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entifying patient deterioration: Using simulation and reflectiveterviewing to examine decision making skills in a rural hospital

th Endacott a,b,*, Julie Scholes c, Simon Cooper b, Tracy McConnell-Henry b, Jo Porter b,aren Missen b, Leigh Kinsman d, Robert Champion e

aculty of Health, Drake Circus, Plymouth PL4 8AA, UK

onash University, School of Nursing (Gippsland), Churchill, Victoria 3842, Australia

entre for Nursing and Midwifery Research, University of Brighton, Village Way, Falmer, Brighton BN1 9PH, UK

chool of Rural Health, Monash University, P.O. Box 666, Bendigo, Victoria 3552, Australia

epartment of Mathematics and Statistics, La Trobe University, P.O. Box 199, Bendigo, Victoria 3552, Australia

What is already known about the topic?

Patients continue to deteriorate on acute medical andsurgical wards, despite extensive work to improve early

identification of disordered vital signs. Ward culture hasbeen identified as an important component of clinicaldecision making for deteriorating patients.� Rural hospitals in Australia manage high acuity patients

less frequently than metropolitan hospitals yet cliniciansin these settings have to manage patients with fewercritical care resources.� Early identification and timely patient management have

been demonstrated to improve patient outcomes.

What this paper adds

� Participants (Registered Nurses) in a single wardsetting demonstrated widely different decision making

R T I C L E I N F O

icle history:

ceived 28 June 2011

ceived in revised form 27 November 2011

cepted 28 November 2011

ywords:

cision making

ral hospitals

fety management

rsing

A B S T R A C T

Objectives: The study aim was to examine how Registered Nurses identify and respond to

deteriorating patients during in-hospital simulation exercises.

Design: Mixed methods study using simulated actors.

Setting: A rural hospital in Victoria, Australia.

Participants: Thirty-four Registered Nurses each completed two simulation exercises.

Methods: Data were obtained from the following sources: (a) Objective Structured Clinical

Examination (OSCE) rating to assess performance of Registered Nurses during two

simulation exercises (chest pain and respiratory distress); (b) video footage of the

simulation exercises; (c) reflective interview during participants’ review of video footage.

Qualitative thematic analysis of video and interview data was undertaken.

Results: Themes generated from the data were: (1) exhausting autonomous decision-

making; (2) misinterpreting the evidence; (3) conditioned response; and (4) missed cues.

Assessment steps were more likely to be omitted in the chest pain simulation, for which

there was a hospital protocol in place.

Conclusions: Video review revealed additional insights into nurses’ decision-making that

were not evident from OSCE scoring alone. Feedback during video review was a highly

valued component of the simulation exercises.

� 2011 Elsevier Ltd. All rights reserved.

Corresponding author at: Monash University, School of Nursing

ippsland), Churchill, Victoria 3842, Australia.

E-mail addresses: ruth.endacott@plymouth.ac.uk,

h.endacott@monash.edu (R. Endacott), J.Scholes@brighton.ac.uk

Scholes), simon.j.cooper@monash.edu.au (S. Cooper),

cy.mcconnell-henry@monash.edu.au (T. McConnell-Henry),

nne.porter@monash.edu (J. Porter), Karen.Missen@monash.edu

Missen), Leigh.Kinsman@monash.edu (L. Kinsman),

hampion@latrobe.edu.au (R. Champion).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

20-7489/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

i:10.1016/j.ijnurstu.2011.11.018

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717 711

strategies. Where a protocol existed, participantsomitted several steps in the patient assessment process.However, assessment and re-assessment of pain wasparticularly poor.

Despite using patient actors rather than mannequins,participants commonly omitted asking the ‘patient’about past medical and medication history.

Video review revealed additional insights into partici-pants’ decision-making that were not evident from OSCEscoring alone; feedback from participants highlightedthe value of video feedback to identify elements of poorperformance.

. Introduction

In recent years the acuity of patients managed on generalards has increased (National Confidential Enquiry into

atient Outcome and Death (NCEPOD), 2005; Nationalstitute for Health and Clinical Excellence (NICE), 2007).

onsequently, the pressure on ward based nursing staff tossess and manage complex patients and events has beenmplified. Recent evidence indicates a high level ofisturbed physiological variables in the general wardopulation (Harrison et al., 2005) and poorer patientutcomes due to mismanaged patient deterioration (NCE-OD, 2005). Missed indicators of deterioration have alsoeen noted in smaller rural hospitals (Endacott and Westley,006); whilst previous researchers have demonstrated thaturses are not always clear about when to call for assistanceioffi, 2000), do not always seek advice in a timely manner

nd fail to appreciate clinical urgency (Harrison et al., 2005;CEPOD, 2005). Small regional hospitals receive high acuityatients less frequently than their metropolitan counter-arts with the risk of skill decline and concerns about skillix (Hore et al., 2003). These issues and the remoteness ofany rural hospitals emphasise the need for good clinical

ssessment skills to identify deterioration earlier. We do notnow what cues clinicians detect and miss nor which cues, ifetected, lead to active patient management.

One way of exploring cue detection is through the use ofimulation. Simulated environments allow skill rehearsal

insman et al., 2009) and may help to reduce medical errorsiv et al., 2005). It is suggested that patient actorstandardised patients) are able to mirror the true

ontextual environment and have a significant impact onarning (Bosek et al., 2007) and students’ perception of theirarning (Buykx et al., 2011). This paper reports a specificataset from a simulation study measuring knowledge,erformance and situation awareness (reported in Coopert al., 2011a). Findings from a time series analysis of vitaligns charting in the study setting before and after theimulation exercises are reported elsewhere (Cooper et al.,011b). This paper reports findings from the analysis ofideo data from the simulation exercises and reflectiveterviews with participants.

.1. Study aims

The aim of the study was to examine how Registeredurses identify and respond to deteriorating patientsuring in-hospital simulation exercises.

2. Method

This aim was addressed through a mixed methodsstudy with two elements: (1) conduct of two simulatedscenarios using patient actors and (2) reflective interviewwhilst viewing the video footage of the simulation. Thepurpose of the reflective interview was to capture theparticipants’ rationale for their actions. Following theinterview participants were given feedback on theirperformance. Data collection took place between Octoberand December 2010; all participants completed allelements of the data collection.

The study was designed using a mixed methodsapproach with convergent triangulation (Cresswell andPlano Clark, 2007). Mixed methods design requiresdecisions to be made about the timing, relative weightand mixing of data; in this study the simulation andinterviews were conducted concurrently, equal weightwas given to qualitative and quantitative data and the datawere mixed at the analysis and interpretation stages(Cooper et al., 2010).

2.1. Setting and participants

All Registered Nurses working on acute (Medical andSurgical) wards at a small rural hospital in Victoria,Australia were invited to take part in the study (n = 40).Nurses registered in Division 2 only (Enrolled Nurses) andRegistered Nurses working a locum shift at the hospitalwere excluded from the study. Thirty-four participantswere recruited (response rate 81%); the average age was41 years (range: 22–60, SD = 10.6) and the majority (74.3%)had been qualified for more than 3 years (range 0–33 years; mean 13.57: SD = 10.27). Fifteen participants(43%) held a postgraduate certificate or diploma, includingfive in midwifery, one in cardiac care and two in critical orintensive care. One nurse held a Master of Nursingqualification. A further participant completed the firstscenario only; these data were omitted from the qualita-tive data analysis as the second scenario and reflectiveinterview were not completed. Ethics approval for thestudy was provided by the University Human EthicsCommittee and participants were fully informed about thegoals of the study.

2.2. Data collection

2.2.1. Simulation exercises

All participants completed two simulation exercises in ahospital ward. Simulated moulaged patient actors wereemployed to reproduce clinical scenarios; each scenariolasted 8 min with the patient/actor simulating deteriorationat the 4 min mark. Scenarios were based on patient cases inthe hospital used for the research and reflected ‘‘theambiguity commonly present in the clinical setting’’(Benner et al., 1999, p. 56). The scenarios were conductedin the participants’ workplace, in an attempt to reduce theperception of stress arising from an unfamiliar environment.

During the simulation exercises, information waspresented in a manner that most clearly reflects the realworld requiring participants to be active searchers,

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717712

ntrolling the selection of information and its sequenceer time (process-based information giving) (Patel andoen, 1986). Levels of relevant information and levels ofcertainty were taken into account (Cosier and Dalton,88) and incorporated into the scenarios (see Table 1).e scenarios were assessed using an Objective Structured

inical Examination (OSCE) format; the items included ine scoring tool were derived from expected practice fore scenarios presented, based clinical practice guidelinesurtis et al., 2007) and an expert panel review (3nicians, mean 21 years experience). Students gainedarks in the OSCE assessment for correct observations,story taking and correct patient management, such asygen administration and pain management.

.2. Video review

The opportunity to reflect on the conduct of real andulated clinical situations is a cornerstone of contem-

rary education and clinical governance in health care.deo recordings of each scenario acted as a memory recallrvice to stimulate each participant to provide a reflectivecount of their decision making processes in response toe simulated event. Reflective interviews were under-ken by two members of the research team withperience of in-depth interviewing (SC, JP), using armat of questions and prompts developed by the teamC/LK/RE/JS) and used in previous studies. This ‘photocitation’ process (Harper, 1994) serves to uncover howeoretical knowledge as well as past clinical experienceforms clinical judgements and actions (Scholes, 1996).terviews lasted between 20 and 40 min, were audio-corded and transcribed verbatim.

.3. Performance feedback and training

Individual constructive feedback from a trainedstructor followed the video review and reflective inter-ew. This included a summary of the main take homeessages regarding the management of a deterioratingtient, allowed the participant to self-assess theirrformance and outlined the common clinical manifesta-ns and management of the clinical conditions.

. Data analysis

Schatzman’s dimensional analysis (DA) was used toalyse the reflective reviews of video performance. Two

(observation of video recordings) and the reflective inter-view, across each participant and then in comparisonacross all participants to identify commonalities andidiosyncratic performance. DA shares a number ofanalytical practices with grounded theory but has itsown specific procedures (Schatzman, 1991, p. 303) thatdistinguish it from grounded theory methods, althoughlatterly it has been labelled a second generation groundedtheory (Bowers and Schatzman, 2009). The procedureincludes: reading transcripts and viewing video footage,labelling data (properties), clarifying the meaning andviewing the concepts with increasing abstraction (dimen-sions), then building patterns between different dimen-sions to explain a social process (Kools et al., 1996). As thedata is viewed with increasing abstraction, or with a newtheoretical perspective, revisiting the original video andinterview transcript enables the researcher to see all that iswithin the data. Dimensions are built inductively but theirauthenticity is confirmed by deduction, seeking evidenceto confirm or contradict the dimension in the data of otherparticipants. This builds new dimensions that are con-solidated or expanded as new data emerges (differentia-tion). Different types of memos are used to maketransparent the interpretative decisions and are set outas an audit trail along the analytical journey (Stern, 2010).

2.4. Findings

Initial analysis of the interview and video data focusedon assessment undertaken and actions initiated by theparticipants during the scenarios. Summary data fromthese two aspects are presented below.

2.5. Assessment

Regardless of whether the actions that followed (orpreceded) the assessment were correct or incorrect, therewere a number of common omissions in the assessmentprocess:

� Capillary Refill Time was assessed by one participant inone of the scenarios (1/68);� Peak flow was not measured during the respiratory

scenario by any participant;� Non-cardiac causes of chest pain were investigated by 5/

34 participants, most commonly asking the patient

ble 1

nario briefings.

espiratory scenario (A)articipant: You are a qualified nurse who has just arrived for a ward shift. You are the only available member of qualified staff on duty but

you have the support of a junior doctor who will assist and support as required. You are required to take observations as per normal but

results will be revealed by your doctor. The patient is in a quiet side ward

he patient: Gladys is a 60 year old who has just arrived on the ward for a breast lump biopsy. She has rung her buzzer complaining of

shortness of breath, you are the first nurse to attend

hest pain scenario (B)articipant: As a qualified nurse who has just arrived for a ward shift you are the only available nurse on duty but you have the support of a

junior doctor who will assist and support as required. You are required to take observations as per normal but results will be revealed by

your doctor. The patient is in a quiet side ward

he patient: Lisa is a 60 year old who was admitted a few days ago with cellulitis of her leg and has completed a course of IV antibiotics.

A student nurse has just completed a 12 lead ECG on her and asks for your assistance as Lisa is complaining of chest pain

whether there was pain on deep inspiration;

ments of data were reviewed: the performance

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717 713

Oxygen saturation was assessed by 28 participants butonly re-assessed by 21 in the respiratory scenario andassessed by 23 but only reassessed by 6 in the chest painscenario;

Pain for the chest pain scenario was initially assessed by25/34 participants but reassessed by 12/34;

Very few participants used a pain score, although mostused some form of the PQRST pain assessment tool;

Respiratory rate for the respiratory scenario was initiallyassessed by 17/34 participants but reassessed by only5/34.

The latter two omissions meant that the participantselied on the patient’s subjective judgement as to whether

eir condition was getting better or worse (‘‘How are you

eling now?’’ P11/Resp/Vid). In the respiratory scenario,hest auscultation was omitted by 11/34 participants;terview data revealed that this was primarily due to

erceived role boundaries (‘‘it’s not my ob’’ P23/Resp/Int).ideo and interview data also revealed aspects ofssessment not captured in the OSCE score, for exampleisual assessment and re-assessment: ‘‘Little subtle cues to

ay what was going on with the patient’’ (P9/CV/Int), ‘‘I’moking at the patient, her colour, her response’’ (P15/Resp/t), ‘‘straight away I noticed that she had her hand on her

hest’’ (P11/CV/Int).In the respiratory scenario, immediate history was

btained by most participants (26/34); however few askede patient about their medication history (7/34) or pastedical history (7/34). This meant that vital clues wereissed. Notably there were very few attempts to elicit a

moking history in either scenario; had a history ofmoking been established the picture may have becomelearer.

.6. Actions

Whilst the OSCE score identified what actions wereken, video analysis revealed the sequence in which

ssessment and action occurred. Oxygen was administeredy all participants in the respiratory scenario and by 33/34articipants in the chest pain scenario. This was morekely to be preceded by a baseline set of observations ine respiratory scenario whilst visual assessment of the

atient, administration of oxygen and recording of vitaligns were more commonly the sequence of events in theardiac scenario.

Analysis of the first ten sets of video and interviewata (phase 1 analysis) revealed two dimensions: com-lete or incomplete assessment and correct or incorrectctions. When displayed as a grid, this gave rise to fouruadrants; data from each of these quadrants (Table 2)ere then analysed in further detail to identify definingatures.

As a result, the following descriptors were applied toe four quadrants:

. Exhausting autonomous decision-making (completeassessment and correct actions).

. Misinterpreting the evidence (complete assessment but

3. Conditioned response (incomplete assessment butcorrect actions).

4. Missed cues (incomplete assessment and incorrectactions).

A number of questions were used to interrogate theentire set of data further (phase 2 analysis) and illuminatefactors that appeared to influence the participants’behaviour during the simulation exercises (see Table 3).Findings presented below represent the outcome of thesetwo phases of data analysis.

The OSCE results showed no statistically significantassociation between total OSCE scores and demographicdata (Cooper et al., 2011a); however, analysis of video datashowed that most of the participants with �1 year’sexperience were in quadrant 4 (incomplete assessment and

incorrect actions) for both scenarios. There were alsoparticipants with considerably greater experience sincequalification but whose performance in the scenarios alsoput them in this quadrant. Similarly, participants withgreatest experience were no more likely to be in quadrant1 (complete assessment and correct actions).

Table 2

Dimensions of assessment and actions.

Complete assessment

and correct actions

Complete assessment but

incorrect actions

Chest pain = 1 Chest pain = 0

Respiratory = 5 Respiratory = 2

Incomplete assessment but

correct actions

Incomplete assessment

and incorrect actions

Chest pain = 27 Chest pain = 6

Respiratory = 15 Respiratory = 12

Table 3

Questions used for phase 2 of analysis.

1. Exhausting autonomous decision-making (complete assessment

and correct actions)

� Does it take longer to ‘do the right thing’?

� To what extent do participants re-assess?

� Are there any patterns in the conduct of the assessment

(e.g. what do they assess first?)

2. Misinterpreting the evidence (complete assessment but incorrect

actions)

� Are the participants missing cues or not interpreting them

correctly?

� Are they misled by the patient ‘story’?

3. Conditioned response (incomplete assessment but correct actions)

� Are there any patterns in the cues missed?

� Are more experienced participants more likely to be in this

quadrant?

� Does the presence of clinical guidelines lead to action

without assessment?

4. Missed cues (incomplete assessment and incorrect actions)

� Do participants in this quadrant display or report greater

anxiety?

� Is there any link between participant knowledge and incorrect

assessment/actions?

General questions:

ow many strands are accumulated before they call for help?

o what extent do participants have insight into their performance?

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717714

. Exhausting autonomous decision-making

Video data revealed that participants who scoredghest in the OSCE were also most likely to do all thatey reasonably could before calling for help. Theynducted multiple strand assessment (for example,orough assessment and history taking) before takinge correct course of action, for example: ‘‘I needed to gauge

at it [pain score] was at the start to know if it is increasing

decreasing after starting treatment’’ (P16/CV/Int); ‘‘Indered if she’d had too much fluid, which was causing

ortness of breath so I check all that first’’ (P7/Resp/Int). Theportance of taking a full history was evident: ‘‘quite often

u ask a patient if they have breathing problems and they say

’ but then after a couple of days they bring out all these

ffers [inhalers]’’ (P16/Resp/Int), ‘‘she said that she’d been

well for a few days. . . I wanted to see what her temperate

s and listen to her chest’’ (P18/Resp/Int).

. Misinterpreting the evidence

Participants undertook fuller assessments for thespiratory scenario; this was the more difficult scenario

the likely diagnosis was unclear. However, mostrticipants missed important components of the respira-ry assessment, as illustrated by the following participantho realised that something was wrong but took therong action: ‘‘blood pressures high, pulse is high, temps up

there’s obviously something going on’’ (P17/Resp/Int).Where a full assessment was undertaken, this did not

cessarily lead to the correct course of action, for example-assessing oxygen saturation to find it has dropped furtherd then lying the patient flat. There was a tendency toisinterpret respiratory distress as anxiety: ‘‘I was still trying

work out if it was anxiety related, so I was thinking [gastric]flux because she was coming in for a biopsy’’ (P6/Resp/Int).e requirement to make decisions unaided also led to

correct or incomplete actions: ‘‘it just feels like you’re so

ne and there’s not a lot of support and um yeah it’s very

essful’’ (P17/Resp/Int).The scenariosranfor 4 min aftertheint of deterioration; this was agreed with the expert panel

a realistic time that it would take for assistance to come.

. Conditioned response

Participants who responded differently in the twoenarios were more likely to undertake the correct action

the chest pain scenario but without undertaking amplete assessment. The study setting had a clearideline in place for management of chest pain but not

r respiratory distress, indicating that the actions takenere ‘protocol-led’ rather than ‘decision-led’:

‘‘I thought ‘oh, cannulas’, I know that we need to have at

least two big gauge cannulas in, especially with AMIs, you

know if they’ve got a cannula, once a resus [resuscitation]has to happen. . . just every now and then things just

popped into my head’’ (P23/CV/Int).

‘‘so I just thought ‘ABC’, um, so I put oxygen on her because

that’s what I do with every patient that is distressed’’ (P21/CV/Int).

Both of these participants completed all the requiredactions but with very little assessment, including exclusionof non-cardiac causes of chest pain. The use of heuristics(rules of thumb) was also evident in the application ofMorphine, Oxygen, Nitrates and Aspirin (MONA) butwithout taking account of assessment findings or patienthistory. One participant also put the oxygen saturationprobe on the patient’s finger at the beginning of thescenario but did not take a reading at any point (P2/CV/Vid).

2.10. Missed cues

The most common pattern of behaviour in thisquadrant was lack of reassessment leading to incorrectactions. For example several participants failed to re-assessoxygen saturation and laid the patient flat (respiratoryscenario) or failed to re-assess saturation when the patientreported increased pain, leading to incorrect action (P3/CV/Vid). Documentation of vital signs was highly variable,with some participants admitting that their usual practicewas to ‘‘write it down on a scrap of paper then transfer it to

the chart later’’ (P2/Resp/Int); this particular participanthighlighted that she noticed this practice when reviewingthe video and would wish to change it. Review of the videodata revealed that most participants had difficulty inter-preting the abnormal ECG as illustrated in the followinginterview excerpt: ‘‘R: So what did you see in the ECG?

P: . . .not quite sure to be true to myself, I think it’s some heart

block’’ (P31/CV/Int). Again this was sometimes attributedto role boundaries ‘‘I’m just hoping that the doctor’s looking

at it. . .’’ (P19/CV/Int).Incomplete assessment often meant that participants

got side tracked: ‘‘I don’t know [what is wrong] that’s why I

asked about the throat swelling and the tongue swelling,

whether maybe she had an allergic reaction to something’’(P19/Resp/Int). The following interview excerpt illustrateshow single strand assessment, in this case blood pressure,led the participant to take the wrong course of action in therespiratory scenario: ‘‘R: So you’ve asked for a GTN patch,

what were you thinking? P: Her blood pressure was going

up,. . . and I was thinking if it was, like, pulmonary oedema or

something it would cause vasodilation’’ (P21/Resp/Int).A central tenet of simulation as a learning experience is

that participants have to uncover information as thescenario progresses; the value of using patient actors ratherthan mannequins for simulation is the ability to askquestions and obtain a history from the patient. A numberof participants missed cues through not talking to the‘patient’; in the less differentiated respiratory scenario only26/34 participants asked the patient questions about theircurrent condition, 7/34 asked about usual medication useand 7/34 asked about their history using questions such as:‘‘have you had anything like this [these symptoms] before?’’.

3. Discussion

In the past two decades, interest in hospital mortalityhas focused on why patients die. Interview data from thisstudy show that many nurses in this hospital were not

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717 715

ncouraged to undertake high level surveillance, such aseak flow recording or ECG interpretation (‘it’s not my job’)nd were dependent on support from doctors, indicatingat the autonomy embedded in nursing roles may be asportant in identifying deterioration as levels of RN

taffing. This supports the findings of Boyle’s (2004) cross-ectional study examining organisational characteristics,urse-sensitive adverse events and failure to rescue (FTR),ndings of which revealed a significant inverse relation-hip between nurse autonomy and FTR (Pearson’s

= �0.53). Autonomy has a very clear social componentooft, 1990) – that is, it has to be acceptable in the social

ontext and not simply mandated by professional bodies.revious work in regional and rural hospitals in Australiaas highlighted considerable variability in the level ofutonomy given to (or indeed accepted by) nursesndacott and Westley, 2006; Endacott et al., 2007). In

ur study the nurses with most and least years ofxperience were those who operated in a less autonomousanner; this reluctance by very experienced nurses toake decisions is in contrast to previous studies (Bakalis

t al., 2003), however, it may reflect professional normsperating at the time of their original pre-registrationducation.

It has been suggested that the culture of a nursing carenit (Tanner, 2006) or the general ward environment

etnitz et al., 2003) can influence clinical judgements. Thentire nursing workforce of one ward were invited toarticipate in this study, with a response of 85%, butemonstrated diverse clinical decision-making and auton-my, implying that ward culture was not a dominant factor.

Despite this variability in autonomy exercised by thearticipants, when faced with uncertainty, participantsenerally initiated more interventions; this is in directontrast to findings from a previous study using simulatedcenarios with nursing students, where uncertainty led toaction (Endacott et al., 2010). This indicates that

xperience, whether or not it is with similar patients,ives nurses confidence to take action. Interview dataevealed elements of deductive reasoning, with partici-ants choosing actions that had the highest probability ofuccess, for example starting oxygen with or without a fullssessment.

Whilst this type of conditioned response (actingithout demonstrating all the previous steps) may reflect

xpert practice (Benner, 1984), the interview data in thistudy revealed that, for some participants, this was clearly

dangerous way of operating. The low level of re-ssessment of oxygen saturation, chest pain and respira-ry rate further contributes to the appearance that actionas separate from assessment as the consequences or

utcomes of actions were not being evaluated. Thisuggests that protocol-based learning in the absence ofedback could lead to poor practice becoming embeddedcting without first assessing). In an attempt to under-

tand why pain assessment was not conducted, standardursing documentation was reviewed at the study site.ain assessment was not included on either the ‘regular’ ore ‘frequent’ vital signs charts.The two scenarios used in this study would have been

miliar to all of the participants and yet mistakes were

frequently made. Previous studies with nurses and doctorshave emphasised the importance of ‘knowing the patient’,both as an individual person and in their response tosymptoms (Tanner et al., 1993; Fairhurst and May, 2006) inorder to plan care appropriately. The lack of history takingby participants in this study suggested that they were notseeking to ‘know’ the patient, hence they were missingimportant clues. However, it is possible that the ‘artificial’nature of each scenario, despite expert acting skills,reduced the fidelity (believability) of the situation. Neverthe less the value of simulation and video review fordeveloping history taking skills has been reported else-where (McKenna et al., 2010); this was an importantcomponent of the feedback provided to participants in thisstudy.

The conduct of the scenarios provided the opportunityfor participants to discuss findings and decisions with thejunior doctor; several participants expressed frustrationthat the doctor was not sufficiently experienced to helpwith decisions. In a study examining sources of uncertaintyin community nursing, Carr et al. (2001) found that theinability to confer with colleagues about decisionsincreased participants’ feelings of uncertainty. Previousstudy findings also emphasise that nurses prefer to consultwith colleagues rather than use online or written sourcesof information (Estabrooks et al., 2005; McCaughan et al.,2005). However, cues of deterioration are missed in thefirst instance by individual nurses and doctors (forexample, Henrichs et al., 2009), hence the focus in thisstudy was on individual, rather than team, performance.

In previous studies exploring the recognition ofdeterioration, there is a focus on assessing vital signs.Respiratory rate has been consistently identified as a keydistinguishing factor between stable and unstable patients(Harrison et al., 2005; Subbe et al., 2003); however, it isalso regarded as ‘the neglected vital sign’ (Cretikos et al.,2008). Similarly, previous studies highlight the incon-sistent use and interpretation of Capillary Refill Time (CRT)(Lobos and Menon, 2008). Both of these vital signs werepoorly completed in our study. Previous interventionsshown to improve vital signs recording have included chartre-design and early warning scoring (Horswill et al., 2010;McBride et al., 2005; Ryan et al., 2004); we found thatcharting of vital signs was not a high priority with ourparticipants. This may reflect the ‘unreal’ simulationsetting; however, our data indicated that there are anumber of organisation issues that need to be addressed inorder to improve recognition and management of dete-riorating patients. The re-design of vital signs charts toinclude pain assessment may prompt nurses to assess andre-assess pain.

Individual and team based simulation exercises con-tinue to be a key educational strategy for developingdecision-making in emergency situations (Scalese et al.,2008; Wayne et al., 2005) with improved performanceover traditional learning experiences for advanced cardiaclife support (Wayne et al., 2005) and airway managementskills (Kory et al., 2007). However, for simulation to havean impact on the timely management of patients whodeteriorate, it is essential to address higher levels of theclinical skills assessment pyramid (Miller, 1990), i.e. to

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R. Endacott et al. / International Journal of Nursing Studies 49 (2012) 710–717716

sess actual skills performance, not simply knowledge.e use of patient actors rather than mannequins appeared

increase the fidelity of the simulation exercises;wever, coupled with the video review and individua-ed feedback, this was a resource-intensive educationaltervention. Future research could examine the effective-ss of team, rather than individual, exercises and feed-ck.

. Limitations

This study was undertaken in a single hospital withrticipants from the one acute ward in the hospital.edback for participants was presented individually andilored to performance; this is likely to be a barrier toture studies as well as implementation programmes.wever, the intensive nature of data collection and dataalysis has allowed the research team to uncoverfferences in the approach taken by participants to theme problem/scenario. In future studies, it would beteresting to explore whether peer review of performances any value.

Conclusions

The reflective interview and feedback on performancecluded in this study are time and resource-intensive;wever our findings illustrate the diverse decisionategies adopted by Registered Nurses and indicate aed for educational preparation and professional devel-ment to enhance decision making and performance.wever, our findings highlight the centrality of feedback

performance to develop skills necessary to optimise thefety of acutely ill patients.Conflict of interest: None declared.Funding: This study was funded by Monash Universityall Grant Scheme. The sponsors have not been involved

design, conduct or publication activity for the study.Ethical approval: Ethical approval was provided by

onash University Human Ethics Committee.

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