Situational awareness of patient deterioration

The early identification and management of patient deterioration has a major impact on patient outcomes. However the ability of nurses to detect and manage deterioration has been shown to be lacking, the reasons for which are unknown. This ability may be influenced by a number of factors including knowledge, experience, and perception of the circumstances – otherwise known as ‘situation awareness’.

Recent years have seen the acuity of patients managed on general wards increasing whilst access to critical care beds decreases. Subsequently, the pressure on general ward nurses to assess and manage complex patients has been amplified with recent evidence indicating poorer patient outcomes due to delayed response to or mismanaged patient deterioration. Further, up to 80% of cardiac arrests are predictable. Missed indicators of deterioration have also been noted in patients following discharge from hospital and in smaller rural hospitals, whilst nurses are not always clear about when to call for assistance. Importantly, it has been established that the management of deteriorating patients can be impacted on by education and past experience, both of which can be strongly influenced by preparation of student nurses.

Project aims

This study aimed to investigate the relationship between knowledge, skill performance and situation awareness in a simulated environment.

Final year student nurses were invited to attend a simulation laboratory for 1.5 hours. Participants completed a knowledge questionnaire and two video recorded simulated scenarios to assess skill performance. The scenarios simulated deteriorating patients with hypovolaemic and septic shock.

Skill performance was rated using a standardised check-list. Situational awareness was measured by stopping each scenario at a random time and asking a series of questions relating to the situation. Video review with a clinical expert was undertaken to facilitate participant reflection. This review was recorded to allow thematic analysis. Participants were also asked to complete an evaluation questionnaire measuring self-rated knowledge pre- and post-simulation exercise.

Project impact

Fifty-one students attended. The mean knowledge score was 74% (range 46 -100%) and the mean skill performance score across both scenarios was 60% (range 30 - 78%). Age and experience had no significant effect on skill performance.

Skill performance declined significantly as the patient’s condition deteriorated. The mean situational awareness score across both scenarios was 59% (range 38% - 82%). Age and experience did not influence situational awareness.

Participants were able to identify physiological indicators of deterioration (77%) but had low comprehension scores (44%). There were no significant associations between measures of knowledge, skill performance and situational awareness measures.

The majority of students appeared to aggregate single findings to stimulate a response e.g. dropping oxygen saturations equates to oxygen mask being applied to the patient. Fewer seemed able or confident to aggregate more than three discrete elements of the physiological change. Student self ratings of pre-post knowledge levels indicated a significant improvement in understanding of patient deterioration following the simulation exercise.

Knowledge scores suggest, on average, a satisfactory academic preparation, but there were significant deficits in students’ ability to manage patient deterioration. Routine assessment tasks became less frequent as deterioration worsened, highlighting the need for a systematic approach to patient assessment (such as primary and secondary survey) to be embedded in nursing curricular.

Simulation techniques appear to be a good way of assessing skill and situation awareness and may improve performance when integrated into curricula.

Research team

Mr Leigh Kinsman

Professor Ruth Endacott

Associate Professor Simon Cooper

Professor Julie Scholes

Dr Penny Buykx

Tracy McConnell-Henry

Output

Results have been fed back to third year nurses in the Monash University School of Nursing and Midwifery, Gippsland campus. Three papers were accepted for presentation at the International Clinical Skills Conference held in Prato in July 2009. All presentations acknowledge the Nurses Board of Victoria as the funding source.

Partners

The research team wish to sincerely thank the following for their support: 

  • The Nurses Board of Victoria for their financial support. 
  • The Monash University Graduate Medical School, Gippsland Campus, for their cooperation and use of the clinical skills laboratory. 
  • The Monash University School of Nursing and Midwifery, Gippsland Campus, for their cooperation in facilitating access to final year nursing students. 
  • Andre Ng for his superb technical leadership and management of the clinical simulation exercises. 
  • Student nurses who gave up their time to voluntarily participate in this project. 
  • Dr Ken Sellick for his highly valued statistical advice.