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Background: Despite the widespread implementation of medical emergency teams (METs) in hospitals to provide immediate interventions to deteriorating ward patients, little is known about how junior doctors and nurses escalate care for deteriorating ward patients in hospitals with established MET services., Objectives: The objective of this research study was to explore the experiences of junior doctors and nurses in escalating care for clinically deteriorating patients in general wards., Methods: Twenty-four individual interviews were conducted with 10 junior doctors and 14 registered nurses of a 1000-bed acute general hospital with the most established MET service in Singapore. Interviews were transcribed verbatim and analysed using an interpretive thematic analysis approach., Findings: Three salient themes emerged from thematic analysis: (1) MET activations versus the primary team doctors' reviews, (2) challenges in obtaining medical reviews, and (3) unspoken rules of the escalation of care. Participants' decisions to call the MET or to escalate to the primary team doctors not only depended on the severity of a patient's deterioration and their perceptions of the primary team doctors' capacity to manage the patient but also were largely influenced by sociocultural factors that were shaped by the hierarchy of medical professions. Key challenges faced by nurses in obtaining medical reviews from junior doctors for patients with early deterioration included presenting "convincing" evidence of patient deterioration and "packaging" information about patient deterioration., Conclusions: The decision to call a MET or the primary team doctors is a complex judgement that is greatly influenced by the dynamics of perceived hierarchy between the medicine and nursing professions and within the medicine profession. Educational and organisational changes that enhance doctor-nurse interprofessional and intraprofessional collaboration among all levels of doctors may improve the process of the escalation of care for deteriorating patients and thus improve patient safety for hospitalised patients., (Copyright © 2019 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The implementation of early warning scoring systems and medical emergency teams that aim to reduce failure to rescue in general wards is only effective if frontline nurses can recognize and act on clinical deterioration in a timely manner. While much of the research to date has primarily focused on registered nurses as recognizers of clinical deterioration, little research has sought to explore the role of enrolled nurses in recognizing clinical deterioration and to provide a big picture of how enrolled and registered nurses recognize clinical deterioration in general ward patients., Objectives: To conduct an exploration of the experiences of enrolled and registered nurses in recognizing clinically deteriorating patients in general wards., Design: A qualitative, descriptive design., Setting: General wards at a 1,000-bed acute general hospital in Singapore., Participants: A purposive sample of 22 enrolled and registered nurses who had at least 6 months of nursing experience and who were working in the general wards., Methods: Individual semi-structured interviews were conducted between October 2016 and February 2017. Interviews were transcribed verbatim and analyzed using thematic analysis., Results: Four salient themes emerged from the data analysis. The first, 'Having a sense of knowing', illustrates how knowing a patient and past experiences facilitated the early recognition of clinical deterioration before the patient turned haemodynamically unstable. The second, 'Patient assessment practices', depicts the physical assessment skills that nurses used to detect clinical deterioration. The third, 'Delegation of routine patient care and assessment to enrolled nurses', demonstrates that nursing activities were delegated to enrolled nurses with lesser directional and supervisory aspects that "delegation" implies, which can potentially compromise patient safety. The fourth, 'Missing the big picture', identifies overwhelming workload and fixation on specific parameters of a patient as reasons for both enrolled and registered nurses missing the big picture of the patient's deterioration., Conclusions: This study provides a snapshot of the recognition of clinical deterioration among enrolled and registered nurses in general wards. Our findings illuminate the need to support the roles of enrolled and registered nurses, with an emphasis on patient assessment and strengthening collaborative practices among nurses, to improve early recognition and timely treatment of clinically deteriorating ward patients., (Copyright © 2019 Elsevier Ltd. All rights reserved.)