Seeing the Whole Picture in Enrolled and Registered Nurses' Experiences in Recognizing Clinical Deterioration in General Ward Patients: A Qualitative Study

Background: The implementation of early warning scoring systems and medical emergency teams that aim to reduce failure to rescue in general wards is only effective if frontline nurses can recognize and act on clinical deterioration in a timely manner. While much of the research to date has primarily focused on registered nurses as recognizers of clinical deterioration, little research has sought to explore the role of enrolled nurses in recognizing clinical deterioration and to provide a big picture of how enrolled and registered nurses recognize clinical deterioration in general ward patients.

Objectives: To conduct an exploration of the experiences of enrolled and registered nurses in recognizing clinically deteriorating patients in general wards.

Design: A qualitative, descriptive design.

Setting: General wards at a 1,000-bed acute general hospital in Singapore.

Participants: A purposive sample of 22 enrolled and registered nurses who had at least 6 months of nursing experience and who were working in the general wards.

Methods: Individual semi-structured interviews were conducted between October 2016 and February 2017. Interviews were transcribed verbatim and analyzed using thematic analysis.

Results: Four salient themes emerged from the data analysis. The first, 'Having a sense of knowing', illustrates how knowing a patient and past experiences facilitated the early recognition of clinical deterioration before the patient turned haemodynamically unstable. The second, 'Patient assessment practices', depicts the physical assessment skills that nurses used to detect clinical deterioration. The third, 'Delegation of routine patient care and assessment to enrolled nurses', demonstrates that nursing activities were delegated to enrolled nurses with lesser directional and supervisory aspects that "delegation" implies, which can potentially compromise patient safety. The fourth, 'Missing the big picture', identifies overwhelming workload and fixation on specific parameters of a patient as reasons for both enrolled and registered nurses missing the big picture of the patient's deterioration.

Conclusions: This study provides a snapshot of the recognition of clinical deterioration among enrolled and registered nurses in general wards. Our findings illuminate the need to support the roles of enrolled and registered nurses, with an emphasis on patient assessment and strengthening collaborative practices among nurses, to improve early recognition and timely treatment of clinically deteriorating ward patients.