present in their practice as a

nurse.

Ethical Considerations

Adult human participants will be used in this study. Anonymity is a human right that will

be protected throughout this research. This will be fulfilled by not asking the names of the

nurses. Additionally, any other potentially identifying information, such as their hospital of

employment will be protected. In this way, participants identify will be kept confidential, and the

ethical consideration of anonymity will be satisfied.

Voluntary consent to participate is essential. This is encased by the participants right to

self-determination. This will be achieved through the initial portion of the survey. It will include

a brief summary of the study being conducted, and the rights they, as participants, would have.
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The nurses will also be informed that their employment will not be affected by their choice to

consent or decline participation in the study. Nurses will not be coerced to participate, the study

will be explained, and the option provided.

The selection of research participants will be fair, as every nurse employed in the selected

hospitals meeting the inclusion criteria will be invited to participate in the study. Biases will be

avoided by offering all nurses that meet this criterion the option to participate. On the opposite

hand, selection of specific participants will be avoided. Any preexisting biases that may

influence selection will be eliminated by random selection.

Annotated Bibliography

Lambe, K., Currey, J., & Considine, J. (2016). Frequency of vital sign assessment and

clinical deterioration in an Australian emergency department. Australasian Emergency

Nursing Journal, 19(4), 217-222.

These three authors are associates at Deakins School of Nursing and Midwifery in

Australia. Quantitative research was conducted. Using a descriptive exploratory

approach, the frequency of vital sign collection and recognition of abnormal

measurements in an Australian Emergency Department was investigated. As defined in

the study vital sign measurements included respiratory and heart rate, level of

consciousness, oxygen saturation, temperature, and systolic blood pressure. A strength of

this study is consistent parameters were used for normal ranges, and vital sign

measurements indicating clinical deterioration. Stratified random sampling was used to

collect data totaling 200 patients. The study could be strengthened by increasing the

sample size, or conducting it in more than one emergency room. The authors major

findings are as follows: a complete vital sign assessment was not always done, and
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patients had their vital signs assessed less than hourly. Additionally, they concluded that

clinical deterioration and abnormal vital sign measurements meeting Medical Emergency

Team (MET) code activation status were not uncommon. Ultimately, further studies are

needed exploring the optimal timing of vital sign assessments, and abnormal parameters

that are cause for alarm. These findings may be used as a resource by researchers, or by

nurses striving to increase their ability to respond to changes in patient status.

Elder, L. (2017). Simulation: A tool to assist nursing professional development

practitioners to help nurses to better recognize early signs of clinical deterioration of

patients. Journal for Nurses in Professional Development, 33(3), 127-131.

Loretta Elder, DNP, RN, CNE, is currently a Professor of Nursing at Madison

Community College in Kentucky. Elder utilizes results from published studies to

support the significance of unrecognized clinical deterioration. For example, of

the 715,000 reported hospital deaths in 2010, 576 were potentially avoidable, and

64 were associated with a worsening in patient condition without nurse

recognition and intervention. A strength of this study is Elders use of

existing studies, and the consideration and incorporation of data found into hers.

The authors study establishes the value of simulated experiences as educational

interventions though a quantitative, quasi-experimental study using a pretest and posttest.

Items tested include pre- and post- knowledge and self-confidence. In regard to both

areas, there was a statistically significant increase of scores from pre-simulation.

Operational definitions were well defined, and methods of data collection were clear.

This study is applicable to those seeking to implement effective forms of education in

nursing schools targeted at recognition and intervention in clinical deterioration

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situations.

Hosking, J., Considine, J., & Sands, N. (2014). Recognizing clinical deterioration in emergency

department patients. Australasian Emergency Nursing Journal, 17(2), 59-67.

Improvement in response to clinical deterioration has been seen through the use of rapid

response systems such as the Medical Emergency Team (MET) and Clinical Instability

Criteria (CIC). These two systems were analyzed and used, which made the study

specific and applicable. Using this as the backbone to their research three colleges at

Deakins School of Nursing and Midwifery in Australia explored their use in in-patient

settings. Using a quantitative, exploratory descriptive design, emergency department

patients in Australia were the population studied. This study thoroughly tracked all

aspects of each participants care including type of presenting problem, health changes

that occurred during hospitalization, patient outcomes, and any MET or CIC criteria met

during their ED stay and for the following 30 days. This long period of time was a

strength of the study as more data was obtained. When analyzed this data provided

insight in regard to the most commonly caught signs of clinical deterioration, outcome

data for those who met MET code criteria, and discusses the differences between CIC

and MET. This would benefit health care professionals working in emergency settings,

and researchers wanting to investigate the utilization of rapid response systems.

Scott, B., M., Considine, J., & Botti, M. (2015). Unreported clinical deterioration in emergency

department patients: A point prevalence study. Australasian Emergency Nursing

Journal, 18(1), 33-41. doi:10.1016/j.aenj.2014.09.002

These three authors are colleagues at the Center for Quality and Patient Safety Research

in Australia. A quantitative, exploratory descriptive point prevalence survey (PPS) design

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was used for data collection. Between May 1 and June 30, 2009 nine PPS were conducted

using convenience sampling to obtain a total sample size of 189. Convenience sampling

is a weakness of this study. The purpose of this study was twofold. The primary purpose

was to determine the frequency of unreported clinical deterioration in emergency care.

This was defined as the number of times nurses documented patient conditions meeting

MET or CIC criteria, but no follow up of care or intervention was documented. This

definition was clear and gave the study strength. Additionally, the study explores the

relationship between unreported clinical deterioration and patient characteristics such as

age, clinical urgency, and type of patient manifestations. Results showed unreported

clinical deterioration in 12.9% of ED patients, with hypotension (33.3%) being the most

commonly overlooked issue. The strongest patient characteristic relationship found was

with age: 75% of unreported clinical deterioration occurred in children aged 5 or less, or

adults aged 65 and over. This study provides insight for health care professionals wanting

to improve the quality of care given, and serves as a resource for further research.

Implications

Nursing Knowledge

The results of this study suggest the role clinical knowledge, gained through experience

as a nurse, plays in recognizing signs of patient deterioration. Those with more experience

working in the nursing field exhibited an increased ability to recognize and appropriately

respond to a change in patient status. The demographic data obtained in this study included the

amount of time the participant had been a nurse, which ranged from 2 months to 19 years. Those

who had been working longer identified patient deterioration more often, which was manifest

through their selection of the appropriate intervention.

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Following selection of the nursing intervention, nurses were questioned about their

confidence level. Another relationship was noted here, between nurses years of experience

working and their self-reported level of confidence in performing the intervention. Recent

graduates, and those who had been working in the field for a shorter period of time reported

feeling less confident in their ability to perform the skills necessary in acute patient deterioration

situations than did the more veteran nurses.

Finally, the more extreme the patient condition was, the more likely a nurse was to

appropriately intervene. Patient assessment data indicating worsening patient conditions was

provided in the knowledge portion of the survey. Scenarios which more subtly suggested clinical

deterioration were more frequently overlooked than patient scenarios containing obvious signs of

worsening patient condition.

Nursing Theory

The results found support Ida Jean Orlandos nursing process discipline theory. Being

observant and taking into account every aspect of a patient assessment results in the nurse

accurately identifying an appropriate intervention, and ultimately an improvement in the

patients health (Abdoli & Safavi, 2010). This further supports the theory because the dynamic

quality of the patient-nurse interaction requires an ability to recognize subtle changes in patient

condition. Additionally, more experienced nurses showed an increased ability to critically think

and problem solve in ways directly applicable to the client. This illustrates quality of care that is

unique to each individual.

Nursing Practice

The results of this study imply confidence and knowledge play a role in the accuracy and

timeliness of nurses intervening. Awareness of these results alone can influence the nursing
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practice. Charge nurses should be aware their nurses skill sets before assigning them to patients.

Competent, confident nurses should be assigned to the more vulnerable patients. For example, a

patient who recently experienced a large amount of blood loss and is at risk of entering

hypovolemic shock should be entrusted to a more experienced nurse.

Members of the health care team should collaborate with each other, and utilize their

resources. Novice nurses can seek guidance from more experienced coworkers. As newly

graduated nurses further develop their assessment skills guidance towards appropriate

interventions could be helpful. This same comradery should encourage nurses lacking confidence

to seek a second opinion, and then to intervene.

Nurses, and all other staff can be educated about the rapid response criteria in their

hospital. Staff will be more likely to utilize these response teams if they have the opportunity to

become familiar with different patient signsuch as changes in level of consciousnessthat are

cause for concern. Through this same process, nurses can be encouraged to utilize this system to

address early signs of warning with confidence.

Improve Patient Care

More acute patients, or clients who are less stable can receive higher quality of care by

having a more experienced nurse assigned to take care of them. Seasoned nurses are more likely

to recognize and respond if subtle signs of clinical deterioration manifest. Timely interventions

improve patient outcomes, and can be life-saving.

Nurses interact with patients frequently, and their observations and assessments of the

patients condition is crucial. In a constantly changing patient-care environment, recognizing

early warning signs of deterioration and intervening appropriately requires perceptive patient
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assessments, and critical thinking skills. Nurses with higher self-perceived confidence provide

needed care to patients, when they need it.

Having a competent nurse caring for patients in a confident manner will result in the

patient being more at ease mentally. This improves patient safety on a psychological level.

Confident nursing helps a trusting, therapeutic nurse-patient relationship to be formed. The

patient may volunteer information that otherwise would have been withheld. If the patient feels

the nurse truly values how they are feeling, the patient may be more open listening to the nurse,

and any teaching provided.

Recommendations

There is need for improvement in nurses ability to recognize and respond to early signs

of clinical deterioration, as it effects patient outcomes. The results of this study suggest

confidence and experience play a role is this ability. Educational simulations may aide in nurses

developing confidence and experience. By exposing nurses to different scenarios with patients in

worsening conditions, they will gain experiences that helps the, become a more competent nurse.

An additional study could be done exploring other factors that may be inhibiting early

recognitions and response to clinical deterioration. A possible issue that could be explored is

how often nurses recognize patient decline and report it to other members of the health care

team, but it goes unacted on or brushed aside. Conducting a study examining in which

department of the hospital patient decline most often goes unnoticed would also be interesting.

Hospitals could make criteria for calling a MET code concise and readily available to all

members of the health care team. Nurses and other staff could be educated on the most common

signs and symptoms exhibited by patients whose condition is deteriorating, and provided red-
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flags to be watched for. By ensuring staff are aware of these parameters, and the appropriate

actions that should follow, timely life-saving measures can be taken.

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References

Abdoli, S., & Safavi, S. S. (2010). Nursing students immediate responses to distressed

clients based on Orlandos theory. Iranian Journal of Nursing and Midwifery

Research., 15(4), 178184.

Elder, L. (2017). Simulation: A tool to assist nursing professional development

practitioners to help nurses to better recognize early signs of clinical deterioration of

patients. Journal for Nurses in Professional Development, 33(3), 127-131.

Hart, P. L., Spiva, L., Baio, P., Huff, B., Whitfield, D., Law, T., Wells, T., and

Mendoza, I. G. (2014). Medical-surgical nurses' perceived self-confidence and leadership

abilities as first responders in acute patient deterioration events. Journal of Clinical

Nursing., 23(19-20), 27692778. doi:10.1111/jocn.12523

Laurens, N., and Dwyer, T. (2011). The impact of medical emergency teams on ICU

admission rates, cardiopulmonary arrests and morality in a regional hospital.

Resuscitation, 82(6) 707-712.

McDonnell, A., Tod, A., Bray, K., Bainbridge, D., Adsetts, D. and Walters, S. (2013). A

before and after study assessing the impact of a new model for recognizing and

responding to early signs of deterioration in an acute hospital. Journal of Advanced

Nursing, 69(1), 4152. doi:10.1111/j.1365-2648.2012.05986.x

Mullany, D. V., Ziegenfuss, M., Goleby, M. A., & Ward, H. E. (2016). Improved hospital

mortality with a low MET dose: the importance of a modified early warning score and

communication tool. Anaesthesia & Intensive Care, 44(6), 734-741.

Patrick, W. B., Stephen, M., Uma, K., Marshall, A., Regan, G., Dawn, H., Marty,
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G., Christine, W., Tracey, M. B., Victoria, D., Maria, G., Jodi, S., Karen, M. T., Jason,

O., Patrick, H. C., Derek, S. (2013). Improving situation awareness to reduce

unrecognized clinical deterioration and serious safety events. American Academy of

Pediatrics. 131(1).

Rosenthal, B. C. (2006). An interactionists approach to perioperative nursing. AORN

Journal, 64(2), 254-260.

Tait, D. (2010). Nursing recognition and response to signs of clinical deterioration.

Nursing Management, 17(6), 31-35.

Watkins, T., Whisman, L. and Booker, P. (2016). Nursing assessment of continuous vital

sign surveillance to improve patient safety on the medical/surgical unit. Journal of

Clinical Nursing, 25(1-2), 278281. doi:10.1111/jocn.13102