Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study

Abstract

Background Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct‐care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians’ delay identification and action on patients’ clinical deterioration. Aim To identify barriers and facilitators that influence clinicians’ absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework. Methods The Theoretical Domains Framework guided: (a) semi‐structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines. Findings Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources. Discussion The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team‐based training. As a result, patient safety was compromised, and clinicians frustrated. Conclusions These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration. Relevance to clinical practice Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision‐making.

Development and psychometric evaluation of the Attitudes Towards Recognising Early and Noticeable Deterioration (ATREND) scale

“…In recent years, there are increasing calls for a behavioural focus approach to address gaps in nurses' early recognition and actions on clinical deterioration (Credland et al, 2018; Smith et al, 2019, 2021b; Walker et al, 2021). While education is an important prerequisite for behaviour change, it alone is rarely sufficient to achieve desired behavioural change (Arlinghaus & Johnston, 2017).…”

Improving sepsis screening and care in a developing nation health setting: A description of implementation

“…This finding suggests there is a need to re-examine the process of sepsis alert activation and response. Evidence on clinical deterioration shows nurses experience negative emotions when interacting with rapid response staff (Massey et al, 2016), fear of criticism, increased workload, and the perception of traditional contextual hierarchies may cause distress when responding to clinical deterioration (Padilla et al, 2018;Walker et al, 2021). These could be possible reasons why a small number of sepsis alerts were activated in the current study.…”

Collaborative practice among general ward staff on escalating care in clinical deterioration: A systematic review

“…This theme, informed by 12 studies, scrutinised ward staff's attitudes and behaviours towards seeking help from their seniors when faced with clinically deteriorating patients (Bingham et al, 2020;Chua et al, 2019Chua et al, , 2020Flenady et al, 2020;Foley & Dowling, 2018;Johnston et al, 2014Johnston et al, , 2015Martland et al, 2015;Rotella et al, 2014;Smith & Aitken, 2015;Smith et al, 2021;Walker et al, 2020). Ward nurses had no qualms about seeking help from their seniors and often consulted the more experienced nurses to seek confirmation on their clinical assessment, as well as advice on care escalation and management of patient deterioration (Bingham et al, 2020;Chua et al, 2019;Smith & Aitken, 2015;Smith et al, 2021).…”