Developing the recognition and response skills of student nurses.

PROFESSIONAL ISSUES

Developing the recognition and response skills of student nurses Claire Perkins and Maria Kisiel

T

he Department of Health (DH) (2009) advocates that all healthcare staff develop competencies in the recognition and response to acute patient deterioration along a chain of response appropriate to the level of care they provide (Figure 1). The roles form a continuum that represents the specific activity that is required for a deteriorating patient to be rescued (Table 1). While the DH does not specifically link roles to health professions, it seems appropriate that student nurses be proficient recognisers at the end of their training and have some primary response skills, e.g. be able to alter patient position and adjust the frequency of observations. The aim of the research was to establish how student nurses at the end of their training at Birmingham City University were performing in terms of these rescuing roles. A significant volume of evidence exists that suggests many frontline healthcare staff do not have adequate recognition and response skills to effectively rescue patients who experience acute deteriorations in their health (McQuillan et al, 1998; DH, 2000, 2005; The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2005; 2009; National Patient Safety Agency (NPSA), 2007). This remains a persistent problem despite a variety of patient safety initiatives (NCEPOD, 2012). A systematic literature review of nursing practice has highlighted the complexity of this important aspect of care (Odell et al, 2009). The need for rescuing skills is predicted to intensify due to the increasing acuity, complexity and age of the acute care adult patient population (Johnstone et al, 2007). It is important therefore that pre-registration education effectively supports student nurses in gaining effective recognition and response skills. A brief summary of the related theoretical preparation that student nurses engage in at this HEI is given in Table 2.

Literature search At present, through a search of the database Cumulative Index to Nursing and Allied Health Literature (CINAHL), using various combinations of keywords such as ‘student nurse, observations, acute deterioration, recognition and acute illness, response and acute illness and patient rescue’ there appear to be no other studies that have explored how nursing students function within the rescuing roles, defined by the DH. Claire Perkins is Senior Lecturer in Adult and Critical Care Nursing, Birmingham City University, Maria Kisiel is formerly Head of Department, Adult and Critical Care Nursing, Birmingham City University Accepted for publication: 28-May-2013

British Journal of Nursing, 2013, Vol 22, No 12

Abstract

Acute deteriorations in health occur in all healthcare settings. Every health professional must therefore have the knowledge and skills to recognise and respond effectively to acute illness, in order to avert further deterioration. It is widely acknowledged that a robust understanding of physiological observations, in addition to effective interpretation and clinical decision-making skills, is required for this task (Odell et al, 2009; Steen, 2010). A significant amount of work has been undertaken in one higher education institution (HEI) to ensure that theoretical preparation adequately equips nurses for this aspect of their role. However, it would appear from this evaluative study that some barriers may exist that prevent this essential theoretical knowledge from being embedded into clinical practice. This gap in transformational knowledge is important to highlight as there is an increasingly urgent need for these skills if acutely ill patients are to be successfully rescued (The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2005; 2009; 2012; National Institute for Health and Care Excellence (NICE), 2007; Department of Health (DH), 2009). The dissolution of barriers that prevent the development of effective recognition and response skills is an important task for all those involved in acute care education, in both HEI and clinical settings. Key words: Student nurse ■ Observations ■ Recognition ■ Response ■ Acute deterioration ■ Patient rescue ■ Clinical decision-making

Aim of study The primary aim of the study was to establish how students from this HEI were functioning at the end of their training, in terms of their recognition (C) and response (P) skills to acute patient deterioration (DH, 2009). There were two additional aims. Via a triangulated project approach insight was also sought to gain understanding of: ■■ How the students evaluated their own recognition and response skills ■■ How the students’ skills changed in the time period between their academic assessment and the end of their final year (6–9 months later). During this time they had three further clinical placements.

Method The project comprised of three stages and involved two adult branch diploma in nursing cohorts (n= 350).

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Non-clinical Staff

Recorder

Recogniser

Primary responder

Secondary responder

Tertiary responder (critical care)

Communication and handover Figure 1. Department of Health (2009) Competencies for recognising and responding to acutely ill patients in hospital ■■ They

Before final placement, students were asked to complete a self-evaluation questionnaire. The questionnaire aimed to establish students’ perceptions of their recognition and response skills to acute patient deterioration (Table 3). A response rate of 48% was given, attributed to the 168 students who completed the questionnaire.

2. Interviews Forty students in their final year were then selected to participate in a focused interview. The interview sample was initially derived via the collation of a list of students who were allocated their final placement in acute general medical or surgical ward settings, at a time when the authors were available. A further inclusion criteria was that the students had to be on placement in one of the two local teaching NHS trusts where permission had been gained to undertake the study. These constraints reduced the potential sample from the total cohort size significantly (n=350). Students were then only invited to participate if: ■■ They had recently taken observations on an acutely ill patient in their care Table 1. Summary of competency roles Role

Summary

Non-clinical staff

A member of the public (e.g. relative or friend) or nonhealthcare staff (e.g. ancillary worker) may be the first to draw attention to a change in patient condition

Recorder

A member of staff who takes designated measurements, records observations and information

Recogniser

A member of staff who monitors the patients’ condition, interprets designated measurements, and adjusts the frequency of observations and level of monitoring

Primary responder

A member of staff who can go beyond recording and further observation by interpreting wider measurements and initiates a clinical management plan

Secondary responder

A member of staff who attends when the patient fails to respond to the primary intervention, or continues to ‘trigger’ or ‘re-trigger’ a response

Tertiary responder

A member of staff who becomes involved who has appropriate critical care competences, e.g. advanced airway management and clinical examination

Source: Department of Health, 2009

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could be released from the ward area at the required time, to participate in the interview. Forty student interviews were achieved as a result of the convenience sampling method. No relationship between whether the students had completed the self-assessment questionnaire was required. Students were not made aware of the intended visit to avoid bias through preparation. The authors arrived in the clinical area in sufficient time to discuss with the student the most appropriate patient to focus on. The authors clinically assessed the patient and then conducted an audio-recorded interview with the student. The interviews took place away from the patient’s bed space, used a standardised interview schedule (Box 1) and had a 35–40 minute duration. The students’ recognition and response skills were explored in relation to the physiological observations they had taken. The interviews were then professionally transcribed and two answer matrices were utilised to achieve measurement of students’ recognition (C) and response (P) skills (Table 4). Data was then analysed from open-ended questions of the interview to achieve insight into factors that may have influenced students’ recognition and response skill development during the 6–9 month period, post theoretical study.

3. Retrospective correlation with academic results The matrices were then applied to the students’ academic results from the related module (Table 4).

Academic assessment of recognition and response skills Student nurses at this HEI are required under examination conditions to interpret a set of observational changes that include early physiological markers of deterioration of a range before triggering most early warning systems (EWS). They need to be able to discuss this deterioration in relation to their understanding of neural, hormonal and chemical compensatory mechanisms and relate this to a patient’s underlying condition and current pharmacology. Students are then required to prioritise and rationalise in detail appropriate, proactive nursing responses that they believe should be undertaken. Both the recognition and response assessment questions require long written answers and so the matrices were also used to gain a prediction of what the students’ recognition and response skills should be at the end of their training (Table 4).

© 2013 MA Healthcare Ltd

1. Self-evaluation questionnaire



PROFESSIONAL ISSUES Ethics Appropriate academic permissions were gained at the HEI for students to participate in this study. Discussion was held with the research departments of both the acute hospital NHS Trusts involved. Both departments gave permission for the project to be carried out without formal permission from the National Research Ethics Service (NRES) due to the project’s evaluative educational nature.This decision was made with the proviso that both study authors worked within the boundaries of honorary contracts and their professional obligations as registered nurses. Students were free at any stage of the project to decline to participate. No student chose to do so. The authors informed the students of the nature of the project and the intention to correlate the interview data with academic results. Students signed a consent form before participation to confirm that they agreed to this. No power issues in terms of students feeling pressurised to participate were foreseen, as the authors had no further assessment responsibility for these students, at this point of their training.

Table 2. Summary of the recognition and response to the critically ill adult: third-year module (BCU) Contact hours/independent 60/120 study hours Academic credits/level

30 credits/level 5

Module aims/objectives

In line with the recommendations from the National Institute for Health and Care Excellence (NICE) (2007) and National Patient Safety Agency (NPSA) (2007) on critical care education provision, this module offers the opportunity to develop an insight into physiological indicators of illness that might lead to complications or medical and surgical emergencies. Students will be able to develop the knowledge, skill and attitudes necessary for the provision of safe, efficient and effective care to patients experiencing episodes of critical illness

Indicative content

■■ Early

Results Self-evaluation questionnaire The majority of students who completed the questionnaire rated their knowledge and skills in this area highly (Table 3). Students mainly perceived themselves to be well-prepared to interpret clinical observations, have the knowledge to interpret altered physiology and respond effectively to it. The majority strongly agreed that being able to interpret and respond to observations was an essential part of their role.

Interviews Recognition skills (C) During the interview, questions were asked to establish if students could recognise the early signs of deterioration that can be signalled by changing physiological observations.When interviewed, 25% of the students demonstrated very weak recognition skills (C0) (Figure 2). The majority of students demonstrated some early recognition skills (C1) (Figure 2), demonstrating awareness of things being ‘not right’, but could not accurately explain why. Students frequently knew that parameters such as increasing respiratory or heart rate can be early indications of deterioration, but heavily relied on EWS tools to indicate whether they should be concerned about a patient. Only 8% of the 40 students who participated in this study demonstrated applied recognition skills that related their understanding of a patient’s observations to their individual health situation (C3). No students on their final placement were found to be able to link observations together to reliably demonstrate good, applied recognition skills, demonstrating the ability to articulate this interpretation appropriately and confidently to others (C4).


Response skills (P) During the interview, questions were asked to establish if the student was making relevant proactive nursing decisions when they encountered deterioration, such as the commencement of fluid balance charts, encouragement of fluid intake, repositioning to optimise gas exchange, alteration of the frequency of observation and the taking or referral for medical


recognition of critical illness through physiological interpretation of observations ■■ Effective planning of priorities of care ■■ Understanding the significance of haemodynamic monitoring ■■ A clinical appreciation of types and stages of shock ■■ Developing an insight into the prevalence and management of acute kidney injury ■■ Pharmacological influences on health and critical illness ■■ Ethical, legal and professional issues pertinent to the care of the critically ill adult ■■ Advocacy, escalation of treatment and consent ■■ A working knowledge of national and European algorithms and protocols that underpin the safe care of critically ill adults ■■ Basic life support and some principles of advanced life support, which include cardiac rhythm recognition ■■ Interpretation of uncomplicated arterial blood gases

Teaching methods

■■ Problem-solving

approach through the use of case studies ■■ Simulation and practice of skills

Assessment method

Invigilated examination (2 hours)

Table 3. Results of the student self-evaluation questionnaires (168 completed) SA

A

NO

D

SD

University modules adequately prepare me to take/ measure clinical observations

83

77

1

6

1

I am unsure how to respond to changes in patient observations

11

16

5

77

59

Interpreting patient observations is an essential part of my role

144

22

2

0

0

I feel confident recording patient observations

139

27

2

0

0

My response to changes in patient observations are 26 only guided by agreed intervention tools, e.g. MEWS

29

13

72

28

I feel knowledgeable when interpreting observations which show altered physiology

43

107

7

11

0

University modules adequately prepare me to interpret clinical observations

64

96

4

3

1

It is important to respond to any changes in patient observations

139

26

2

1

0

53

28

62

17

I believe that there is a deficit in my understanding of 8 altered physiology associated with patient observations

A: agree; D: disagree; MEWS: modified early warning score; NO: no opinion; SA: strongly agree; SD: strongly disagree

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Table 4. Summary of the interview and academic assessment coding matrix Level

Recogniser C Code

Prediction Level (Exam) Recognition question mark

Responder P Code

Prediction (Exam) Response question mark

C0

Fully dependent on early warning systems (EWS). No recognition skills

0–19%

P0

Fully dependent on modified early warning score (MEWS) to give responder prompts Carries out observations/care only on the instruction of others

0–19%

C1

Demonstrates some early recognition skills. Awareness of patients as individuals. May report to having intuition of ‘not quite right’ but is unable to explain further. May have some mixed concepts

20–39%

P1

Some response skills. Aware action 20–39% is needed but the identification of nursing action is weak. Student is significantly dependent on others to direct an appropriate response

C2

Reliably recognises alterations in a patient’s observations and provides some explanation of them. Is not however able to explain observation changes physiologically and/or in the context of the patient’s condition/ pharmacology well

40–59%

P2

Demonstrates some appropriate basic nursing responses, e.g. sit patient up, adjust frequency of observations. The student can rationalise these actions in a simple way

40–59%

C3

Some applied recognition skills. Demonstrates some physiological and/or pharmacological understanding, but may not be able to articulate this confidently

60–79%

P3

Is able to respond effectively to a change in patient condition. Considers a wide range of appropriate nursing actions. Is able to rationalise interventions to some degree physiologically, but may not be confident in articulating this to others

60–79%

C4

Links observations together to reliably demonstrate good applied recognition skills. Is able to articulate this interpretation appropriately and confidently to others

80–100%

P4

Is able to respond effectively to a change in patient condition. Considers a wide range of appropriate nursing actions. Is able to rationalise interventions physiologically and is confident in articulating this to others Evaluates patient response to interventions

80–100%

Box 1. Interview schedule: question examples ■ Which

observations did you take at the last set for this patient? ■ What did you feel that they indicated about the patient’s current state of health? ■ Taking each of the observations in turn, can you tell me what your thoughts were in particular about this patient’s; heart rate, blood pressure, respiratory rate, urine output, etc ■ Which of the clinical observations that you took were of the most concern to you? ■ Which of this patient’s observations do you plan to take again and why? ■ What is your plan of care for this patient over the next few hours? Interviews were audiotaped to enable accurate transcription and analysis

718

Summary of interview results The majority of students at the end of their training who participated in this study appeared to have limited recognition and response skills to acute deterioration. Therefore, students at the end of their training may not fully understand the clinical relevance of the physiological observations they take (NICE, 2007). They also may not be able to effectively undertake the primary responder role that the DH (2009) advocates when an acutely ill patient requires rescuing.

Correlation of predicted and actual recognition (C) practice For more than 3 years the related academic module has achieved a 77–83% pass rate at first submission (40% or above is considered a pass). Of the students who pass, 41–51% achieve a mark of 60% or above. This provides indication from the related theoretical component of these students’ training that their recognition and response skills should be effective in clinical practice. When the marks awarded to the recognition question on the


review. The majority of students also demonstrated weak response skills (P1 or P2) (Figure 3). Response options were often only considered that were solely based on EWS escalation protocol (Table 4). Many students demonstrated a tendency to rely on medical review to indicate what to do. Very few of the 40 students interviewed had considered a wide range of appropriate nursing actions (P3). None were able to rationalise the interventions they had chosen physiologically and were confident in articulating this to others (P4).



PROFESSIONAL ISSUES

3% 8% 25%

22%

30% 22%

n CO n C1

n P2

n C3

n P3

Correlation of predicted and actual response (P) practice When the marks awarded to the response question on the students’ exam papers were obtained, a similar situation was encountered. It was predicted that 15% of students would be functioning at responder level P4 (examination response question mark 80–100%), 35% at P3 (60–79%), 32.5% at P2 (40–59%), 10% at P1 (20–39%) and 7.5% at P0 (0–19%).These predicted expectations were similarly not seen at interview. There was a significant reduction in students demonstrating response skills at level P3 and P4 than was predicted (Figure 5). There was little difference between predictions and interview performance at response level P2. Weaker academic students, who were predicted to achieve response level P0 or P1, did, however, appear to develop their response skills in the 6–9-month period after academic assessment, though not to a level higher than P2. In congruence with the recognition results, students who demonstrated a high academic ability to respond to changes in physiological observations did not appear to be doing so in clinical practice, 6–9 months later.

Figure 3. Results of response (P) practice (clinical interviews)

0

Academic percentage score for the recognition (C) section exam

students’ exam papers were obtained, prediction scores were given based on how well the student had answered (Table 4). Of the 40 students who participated in the interviews, it was predicted that 25% of the students at interview would be functioning at recognition level C3 (examination recognition question result 60–79%), 30% at C2 (40–59%) 22.5% at C1 (20–39%) and 22.5% at C0 (0–19%). This was the minimum expectation, as it seemed reasonable to assume that students’ recognition performance should improve over time, with the additional experiential benefit of further clinical placements. These predicted expectations in actual recognition practice were not seen at interview. The number of students achieving recognition level C3 in practice was significantly lower than predicted. Fewer students achieved recognition level C2 than predicted, though the decline was not as significant (Figure 4). Students who demonstrated a high academic ability to recognise physiological deterioration, did not appear to be doing so in clinical practice 6–9 months later.


n P1

n C2

Figure 2. Results of recognition (C) practice (clinical interviews)


n PO

45%

C4

n Predicted n Actual

0 25

C3

7.5 30

C2

22.5 22.5

C1

45 22.5

C0

25 0

10

20

30

40

50

Number of students C4 = 80–100%, C3 = 60–79%, C2 = 40–59%, C1 = 20–39%, C0 = 0–19% Figure 4. Predicted and actual level of recognition skills (C)

Academic percentage score for response (P) section exam

45%

Predicted Actual

15

P4 0

35

P3

2.5 32.5 30

P2 10

P1

45 7.5

P0

22.5 0

10

20

30

40

50

Number of students P4 = 80–100%, P3 = 60–79%, P2 = 40–59%, P1 = 20–39%, P0 = 0–19% Figure 5. Predicted and actual level of recognition skills (C)

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Qualitative data themes The need for in-depth investigation into factors that enhance or hinder high-quality patient care in this field has been previously identified as being an integral part of addressing the problem of suboptimal rescue (Odell, 2010). For this reason an analytical approach was applied to the analysis of the qualitative data gathered from the open-ended question part of the interviews. Analysis was based upon the work of Giorgi (1985) as this method produces thematic and descriptive data. Data analysis of the transcripts led to the identification of four themes. These themes illustrate some barriers that may exist in the clinical placement environment to the development and consolidation of effective recognition and response skills.

Theme 1: early warning scoring (EWS) systems The existence of EWS systems in the clinical area may be creating a barrier to the successful transformation of theoretical knowledge. Many students in this study, contrary to their theoretical teaching (Table 2), developed in the 6–9 month period post-theoretical study, a confident belief that an EWS system alone will adequately identify acute deterioration in a patient; ‘It’s a really good tool because, on the basis of the MEWS score, you can tell how acutely ill they are becoming.’ C01. Some students appeared to have developed a belief that the EWS would identify early deterioration: ‘Green means he’s alright, amber means we should monitor him and red is we need to call the doctor’ A2. When the parameters in that Trust’s EWS are considered, green should not signify ‘alright’ for all patients as the green heart rate range at the time of the study was 50–110 beats per minute. It is not a new concept that novice nurses may govern their practice with rule-orientated behaviour (Benner, 1984). However, it is disappointing that at academic assessment many students showed signs of understanding a situation as a whole and appeared to be able to derive meaning from it. This provided promising indication of proficiency in terms of Benner’s (1984) seminal work. The results of this project, however, have indicated that this may not actually materialise. The recognition and response skill levels that have been reported, in combination with the qualitative data from the interviews, suggest that at the end of their training students at this HEI are likely to be at best performing as novices, in terms of their recognition and response skills. Students also frequently alluded to the cultural impact that EWS systems have; ‘I think it is true (unprompted), we do rely on them. It is like pretty much a culture now. As

720

long as they are not getting MEWSs of 3s or 4s then it’s pretty much okay on this ward.’ A01 When asked about whether they felt an observation parameter was appropriate, students frequently referred to the parameters on EWS charts to make this decision; ‘Yes, it is in the green, the green is (um) normal range.’ A3 EWS scores are based upon the premise that there is a common physiological pathway for deterioration in acutely unwell patients (Higgins et al, 2008). However, the increasing acuity and complexity of the adult patient population requires nurses to recognise deterioration where the physiological pathway is not common. If an elderly patient is hypovolemic, for example, and is receiving beta-blocker medication, his or her heart rate is unlikely to trigger an EWS at an early stage in deterioration. Patients receiving opiates may have a delayed rise in their respiratory rate. EWS systems are unable to account for these or other complexities of presentation. Indication has also emerged that the values chosen as parameters on EWS systems may be flawed (Chapman et al, 2010). Chapman et al (2010) found, via systemic review of values used in paediatric EWSs, that parameters were derived from a combination of reference ranges and expert consensus, rather than research evidence. There is no evidence to suggest that this is not the case with the recently published national early warning score (NEWS) (Royal College Of Physicians, 2012). At a time where evidence is also emerging that challenges previously accepted vital sign parameters, such as Smith et al’s (2012) study relating to pulse oximetry values, an over-reliance on EWS systems is clearly undesirable. The potential apparent culture of reliance on EWS tools is therefore concerning. Some students appeared to have also become particularly protocol-focused in their response to physiological observations. They often explained their actions in relation to EWS-escalation protocol, and did not seem to be aware that there were many other nursing interventions that could have been implemented. During their interview, when a patient’s observations were being discussed, one student said; ‘If I were qualified I would make sure that everything was done to every policy and every guideline.’ D4 Patient safety initiatives related to the rescuing of acutely deteriorating adults have led to the development of multiple new policies and protocols surrounding physiological observations. This is justifiable when such basic problems such as the insufficient documentation of key physiological parameters appear to persistently exist (Gordon and Beckett, 2011; Jonsson et al, 2011; Ludikhuize et al, 2012). However, this may be creating a clinical environment where more importance is placed on the following of protocols and procedures then the clinical judgement of a health professional. The ability to apply robust theoretical knowledge may not be sufficiently valued from a student’s perspective. More research is needed to explore this possibility further. In light of these findings it would seem appropriate that greater consideration of the potential negative impact of EWSs


Some of the potential reasons for the lack of transformation of theoretical knowledge into practice are identified in the qualitative data themes.



PROFESSIONAL ISSUES and related patient-safety initiatives on the development of effective recognition and response skills in health professionals is given.

Theme 2: exposure to clinicians on placement Thematic analysis also indicated that an additional barrier to the development of effective recognition and response skills may be the exposure to clinicians that students work alongside during clinical placement. Several students explained their reticence to highlight concerns they had about early signs of patient deterioration. At times they felt intimidated by the greater hierarchical position of others; ‘I mean, with medical staff I find, I find it sometimes slightly intimidating to call them. I suddenly then feel incompetent in that area.’ B2. This is not a new phenomenon. Manias and Street (2001) via a critical ethnography approach, identified that nurses often experience a sense of marginalisation during their encounters with doctors when discussing the care of critically ill patients. Conversely, another student stated; ‘We were quite short-staffed today, so I discussed them (the observations) with the doctor.’ D01 The willingness of qualified nursing staff to listen to the recognition and/or response judgements of student nurses, also seems to be influential. Student B01 suggested that not all clinical staff listen to their concerns; ‘You quickly know which staff to go to, don’t you?’ B01 Student A6 further substantiates this with: ‘Your decision to highlight your concerns depends upon the reaction of staff you are going to get. My mentor replied the other day, “Just hurry up with the observations. I want to go home.”’ Examples were recorded where clinical staff appeared to dismiss relevant proactive recognition or response nursing decisions that students attempted to make. One student who described her decision to attach a patient to a three-lead cardiac monitor after they had reported a further episode of chest pain said; ‘I was going to just have a look for a while to make sure everything was okay, but my mentor said it wasn’t necessary, but didn’t explain why.’ C01


Therefore, clinical staff may not be always adequately supporting students in transforming their theoretical knowledge into practice: ‘Some of the nurses haven’t been able to help me as much as I thought they would, they won’t go into the physiology. They have basic concepts of why observations are changing, but I am not sure they understand in any depth.’ D2 ‘The physiological side, nobody talks about on placement.’ B1


This is congruent with the literature cited earlier that indicates that many frontline clinical staff do not have robust recognition and response skills to effectively rescue patients. This may partly explain how students’ skills in this study appear to have deteriorated during the 6–9-month period post-theoretical study.The Willis report (2012) has highlighted that the quality of many practice-learning experiences needs urgently improving. How this is to be achieved, particularly in consideration of the findings of theme 3, is not clear.

Theme 3: resource limitation in clinical placement The pressure on resources in the clinical practice environment may also be influencing students’ recognition and response skill development. ‘Ideally we are supposed to do observations around 10:00, but we are just too short staffed today.’ A4 Many students suggested that time is frequently not available in clinical practice to interpret patient observations and effectively plan response care; ‘You don’t get time to do it. I mean I don’t think I have ever actually had time to stand there after taking some observations and go, now this could mean this and this could mean that.’ D4 Some students also identified that a variation in their selfconfidence regarding their response skills had arisen due to exposure to many different types of nursing practice, in different ward placements: ‘When I was on ward X, I was confident about taking nursing actions, but then I came here and staff do things very differently. You just have to follow the care plans.’ C0 The skills that students have had the opportunity to practice while on placement also appeared to influence their response skill development: ‘If I was thinking a patient might be having a hypo, the simplest thing would be to get a blood glucose measurement (BM) done, but this ends up a big deal because I am not allowed to do blood sugars and so I have to grab someone which takes time. I could have done it myself.’ A1 This situation arose due to a local trust policy that had been implemented that prohibited student nurses from undertaking this task. Several students identified high levels of stress among staff they worked with to also be a potential constraint upon care delivery: ‘Stress is definitely a factor, it can cause people to miss things out if they are stressed and really busy.’ C04 With what could be suggested as the poorest qualified nursing staff–to-patient ratios on acute hospital wards in the western healthcare world, it might not be a surprise

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Theme 4: medication administration One final barrier that emerged from the interview data was a lack of opportunity for student nurses to use their theoretical pharmacological knowledge when developing their recognition and response judgements. Many of the students showed awareness that pharmacological understanding was important: ‘I did consider the medications, because certain drugs you wouldn’t give. If the blood pressure was low and they were on an anti-hypertensive drug, then you wouldn’t give it.’ B2 Some students also demonstrated clinical application of their pharmacological knowledge: ‘A lot of our patients are on steroids and their BMs are touching the ceiling because of it.’ C0 Many students in this study frequently reported a lack of access to pharmacological information, and at times attributed this to medication administration record systems. ‘It all depends upon whether you are included in the drug rounds. I wouldn’t know anything about the drugs my patient was on unless I was.’ D04 ‘I used to do it a lot more when we had paper drug charts, but now on the electronic prescribing system I can’t get into the system, so I can’t link the patients’ drugs to their observations.’ B02 In light of the example scenarios discussed in theme 1, this highlights an additional important constraint to effective recognition and response skill development. Consideration of pharmacological influence is an essential part of holistically interpreting physiological observations (Mulryan, 2011). If student nurses are not included in medication administration rounds (MARs) and are not able to access medication records, it is difficult for them to assess the adequacy of a patient’s urine output. Accurate interpretation of urine output requires awareness of the existence and type of any diuretic therapy. Student nurses often anecdotally report to not always being sufficiently involved in MARs. Inexperience in reading or interpreting the medication administration record accounted for 42% of the medication errors by student nurses in Harding and Petrick’s (2008) study. Insufficient time involved in MARs, however, is understandable in light of the issues raised in theme 3.

Limitations Defining suboptimal care is inherently difficult (Quirke et al, 2011) and similar to other studies (McQuillan et al, 1998), this study relied on the assessors’ opinion. Due to the lack of existing applicable research, the authors devised and applied

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the matrix themselves. The tool that was used in this study (Table 4) is therefore inherently subjective, although expert opinion and relevant literature was used in an attempt to validate it wherever possible. The results of this study must be viewed with caution. A convenience sampling technique was used to select the participants of the clinical interviews. Time constraints permitted only 40 students to be interviewed, a relatively small proportion of the cohorts. Therefore, the results cannot be generalised for this HEI, or indeed anywhere else. The response the students gave at the time of interview may equally not have been a consistent reflection of their skills at other times. For example, the student may not have fully understood the clinical condition of the patient in question. Some students may have benefitted from caring for the patient discussed, during previous shifts. This was not accounted for. Although many do, it was also disappointing that the interview sample incorporated no students who had academically achieved recognition level C4 (examination 80–100%). In the sample the authors also found that they had comparatively few predicted recognition level C3s and response level P3s when they reflect upon the whole cohort’s grades.This may also have influenced the level of clinical skills that were achieved.

Discussion Many students in this study, who clearly demonstrated theoretical knowledge in the related academic assessment, did not robustly transfer this knowledge into effective early recognition and proactive clinical nursing practice during the course of their subsequent placements. A gap between theory and practice is not a new phenomenon (Lindsay, 1990). This should raise concern for both clinically and academically based nurse educators in light of the increasing acuity of patient population previously discussed, and the Department of Health competencies upon which this study is based. This project has highlighted some barriers that may exist to the development of these essential skills. Urgent further exploration of these is required if student nurses are to be successfully equipped with the skills needed to rescue deteriorating patients effectively. Despite the study’s limitations, the results of the thematic analysis of the interviews do concur with other research. Environmental and cultural influences, increased resource and staffing pressures have been previously found to influence the process for detecting and managing deterioration (Odell et al, 2009). Complex social factors in the clinical learning environment have also been found to influence students’ learning outcomes (Papastavrou et al, 2010). It is important therefore, that further analysis of the factors that impact upon the transformation of students’ theoretical knowledge on clinical placement occurs. It has indeed been recognised that one of the most important factors in training to become an excellent health professional is the student’s clinical environment (Royal College of Nursing, 2007). It is important, however, not to assume that all the barriers originate from the clinical practice environment. The Willis report (2012) has recently recommended that nursing education programmes comprehensively evaluate themselves and become increasingly based on extensive


that lack of time and resources may have become a barrier to these essential skills becoming transformed into practice. Willis (2012) has highlighted that employers must ensure that mentors have dedicated time for mentorship. It will be interesting to see if this can be achieved when qualified nursing posts are being cut due to hospital budget and debt constraints (Warren, 2010).




PROFESSIONAL ISSUES research. There is no research evidence currently available to support that the related theory is taught or assessed in the optimal way. The Nursing and Midwifery Council (NMC) (2010) has supported for example the use of Objective Structured Clinical Examinations (OSCEs) as an appropriate method of assessment to ensure that theoretical knowledge is transformed into clinical practice. A significant amount of positive experience with the use of OSCEs in nursing programmes has been reported (Clarke et al, 2011; Oranye et al, 2012). McWilliam and Botwinski (2012) have conversely highlighted the complexity involved in achieving rigorous assessment by this method, particularly in large groups. This is a potential area for exploration in the quest to enhance recognition and response skill development. Many students in this study, who completed the selfevaluation questionnaires, evaluated their recognition and response skills highly (Table 3). As no relationship was required between those who completed the questionnaire and those who participated in interview, it is not possible to draw conclusion that the students who interviewed held misconceptions about their recognition and response skills. However, if many students in their final year are only in the first stage of the learning process, cited by many authors including Flower (1999) as ‘unconscious incompetence’, this would further illuminate the depth of the challenge that may exist to ensure that nursing staff develop robust rescuing skills during their preceptorship period. This study has highlighted some relatively simple areas to address. Local policies and systems that exist in both the Trusts involved in this study, that prevent student nurses from measuring important physiological parameters such as blood glucose and gaining direct access to patient’s MAR should perhaps be reviewed. While these specific constraints may not be widespread, there may be constraints of a similar nature in other clinical practice environments. The impact of lack of resources and presence of EWS systems may provide more of a challenge. In terms of the latter, some advocators of EWS (Higgins et al, 2008) have suggested that regular recording of observations and simple adherence to the related reporting procedures are what is required of a registered nurse to improve patient safety in this area. A decade on since the introduction of EWSs it may be however that we are learning of their potential negative educational impact on the development of recognition and response skills. A ‘one size fits all’ recognition system (EWS) that does not take into account age, disease process, medications, among other individualities was never intended to replace the need for clinical judgement (Watson et al, 2006). If an over-reliant culture does exist on EWS systems then this may also partly explain why many mentors in this study appeared to be unable to support student nurses in transforming their theoretical knowledge. EWS systems may have prevented mentors themselves from developing the highly skilled analytical abilities that are required to become proficient and expert in these particular clinical skills (Benner, 1984).

Conclusion If the findings of this study are supported by further research, there appears to be a pressing need for enhanced preparation


KEY POINTS n Student nurses require robust recognition and response skills to prepare them to effectively rescue n Rescuing is currently challenging due to the increasing acuity and complexity of the adult patient population n The recognition and response skills of student nurses need to be fostered and supported during clinical practice placement n Higher education institutes and their clinical partners need to evaluate the impact of patient safety and education initiatives in order to ensure effective recognition and response skills are developed n Student nurses may need support in their preceptor ship period to ensure that they can recognise acute deterioration early, and respond effectively

of nurses in this important aspect of their role. NICE (2007) have set the standard that: ‘Physiological observations should be recorded and acted upon by staff specifically trained to undertake them and understand their clinical relevance.’ The DH (2009) guidance is clear that professionals who are responsible for acutely ill patients need to be able to incorporate appropriate clinical intervention in a timeframe that reflects the risk of further clinical deterioration. If student nurses at the end of their training continue to have a limited, functional approach to interpreting and responding to changes in physiological observations then this could have concerning implications for the successful rescue of acutely ill patients in the future. This study has highlighted that the preparation of nurses to gain skills in this area is affected by many factors. It appears that developments of the theoretical content of nursing programmes in this area can only successfully transform into robustly embedded clinical skills if the environment is right in clinical placement. This study has highlighted that some nursing students may be clinically placed in areas where differing environmental cultures, clinician role models, a lack of resources and access to MARs (and records), can provide barriers to the effective transformation of skills. As nurse educators it appears to be important to immerse regularly in the clinical placement areas.This has recently been encouraged by Willis (2012). This may facilitate the development of enhanced theoretical teaching approaches that acknowledge the transformational knowledge barriers that student nurses may encounter. Further research into the nature and extent of the problem is, however, imperative due to the localised BJN and small-scale nature of this project. Conflict of interest: none Benner P (1984) From Novice To Expert: Excellence And Power In Clinical Nursing Practice. Addison-Wesley, Menlo Park Chapman S, Grocutt MP, Franck LS (2010) Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med 36(4): 600–611 Clarke S, Rainey D, Traynor D (2011) Using the objective structured clinical

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examination to assess orthopaedic clinical skills for the registered nurse. International Journal Of Orthopaedic and Trauma Nursing 15(2): 92–101 Department of Health (2000) Comprehensive critical care: a review of adult critical care services. http://tinyurl.com/nzbdsmd (accessed 12 June 2013) Department of Health (2005) Quality critical care: beyond ‘comprehensive critical care’, a report by the critical care stakeholder forum. http://tinyurl. com/psqgk3a (accessed 12 June 2013) Department of Health (2009) Competencies for recognising and responding to acutely ill patients in hospital. http://tinyurl.com/nnagasz (accessed 12 June 2013) Flower J (1999) In the mush. Physician Exec 25(1): 64–6 Giorgi A (1985) Phenomenology And Psychological Research. Duquesne University Press, Pittsburgh Gordon CF, Beckett DJ (2011) Significant deficiencies in the overnight use of standardised early warning scoring system in a teaching hospital. Scott Med J 56(1): 15–8 Harding L, Petrick T (2008) Nursing student medication errors: a retrospective review. J Nurs Educ 47(1): 43–7 Higgins Y, Maries-Tillot C, Quinton S, Richmond J (2008) Promoting patient safety using an early warning scoring system. Nurs Stand 22(44): 35–40 Jonsson T, Jonsdottir H, Moller A, Baldursdottir L (2011) Nursing documentation prior to emergency admissions to the intensive care unit. Nurs Crit Care 16(4): 164–169 Johnstone C, Rattray J, Myers L (2007) Physiological risk factors, early warning scoring systems and organizational changes. Nurs Crit Care 12(5): 219–223 Lindsay B (1990) The gap between theory and practice. Nurs Stand 5(4): 34–5 Ludikhuize J, Smorenburg S, De Rooij S, De Jonge E (2012) Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the modified early warning score. J Crit Care 27(4): 424–7 Manias E, Street A (2001) Nurse-doctor interactions during critical care ward rounds. J Clin Nurs 10(4): 442–450 McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielson M, Barrett D, Smith G (1998) Confidential inquiry into quality of care before admission to intensive care. BJM 316(7148): 1153–1858 McWilliam P, Botwinski C (2012) Identifying strengths and weaknesses in the utilization of objective structured clinical examination (OSCE) in a nursing program. Nurs Educ Perspect 33(1): 35–9 Mulryan C (2011) Acute Illness Management. 1st edn. SAGE Publications, London National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2005) An acute problem? A report of the National Confidential Enquiry into Patient Outcome and Death. http://tinyurl.com/q4z4hvs (accessed 12 June 2013) National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2009) Caring to the end? A review of the care of patients who died within four days of admission. A report of the National Confidential

Enquiry into Patient Outcome and Death. http://tinyurl.com/ye9otfm (accessed 12 June 2013) National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2012) Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. A report by the National Confidential Enquiry into Patient Outcome and Death. http://tinyurl.com/d8jf2ba (accessed 12 June 2013) National Institute for Health and Care Excellence (2007) Acutely Ill Patients In Hospital. Recognition of and Response to Acute illness in Adults in Hospital. NICE clinical guideline 50. http://www.nice.org.uk/CG50 (accessed 12 June 2013) National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. http:// tinyurl.com/yk8ao5x (accessed 12 June 2013) Nursing and Midwifery Council (2010) Standards for pre-registration nursing education. http://tinyurl.com/6zodwq9 (accessed 12 June 2013) Odell M, Victor C, Oliver D (2009) Nurses’ role in detecting deterioration in ward patients: systemic literature review. J Adv Nurs 65(10): 1992–2006 Odell M (2010) Are early warning scores the only way to rapidly detect and manage deterioration? Nurs Times 106(8): 24-6 Oranye N, Ahmad C, Ahmad N, Abu Bakar R (2012) Assessing nursing clinical skills competence through OSCE for open distance learning students in Open University, Malaysia. Contemp Nurse 4(2): 233–41 Papastavrou E, Lambrinou E, Tsangari H, Saarikosi M, Leion-Kilpi H (2010) Student nurses experience if learning in the clinical environment. Nurse Educ Pract 10(3) 176–82 Quirke S, Coombs M, McEldowney R (2011) Suboptimal care of the acutely unwell ward patient; a concept analysis. J Adv Nurs 67(8): 1834–45 Royal College Of Nurses (2007) Guidance for mentors of nursing students and midwives: an RCN toolkit. http://tinyurl.com/64pu4w9 (accessed 12 June 2013) Royal College Of Physicians (2012) National Early Warning Score (NEWS). Standardising the assessment of acute-illness severity in the NHS. http:// tinyurl.com/c3kw92n (accessed 12 June 2013) Steen C (2010) Prevention of deterioration in acutely ill patients in hospital. Nursing Standard 24(49): 49–57 Smith G, Prytherch D, Watson D et al (2012) S(p)O(2) values in acute medical admissions breathing air-implications for the British Thoracic Society guidelines for emergency oxygen use in adult patients? Resucitation 83(10): 1201–5 Watson W, Mozley C, Cope J et al (2006) Implementing a nurse-led critical care outreach service in an acute hospital. J Clin Nurs 15(1): 105–110 Warren D (2010) Facilitating pre-registration nurse learning: a mentor approach. Br J Nurs 19(21): 1364-67 Willis P (2012) Quality with compassions: the future of nursing education. Report of the Willis Commission 2012. http://tinyurl.com/cvugp8t (accessed 12 June 2013)

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Developing mentoring skills as a student.

Effectiveness of narrative pedagogy in developing student nurses' advocacy role.

Developing a new uniform policy for student nurses.

Developing renal nurses' buttonhole cannulation skills using e-learning.

The assessment of student nurses.

Developing pharmacy student communication skills through role-playing and active learning.

Learning clinical skills in the simulation suite: the lived experiences of student nurses involved in peer teaching and peer assessment.

Cultivating social justice learning & leadership skills: a timely endeavor for undergraduate student nurses.

Interpersonal skills development in Generation Y student nurses: a literature review.

Human Problems of Student Nurses.

Presentation skills for nurses.

Medical student communication skills and specialty choice.

Cognitive skills, student achievement tests, and schools.

Developing clinical skills bundles.

Developing skills in interpretation.

Professional practice skills for nurses.

Nurses' interpersonal skills: a study of nurses' perceptions.

Developing critical thinking skills.

Nurses' interpersonal behaviours and the development of helping skills.

Where is the recognition of community nurses?

Strengthening Clinical Skills Using Peer-Student Validation.

Improving the Conversational Skills of a College Student with Peer-Mediated Behavioral Skills Training.

Early word recognition and later language skills.

The impact of peer-led simulations on student nurses.