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Student nurses show poor skills in treating deteriorating patients

Final year student nurses have performed poorly in an experiment designed to test their understanding of and ability to deal with deteriorating patients.

The simulation involved 51 final-year student nurses and combined quantitative measures of the trainees’ knowledge, skill and situation-awareness, as well as a qualitative review of how decisions were made.

The video-recorded scenarios involved hypovolaemic and septic shock on mannequins. Each simulation was stopped at random points and students were asked questions to measure their level of awareness of what was taking place.

The researchers found that when the condition of the “patient” deteriorated, so did the students’ own response.

How a patient’s condition ended up seemed heavily dependent how well staff identified and managed the deterioration.

The mean knowledge score was 74% (range 46-100%) and the mean skill-performance score across both scenarios was 60% (range 30-78%).

Student performance markedly improved for the second scenario, but when the condition of the patients in both scenarios got worse, the students’ skill performance worsened significantly during the tests.

The mean situation-awareness score for the two scenarios was 59% (range 38-82%).

Students were more inclined to identify physiological causes for the deterioration (77%) but scored badly on their understanding of what went on (44%).

The findings, which are published in the Journal of Clinical Nursing, showed that the students’ ability to manage patient deterioration is poor.

Readers' comments (35)

  • I'm not surprised at this; and don't get me wrong this is not an attack on the students themselves who work damn hard and try to teach themselves everything they know, it is an attack on the state of Nurse education at the moment.

    I agree wholeheartedly with the move toward degree level Nursing, but I do not agree with the superfluous, pointless modules that have been 'tacked on' as a result! 75% of the course is utterly pointless, and ths is made even worse when the placements are often hit and miss. There needs to be a deeper and more thourough base of modules based around A&P, pathophysiology, illness and pharmacology, as well as regular weekly skills labs.

    If that were the case, then what to do with a deteriorating patient would be second nature to a student Nurse, which they can then expand upon and perfect with their own learning and experience.

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  • I am just about to commence my 2nd year and quite frankly, I do not feel that this subject is taught adequately either.

    We have received two 1/2 hour lectures and zero sim man practicals on this very important subject, we make collages In our learning groups in stead!
    As an adult learner I would rather be hammering out pharmacology, and real time 'situations' instead of pink and fluffy 'add ons'

    Luckily for me, I have been shown by my experienced mentors and further 'home study' on deteriorating patients.

    I agree with the comment above, there are some modules that are, in my opinion, not relevant (and I am a mature student) and the very essence of basic nursing care is often overlooked with the idea of 'you will learn it on the job' .

    May I add to that many students do not have the best matched mentor or working environment or time to put in extra study because they may be supplementing this time to work extra hours to pay their way.

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  • I have been saying for years that we need to adopt a course that contains more A&P etc and less phycho-babble. Many of the degree nurses that I now work with trained in the US and seem to know so much more than their British counterparts. The NMC and universities need to pull their fingers out and follow the US on this one.

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  • Maz Wilson

    I must say that I find this article totally misleading and wonder if those that have already commented accessed the research article. the study was NOT conducted in the UK, but in Australia where the education and health care systems differ from those in the UK.
    At the University where I work as a nurse educator we take the subject of 'The Deteriorating Patient' very seriously and work closely with the critical care outreach teams within the trusts that we serve. The students get the ABCDE approach and the use of Early warning Scores drummed into them and are expected to manage sick patient scenarios by the time they reach their 3rd year. We strongly believe in teaching the students how to manage peri-arrest situations and encourage them to use the SBAR and RSVP models of communication when dealing with patients who are unwell. Maybe thats why this University is 1st in England for student satisfaction.

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  • maybe

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  • Marion I have to say I wasn't aware that this was based in Oz, and I was remiss in that, but my comments still stand for English universities.

    I cannot comment on your specific university, however I do not think you speak for the majority of Nursing courses, none of which have a unified cirriculum and the majority of which I think is as bad as I said earlier.

    My own course had lectures on the deteriorating patient and so on using the ABCDE approach etc, just as yours did. We were 'taught' them, yes. The problem is these were hour or two hour long lectures and then that was it, they constituted such a small proportion of the overall module content with the staff holding the attitude that it was 'our responsibility to go away and learn it ourselves!' If that is really the case what is the point in us attending university for three years?

    A few hour long lectures over a three year course is not enough.

    Let me give you an example from another field that I think Nursing can learn from. In the Army we are given a rifle; we are not taught mettalurgy because that is what the bullet casings are made of, we are not taught the physics of how a bullet travels through the air, nor the chemical make up of gunpowder, we are just taught how to shoot the bloody rifle. Over and over and over. It is TRULY drilled into us. And guess what? At the end of the training (which is significantly shorter than Nurse training), soldiers are damn good at what they do.

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  • I agree with you Mike. Nurse education should be about teaching the theory of A&P, health, disease and treatment of the whole person, followed up by applying that theory in practice situations (both real and simulated) and repeating the practice over and over until the response to the patient's changing condition is informed, prompt and thorough.
    Nursing has got to be about theory applied in practice, dare I say it, as it used to be.
    This approach should incorporate the fact that nurses have taken on extended roles and so if anything, their response to the deteriorating patient ought to be better and more effective than it was years ago. For example, when I trained we would have had a delay in giving IV drugs to a deteriorating patient as only few and far between nurses could give them- now any nurse should be able to give them as soon as prescribed.
    A nurse in training needs have a firm grasp of the basic essentials by the time he/she qualifies; the 'add-ons' can be developed later.

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  • Bed side nurses should be able to detect a deteriorating patient before they get to the point that a code blue needs to be called. Then a doctor needs to be called and orders received to treat the patient according to what is wrong. In our hospital in Canada we have a RRT (Rapid Response Team) which is staffed by the ICU nurses and Respiratoy therapists. The ward nurses can call us if they suspect a patient is deteriorating and we are given authority to start IV's, doing ECG's, give volume, do bloodwork and then the Doctor is called. We can also admit patients to ICU if their condition warrants. This works really well in our small community hospital.

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  • This article might be about Australia but Mike and others are correct. The clinical skills of many nurses in the UK is dire. Basic care skills are missing let alone being able to detect subtle changes and a deterioration in condition.
    "Education" is to blame and more emphasis is needed on the clinical needs of people in our care

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  • ......it's not entirely the fault of the universities. Don't students spend half of their time on placements?

    I don't prescribe to the too posh to wash hocum either. I remeber being a patient 25 years ago and receiving abysmal nursing care after an operation.

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  • I am a mature second/going into 3rd year nursing student.I have just finished my critical care exam and placement .However,it was highlight by my mentor on placement that although my nursing theory base was "impressive" in areas my profession attitude exceptional , patient interaction/ inter profession team working was very good (all of which I have strived to achieve during my training).My inabilty to be able to pick up on the deteriating patient was an intial concern.Feel now upon reflection having spoken to other student nurses this may have been due to limited lecture output , previous placement opportunities. Please give thoughts.

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  • Excellent point P.Damien, like I said earlier the universities (in general) attitude is 'go away and learn it yourself', with the expectation that placements will teach us clinical skills. This is not always the case however as placements are often hit and miss in terms of experience and training.


    June, I see what you mean. I think 'picking up on a deteriorating patient' must first and foremost be taught in the classroom, not just in and of itself, but students must first have a full grasp of the A&P of the body to understand what is right and what is going wrong. How do you know if something is not right if you do not know the norm? Then they need to be taught about specific illnesses and the processes of these illnesses, including deterioration from the norm. Then of course is the skills labs on observations and detecting patterns. There is more of course but you see what I mean. This all starts in the classroom, then should be expanded on in placement, where the student can get experience in putting the theory into practice. I think students are being failed in both respects a lot (not all, but a lot) of the time.

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  • I experienced the situation as a student of looking after a patient who was deteriorating but I was unable to do anything about it because neither the content of the universities lectures nor the teaching ability of ward staff enabled me to make a discriminatory analysis of what was going on - even though senior medical staff were involved in the 'care' of the patient, it is often the nurses who actually prevent injury and deterioration.

    MEWS or EMEWS was created because nurses (and most junior medics ) in the U.K. had the clinical acumen of donkeys.

    So don't tell us you are teaching MEWS to your students is anything short of total failure to teach any relevant clinical examination of the acutely ill patient.

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  • tich x

    i would be interested in reading the whole simulation study some time. i wonder what was the control for this study. hopefully a similar study comparing qualified nurses & students doesnt sound so bad. i am sure a lot of qualified nurses wouldnt have problems here and there so maybe we shouldnt only look at students. if you lackthese skills as student are we assuming once qualified you suddenly become well equiped?

    contrary to various articles above the university i went to had the module 'care of the deteriorating patient' in 3rd yr & 3rd yr students were placed in critical wards such as ICU, HDU, CCU, theatres, A&E, assessment units to try and balance theory & practice. as a result i dont see anything special about the ABCDE approach for that matter because all students had to sing that during lectures & simulated practicals. whilst we can improve the course structure we dont have to be critical for the sake of it. i believe most modules may not seem essential but they open your mind a bit more. just because your kid want to be a farmer doesnt mean that at GCSE they shouldnt do their maths, arts & sciences.

    i just believe that nurse's role has become limited & we just have to go with what doctors say. even if u identify the unwell patient i dont believe you have much input as to the plan of action once you have informed the doctor.

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  • Tich I could not disagree with you more.

    'i just believe that nurse's role has become limited & we just have to go with what doctors say. even if u identify the unwell patient i dont believe you have much input as to the plan of action once you have informed the doctor.'

    I'm sorry but that is completely backward, the Nurses role has expanded exponentially over the last decade or so,to the point where outdated notions of 'going with what the doctors say' have no place any more. And I'm sorry, but if you have no or very little input into the care of your patients, then you are failing them, it is as simple as that.

    As for the modules, noone is being critical for the sake of it, there are genuine concerns about the content of courses at the moment. Of course disciplines such as Sociology and Psychology, or modules on communication skills or research for example have their uses and do input into our wider training, noone is saying that they do not, but what myself and others are arguing is that these modules should not be making up the bulk of the course as they do now in many universities. Instead, the bulk of the course should be medically based.

    After all, when a patient is suddenly deteriorating in front of a Nurse or goes into arrest for example, it isn't going to do the patient a damn bit of good that Nurse knowing the difference between quantitative and qualitative research methods instead of knowing exactly what is wrong with them and how to fix it.

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  • I am a mature student about to go into my 3rd year next year on the degree route and I agree with Mike, June and the others. I think that that nurse education needs a little bit of an overhaul. Dedicating whole modules to things that have no relevance instead of giving extra practical skills, A&P, Acute Situations and more lectures involving The Deteriorating Patient from year 1 would be welcomed by us students.

    June, I too excel when it comes to academic skills in Theory, working with others ect but I, like thousands of other students would benefit from more teaching with regards to acute situations before practice placements so that I can apply what I have learned in practice.

    After all we are not preparing to work in a cafe, the preparation and training we are doing as students really does make the difference between writing a fantastic essay or preventing a death. If we are not completely competent in our final year then what good are we going to be when qualified and faced with an acute situation!

    Anyone agree?

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  • What is a 'doctor' and what is a 'nurse', in this context the leader is the person with the most experience / knowledge - plenty of times I've pointed out to a SHO that they are wrong and they need to do X,Y,Z and call their boss now because they're out of their depth.

    Unfortunately most of my knowledge about patient deterioration came from bad experiences on the ward and I eventually thought, enough of this hideous repeating bullshit and went to work in A&E - where to be honest the staff were not that much more clued up than ward staff, but at least most of 24hr shift you have senior medical cover in the department and plenty of pairs of hands. You are correct though on one point - qualified staff are often not much better than students in spotting sick patients.

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  • Nurses are with the patients 24/7 and they need to be the patients advocate in recognizing potential problems and preventing them altogether from happening or getting worse. A&P is taught in training and direct experience working with varied conditions gives the ability to spot and deal with a deteriorating patient. I believe working with patients directly and not in SIM labs is the best way to learn. Support and help at the bedside from other nurses is vital. If you don't agree with the Doctors plan or action then you must speak up and offer your ideas. In the end don't do anything that is going to jeopardize your licence or ruin your career. Doctors make mistakes too!

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  • >A&P is taught in training

    To what level?

    On my course in wasn't even at 'A' level biology level.

    SIM labs have been demonstrated to be very effective in teaching the whole team, especially in peri arrest and arrest scenarios.

    >In the end don't do anything that is going to jeopardize your licence or ruin your career.

    Meaningless nursing statement number 1. I'm sick of hearing it. It means nothing.

    If your ignornant of what you don't know because neither the university never wondered what kind of nurses they were producing, clinical supervsion / mentorship non existent, nor the NMC ever bothered to stake a claim on nurse education then how can you ruin your career? You might on the otherhand ruin a good few people's health.

    Let's just all spend a thirty year career filled with clinical ignorance and the consequent anxiety, trotting out that phrase to all and sundry shall we, no?

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  • tich x

    mike i think this is one of those cases where we may never agree.
    when i say little/ no input i dont mean walking away from patient & i dont think i am failing patients in any way. from my own point of view i simply mean that i feel nurses can be allowed to do more. to someone else maybe what i consider little is more. to give you a simple example in my trust you can not give a bag of IV fluids unless prescribed by the doctor at a certain rate as well and on weekends or nights depending on how busy it is we may be talking even 4hrs whether patient might be nil by mouth or dehydrated. In another trust where my friend works its the nurse's discretion as to what rate to run IV fluids. again if my patient has slightly low O2 sats i can not just go well 2Lof O2 will help unless the doctor has said so. therefore in my opinion nurses can play a much wider role.

    yes the whole course can be improved but i think some modules are good enough. however each university does their own thing so we may be are probably considering different things altogether. just browsing the nursingtimes home page its all studies & research.... so whats wrong with doing research module so that you can critically analyse these studies?

    Neesy.... i have been qualified for 3yrs this week and until you qualify and look after a group of patients full time i dont think you will ever feel ready for the real life situation. even if you study pharmacolgy daily what good will it be for someone working in respiratory ward learning about drugs used in ICU? surely the information will still go out of your head the less you use it.

    and anonymous... yes you are 100% correct that you can provide some input but as you suggested 'offering ideas' doesnt mean they will be always taken on board. i agree with you though but its always essential to balance theory and practice. when i was a student senior nurses would show me a procedure but lack of theory meant there was no rationale given for doing certain things.

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