Visualising Deteriorating Conditions

By Tom Andrews, RN, B.Sc. (Hons), M.Sc., Ph.D. &
Heather Waterman, RN, B.Sc. (Hons), Ph.D.

Abstract

The research aims were to investigate the difficulties ward staff
experienced in detecting deterioration and how these were resolved.
The emphasis within the literature tends to be on identifying
premonitory signs that may be useful in predicting deterioration.
Changes in respiratory rate is the most consistent of these
(Fieselmann et al. 1993; Sax and Charlson 1987; Schein et al.
1990; Smith and Wood 1998) but in common with other signs, it
lacks sensitivity and specificity. The sample consisted of 44 nurses,
doctors (Interns) and health care support workers from a general
medical and surgical ward. Data were collected by means of nonparticipant
observations and interviews, using grounded theory as
originated by (Glaser and Strauss 1967) and (Glaser 1978). As data
were collected, the constant comparative method and theoretical
sensitivity were used as outlined in grounded theory. A core category
of “visualising deteriorating conditions” emerged, together with its
sub-core categories of “intuitive knowing”, “baselining” and “grabbing
attention”.

The main concern in visualising deteriorating conditions is to ensure
that patients suspected of deterioration are successfully referred to
medical staff. The aim is to convince those who can treat or prevent
further deterioration to intervene. Through intuitive knowing they
pick up that patients have changed in a way that requires a medical
assessment. To make the referral more credible, nurses attempt to
contextualise any changes in patients by baselining (establishing
baselines). Finally with the backup of colleagues, nurses refer
patients by providing as much persuasive information as possible
in a way that grabs attention. The whole process is facilitated by
knowledge and experience, together with mutual trust and respect.

Background

Mortality from shock of whatever aetiology remains depressingly
high, and avoidable components are contributing to physiological
deterioration (McQuillan et al. 1998) often resulting in cardiorespiratory
arrest (Rosenberg et al. 1993). Of all patients undergoing
resuscitation75% will not survive more than a few days (George
et al. 1989) with a survival rate to hospital discharge of 10% to
15% (Peterson et al. 1991; Schultz et al. 1996). Out of 9% of
patients discharged from hospital having survived cardiopulmonary
resuscitation, 4.3% were in a vegetative state, signifying severe
neurological damage (Franklin and Mathew 1994). In an effort to
detect shock early, a number of parameters have been measured.
Blood pressure, heart rate, respiratory rate, temperature, conscious
levels, shock index, central venous pressure, blood gases, blood
lactate, pulmonary artery blood pressure, cardiac index, all correlate
poorly with physiological deterioration and severity of shock (Rady
et al. 1994). Early detection of physiological deterioration remains
elusive. A further difficulty is that there are over two hundred normal
physiological reflexes that affect the pulse and respiratory rate
(Shoemaker et al. 1988).

Current emphasis in the literature is on the early detection of
physiological deterioration either through premonitory signs such as
changes in respiratory rate (Fieselmann et al. 1993; Franklin and
Mathew 1994; Goldhill et al. 1999; Sax and Charlson 1987; Schein
et al. 1990) or more recently an early warning score (Department
of Health 2000; McArthur-Rouse 2001). The latter attaches a
score to changes in such variables as blood pressure, pulse rate,
respiratory rate and temperature as a means of detecting early signs
of physiological deterioration. The greater the score, the greater is
the risk of physiological deterioration. To date these variables lack
sensitivity and specificity. The current study is an attempt to redress
the continued emphasis on physiological variables by exploring the
nature of this complex phenomenon.

Methodology

The research aims in relation to deterioration were to investigate
the difficulties ward staff experienced in detecting deterioration and
how these were resolved. The study was conducted on a surgical
and general medical ward of an inner city University teaching
hospital. Theoretical sampling was used and data collected until
saturation was reached (Glaser and Strauss 1967). A total of 44
participants were interviewed, nurses (n=30), doctors (n=7) and
health care support workers (n=7). The length of interviews varied
between 30 minutes and 1 hour 20 minutes approximately with a
mean length of 55 minutes. Interviews were conducted in a quiet
area off the ward. In keeping with the inductive nature of grounded
theory, the initial themes for the interviews were generated through
spontaneous conversations with participants on the surgical ward.
These were supplemented with observations lasting between 3 and
8 hours, over a period of eleven months. Following an initial period
of participant observation, the stance of non-participant observer was
adopted. It involved the routine of watching what was going on and
accompanying nurses if felt appropriate. No participant refused to be
observed.

Ethical approval was sought and granted from the Local Research
Ethics Committee and the University Ethics Committee. All potential
participants received a letter informing them of the study, with
an invitation to participate. Verbal consent and agreement was
sought before the period of observation, while consent forms were
signed prior to each interview. In any event, I observed very little
deterioration while on the wards. This had not been anticipated, but
may well reflect the subtle and progressive nature of much of the
deterioration that patients experience (McQuillan et al. 1998).
Data were analysed concurrently with data collection and in turn
this was guided by theoretical sampling (Glaser and Strauss 1967).
The content of each interview was analysed as soon as possible
and coded line by line (Glaser 1978). Its aim was to generate an
emergent set of categories and their properties which fit, work
and are relevant for integration into a theory. This led to the initial
generation of some 83 categories and sub-categories. Writing
theoretical memos leads to further theoretical sampling and the
generation of more categories and their properties. These were
integrated through constant comparison leading to the generation of
a core category and three sub-cores.

Visualising Deteriorating Conditions

The main concern in visualising deteriorating conditions is to ensure
that patients suspected of deterioration are referred successfully to
medical staff. The aim is to convince those who can treat or prevent
further deterioration to intervene. This needs careful management
by whoever is making the referral, which in the context of this study
is the nurse. It means presenting evidence of the deteriorating
condition in a convincing and credible manner, a way that invokes a
response. It is based on knowledge of the situation, however subtle,
personal knowledge of the person involved, exercising judgement,
as well as knowledge and experience. Establishing trusting relations
based on mutual trust and respect with those who can intervene
greatly facilitates the process. In this study, the sub-core categories
of intuitive knowing, baselining and grabbing attention emerged as
the processes involved in visualising deteriorating conditions.

Intuitive Knowing

Intuitive knowing is the first stage of detecting deteriorating
conditions. Far from being vague, nurses know exactly what they
are picking up when they are detecting deterioration in a process I
term visualising. Intuitive knowing is dependent on nurses knowing
patients, having knowledge and experience of their specialist area of
practice, as well as understanding the nature of illness. Nurses rely
on intuition as a means of detecting deterioration.

Visualising

If someone looks unwell, then they are unwell. This is categorised
as visual pickup. It is considered a more holistic basis for visualising
deteriorating conditions since subtle indicators such as mental
status, mood, making eye contact and reduced motivation are
accepted as evidence of deterioration. Initially nurses notice if
patients look unwell. This look is different for each patient and is
difficult to describe to someone else. An unwell look is characterised
as physiological and psychological. For example, patients can
be pale and clammy, slumped in a chair or withdrawn. All are
considered evidence of a deteriorating condition. Among the first
signs is a change in colour. This can be anything from pale or grey,
to blue or sweaty. There is no one particular colour associated with
deterioration but rather any change in colour from patients’ usual
one. Patients might be confused or withdrawn, not themselves
in terms of how they interact with others. Nurses and doctors
notice gross changes such as in mood and confusion but the more
well known patients are, the more likely it is that subtle changes
will be picked up. Nurses spend a greater amount of time with
patients and so come to know them better than other members
of the multidisciplinary team. Consequently they have a greater
appreciation of any changes in patients, however subtle, and accept
them as evidence of deterioration. Visual pickup will prompt further
investigation such as recording of vital signs to confirm suspicions.
If patients are not progressing then they are deteriorating since
ward staff have a mental picture of how they should be progressing
given their diagnosis, age and underlying pathology. Again this
is experience dependent. Failure to progress is associated with
any number of factors such as vomiting, continued use of oxygen,
drowsiness, pain, abdominal distension, not eating, not drinking,
reduced motivation, not getting out of bed, and any neglect on the
patient’s part. Visual pickup is based on experience and formal
knowledge. It is through caring for deteriorating patients that the
condition is recognised.

Doctors generally do not accept subtle indicators as evidence of
deterioration but need more convincing evidence. This is usually
in the form of objective, physiological change such as in vital signs
(blood pressure and pulse rate) conceptualised here as hard pickup.
They are used by nurses to get the attention of doctors and convince
them that patients are deteriorating. They provide objective evidence
of deterioration in what is conceptualised here as hard pickup,

Sometimes they’re a good way of actually grabbing medical
staff’s attention (No. 10- Sister 7 years).

It is more usual for nurses to use changes in vital signs to confirm
what they already suspect rather than as the primary way of picking
up deterioration and as a means of making their referral more
credible. There is an appreciation that acting on visual pickup alone
is insufficient,

…I think it’s just a way of formalising….what you do know and
what you can observe but you can’t write that down (No. 5-
Staff Nurse 2 years).

Observations are also used to get the attention of doctors in getting
patients reviewed and are used by them to confirm that something is
wrong rather than accepting the more holistic evidence that nurses
do.

There are occasions when nurses just know when patients are
deteriorating. This is so subtle that often they cannot articulate
what they are picking up in a process of intuitive knowing. They
are drawing on things that remain outside of conscious awareness
and for this reason they are difficult to describe. It is that element of
knowledge and experience that cannot readily be articulated. It is
invariably described as instinct or gut feeling,

I don’t know. I think some of it is instinct (No. 12- Sister 14
years).

Experience in this context is essentially dealing with patients in the
same or similar situations over a period of time. Intuitive pickup is
a matter of seeing and remembering, the making of a connection
between knowledge and experience. It is a type of pattern
recognition, where something is remembered from past experience
that enables recognition that cannot readily be articulated. It is then
extrapolated to the new situation which bears a similarity to the
past one. Similar cases have been seen before and participants
recognise this in the new one,

I’m not sure that it’s just good old pattern recognition and
you’re giving it a different label (No. 42- Sister 8 years).

Knowledge is an essential element of intuition but only when put into
context by experiencing situations that it is consolidated and can
form the basis for intuition. Although based on some experience, it
has the potential to develop fairly quickly,

So in reality intuition is actually based on past experience, it’s
just you can’t find the verbal tool to express it. You recognise
something but you’re still waiting for the old memory cells to
produce an awareness (No. 27- Staff Nurse 4 years).

Intuitive knowing is similarly dependent on knowing patients in
that the better the patient is known the more likely that it will be
used to detect deterioration. Given time, investigating further
has the potential to support the initial gut feeling that patients are
deteriorating by uncovering objective evidence. This is consistent
with the belief that the evidence is there and simply has to be
discovered through further investigation,

I think you can, working around the problem, you probably
come up with the reasons why (No. 18- Staff Nurse 11
years).

There is a sense in which intuition is not any particular thing but
rather a collection of things that are so subtle that nurses may
not often be aware of what they are picking up and so find the
concept difficult to articulate. When considered together rather
than in isolation, these subtle changes are a cause of concern and
are the initial trigger for further investigation. Intuitive knowing is
inherently difficult to articulate because often nurses are unaware
of how they make decisions or what those decisions are based on.
Consequently, when patients are referred based on intuitive knowing
alone this results in vague reporting. The language may not exist
to adequately describe what it is they are picking up. Changes may
be sufficient in themselves to convince nurses to refer patients to
doctors. However there is no guarantee that patients picked up in
this way are in fact deteriorating. Intuitive knowing can simply be
wrong, misled by the changes that are being picked up.

Being with patients for prolonged periods of time facilitates a nurse’s
knowing and therefore helps in detecting the more subtle physical
and psychological changes associated with deterioration. Although
subtle changes are difficult to articulate in clinical practice, there
is little difficulty in describing them, particularly in relation to looks.
Appreciating the significance of any changes detected, particularly
in relation to looks is based on knowledge and experience and is a
learned process. The properties of the category of visualising are:
visual pickup, hard pickup and intuitive pickup.

Experiential Knowing

This is defined as knowing through the integration of knowledge
and experience. It forms the basis of intuitive knowing because
they share some indicators as both are based on knowledge and
experience. Experiential knowing is so fundamental and important
that it underpins many of the processes that are used in detecting
and reporting deterioration. It is based on formal and informal
knowledge. The former is invariably based on knowledge of
physiology, pathophysiology and knowledge gained from clinical
practice which is situational since it is determined by the clinical
speciality. Nurses rely greatly on knowledge gained from or
consolidated in clinical experience. This is developed by caring for
patients in different situations and with differing conditions. It is of
necessity gained over time and there is a reciprocal relationship
between experience and knowledge in that experience enables a
connection to be made between formal knowledge and its clinical
application,

I think once you’ve experienced something once you’re ok.
You put in your knowledge file (No. 36- Staff Nurse 1 year).

While experience is a prerequisite in having the knowledge to
deal effectively with deteriorating conditions there is no guarantee
that knowledge will come with experience. It is difficult at times to
appreciate the influence that formal knowledge has in detecting
deteriorating conditions simply because of its reciprocal relationship
with experience in that it is so embedded in practice that it is often
taken for granted making it difficult to articulate what knowledge
is being used. A lack of formal knowledge may result in increased
stress since participants may not know what to do in particular
situations or be unable to assess patients effectively,

I think knowledge is the thing that decreased your stress and
tensions a lot because you know what you’re going to do (No.
33- Staff Nurse 2 years).

Also they underestimate the skill, knowledge and experience that is
predicated on knowing when something is wrong with patients,

I can’t describe it. I can’t …… don’t know, you just know. You
know when somebody is sick (No. 3- Sister 13 years).

If physiology and pathophysiology are not emphasised in education
and drawn on explicitly in clinical practice this leads to problems in
articulation and application of that knowledge. It is important to keep
up to date in the ever changing clinical environment. Clinical work
takes precedence over all else and if individuals are not supported
in a formal way by organisational support then keeping up to date is
problematic.

I did want to keep on top if it but I find that when you’re here
it’s just like this is work, work, work isn’t it

Creating an environment that encourages and supports life long
learning is essential in enabling individuals to keep up to date with
clinical practice. This is more likely where there is organisational
support for continuing education and where there is ready access
to educational material in the form of books and journals at clinical
level.

Functional Relations

As discussed earlier, knowing patients is essential in detecting
deteriorating conditions. Nurses attempt to know patients by
establishing functional relations. This is based on personal contact
achieved through communication. It is a function of proximity and
time in that the closer the proximity to patients and the longer the
time spent with them the greater is the perception of knowing them.
This makes it easier to detect deterioration,

But when you see patients that you know nothing about,
it’s quite difficult to know where to start (No. 20- Doctor 10
months).

Knowing patients enables the establishment of a baseline as to
how patients normally are. This can be social, psychological or
physiological, but usually is a combination of all three. It is used to
determine if patients are deviating in any way from their established
norm and to evaluate its significance, enabling subtle changes to be
detected and is inextricably linked to the process of visualising and
baselining.

There is a sense that this is a functional relationship rather than an
interpersonal one. The intention is to build up a picture of patients’
normal condition and behaviour rather than to get to know them on
a personal level. Talk is not social but has the function of patients’
norm,

Not going into detail with their social lives but just his or her
medical condition (No. 26- Staff Nurse 3 years).

Establishing functional relations is facilitated by a constant presence.
The expectation is that patients will respond to and develop a
relationship because this. It enables them to be known in a social
as well as a medical sense and helps in establishing a baseline as
to how patients are responding to their illness. To facilitate functional
relations, information is sought from a number of sources such as
patients themselves, relatives, other personnel, formal reporting,
charts and records. This further facilitates the gathering of baseline
data. Any serious deviation is taken as a sign of deterioration as
well as facilitating the pickup of subtle signs of deterioration.

Through visualising, experiential knowing and establishing functional
relations nurses begin to pick up on deteriorating conditions in
a process conceptualised here as intuitive knowing. It is the
integration of knowledge, experience and knowing patients in the
realisation that something has changed, that the patient is somehow
different. Initially these changes are so subtle as to be very difficult
to articulate. By establishing how patients are in terms of their
interaction and progression that any changes can be contextualised.
How this is done will be discussed next.

Baselining

This second stage in visualising deteriorating conditions is concerned
with establishing norms. It is the process of establishing a patient’s
usual condition to enable any changes to be contextualised in
deciding if patients are deteriorating. Nurses do this by establishing
how patients are in terms of their vital signs (e.g. blood pressure,
pulse rate), their response to any treatment, their progression and
how they generally interact with staff. This is done by establishing a
baseline against which any changes can be compared in a process
termed baselining. How this is done will now be outlined.

Vigilising

Nurses in particular are keen observers of patients. They assess
patients both formally and informally by being continuously vigilant
or what is conceptualised here as vigilising. It seems that every
opportunity is used to observe patients in establishing a baseline,

Every time that you’re in a bay near patients, you need to
be looking at them and observing them to some degree
or another. I don’t think you can just do it when it’s blood
pressure time (No. 5-Staff Nurse 2years).

To facilitate the process of vigilising nurses need to assess patients
to establish patients’ baseline and also to pick up on any deviations
from it. This enables changes to be contextualised. Like so many
elements of deterioration, nurses in particular are often unaware of
how they assess patients or make clinical decisions. However in
patients presenting with obvious signs of deterioration, assessment
is done very quickly. Unlike doctors, nurses differ from each other
in how they assess patients. One way is to have a systematic
approach whereby nurses use a predetermined series of questions
or ways of looking at patients. This can help them to more effectively
prioritise care ensuring that nothing is missed and provides a
framework for assessment. Developing such an approach is a
function of experience and developed over time and not every nurse
uses this but instead have what can best be termed an idiosyncratic
approach in that it is particular to the individual,

Newly qualified will do it in another way; someone who’s been
here 3 or 4 years do it another way (No. 33- Staff Nurse 2
years).

Despite not sharing a common way of assessing patients, nurses go
through a similar process of looking at patients, asking a series of
relevant questions either of patients or of themselves to account for
the problem as well as measuring vital signs but not necessarily in
any order in a process of seeking confirmation. These are the steps
in determining if patients are deteriorating while at the same time
ruling out obvious causes such as blocked urinary catheters being
responsible for poor urine output. Once an assessment has been
made and all relevant information gathered it is pieced together, as
an artful interpretation, in deciding if patients are deteriorating. In
this context the focus of the assessment is on the likely problem and
its cause,

We tend to concentrate on the area we think there’s a
problem and then spread out from there….gathering as much
information as possible for them to make a diagnosis (No. 12-
Sister 14 years).

A deficit in knowledge leads to a poor assessment of patients,
something that is recognised in practice. Therefore a prerequisite
for a good assessment is a sound knowledge base. The greater the
knowledge and experience the more effectively and confidently an
assessment is carried out. Assessment relies on baseline data in
order to establish if there have been any changes and to place those
changes into some context, particularly changes in physiological
variables. The way nurses assess patients is therefore modifiable
with time and experience. Less experienced staff rely on keeping
charts up to date in an effort to exert some control over what is
happening and as a means of dealing with uncertainty,

It was so much based on: if your charts were right your patients
were well looked after because you had seen them each hour
making sure they were ok (No. 2- Staff Nurse 9 years).

A more holistic assessment facilitates the contextualising of the
findings. The less the experience, the more the concentration
on individual tasks and the more difficult it is to contextualise the
information gathered. As confidence grows with experience and
familiarity with the work of the ward, this changes and nurses
are able to assess patients more effectively and understand the
significance of their findings. Also it is a matter of learning how to
apply their knowledge in a more effective way, essentially linking it to
practice. This is done through exposure to patients and experiencing
patients with different conditions. It further reinforces the reciprocal
relationship with intuitive knowing.

Routinising

Having a routine is another way of vigilising. This is needed to
reduce the uncertainty of missing something vital. Routine is a
way of organising work, particularly that of more junior nurses and
support workers. It provides structure and security. One example is
the frequent measurement of vital signs. Its importance in relation
to deterioration is to ensure that nothing is missed while monitoring
patients for how they respond to treatment,

I think you need routine ones ‘cause otherwise they’d just
never get done and people would get missed (No. 11- Staff
Nurse 3 years).

Importantly they provide a baseline against which patients are
ultimately judged to be deteriorating or not, a permanent record of
how patients are progressing. Routinising the observations also has
the benefit of freeing staff from the need to constantly review how
often they need to be done. It also avoids the confusion that may
arise out of different decisions being made about the same patients
regarding the frequency of monitoring vital signs. It is difficult in
practice, particularly when busy, to differentiate between a conscious
decision to reduce frequency and a simple omission. One way this
is dealt with is by getting on with the work reducing the need for
constantly referring to someone else. There is a tension however
between the time consuming nature of doing observations routinely
and their sometimes limited application. Currently there is no
strategy for reviewing how frequently these measurements should be
made,

So I would reduce if I felt that people would do them properly
and would discriminate on who needed 4 hourly observations
and stuff (No. 12- Sister 14 years).

However, routinising observations gives no guarantee that
abnormalities will be detected or reported as it depends on many
factors such as who is measuring the vital signs as well as how busy
the ward is. In addition, staff need some knowledge and experience
to enable them to interpret what they are picking up. As a result,
something could be missed. As with any routine, measuring vital
signs can become an end in itself with the emphasis on the task.
This could result in nurses becoming desensitised to any changes.
The trained nursing staff try to overcome these problems by counter
checking, sometimes while doing other things such as drug rounds.
The paradox remains that if changes in vital signs are relied on as
the only indicator of deterioration, then nurses will not pick up on
more subtle indicators or investigate other causes such as bleeding
from surgical wounds.

Mechanicalising

In order to overcome the time consuming and routine nature of
“doing the observations” ward staff mechanicalise the process by
use a machine (dynomap) which automatically measures blood
pressure, pulse rate temperature and oxygen saturation. It offers
both convenience and quickness in dealing with this problem.
However mechanicalising results in the loss of valuable information,
such as the detection of cardiac arrhythmias, since the pulse is not
palpated. The only touch required is to apply the blood pressure
cuff. Other problems include deskilling,

that’s taken all the skills out nursing hasn’t it (No. 40- Staff
Nurse 10 years).

Despite worries about its accuracy, vital signs are seldom manually
check, unless there is a convincing reason for doing so simply
because it is too time consuming and often the task is delegated
to health care support workers. However nurses are becoming
deskilled not only in the task of measuring blood pressure manually
but in failing to pick up the vital information gained by palpating
pulses and the close physical contact with patients that this entails.
Touch alone has the potential to provide valuable information about
patients’ condition.

No one sign has the sensitivity or specificity to detect deterioration
but together with other signs and symptoms are used to
contextualise deterioration. Nurses deal with this lack of sensitivity
and specificity by focusing on patients’ diagnosis in evaluating any
changes in vital signs and also by emphasising general changes
such as the more subtle changes picked up in the process of intuitive
knowing. However, with education and experience both nurses and
doctors come to understand the significance of any alteration in
respiratory rate and its sensitivity in relation to other observations.
This is especially so where the early warning score has been
introduced to aid detection of deterioration.

Constraining Professional Factors

Both nurses and doctors face practical difficulties in dealing with
patients who are deteriorating. These centre on interacting with each
other, dealing with patients and lack of knowledge and experience.
Disagreement between nurses and doctors about the appropriate
treatment for patients is one source of professional difficulty. To
enable a complete assessment of their condition to be made,
patients must be active participants in that examination. If they are
unable to co-operate in any way, for example through confusion,
being poor historians, then it is likely to lead to an incomplete
assessment and a missed or inappropriate diagnosis resulting in
possible delays in treatment,

So co-operation of patients really to make it more of a team
effort (No. 21- Staff Nurse 4 months).

A lack of education or knowledge and experience is a constraining
factor in detecting deterioration. This may result in a failure to
understand the seriousness of the deterioration and a failure to act
on the information. For example, there is often confusion about
when to refer patients to the critical care team or seek appropriate
expertise and when or how to intervene,

But I think the more advanced step I think our teaching’s
probably quite poor in terms of recognising when you need to
get someone else involved (No. 23- Doctor 10 months).

There are occasions when staff simply do not know how to deal with
the situation that faces them provided they recognise its significance
to begin with. Consulting with others is a means of overcoming
a lack of knowledge and experience, provided limitations are
acknowledged.

Constraining Organisational Factors

Time constraints are a problem for many staff since often there
is not enough time to do what is needed. This may result in an
inadequate assessment particularly when dealing with complex
signs and symptoms and lack of opportunity to consult with others.
For example, nurses are sometimes unable to attend ward rounds
with resulting in a loss of opportunity for them to contribute to and
influence care in a meaningful way. It diminishes the role of nurses,
making it seem as if they have little to contribute. The ward round
is after all the forum where patient care is discussed and decisions
made. The organisation of medical work is problematic in that the
greater the geographical spread of patients and the greater their
number, the less likely doctors will respond promptly to referrals
from nursing staff, particularly when referrals are based on intuitive
knowing, particularly when this is not backed up with objective
evidence. It also makes it difficult for nurses to appreciate the work
of doctors. Doctors attempt to deal with these constraining factors
by trying to prioritise care. At times, this leads to delay in seeing
patients as well as frustration and misunderstanding,

Sometime if you don’t get there fast enough, and even if
you’ve explained it to them, they will start getting a bit ratty
with you; it’s difficult for them to appreciate because you know
that you’ve not stopped working since the morning (No. 25-
Doctor 10 months).

Distraction tasking is time consuming and is anything that is
not directly related to patient care. It is a significant source of
frustration for all and involves staff dealing with things that could
more appropriately be dealt with by someone else. For example,
trying to find essential equipment that is not readily available is both
time consuming and frustrating. Distraction tasking also includes
convincing others to carry out investigations that are needed to
confirm a medical diagnosis. This leads to more time wasted on
negotiation or argument, time that could be spent on direct patient
care. Co-operation is essential in detecting deterioration since
team work is essential for its detection. Currently, diagnoses can
rarely be made in isolation and need the confirmation of laboratory
investigations as well as other tests,

It’s like arguing with radiographers and biochemists in the
middle of the night, echo technicians. It’s like why do you
have doctors if you’re not going to believe us? (No. 24- Doctor
10 months).

For nurses distraction tasking includes essential housekeeping
matters that ensure the smooth running of clinical areas. Examples
of these include organising television rental, serving meals and
unnecessary paper work. Distraction tasking is wholly inappropriate
for professionally and academically prepared personnel to engage
in. Where adequate support is provided by giving as much relevant
information as necessary and being readily available to assist, the
task of assessment and treatment is made much easier.

Hierarchical Intervening

Once physiological deterioration is established the next step is to
intervene whether to prevent further deterioration, reverse the current
trend or both. This is done through hierarchical intervention. Nurses
act either to prevent further deterioration, reverse the deterioration or
both. If the situation is judged not to be immediately life threatening,
than nurses will intervene within their capabilities and then reassess
patients as to its effectiveness. However there is a professional
boundary that nurses will not cross therefore they only intervene
within their scope of practice rather than within their capabilities.
Junior nurses however exercise excessive caution. They are less
likely to act autonomously,

Yes, as long as I have been given appropriate instruction to
and it had been charted, prescribed as such (No. 14- Staff
Nurse 9 months).

Senior nurses are willing to take actions in situations they judge to
warrant immediate intervention even if in their opinion they are in
conflict with their regulatory body and hospital policies governing
practice. However nurses need the tacit approval of nursing
management and permission from doctors to support what on the
face of it appear to be autonomous, independent actions. They are
willing to take verbal instructions via the telephone and act on them.
Initiating treatment is a matter of pragmatism since it ensures prompt
intervention given the geographical spread of doctors’ work. Nursing
intervention is therefore characterised by seeking backup and
cautious intervention.

If problems persist then patients are referred to doctors. If
patients continue to deteriorate despite nursing intervention or do
not respond to therapy, nurses refer patients to doctors. It is a
matter of recognising the limitations of what they can achieve by
their interventions. However in life threatening situations nurses
refer patients immediately while they support patients in whatever
way they can. Hierarchical intervention therefore comprises of a
series of steps. Following an assessment, nurses intervene within
their capabilities and professional regulations to prevent further
deterioration. If patients do not respond then they are referred to
doctors except where it is life threatening, in which case, referral is
immediate.

The aim of baselining is to establish patients’ usual condition so
that any changes can be contextualised. The routine of baselining
is accomplished by vigilising, routinising and mechanicalising.
When deterioration is detected, it is dealt with through hierarchical
intervention. Constraining professional and organisational factors
detract from the early detection of deterioration. For a referral to be
successful, it must be presented in a way that grabs the attention of
doctors. How this is done will be discussed next.

Grabbing Attention

This final stage in visualising deteriorating conditions is the process
that nurses engage in when presenting evidence of deterioration to
doctors. It is how they make a convincing referral, one that ensures
medical assessment and intervention. Its categories will now be
presented.

Legitimising

When nurses are convinced that patients are deteriorating whatever
its basis, they attempt to refer patients to doctors. This conviction
is often based on subtle changes as well as objective, quantifiable
changes such as in vital signs. Nurses want patients to be reviewed
when they suspect deterioration but face the difficulty of convincing
doctors, especially if they refer based on intuitive knowing only, since
doctors often only respond to quantifiable evidence. They overcome
this difficulty feed doctors information in such a way as to ensure
a credible referral. Their strategy is to legitimise their worries any
way they can. Nurses consult with others in order to legitimise their
concerns as well as seeking general support for any proposed action
including making a referral. This is in situations where they are
worried about patients but are unsure as to the significance of those
changes. Nurses are prepared to consult with anyone who knows
the patient involved. These include relatives as well as other nurses.
Also they seek advice on what else to do particularly if they are less
experienced. Discussing matters is also a means of supporting less
experienced nurses and to provide them with guidance, ensuring that
they benefit from the experience of others as well. This legitimises
their actions and the decision to refer patients.

Referrals have to be persuasive if they are to be successful. This is
more likely if nurses present factual information that is contextualised
within patients’ baseline state so that the relevance of any deviations
from that can be more easily established. If doctors are well known
to nurses, then this information is reinforced by personal opinion.
When they do not respond in a way that nurses consider appropriate,
they persist in contacting doctors until they do. If they are reluctant
to come and review patients, nurses use emotionalised inflection of
their voice as a strategy. This helps to convey the urgency of the
situation and the expectation that something needs to be done. It
complements the persistence strategy.

In situations where nurses are convinced that a patient needs to be
reviewed and they cannot convince a doctor, nurses do not hesitate
in threatening to contact a more senior doctor. Generally this is done
in an assertive way,

Perhaps you would like to come and review this patient or
perhaps I can speak to your SHO or perhaps I’ll speak to the
Registrar (No. 18- Staff Nurse 11 years).

If a doctor is perceived as being obstructive or difficult then the
individual is referred to more senior nursing staff in the expectation
that they will deal with the situation and convince those reluctant
to attend the patient. If nurses are unsure about whether to refer
patients to doctors or not, they usually err on the side of caution
even if subsequently proved wrong rather than take the risk of
further deterioration. This is similar to the cautiousness that is
characteristic of nursing intervention. In referring patients there is
an element of opportunism in that if doctors are readily available on
the ward nurses take advantage of this and ask them to see patients
irrespective of their seniority. This has the effect of ensuring that
things are done for patients that otherwise might not be and also
nurses can reinforce and further legitimise their referral to junior
doctors by invoking the authority of more senior ones,

While I’m passing I’ll just have a look because they can say:
right get the house officers to do this, this and this and then
the house officer can’t argue really (No. 11- Staff Nurse 3
years).

Presenting quantifiable evidence of deterioration convinces doctors
of the need to review patients. Vague reporting by nurses makes it
difficult for doctors interpret what is happening to patients. Despite
this, if convenient they will come and assess patients. Quantifiable
changes are used by doctors to prioritise workload and judge the
serious nature of illness. However factual information has to be
contextualised and trends reported thereby linking this to the process
of baselining presented earlier. For example, using the early warning
score doctors need to know why patients are triggering. Factual
information also enables doctors to start thinking of a diagnosis or
the likely cause of the problem and possible interventions before
they see patients. With vague reporting or reporting based on
intuitive knowing alone, doctors often find it difficult to interpret
what is happening to patients since they have not changed in any
quantifiable way making it difficult to know what to treat. The vital
signs effectively package deterioration in that they provide a succinct
way of communicating deterioration and its degree.

To be convincing nurses need to present factual information in a
particular way. Referring speech itself must be convincing. This
is sometimes problematic since nurses use intuitive knowing in
detecting deterioration making it difficult to articulate subtle changes.
Another problem is not being able to use medial language in an
articulate and confident way to convey deterioration,

The junior nurses don’t know what words to use to get their
patient reviewed. I think that’s part of the problem (No. 44-
Sister 5 years).

Nurses take time to understand and develop confidence in using
such language. Convincing reporting is indicated by familiarity
with medical language and the confidence to use it. If nurses lack
the confidence in using medical language then they use lay terms
because they are afraid of looking stupid or being undermined and
ridiculed if terms are used out of context, running the risk of not
being able to legitimise their concerns,

Whereas you wouldn’t say to them (doctors) – the man in bed
whatever, his saturation’s are this and his respirations are
that. You’d just say- his breathing’s gone off If you think about
it that way it is more of a social sort of speaking mode (No.
36- Staff Nurse 1 year).

Packaging

With confidence and education, nurses are able to draw together
their clinical findings and present them much more convincingly.
They learn how to package deterioration convincingly. The more
confidence and experience, the more likely is the use of medical
language. There is a sense that nursing students are being
socialised into this use of non-medical language rather than being
educated in its use, simply because it is the way nurses speak
to each other. Disadvantages associated with it include nurses
undermining themselves and their knowledge base since the use of
language is linked to credibility. This makes them seem inarticulate,
increasing the possibility of ridicule. Even where there is an objective
scoring system such as that for assessing consciousness (Glasgow
Coma Scale), nurses tend not to use it but instead continue to
report using subjective terms. Doctors take time to understand this
use of lay language and understanding develops as they get to
know nurses better. Often they have to seek further clarification and
information resulting in nurses becoming antagonistic because they
think that doctors are looking for an excuse not to come. This is less
of a problem where nurses and doctors have good relations.
The early warning scoring system has improved communication
between nurses and doctors and compliments the reporting of
vital signs. Doctors are obliged to act on it and nurses derive their
empowerment and confidence from this. It provides nurses with
a precise, concise and unambiguous language to communicate
deterioration to doctors. It enables doctors to focus quickly on the
problems identified by nurses. For both therefore, it provides a way
of assessing patients in that it guides them to identify problems
commonly associated with deterioration. It provides commonly
agreed criteria against which deterioration can be measured. It
has changed practice since it has made nurses more aware
of deterioration and particularly the significance of measuring
respiratory rate.

Trusting Relations

Trust is fundamental in convincing doctors to come and see patients.
It is something that has to be worked at and gained. When it is
present, things run a lot smoother and people get on better together.
Trust is indicated by listening, discussing and mutual decision
making. Likewise, where these are lacking, there is no trust and
relations are poor. If doctors respect nurses’ judgement, then
less quantifiable evidence is needed to convince them to review
patients. As it develops nurses and doctors learn to trust in each
others’ judgements so that the greater the trust the less the evidence
and this trust is based on how experienced nurses are. Trust is so
powerful that even doctors on call will respond to vague reporting.
It is also based on social interactions, simply how well nurses and
doctors interact with and know each other,

If you get along with them socially and you can have a laugh
with them then you learn to trust them (No. 7- Doctor- 10
months).

Where there is mutual trust nurses can express themselves more
freely and with more confidence in getting patients reviewed.
Communication is therefore less inhibited and much more effective.
Simple measures for developing trust and maintaining good relations
include being mutually supportive, ensuring that doctors are familiar
with the way the ward operates by using experience to guide those
with less experience to enable them to do their job more effectively
and to help them to establish priorities. Where there is mutual
respect between nurses and senior doctors, then it is more likely that
junior doctors will respond likewise. This sets the tone of relations
between nurses and doctors.

The essential basis of trust is a matter of having confidence in the
thoroughness of the assessment that competence in dealing with
situations, intervening within remit and referring appropriately,

So there is that influence from above where they do, the
senior ones listen to the nurses (No. 12- Sister 14 years).

Other factors influencing good relations include having ward based
teams of doctors, informal social gatherings and shared facilities. All
promote effective communication about patients since nurses and
doctors are more likely to meet informally, providing the opportunity
to discuss patients. This tends to be done spontaneously.
Establishing and maintaining trust and good relations is all about
promoting team work. However there is nothing done at an
organisational level to promote this. However good relations are
difficult to establish and maintain when doctors move wards regularly
and when the workload is heavy.

Negotiated Intervening

This is the process of intervening effectively to treat patients in
physiological deterioration. It is where nurses and doctors come to
a mutual decision about any interventions that are appropriate while
trying to maintain each others professional integrity by trying not to
undermine credibility. It includes giving treatment time to make a
difference to patients, essentially seeking evidence of improvement.
If there is no improvement then nurses will suggest alternatives.
Keeping options open and appealing to protocols are effective
strategies in dealing with any disagreement about treatment and
avoids alienation. An undertaking to review treatments, explaining
interventions and generally listening to concerns and suggestions
ensures that everyone feels that their point of view has been
acknowledged and nobody feels undermined. If disagreements
persist nurses will refer patients to more senior doctors. Provided
this is done assertively rather than subversively, this is relatively
unproblematic. The partnership approach to decision making is
much more effective in ensuring that the right decision is made,

They don’t trust you, they don’t trust your decisions….You
feel undermined, you feel incompetent and you feel what’s
the point (No. 24- Doctor 10 months).

Trust plays a major part in maintaining self-confidence. The
uncertain nature of physiological deterioration means that nurses
sometimes refer patients inappropriately. As a result nurses have a
fear of being ridiculed. One way of overcoming this fear is by having
their findings and worries confirmed by some external source, usually
a more senior nurse or even a protocol. Confidence is a function of
time and personality. Confidence can develop fairly quickly and is
linked to experience. The more experience gained the more likely
individuals will be confident in their ability to detect deterioration.
It also depends on personality in that the more assertive the
personality the more confident will be the referral.

Non-Responding

There are times when doctors do not respond. The more a referral
is judged to be inappropriate, the more likely it is that doctors will not
respond to future referrals. This includes contacting doctors for more
routine work such as replacing IV cannulae as well as inappropriate
referrals such as patients with nothing obviously wrong with them.
Inappropriate referrals are time-consuming to deal with. There are
times when despite clear quantifiable evidence that patients are
deteriorating doctors still do not respond. Workload, geographical
spread of work, reluctance to refer to more senior doctors,
inexperience and lack of knowledge are considered common
reasons for not responding. However a more compelling reason
may be simply that doctors do not know what to do w and instead
of referring patients they simply ignore what is happening in what is
termed here as problem avoidance behaviour,

It was pure and simple he didn’t know how to deal with it.
It scared him so he didn’t deal with it (No. 24- Doctor 10
months).

Grabbing attention is the final step in detecting deteriorating
conditions. It is based on legitimising suspicions of deterioration and
presenting the evidence in a way that results in a successful referral.
Trusting relationships are a significant factor in ensuring an effective
referral and when present facilitates mutual respect and cooperation.
Negotiated intervening means that where there is mutual decision
making and where different points of view are acknowledged and
accommodated, then professional integrity is maintained. This
facilitates the management of deteriorating conditions.

Discussion

Visualising deteriorating conditions is a three stage process.
Through intuitive knowing, nurses pick up that patients have changed
in a way that requires a medical assessment. To make the referral
more credible, they attempt to contextualise changes by baselining
that is, establishing how patients are in terms of their progression
and vital signs through vigilising. Finally, grabbing the attention of
doctors is facilitated by nurses seeking the backup of colleagues,
and providing as much persuasive information as possible in a way
that most effectively packages deterioration. The whole process is
facilitated by knowledge and experience, together with mutual trust
and respect. Cautiousness characterises each step.

Nurses report that they just know when patients are deteriorating.
They primarily rely on subjective evidence in its detection,
particularly on how patients look. Cioffi (2000b) describes similar
changes in patients such as “not right”, colour, agitation and changes
in observations. Others refer to changes in mood and reduced
eye contact as neurological alterations (Goldhill et al. 1999). The
subjective nature of nurses’ initial detection of deterioration is well
supported in the literature (Daffurn et al. 1994; Grossman and
Wheeler 1997; Rich 1999; Sax and Charlson 1987; Schein et al.
1990; Smith and Wood 1998). In a study of triage in accident and
emergency nurses, Gerdtz and Bucknall (2001) comment on how
little objective physiological data were collected when deciding
urgency.

To get to know patients nurses must spend time with them. This
enables them to detect more subtle physical and psychological
changes associated with deterioration. This is similar to the
findings of Taylor (1997), Chase (1995) and Cioffi (2000b) and is
supported in this study by nurses establishing functional relations
with patients. In the present study, knowledge and experience
emerged as important factors in picking up deterioration. Taylor
(1997) also found that knowledge and experience form the basis of
cue acquisition in that the greater the knowledge and experience
the more effective the assessment. Nurses attempt to corroborate
their subjective awareness of change with objective evidence and
has been described by Smith (1988) and Cioffi (2000b) also. Pattern
recognition as the basis of intuition is widely supported in the
literature (Benner 1984). This process has been conceptualised in
the current study as intuitive knowing.

The more knowledge and experience nurses have the more likely it
is that they will have a systematic approach to assessing patients.
Having some routine in place enables the acquisition of multiple cues
and that knowledge leads to the recognition of signs and symptoms
(Taylor 1997). King and Macleod Clark (2002) also report increased
vigilance in response to worries about patients and maintain that
nurses with more knowledge and experience have a more analytical
approach to assessment, the ability to look beyond the initial trigger.
By this they mean that experienced nurses look for further evidence
of deterioration to substantiate their worries. This is consistent with
the sub-core category of baselining conceptualised in the current
study.

There are similarities between the sub core category of “grabbing
attention” and persuasion or argument theory. Van Eemersen
et al. (1987) defines an argument as a social, intellectual, verbal
activity serving to justify or refute an opinion consisting of a series
of statements and directed at convincing someone of something.
Simons (1976) defines persuasion as communication designed to
influence others by modifying their beliefs, values or attitudes. The
more someone is known the better prepared the persuader is to
select persuasion strategies that work (Reardon 1991). However
there is no consensus at present about how relationship influences
persuasion outcomes and the process of gaining compliance (Boylan
1993) but emerged as very significant in this study since mutual trust
and respect form the basis of good working relationships resulting in
less inhibited communication.

In grabbing attention, there is always the fear that nurses will be
ridiculed for referring patients inappropriately, a similar finding to
Smith (1988) and Cioffi (2000a). One way of overcoming this fear
is by having their findings and worries confirmed by some external
source such as a more senior colleague or by protocols. This has
the effect of increasing confidence in referring patients. It is termed
collaborative decision making, evident when nurses are unsure
about diagnosis (Cioffi 2000a). Similarly Smith (1988) found that
nurses consulted with other nurses and reassessed patients when
they became subjectively aware of changes. Clinical judgements are
almost made in a group context, involving other nurses and doctors
(Chase1995). This has been conceptualised in the current study as
legitimising.

Limitations

• Few incidences of physiological deterioration were observed
therefore it is always possible that there are more categories
to emerge.
• The study was limited to doctors of house officer (intern)
grade. It is possible that the inclusion of more senior doctors
would have generated more categories.
• Theoretical sampling could have been carried out elsewhere
such as critical care areas, medical or surgical specialities
and in other substantive areas in an effort to further
elaborate the emerging theory.

General Theoretical Implications of the Theory

The concepts generated from the study are unique. No other
research has generated them but instead rely on descriptive
categories such as looks (Cioffi 2000b) as well as changes in mood
and reduced eye contact (Goldhill et al. 1999; Rich 1999; Schein
et al. 1990; Sax and Charlson 1987). The study focuses on the
complexity of detecting deterioration, rather than on describing the
signs and symptoms usually associated with this phenomenon. With
further theoretical sampling in different substantive areas, this theory
could be generalised to all situations of deteriorating conditions
and not just to hospitals patients. As the findings stand, it has the
potential to be used by ward staff to understand the complexity of
deterioration, how they make decisions, the importance of trust, and
the steps involved in making a successful referral.

Conclusion

This is the first study to attempt to place the detection of
physiological deterioration within the context of clinical practice and
the difficulties faced in making a successful referral, rather than
concentrating on any one particular aspect such as subtle indicators
(Cioffi 2000a; Cioffi 2000b; Grossman and Wheeler 1997) or vital
signs (Davis and Nomura 1990; Hill et al. 1995; Schumacher 1995).
Early detection of physiological deterioration is inherently difficult.
To date no sensitive or specific sign has been identified that reliably
predicts deterioration. The early warning score is an attempt to
address this difficulty, although its sensitivity and specificity has
not been established. The role of staff at ward level in the process
of detection, its reporting and the difficulty they face has not been
previously evaluated. The findings confirm the complex nature of
this phenomenon and reinforces the importance of teamwork in the
detecting deteriorating conditions.

Acknowledgements

We extend my sincere thanks to all who participated in this study and
who gave so generously of their time. They shared their experiences
with and confided in us without hesitation.

Authors

Dr. Tom Andrews, RN; BSc (Hons), MSc; PhD,
Lecturer,
School of Nursing and Midwifery,
Brookfield Health Science Complex,
University College Cork,
College Road,
Cork,
Ireland
Email: t.andrews@ucc.ie

Professor Heather Waterman, RN; BSc (Hons), PhD
Professor,
School of Nursing, Midwifery and Social Science,
Coupland 3,
University of Manchester,
Manchester M13, 9PL,
England,
United Kingdom

Reference List

Benner, P. (1984). From novice to expert: excellence and power
in clinical nursing practice. Addison-Wesley Publishing
Company, Menlo Part California.

Boylan, M. (1993). Process of argument. University Press of America,
Lanham.

Chase, S. (1995) The social context of critical care clinical judgment.
Heart and Lung 24(2), 154-162.

Cioffi, J. (2000a) Nurses’ experiences of making decisions to call
emergency assistance to their patients. Journal of Advanced
Nursing 32(1), 108-114.

Cioffi, J. (2000b) Recognition of patients who require emergency
assistance: a descriptive study. Heart and Lung 29(4), 262-
268.

Clarke, M. (1995) Nursing and the biological sciences. Journal of
Advanced Nursing 22(3), 405-406.

Coombs, M. and Dillon, A. (2002) Crossing boundaries, redefining
care: the role of the critical care outreach team. Journal of
Clinical Nursing 11(3), 387-393.

Daffurn, K., Lee, A., Hillman, K., Bishop, G., and Bauman, A. (1994)
Do nurses know when to summon emergency assistance?
Intensive and Critical Care Nursing 10, 115-120.

Davis, M. and Nomura, L. (1990) Vital signs of class 1 surgical
patients. Western Journal of Nursing Research 12(1), 28-41.

Department of Health .(1999) Making a difference. Strengthening the
nursing, midwifery and health visiting contribution to health
and healthcare. London.

Department of Health .(2000) Comprehensive critical care: a review
of adult critical care services. 1-32. London, Department of
Health.

Fieselmann, J., Hendryx, M., Helms, and Wakefield, D. (1993)
Respiratory rate predicts cardiopulmonary arrest for internal
medicine inpatients. Journal of General Internal Medicine 8,
354-360.

Franklin, C. and Mathew, J. (1994) Developing strategies to prevent
inhospital cardiac arrest: analyzing responses of physicians
and nurses in the hours before the event. Critical Care
Medicine 22(2), 244-247.

George, A., Folk, B., Crecelius, S., and Campbell, B. (1989) Pre-arrest
morbidity and other correlates of survival after in-hospital
cardiopulmonary arrest. American Journal of Medicine 87,
28-34.

Gerdtz, M. and Bucknall, T. (2001) Triage nurses’ clinical decisionmaking.
An observational study of urgency assessment.
Journal of Advanced Nursing 35(4), 550-561.

Glaser, B. (1978). Theoretical sensitivity: advances in the methodology
of grounded theory. The Sociological Press, Mill Valley,
California.

Glaser, B. (1998). Doing grounded theory: issues and discussions.
Sociology Press, Mill Valley.

Glaser, B. and Strauss, A. (1967). The discovery of grounded theory:
strategies for qualitative research. Aldine De Gruyter, New
York.

Goldhill, D., White, S., and Sumner, A. (1999) Physiological values
and procedures in the 24 h before ICU admission from the
ward. Anaesthesia 54, 529-534.

Grossman, S. and Wheeler, K. (1997) Predicting patients’ deterioration
and recovery. Clinical Nursing Research 6(1), 45-58.

Hill, M., Fieselmann, J., Nobling, H., O’Neill, P., Barry-Walker, J.,
Dwyer, J., and Kobler, L. (1995) Preventing cardiopulmonary
arrest via enhanced vital signs monitoring. MedSurg Nursing
4(4), 289-295.

Hogston, R. (1995) Nurses’ perceptions of the impact of continuing
professional education on the quality of nursing care. Journal
of Advanced Nursing 22(3), 586-593.

Jordan, S. and Reid, K. (1997) The biological sciences in nursing: an
empirical paper reporting on the applications of physiology to
nursing care. Journal of Advanced Nursing 26, 169-179.

King, L. and Macleod Clark, J. (2002) Intuition and the development of
expertise in surgical ward and intensive care nurses. Journal
of Advanced Nursing 37(4), 322-329.

McArthur-Rouse, F. (2001) Critical care outreach services and early
warning scoring systems: a review of the literature. Journal of
Advanced Nursing 36(5), 696-704.

McKenna, H. (1995) Nursing skill mix substitutions and the quality
of care: an exploration of assumptions from the research
literature. Journal of Advanced Nursing 21(3), 452-459.

McQuillan, P., Pilkington, S., Allan, and Taylor, B. (1998) Confidential
inquiry into quality of care before admission to intensive care.
British Medical Journal 316, 1853-1858.

Peterson, M., Geist, L., Schwartz, D., and Moseley, P. (1991) Outcome
after cardiopulmonary resuscitation in a medical intensive
care unit. Chest 100, 168-174.

Prowse, M. and Lyne, P. (2000) Clinical effectiveness in the postanaesthesia
care unit: how nursing knowledge contributes
to achieving intended patient outcomes. Journal of Advanced
Nursing 31(5), 1115-1124.

Rady, M., Smithline, H., Blake, R., Howak, R., and Rivies, E. (1994)
A comparison of the shock index and conventional vital signs
to identify acute critical illness in the emergency department.
Annals of Emergency Medicine 24(4), 685-690.

Reardon, K. (1991). Persuasion in practice. Sage Publications,
Newbury Park.

Rich, K. (1999). Inhospital cardiac arrest: pre-event variables and
nursing response. Clinical Nurse Specialist 13, 147-153.
92
The Grounded Theory Review (2005) vol. 4, no. 2

Rosenberg, M., Wang, C., Hoffman-Wilde, and Hickham, D. (1993)
Results of cardiopulmonary resuscitation- failure to predict
survival in two community hospitals. Archives of Internal
Medicine 153, 1370-1375.

Sax, F. and Charlson, M. (1987) Medical patients at high risk for
catastrophic deterioration. Critical Care Medicine 15(5), 510-
515.

Schein, R., Hazday, N., Pena, Ruben, B., and Sprung, C. (1990)
Clinical antecedents to in-hospital cardiopulmonary arrest.
Chest 98, 1388-1392.

Schultz, S., Cullinane, D., Pasquale, M., Magnant, C., and Evans, S.
(1996) Predicting in-hospital mortality during cardiopulmonary
resuscitation. Resuscitation 33, 13-17.

Schumacher, S. (1995) Monitoring vital signs to identify postoperative
complications. MedSurg Nursing 4(2), 142-145.

Sheperd, J. (1995) Findings of a training needs analysis for qualified
nurse practioners. Journal of Advanced Nursing 22 1, 66-71.

Shoemaker, W., Appel, P., and Kram .(1988) Prospective trial of
supranormal values of survivors as therapeutic goals in highrisk
surgical patients. Chest 94, 1176-1186.

Simons, H. (1976). Persuasion: understanding, practice and
analysis. Addison-Wesley Publishing Company, Reading,
Massachusetts.

Smith, A. and Wood, J. (1998) Can some in-hospital cardio-respiratory
arrests be prevented? a prospective survey. Resuscitation
37, 133-137.

Smith, G. (2001). Alert- a multiprofessional course in care of the
acutely ill patient. The Open Learning Centre, Faculty of the
Environment, Portsmouth.

Smith, S. (1988) An analysis of the phenomenon of deterioration in the
critically ill. Image- the Journal of Nursing Scholarship 20(1),
12-15.

Spilsbury, K. and Meyer, J. (2001) Defining the nursing contribution
to patient outcome: lessons from a review of the literature
examining nursing outcomes, skill mix and changing roles.
Journal of Clinical Nursing 10(1), 3-14.

Taylor, C. (1997) Problem solving in clinical nursing practice. Journal
of Advanced Nursing 26, 329-336.

van Eemersen, F., Grootendorst, R., and Kruiger, T. (1987). Handbook
of argumentation theory. Foris Publications, Dordrecht-
Holland.