Aims and objectives: To develop and evaluate the psychometric properties of an instrument that measures nurses' Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND).Background: General ward nurses play an important role in recognising patient deterioration. However, their attitudes towards early recognition of clinical deterioration have not been adequately explored due to the lack of a valid and reliable scale. Design: An instrument development and validation study.Methods: A three-phase structure that followed the STROBE checklist was used: (1) item generation, (2) content and face validity assessment and (3) psychometric properties evaluation. The scale items were developed based on a comprehensive literature review and content validity assessment by 15 international experts from five countries. The psychometric properties of the ATREND scale were tested on 434 registered nurses, with retest evaluations (n = 100) at two hospitals. Exploratory and confirmatory factor analyses were used to examine the factor structure of the scale. The scale was also evaluated for its internal consistency, test-retest reliability and convergent validity.Results: The scale's content validity was 0.95. A 3-factor solution was identified from the final 11 items: (1) beliefs about importance of patient observation, (2) use of broader patient assessment skills and (3) confidence in recognising clinical deterioration. The internal consistency reliability of the scale was supported with an acceptable Cronbach's alpha value of 0.745. Test-retest reliability of the scale was excellent, with an intraclass correlation coefficient of 0.825. The ATREND scale shows evidence of good convergent validity.

AimTo explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation.BackgroundThere is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns.DesignA mixed‐methods study.MethodsOnline survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross‐sectional studies and the COREQ guidelines for qualitative studies.ResultsMany nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the ‘middleman’ between the intensive care unit outreach nurse and primary team doctors.ConclusionsAlthough nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration.Relevance to clinical practiceNurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management.No patient or public contributionNo patients, service users, care‐givers or members of the public were involved in the study.

Objectives: Do Not Attempt Resuscitation (DNAR) orders have been used in hospitals worldwide for the past 30 years, but are still considered to be a challenging and difficult area of practice. Nurses being the frontline healthcare professionals should be involved during the decision-making process and are required to have good understanding of the DNAR order, in order to provide effective and efficient care. Our aim was to investigate: nurses' involvement during decision-making process, level of understanding of issues surrounding DNAR orders; and how they perceive care for patients with DNAR orders. Methods: A descriptive crossed sectional study design using electronic questionnaires was adopted for the study. The study was conducted among 400 nurses at a tertiary hospital in Singapore. Results: This study showed that 44.5% of nurses reported physicians did not involve them in decisions for DNAR orders; only 8% felt that they should be involved in the decision-making process. Even if they did not agree with the order, 63.2% would still comply whilst 21% of them were willing to discuss this further with the treatment teams. Most agreed that antibiotics, intravenous fluids, oxygen therapy and artificial feeding were appropriate for patients with DNAR orders. Majority (57.1%) expressed uneasiness in discussing end of life issues with patients even in specialty areas. Conclusion: Nurses should be encouraged to advocate for their patient and take part in the decision-making process. Communication between the medical team and nurses can be improved and there is an obvious need for further improvement in education and collaboration in this area.