Detecting and managing the deteriorating ward patient : an exploratory study of nursing practice

Hospital in-patients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, mis-interpret or mis-manage the signs. Rapid Response systems have been implemented in an attempt to address this problem. These systems consist of two phases. The initial, afferent phase, involves the detection of deterioration and referral decision for more expert help, and the efferent phase, where critical care teams attend the patient for more expert assessment and management. Research has tended to concentrate on the efferent phase of the process, and has failed to show a significant impact on patient outcome. This study was set in a single site, UK district general hospital, and focuses on the afferent phase of detecting the deteriorating ward patient, with the aim of enumerating and describing the phenomena of patient deterioration on the wards, and seeking explanations of nursing practice in observation practices and referral decisions. Utilising Critical Realist philosophy, multiple methods were used, utilising both quantitative and qualitative data collection and analysis, to focus progressively from a high level of inquiry, enumerating and describing cardio-respiratory arrests (CRAs) as a surrogate marker of deterioration, to a deeper level that focussed on nursing practice during the 12 hour period preceding the CRA event, seeking associations between the quality of nursing practice and CRA variables. Lastly, the enquiry concluded in an in- depth Critical Discourse Analysis technique applied to the nursing records pertaining to the CRA event. The findings suggest that the implementation of Rapid Response systems may have been an oversimplified solution to a highly complex problem that involves a multitude of factors. Ward nurses are struggling to detect and adequately manage the deteriorating ward patient. Cultural, organisational and professional influences have contributed to their disempowerment, therefore radical multi-disciplinary collaboration may be the only viable solution.EThOS - Electronic Theses Online ServiceGBUnited Kingdo