A cross-sectional study on the nurses’ attitude towards rapid response system activation for clinically deteriorated patients

Background: Hospitals have reported that implementing rapid response system activation (RRS) activation has increased patient safety. As a result, there has been growing interest in identifying factors that lead to successful RRS activation. While introducing an automated RRS activation system has prompted nurses to be more vigilant about monitoring vital signs, it has not necessarily encouraged them to conduct thorough patient assessments to identify early signs of deterioration. Purpose: The current study aimed to assess nurses’ attitudes towards RRS activation for clinically deteriorated patients in the clinical units of King Abdul-Aziz Hospital. Methods : A descriptive cross-sectional research design was utilised in the study, and 144 nurses working in the medical and surgical units of King Abdul-Aziz Hospital were recruited to participate using a convenient non-probability sampling technique. Results : The study’s findings reported that nurses have a positive attitude towards RRS benefits (Mean = 3.70; SD = 0.70). Their overall attitude towards RRS activation among clinically deteriorated patients is still low positive (Mean = 2.71; SD = 0.61). The nurses’ attitudes towards RRS benefits significantly differ among nationalities and the clinical area/unit where they were assigned, with a P -value of 0.0194 and 0.000, respectively. Attitudes towards RRS barriers significantly differ among nationality ( P -value = 0.0037), education level ( P -value = 0.0032), area of assignment ( P -value = 0.020), and whether they have a good understanding of abnormal observations ( P -value = 0.0122). Regarding the nurses’ attitude towards management belief, the significant result is only with the clinical area/unit of assignment with a P -value of 0.000. Conclusion: The current study found a low positive attitude towards RRS activation among ward nurses, especially given that monitoring vital signs is critical to their job. Nurses may fear being perceived as clinically inept for redundant activations caused by poor quality, but their attitude towards activating the RRS in clinical deterioration is still largely negative. This is because most RRSs rely on ward nurses to recognise clinical deterioration and manually alert responders through phone calls, hospital communication systems, or face-to-face communication.


Introduction
The implementation of the rapid response system (RRS) began in Sydney, Australia in the early 1990s [1].Research conducted in the early 1990s investigated the reasons for hospital mortality and found that many of the deaths could have been prevented if patients had received intensive care earlier.It was discovered that more than half of hospital deaths occurred outside of intensive care units (ICU) [2].Acute hospitals frequently RRSs to identify and manage patients who are experiencing clinical deterioration outside of the ICU, with the primary aim of reducing cardiac arrests in general wards and minimising unplanned ICU admissions [3].
The Agency for Healthcare Research and Quality (AHRQ) has described RRS as a straightforward concept where a team of healthcare professionals is summoned to the patient's bedside upon observing indications of severe clinical deterioration.This prompt assessment and treatment aim to avoid a transfer to a critical care unit, cardiac arrest, or death [4].The RRS comprises various systems, including quality control, auditing, and administration, in addition to both afferent and efferent components, as stated by several sources [5].
Phillips et al. (2021) stated that the RRS is essential in managing the deterioration of patients to prevent cardiac arrest, thereby enhancing patient safety and reducing hospital mortality rates [6].According to several studies, patients in hospital wards can display indications of physiological instability over an extended period through changes in their vital signs and observable symptoms [7,8].However, these indications may not always be recognised or responded to correctly by ward staff, resulting in avoidable admissions to the ICU, cardiac arrest, or even death in some cases [7].To identify clinical deterioration and ensure timely and appropriate responses to deteriorating patients outside of the ICU, acute hospitals commonly use RRSs [3,5].In order to activate the RRS in a timely manner, whether through phone calls, the hospital clinical deterioration [9,10].Nevertheless, the global problem of delays or failure to identify and respond to clinical deterioration in hospitalised ward patients persists despite the adoption of RRSs and track and trigger processes [11].
The identification and treatment of patients whose clinical conditions are deteriorating in general ward settings has become an increasingly studied area over the past decade [9].Delays or failures may be related to inaccurate or incomplete early warning score assessments.In addition, inter-professional hierarchies and sociocultural barriers may lead to noncompliance with escalation policies [12,13].The hospital escalation policies require ward staff to escalate to the appropriate clinician within a specific time frame.However, previous research indicates that adherence to these protocols ranges from 8% to 62% [11].
Automated clinical deterioration notification systems are being studied and implemented in hospitals as a safety measure to ensure prompt intervention in clinical deterioration cases, this approach gained popularity and demonstrated its effectiveness [14,15].Unlike the traditional phone call-based activation of RRS, automated systems use electronic medical records (EMRs) such as EWS and/or laboratory results as screening criteria to identify clinical deterioration.Following a breach of predetermined thresholds, an automated notification is generated and transmitted to senior clinicians or clinical response teams, improving the reliability of detection and escalation of care.The use of automated systems can potentially overcome human-related response failures and improve patient outcomes on general wards [14].
Nurses play a crucial role in patient safety through their direct care and accurate assessments, which aid in identifying any abnormalities in the patient's condition at an early stage.Additionally, to guarantee that patients receive high-quality care, nurses are responsible for monitoring patients for clinical deterioration, identifying errors and near misses, understanding care processes and system deficiencies, recognising and reporting changes in patient status, and performing a range of other duties.Nurses, both in adult and pediatric settings, often recognise early subtle signs of patient deterioration, supported by their understanding of patients and intuition [16].This subjective recognition of patient deterioration contrasts with doctors' dependence on objective indicators, which can lead to delays in care escalation [17].
Recently, Azimirad et al. ( 2021) conducted a study comparing the RRSs of English and Finnish nurses [18].The researchers discovered that in half of the cases, nurses failed to activate the rapid response system in a timely manner.This was a persistent trend observed among the nurses sampled from both countries.The study also found that in 2021, nurses did not perceive disapproval from medical colleagues as a significant obstacle to applying the RRS.The Finnish nurses held different views on doctor-patient disagreements than their British counterparts [18].Azimirad et al. (2022) recommended that nurses receive more training on how to activate the RRS promptly [19].Improving the clinical outcomes of critically ill patients necessitates the implementation of knowledge and perception as well as attitude measures

Study purpose
The current study aimed to assess nurses' attitude towards RRS activation for clinically deteriorated patients in the clinical units of King Abdul-Aziz Hospital.

Research design
This study utilised quantitative descriptive cross-sectional research design to assess nurses' attitude towards activating RRS for clinically deteriorated patients in the clinical units of King Abdul-Aziz Hospital.

Population, sampling technique and sample size
This study was conducted to nurses working in inpatient care units particularly in medical and surgical units of King Abdul Aziz Hospital in Jeddah, Saudi Arabia.The nurses were recruited from the following units using a convenience sampling technique: male medical 1 (MM1) (28), male medical 2 (MM2) (28), female medical (44), dialysis (20), rehabilitation (24), MS1 (26), MS2 (30), and female surgical 1 (FS1) (28) for a total sample of (144) from a total population of 228.Furthermore, the total number of sample size was calculated using the Raosoft online sample size calculator with a 95% confidence level and ± 5% margin of error (Figure 1).
Additionally, the following inclusion criteria was observed in the selection of participants: 1. must have a diploma, bachelor's or masters' degree in nursing; 2. respondents must have a license to practice from Saudi Council for Health Specialties (SCHS); 3. have year and above working in the medical or surgical units; 4. any nationality were welcomed to participate.Nurses not meeting the criteria was excluded from the study.

Setting/location of the study
The study was conducted at King Abdul Aziz Hospital located in Jeddah, Saudi Arabia where the nurses working in different units.King Abdul-Aziz Hospital-Jeddah is a referral Ministry of Health (MOH) hospital with a 436-beds capacity situated in southern suburbs of Jeddah adjacent to the industrial sector and receives almost all industrial injuries as well as road -traffic accident victims from the Jeddah-Makkah highway.
Patients were provided appropriate procedures, treatments, interventions and care according to established policies, procedures, protocols and order sets that have been developed to ensure patient safety and positive outcomes.

Research scale/instrument
The study utilised an adopted a self-administered questionnaire of the "Nurses' Attitudes Towards the RRS Survey" that was developed by Azimirad et al. (2021) to assess nurses' attitude towards activating of RRS for clinically deteriorated patients [18].Azimirad et al. (2021) confirm construct validity of the tool including internal consistency Figure 1 Sample size calculation evaluation through testing the reliability with a Cronbach's alpha result of 0.70 [18].
Furthermore, the final questionnaire used in the present study was consist of demographic profile of the respondents including age, gender, nationality, educational level, length of experience, and clinical unit/area of assignment.The 16 items in the questionnaire were categorised into three parts that designed to assess nurses' attitudes on RRS benefits (six items), RRS barriers (eight items), and RRS patient management (two items).All items of the questionnaire used five-point Likert scale: strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, strongly agree = 5 [19].

Data collection procedure
Data collection begun after the approval from the Institutional Review Board of Fakeeh College for Medical Sciences (FCMS).The researcher visited the study place/location and the target population, and the sample size was selected based on the standards set in the inclusion criteria.The purpose of the study including the rights of every respondent was clearly explained to the respondents and it was also written at the beginning of the consent form.The research made sure that the respondents understand the terms and the consent was secured before the data gathering.Informed consent is a vital principle to protect the rights of participants while conducting a study.Obtaining consent from the study participants is the basic step prior to beginning to conducting field research, and the researcher must ensure that consent is voluntary and informed.
In addition, participants were given a study information package explaining their responsibilities and the likely risks and benefits incurred by their participation.The nature of the data needed for study purposes were explained to participants and they have the right to enroll in this study without coercion and to withdraw from the study at any point.The questionnaires were distributed to the participants by the researcher itself.

Data analysis
The data gathered was analysed using the SPSS v.26.Data were treated using appropriate descriptive and inferential statistical tests.Statistical analysis was conducted according to the most currently reliable and valid statistical methods.Frequency and percentage was utilised to analyse the demographic profile of the respondents in terms of age, gender, nationality, educational level, length of experience, and clinical unit/area of assignment.A weighted average and standard deviation (SD) was used to evaluate the attitude of the nurses toward the activation of RRS for clinically deteriorated patients.Furthermore, a t-test and ANOVA were utilised to evaluate the significant differences between the demographic profiles of the respondents and the perspective towards RRS activation.

Ethical consideration
The study adhered to the ethical principles by the Research Ethical Committee of FCMS IRB.The nurses' participation was voluntary without any coercion (Ethical approval number is A01622).An informed consent was obtained prior to data collection, explaining the purpose of the study and the ethical right of participation as the survey will be fully anonymous, the questionnaires contain no names or other information about the participant, and participants were free to withdraw at any time and without giving a reason.

Results
Table 1 show that nurse participants were dominated by female (86.11%).The participants were also dominated by Saudi nationals corresponding to 42.36%, having bachelor's degree (72.92%), with more than 10 years of experience corresponding to 40.28% of the total respondents.
The nurses' attitude towards RRS benefit significantly differ among nationality and the clinical area/unit where they were assigned.The P-values are both were less than 0.05.This implies that the nurses' attitude towards RRS benefit depends on their nationality and unit where they are assigned.Looking at the mean values, the Filipinos have the highest level of attitude of 4.03 (positive) while the Sudanese has the lowest level of attitude of 2.83 (low positive).In terms of the assigned area, those who were assigned in FS1 have the highest level of attitude of 4.03 (positive) while those who were assigned in rehabilitation have the lowest attitude level of 2.70 (low positive).The rest of the demographics show not significant results with P-values greater than 0.05, which mean that the nurses' attitude was not affected by age, gender and other demographics.
Nurses' attitudes towards RRS barriers vary significantly based on nationality, education level, clinical assignment, and understanding of abnormal observations.All P-values are below 0.05, indicating these factors influence nurses' attitudes.Sudanese nurses exhibit the highest attitude level at 2.50 (low positive), whereas Filipinos show the lowest at 1.79 (very low positive).Diploma holders express the highest attitude level at 2.45 (very low positive), whereas master's degree holders show the lowest at 1.63 (still very low positive).Those assigned to MM2 exhibit the highest attitude at 2.44 (still very low positive), while those in rehabilitation show the lowest at 1.48 (negative attitude).Respondents with poor understanding of abnormal observations show higher attitude levels at 2.71 (low positive) compared to those with good understanding at 2.06 (very low positive).Other demographics show nonsignificant results with P-values above 0.05, indicating no impact on nurses' attitudes.
In terms of the nurses' attitude towards management belief, the significant result is only with the clinical area/unit of assignment, with a P < 0.001.The rest of the demographics show not significant result.This implies that the nurses' attitude towards management belief depends only on their area of assignment.Looking at the mean values, those who were assigned in MM2 have the highest level of attitude of 2.77 (low positive), while those who were assigned in rehabilitation have the lowest attitude level of 1.36 (negative attitude).Submit a manuscript: https://www.tmrjournals.com/inIn terms of the overall nurses' attitude towards RRS, the significant result is only the clinical area/unit of assignment, and whether they have good understanding of abnormal observations with P-values less than 0.05.The rest of the demographics show not significant result.This implies that the nurses' attitude towards RRT depends only on their clinical area/unit of assignment and whether they have good understanding of abnormal observations.Looking at the mean values, those who were assigned in MM2 have the highest level of attitude of 3.01 (low positive), while those who were assigned in rehabilitation have the lowest attitude level of 1.85 (very low positive).Those who responded that they have no good understanding of the abnormal observations have higher level of attitude of 3.14 (low positive) as compared to those who have good understanding with low positive attitude as well (2.68).
Table 2 illustrate the nurses' attitude towards RRS activation in terms of benefits, barriers, and patient management.In terms of RRS benefits, it appears that statement 1 obtained the highest mean response of 4.42, which was verbally interpreted as agree.This means that the respondents generally agree that the RRS prevents unwell patients from having cardiac and respiratory arrests.On the other hand, the item with the lowest mean response is statement number 4, with a mean response of 2.49, which was verbally interpreted as disagree.This implies that the respondents generally disagree that they would make call to a RRS for a patient when worried about even if his/her vital signs are normal.The composite mean of 3.70 implies that the respondents have generally positive attitude in terms of RRS benefits.In terms of SD, number 4 statement also obtained the highest value of 1.38, which means that the respondents' opinion regarding this was more varied as compared to other statements.On the other hand, the statement with the lowest SD of 0.73 was obtained by statement number 1.This means that the respondents have consistent and same level of agreement in this statement.
In terms of RRS barriers, the statement with the highest mean response is statement number 2. The mean response was 2.88, which was verbally interpreted as neutral.This only shows that the respondents generally are not sure if they will call the covering doctor before calling an RRT when one of their patients is unstable.On the other hand, the lowest mean response was obtained by statement number 1, with mean response of 1.78 which was verbally interpreted as disagree.This means that the respondents generally disagree that RRS is not helpful in managing sick patients on the unit.This also implies that RRS is helpful.The composite mean of 2.10 implies that generally, the respondents have very low positive attitude in terms of RRT barrier.In terms of SD, the item with the highest value of 1.31 is also statement 2, which implies a varied response among the nurses.On the other hand, the item with the lowest SD of 0.93 was obtained by statement 5.This implies that the nurses are consistently disagreeing that they don't like calling an RRS because they will be criticised for not looking after their patient well enough.
Furthermore, respondents generally disagreed with both management belief statements, yielding a composite mean of 2.32, indicating a significantly low level of positive attitude.Overall, the mean response was 2.71, suggesting nurses generally hold a low level of positive attitude toward RRS (Table 2).

Discussions
The current study focused on assessing nurse's attitude towards RRS activation in the clinical units.The findings of the study reported that nurses have positive attitude towards RRS benefits.However, in terms of RRS barriers and management beliefs were reported to have very low positive attitude.Furthermore, their overall attitude towards RRS activation among clinically deteriorated patients is still low positive.Additionally, the nurses' attitude towards RRS benefit significantly differ among nationality and the clinical area/unit where they were assigned.On the other hand, attitude towards RRS barriers significantly differ among nationality, education level, area of assignment, and whether they have good understanding of abnormal observations.In terms of the nurses' attitude towards management belief, the significant result is only with the clinical area/unit of assignment.Additionally, in terms of the overall nurses' attitude towards RRS activation, the significant result is only the clinical area/unit of assignment, and whether they have good understanding of abnormal observations.In prior research, it was noted that RRS nurses were more likely than ward staff to acknowledge the potential of RRS in preventing cardiac arrests and enhancing patient safety.The majority of RRT nurses observed an improvement in ward staff's identification and treatment of critically ill patients following the implementation of RRS [20,21].The impact of RRS on the skills of ward nurses in recognising and treating critically ill patients was reported positively by 48%-85% of ward nurses [22].Despite a previous report by Olsen et al. (2019) indicating that one out of nine ward nurses feared being criticised by RRS for unnecessary RRS calls, only 11% of RRS nurses considered such calls to be anything other than rare occurrences, suggesting that these fears may be unfounded [22].As a matter of fact, the nurses who are part of the RRS team perceived the ward nurses as better equipped to detect patient deterioration compared to the ward doctors.RRTs encountered twice as many differences of opinion regarding patient care with ward doctors as with ward nurses.This observation aligns with earlier research that identified similar challenges in the relationship between ward nurses and ward doctors [21,23].Loisa et al. (2021) found that ward nurses and RRTs were more likely to agree on a patient's condition than ward doctors [21].However, the data does not clarify whether the ward doctors overestimated or underestimated the degree of deterioration in the patient, according to the RRT.Nonetheless, it was reassuring to note that conflicts between RRT nurses and physicians did not seem to be a significant problem, indicating that the RRT functioned effectively as a unit.
According to Bucknall et al. (2022), the evaluation of vital signs (VS) is crucial for recognising clinical deterioration, and therefore necessary before data interpretation [24].They conducted a study to encourage frequent VS assessment using an intervention, which guides decisions on appropriate care pathways.Results indicated a noteworthy rise in escalation as per hospital policy among the intervention group after 6 months of facilitation, but it was not sustained at 12 months.Conversely, VS assessments increased significantly at 12 months in the intervention group compared to the control group.However, there were no statistically significant differences in practice changes between the two groups at either time point.
Furthermore, in Olsen et al. (2019) study, it was found that RRT nurses faced unique obstacles such as feeling undervalued and having a heavier workload compared to other ICU nurses [22].The study also revealed that frequent participation in RRT activities positively influenced nurses' attitudes towards RRT work, whereas irregular involvement resulted in disappointment, which could ultimately reduce their commitment.Lastly, the study emphasised the significance of providing feedback on RRT work to ensure effective RRS implementation.Loisa et al. (2021) found that the median RRT experience of their participants was three years (0.8-5) and the median number of RRT activations per month was two [1][2][3][4][5].The study revealed that over 90% of RRT nurses believed that RRS prevented cardiac arrests and enhanced patient safety [21].Those with five or more RRT activations per month had a higher perception of improvement in critical care skills (94% vs 71%, P = 0.01), found their RRT work more meaningful (94% vs 76%, P = 0.05), and expressed a higher inclination to continue working as RRT nurses (91% vs 74%, P = 0.15) compared to those with less than five RRT activations per month.Nonetheless, some RRT nurses reported negative experiences with RRS, such as feeling overworked (68%) or undercompensated (94%) for their RRT duties, and conflicts with ward doctors (25%).The study concludes that although RRT nurses perceive their work as valuable and critical to fostering improved critical care skills, infrequent RRT participation, feelings of being overworked and/or undercompensated, and conflicts with ward doctors can pose as barriers to successful RRS implementation among RRT nurses.
The study of Azimirad et al. (2020) found that the level of knowledge about timely RRS-activation among nurses from Finland and the United Kingdom was moderate, and their management of case scenarios for such activation was suboptimal [10].The authors recommended ongoing education for nurses and a cultural shift.However, AlDhoon et al. (2022) reported that a majority (54.4%) of their respondents had knowledge about RRT activation, which contrasts with the findings of the earlier study [25].According to the research, a significant proportion (around 40.3%) of individuals opt not to activate RRT due to concerns of potential criticism.Nurses tend to rely more heavily on physicians to initiate RRT.To enhance the effectiveness of RRT responses, professionals have developed various tools and instruments to aid in the identification of clinical deterioration indicators, team activation processes, and patient case handoffs.The utilisation of assessment instruments has been associated with reduced mortality rates.This finding may be attributed to the presence of ongoing education and training programs aimed at teaching professionals how to properly utilise these tools.These results suggest that while such tools can enhance responses, their benefits may not be realised without appropriate training.
Moreover, Chua et al. (2020) revealed that the decision-making process of junior physicians and bedside nurses regarding RRT activation or referral to the primary medical team was influenced not only by the RRT notification criteria but also by profession-specific sociocultural factors [17].To enhance the quality of care culture for junior nurses and promote doctor-nurse collaboration, future initiatives should focus on improving nursing communication about patient deterioration.Additionally, Padilla et al. (2018) identified nursing experience and education as significant variables affecting RRS activation at the bedside [1].Furthermore, the study investigated various barriers to RRS activation.According to Audet et al. (2018) literature review, nurses have inadequate comprehension and proficiency in activating RRTs, despite the long-standing existence of RRTs [26].Therefore, Tormey (2020) suggests that further investigation is required to identify the specific clinical nursing skills required for early detection of patient deterioration [27].
One limitation of the study is its representativness as the sample was only collected from one hospital that is why generalization can be interpreted with caution.

Conclusions
The nurses' attitude towards activating the RRS in cases of clinical deterioration is still largely negative.This is because most RRSs rely on ward nurses to recognise clinical deterioration and manually alert responders through phone calls, hospital communication systems, or face-to-face communication.Nurses are concerned about being seen as incompetent if they fail to closely monitor their patients, but they are also worried about triggering false alarms due to errors in vital signs monitoring.
It is surprising that the current study found a low positive attitude towards RRS activation among ward nurses, especially given that monitoring vital signs is a critical aspect of their job.Nurses may fear being perceived as clinically inept for redundant activations caused by poor quality vital signs monitoring.Submit a manuscript: https://www.tmrjournals.com/in

Recommendation
After analysing the study findings, the researcher suggests implementing regular educational initiatives like lectures, workshops, and simulation training to enhance the attitude of nurses towards RRS activation.Besides, the use of automated RRS activations can decrease the burden of repetitive tasks on nurses while also detecting patients' deteriorating condition automatically.

Table 1 Sociodemographic profile of the nurses
0 Submit a manuscript: https://www.tmrjournals.com/in