Background: Medical Emergency Teams (METs) have been developed and implemented with the aim ofimproving recognition of and response to deteriorating patients. Yet, METs are often not activated orused effectively by nursing staff. The reasons for this are not fully understood.Objectives: The aim of this study was to explore nurses’ experiences and perceptions of using and acti-vating a MET, in order to understand the facilitators and barriers to nurse’s use of the MET.Design, setting and participants: An interpretive qualitative approach was adopted to explore nurses’experiences and perceptions of using and activating the MET. This study was set in a large public teachinghospital in Southeast Queensland, Australia. Fifteen registered ward nurses who had cared for patientswho had deteriorated on the ward, and as a result of this deterioration were admitted to the IntensiveCare Unit (ICU) as an unplanned admission, were interviewed about their experiences and perceptionsof using a MET.Methods: In-depth, semi-structured interviews were conducted with ward nurses who had cared for apatient who had deteriorated. Interviews were recorded and transcribed verbatim. The interviews wereanalysed thematically.Findings: Four themes relating to the participants’ experiences and perceptions of using a MET emerged
from the data. These themes were: (1) sensing clinical deterioration; (2) resisting and hesitating; (3)pushing the button; and (4) support and leadership.Conclusion: This work identifies why nurses do not activate METs appropriately. This delay in MET acti-vation potentially exposes the deteriorating patient to suboptimal care and increases the risk of adverseevents.
ks Au
of Reed International Boo
ackground
The past decade has seen increasing focus on recognising andesponding to the deteriorating hospitalised patient.1–3 Much of
Please cite this article in press as: Massey D, et al. Nurses’ perceptions of acc(2013), http://dx.doi.org/10.1016/j.aucc.2013.11.001
his interest has been prompted by findings that have demon-trated patient deterioration is often not recognised or respondedo in a timely manner.4–6 Failure to recognise and respond to patient
deterioration and to escalate care has led to an increased risk ofadverse events in hospitalised patients that may have been avoidedhad appropriate care been instituted earlier. Patients who deterio-rate in hospital exhibit premonitory signs of physical decline manyhours before this clinical deterioration.7–9 Failure to escalate carefor deteriorating patients can have devastating consequences; itmay lead to increased length of hospital stay,9 decreased qualityof life,10 or death11 as well as a significant increase in health-carecosts.12–14
In response to this recognised threat to safe, high-quality care,
essing a Medical Emergency Team: A qualitative study. Aust Crit Care
the Medical Emergency Team (MET) has been implemented. METshave been implemented in Australia, America and Europe. Cur-rently, there are a number of different MET models in clinicalpractice.8 For example; METs can be either physician or nurse led.
tional Books Australia Pty Ltd) on behalf of Australian College of Critical Care Nurses Ltd.
ETs have been developed as an early intervention strategy foratients who deteriorate suddenly. The aims of the METs are tovert admission to critical care units, facilitate discharge from crit-cal care units and share critical care skills throughout the hospital.8
he potential for a MET to improve patient outcomes is compelling,ut researchers have struggled to demonstrate consistent improve-ents in patient outcomes.15
A recurrent research finding is METs are under-utilised byealth-care practitioners, particularly nurses, who are responsi-le for activating 80% of METs.16–18 The under-utilisation of METsuggests that opportunities for early intervention and escalation ofare for deteriorating ward patients are missed and this may jeop-rdise patient safety, lead to adverse events and prevent effectivetilisation of scarce critical care resources.
tudy aims
The aim of this study was to explore nurse’s experiences anderceptions of accessing a MET in an Australian hospital. We alsoimed to understand what facilitated nurse’s use of a MET and whaturses identified as the barriers to using a MET.
ethods
An interpretive qualitative approach was adopted to exploreurses’ experiences and perceptions of using a MET. Qualita-ive research is inductive, rather than testing pre-determinedypotheses19,20 allowing for an in-depth understanding ofhe experiences and meanings that individuals attach to ahenomenon.20
etting
The setting for this study was a large public teaching hospitaln Southeast Queensland, Australia. The hospital was purposefullyelected because it has an organisational culture that supported theims and objectives of the MET and also had a well established MET.n this research setting a single parameter system that incorporated
ET calling criteria was used.8 Clinicians using the single parame-er system undertook periodic observations of selected vital signsnd compared these vital signs to a set of criteria with a prede-ned threshold, and if any of the criteria for activation were methen a response algorithm was activated. These calling criteria wereisplayed throughout the hospital and displayed on cards worn on
anyards. The response to clinical deterioration, was determined byhe activation of the MET in order to escalate care for patients expe-iencing, or at risk of, clinical deterioration. The research settinglso used the traditional method of accessing immediate help andupport—a separate cardiac arrest team—in the event of a cardio-espiratory arrest.
ample
A consecutive sample of consenting registered ward nurses whoad cared for medical patients, within the 12 h prior to the patient’snplanned admission to ICU were invited to participate in thistudy. A total of 15 registered ward nurses were recruited fromve medical wards in the hospital. The timeframe of 12 h prioro unplanned admission to ICU was chosen to cover the periodhen patients were unstable and, therefore, most likely to have
Please cite this article in press as: Massey D, et al. Nurses’ perceptions of ac(2013), http://dx.doi.org/10.1016/j.aucc.2013.11.001
equired a MET. The mean number of years of nursing experiencef the participants was 5 years and 3 months, with the shortesteing 6 months and the longest 22 years. Three of the participantsere clinical nurses, in other words senior registered nurses; one of
PRESSal Care xxx (2013) xxx– xxx
the participants was a new graduate nurse. Recruitment of partic-ipants continued until no new information was forthcoming fromparticipants.
Procedures
Data collection occurred over a 6-month period between March2011 and August 2011. The ICU admission book was checked everymorning between Monday–Friday to identify patients who hadexperienced unplanned admissions from the medical wards. If apatient met these criteria, the appropriate Nurse Unit Manager(NUM) was contacted and, following their approval, informationsheets and consent forms were left with the NUM to distribute tothe nurses who had cared for the patient during the 12 h prior tothe patient’s unplanned admission to ICU. The registered nurses(RNs) then contacted the researcher if they were interested in beinginterviewed. In-depth interviews were conducted within 48 h ofthe patients’ admission to ICU; this timeframe was used to improveparticipants’ recall and recollection of caring for each specific dete-riorating patient. Face to face interviews were held between theparticipants and the researcher. Interviews were conducted in aroom at the hospital separate to the ward area and were arrangedat a date and time convenient to the participant. All interviews wererecorded using a digital recorder and transcribed by the researcher.Interviews took between 40 min and 1 h. Given that factors affect-ing nurses’ experiences, perceptions, and practices of using METshave been explored in a limited manner, interview questions werebroad, giving participants the opportunity to tell their stories andrecount their experiences. The questions used in the interviewguide were developed from literature and from discussions withthe supervision team. An interview guide was developed to ensurethat all relevant issues were discussed. Initial interview questionsincluded:
1. Can you tell me about your experience of caring for a specificpatient who was admitted to the Intensive Care Unit?
2. Can you tell me about the patient management decisions youmade while caring for this patient?
3. What factors influenced your decision to activate or not activatethe MET?
4. What are your experiences of using the MET?5. What do you identify as the barriers in relation to activating the
MET?
In qualitative research, the researcher is regarded as a researchinstrument and this necessitates the identification of personal val-ues, assumptions, and biases at the outset of the research study.The researcher’s perceptions of the care and management of thedeteriorating ward patient has been shaped by personal experi-ences. She is an experienced ICU nurse and a lecturer who teachesstudents enrolled in a Masters of acute care. The supervision teamprovided expert guidance in relation to managing potential biasand assumptions.
Ethical considerations
Ethical permission was granted from the hospital and uni-versity ethics committees and the study satisfied the researchgovernance requirements of participating organisations. Written
cessing a Medical Emergency Team: A qualitative study. Aust Crit Care
informed consent was obtained from each participant prior to eachinterview. Particular attention was paid to ensuring that the partic-ipants’ identity remained protected at all times; achieved by usingpseudonyms.
Themes derived from this study’s data were developed usingn inductive approach.21 The process of inductive analysis usedn this study involved two levels of interpretation. The analysis ofndividual transcripts was the first level of analysis, and involvedeading and re-reading individual participant transcripts severalimes to identify themes.21,22 Continuous re-reading allowed foronsistencies and inconsistencies to be discovered and emerginghemes to be developed. This entailed grouping segments of textso parallel the similarities and differences of the transcripts, andid the development of overarching themes.21 These themes wereontinuously reinterpreted and given broad descriptive names inrder to capture the significant lines of inquiry.23 Initial inter-retation of the transcripts revealed multiple themes. However,ith repeated immersion and analysis of the transcripts, prelimi-ary themes were combined during the second level analysis. This
nvolved combining and collapsing the themes from all the differ-nt interview transcripts until each theme clearly represented aingle but complete concept.23 Each theme was then labelled. Thisonceptual, iterative theme development acknowledged that theoundaries for themes might sometimes become blurred.21 Onceo new themes emerged; it was assumed that data saturation hadccurred.
igour
Recommended guidelines24 were used to strengthen therustworthiness of the data. The inclusion of a clear and trans-arent audit trail facilitated dependability of the study. Prolongedngagement with the data through repeated analysis of thenterview transcripts and emerging sub-themes and themeslso enabled a deeper understanding of the data and ensuredredibility of the study. Credibility was also achieved througheer reviews. This involved the research supervisors review-
ng the interview transcripts and the emerging sub-themes andhemes.
indings
Four themes relating to the participants’ experiences and per-eptions of using a MET emerged from the data: (1) sensing clinicaleterioration; (2) resisting and hesitating; (3) pushing the button;nd (4) leadership and support.
ensing clinical deterioration
The first theme identified was sensing clinical deterioration.t denoted the characteristics that participants used to identify aatient’s physiological decline. Participants frequently mentioneddoing the obs”, “the obs were ok”, “we did a set of obs”, andthe obs were all over the place”. The “obs” in the context of thistudy, related to patients’ vital signs. The participants explainedhat changes in a patients’ vital signs were what alerted them tolinical deterioration and that they used this information to activate
MET. This was illustrated in Ann’s comment:
“Then when I went to see her—that’s why I went in becauseshe was tachycardic; she just was in respiratory distress. So Icame round and said to the team that she was quite respiratorycompromised at the moment and they’re like, ‘Oh yeah, we’vejust seen her’, and I said to them ‘Well, you had better come and
Please cite this article in press as: Massey D, et al. Nurses’ perceptions of acc(2013), http://dx.doi.org/10.1016/j.aucc.2013.11.001
look at her again’, and then they came in and I think they werea bit like shocked at her deterioration.” (Ann)
As Ann identified, she was the first person to identify theatient’s clinical deterioration and activate a response for the
PRESSal Care xxx (2013) xxx– xxx 3
patient. The ability to sense patients at risk of clinical deteri-oration clearly facilitated appropriate and timely activation ofa MET.
Resisting and hesitating calling a MET
This theme is understood as either refusing to activate a METor pausing before activating a MET. Participants said, “I don’t knowif it would be the right thing to do”, “I don’t want to look like anidiot”, and “I may get into trouble”. Participants admitted that theyresisted or hesitated before activating a MET because they wereanxious or frightened about the consequences and the panic thatwould ensue following the arrival of a response team. Participantsidentified that they were “scared of the MET” and scared of thefeelings that the MET evoked in them. Fear of reprisals or punish-ments were linked to failure to correctly recognise a patient whowas deteriorating because of clinical inexperience and uncertainty.This is clearly illustrated in Tanya’s example when she talked aboutquestioning her clinical and professional ability and how this maylead to her being “told off”:
“Maybe questioning my decisions: Am I over-reacting here? Isthis real or am I just panicking? So just questioning my abilityor my reality around what’s happening. Just not having enoughexperience. Just feeling I’d better not do that kind of thing or Imight get told off.” (Tanya)
The fear of “being reprimanded”, “looking like an idiot”, or “beingtold off” was a powerful motivator that participants used to justifydelaying activating the MET. Mary said:
“Nurses feel like they are going to be told off for wasting themedical emergency team’s time. Even though worried or con-cerned is on the little cards that we all carry around. Thatmessage has not been embraced by the nursing staff becausepeople are still frightened I think. Talking to people they stillthink they are going to get told off or there are going to berepercussions.” (Mary)
Participants spoke about being reprimanded by members of theMET during previous MET calls. This experience created negativefeelings and emotions for participants, who clearly wishing to avoidthese negative emotions created certain coping responses. Theseresponses included resisting the MET and hesitating in activatinga MET. Both responses may have led to a delay in escalating carefor the deteriorating ward patient and acted as a significant bar-rier to MET activation. The subsequent theme “pushing the button”denotes tactics that participants used to justify not activating theMET.
Pushing the button
This theme captured the notion of participants reacting to thedeteriorating ward patient by engaging in a concerted effort toaccess immediate help and support. The button in this context wasthe emergency button that the participants associated with a med-ical emergency. In the acute care setting, the emergency button ispushed as a means to call for expert help and support, and has tradi-tionally been used when a patient has suffered a cardio respiratoryarrest. Pushing the emergency button rather than calling the METon the phone represented a ‘true’ emergency and in this hospital itactivated the cardiac arrest team. This is illustrated in the examplesbelow. Helen talked about deciding if the patient can hang on a few
essing a Medical Emergency Team: A qualitative study. Aust Crit Care
more minutes and Tanya reported that if a patient was deteriorat-ing, she would go to the nurse in charge whereas if a patient thatwas having a cardiac arrest, she would push the button and activatethe cardiac arrest team.
“It would depend if I thought the patient could, I don’t know,hang on a few more minutes until people got there. But if I didn’tthink I was going to get a quick response, I wouldn’t. I’d just doit; I’d push the button.” (Helen)
“If it’s a MET call, you go to the nurse in-charge. If it’s an arrest,I push the button and then it’s real because our buzzers call outat the time and everybody comes.” (Tanya)
In reality, this means that the MET was often not used as anarly intervention strategy but rather the MET was called whenhe patient suffered a cardiac arrest. What the interviews clearlyemonstrated was that the participants had difficulty separatinghe purpose of the cardiac arrest team from that of the MET.
Misinterpretation and lack of understanding of the role of theET led to confusion and uncertainty about when to activate theET. Participants identified that, in their experience, METs were
ot perceived as an early intervention strategy but were unable torticulate how this perception could be challenged and changed.atie discussed this in her interview:
“I think it’s probably a lack of understanding of the MET and howit should be used. People don’t see it as an early interventionthing; I am not sure how you go about changing that. I can seethat the patient is deteriorating and I can see that poor decisionsare being made and it’s very frustrating, yet a MET is not calledbecause the patient is not sick enough for a MET; it’s amazing.”(Katie)
The participants identified misunderstanding the MET and itsole in preventing deterioration and escalating care as a barrier toET activation. This misunderstanding of the MET led to a delay in
ctivating the MET and prevented the MET from being used as anarly intervention strategy.
eadership and support
Leadership and support were acknowledged as important fac-ors in supporting or hindering MET activation. The participantsighlighted the identification of a leader as important because itnsured that activation of the MET was less stressful and less dis-ointed. By promoting a more organised approach to managing theeteriorating patient, participants identified that they were more
ikely to activate a MET in future. Tanya stated:
“I think if a clear leader is designated to manage and lead thecode or the MET call that would be a big improvement. At themoment, it is chaotic and can be uncoordinated and that addsto an already stressful event.” (Tanya)
Participants acknowledged that they often required supportnd advice in relation to when to access the MET and, in ordero access this support, they sought consultation from their peers,
ore senior nurses, or medical staff. The ability to seek appropriatend timely support and advice appeared to be related to effectiveommunication within the clinical team. The ability to “package”linical deterioration effectively and therefore justify MET activa-ion appeared to depend on knowledge, confidence, and level ofxperience of the participants. However, the ability to access sup-ort may, in fact, delay the use of a MET. The participants talkedrequently about “going to the nurse in charge first”. This effectivelyypassed the MET and prevented its use as an early interventiontrategy. Rachel said:
“Yeah, I think if I was concerned about someone in the first
Please cite this article in press as: Massey D, et al. Nurses’ perceptions of ac(2013), http://dx.doi.org/10.1016/j.aucc.2013.11.001
instance and it wasn’t—what’s the word?—critical, I’d certainlyconsult with the person in-charge and say, ‘Look, I’ve got Mr.Jones over here and I really don’t think he’s doing well. His bloodpressure has dropped a little bit and he looks a bit grey looking,
PRESSal Care xxx (2013) xxx– xxx
he seems to be sort of deteriorating slowly but seems relativelystable. Can you come and review him at some point? But thenthat could be, it could be 10 min time or it could be 3 h. I wouldstill talk to the person in-charge first perhaps before we got tothe decision-making of a MET call.” (Rachel)
The narrative above illustrates how the culture of seeking sup-port to validate clinical decisions and actions may impede theeffective use of a MET and prevent escalation of care needs.
In summary, participants highlighted that an identified leaderwas an important factor in ensuring a positive experience of METactivation and indicated that this was more likely to result in themactivating a MET for a deteriorating patient in the future. Seekingsupport and advice from peers and colleagues delayed participant’sactivation of the MET.
Discussion
Four themes relating to the participants’ experiences and per-ceptions of using a MET emerged from the data: (1) sensing clinicaldeterioration; (2) resisting and hesitating; (3) pushing the button;and (4) leadership and support. The findings of this study suggestthat participants used information gained from patient assessmentto recognise and respond to patient deterioration. Nurses discussedhow they perceived the MET activation criteria useful in identify-ing and sensing clinical deterioration of a patient. Despite this, someparticipants choose not to use the criteria to initiate activation ofthe MET. MET criteria were designed to alert health-care providersto potential and actual clinical deterioration of a patient basedon changes in the patient’s vital signs. Changes or alterations ina patient’s vital signs have been repeatedly identified as importantpredictors of clinical deterioration.25–27 The barriers that nursesperceived as responsible for delaying or not activating the hospi-tal MET were identified. Barriers to activating the MET includedfear of being reprimanded, misunderstanding the MET and the METactivation criteria and the ability to access advice and support. Inthis study, the fear of “being reprimanded” was a powerful moti-vator used by the participants to justify delaying activation of theMET and the escalation of care. Nurses were anxious about mak-ing the wrong decision and looking foolish. There is an increasingbody of research supporting the view that nurses delay or activelyresist activating a MET because of fear of being reprimanded.28–30
There is general consensus that a practice environment that facil-itates both reporting mistakes and learning, also known as a ‘just’culture, is important for implementing and operating a successfulMET.8,16 However, this important message may not be translatedinto clinical practice.
Another important barrier to MET activation identified by theparticipants was misunderstanding of the function of a MET, whichcontributed to under-utilisation or incorrect use of the MET. Thisfinding has also been reported previously.18,31 The nurses inter-viewed said that they and their colleagues did not see or viewthe MET as an early intervention strategy. Instead, the participantsspoke about the MET as being a last resort, reflected in their actionsof pushing the button, and only accessing the MET if the patient wasin cardiac arrest. A ‘true’ emergency, therefore, required the buttonto be pushed rather than calling the MET. This perception of therole of the MET being the same as a cardiac arrest contributed todelays in activating the MET.
Access to support also delayed activation of the MET. Par-ticipants frequently talked about “going to the nurse in chargefirst”. This delay in MET activation limits or prevents its use
cessing a Medical Emergency Team: A qualitative study. Aust Crit Care
as an early intervention strategy. Previously, nurses and physi-cians have tended to operate in hierarchical silos of care and thismodel of practice may create professional barriers that need to beacknowledged and understood if the MET is going to be integrated
of critical illness predict in-hospital death-the SOCCER study (signs of critical
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D. Massey et al. / Australian
uccessfully into the hospital culture. Nurses appear to prefer toccess help or support from among their team and “use the homeeam” rather than the MET because that is how they have practicedistorically.32–34
As well as misunderstanding the aims and objectives of the MET,articipants also appeared to misunderstand the role of MET activa-ion criteria. The nurses interviewed in this study highlighted thathey ignored these activation criteria if they disagreed with the setarameters. Other researchers have also reported this finding,33,34
y not responding to predetermined activation criteria, nurses areailing to promote and use METs as an early intervention strategynd this may expose patients to suboptimal care.35
trengths and limitations
In this study a detailed exploration of a complex clinical phe-omenon, the deteriorating patient within the context of the MET,as undertaken. This has resulted in a better understanding of howurses recognise and respond to the deteriorating patient and use,r do not use METs. This is a sensitive clinical issue that impactsn, patient outcomes, quality of care and healthcare resources.ccessing and exploring the experiences and perceptions of front-
ine staff within the clinical environment adds to the strength ofhis study. However a limitation of the study was participants werenterviewed retrospectively about a patient they had cared for whoad experienced a major adverse event and it is possible that the
nterview data could have been affected in part by this knowledge.nother limitation of undertaking the research in the clinical envi-onment is that the hospital wards were extremely busy, whichay have impacted on participants’ availability to participate in
he study. Some of the participants were still busy or tired after aong shift and this may have impacted on the quality of data. Inddition, this study was conducted on a single site. The inclusion ofultiple sites may have presented a more comprehensive under-
tanding of the phenomenon of interest and provided findings thatere more transferable and generalisable to other settings.
ecommendations
Despite its limitations, this study has contributed to the bodyf knowledge of nurse’s experiences and perceptions of activatingnd using METs and recognising and responding to the deteriorat-ng patient. The nurses interviewed in this case study identifiedhat they were frequently reluctant to use the METs. This suggestshat further interventions need to be undertaken to help nurseshange their behaviour in relation to activating a MET. However,ehavioural change is perhaps one of the most challenging aspectsf introducing a new intervention into a health-care system.36
cceptance of any system depends on how the system is perceivedy its users. The results of this study indicate that the MET mayot have been fully integrated into Australian ward nurses’ clin-
cal practice and this may lead to under-utilisation. Given that aelay in activating a MET worsens patient outcomes,37,38 research
s needed to better understand how ward nurses accept, implementnd integrate new patient safety initiatives into their everyday clin-cal practice.36 Using behaviour change and knowledge transferheories to underpin this transfer may be beneficial. Following this,nterventions will need to be developed that help nurses changeheir behaviour.
Reluctance to activate the MET was linked to the hierarchalature of clinical practice and that participants felt that they would
Please cite this article in press as: Massey D, et al. Nurses’ perceptions of acc(2013), http://dx.doi.org/10.1016/j.aucc.2013.11.001
e reprimanded for calling the MET. This clearly acted as a barriero nurses activating the MET and delayed escalating care for theeteriorating patient. Activities that promote collaborative prac-ices and a ‘just’ culture are required. It is recommended that new
1
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PRESSal Care xxx (2013) xxx– xxx 5
and existing members of METs encourage staff to react positivelyto their presence. Hospitals leaders need to continue to explorestrategies and solutions that can be developed and implemented tominimise the chances of ward nurses experiencing negative emo-tions when they are considering activating METs. Implementationof team training interactions may be a possible solution to addressthis issue.39
Some participants identified that they resisted activating theMET because they thought the patient was not sick enough.This occurred even when the MET activation criteria were met.Arguably, not activating a MET once criteria are met exposespatients to suboptimal care40 and potentially negative outcomes.37
Health-care providers, educational providers, and policy makersclearly need to re-examine the content, the learning outcomes, andthe assessment strategies of educational programmes and hospitalin-service education to ensure they incorporate the recognition of,appropriate response to, and effective management of deteriorat-ing ward patients.
Conclusion
In conclusion, recognising, and managing the deterioratingpatient is complex, challenging, and multifaceted. Patient acuitywill continue to increase in hospitals as the inpatient populationbecomes older and sicker with more complex clinical care needs.METs have been embraced as part of the patient safety agenda byleaders and organisations both nationally and internationally, andappear to be here to stay. There are, however, challenges in rela-tion to how METs are integrated, adopted, and used by nurses andother health-care workers. There is an urgent need for researchexamining implementation strategies that will promote successfuladoption and use of the MET by nurses.
Authors’ contributions
Debbie Massey, Wendy Chaboyer and Leanne Aitken concep-tualised and designed the study. Collection of data was done byDebbie Massey. Analysis of data was done by Debbie Massey,Wendy Chaboyer and Leanne Aitken. They also drafted and revisedthe article and gave final approval of the version to be submitted.
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