I need these questions answered using this article that's copy & pasted below these questions.

Questions 1 - 4: Research Problem and Purpose. (For help with these questions, refer to chapters 2, 5, and 12)

1. Which choices below best reflect the problem statement for the instructor-assigned article?
2. The purpose of this study was to explore and understand medical-surgical nurses' perceived self-confidence and leadership abilities as first responders in recognizing and responding to patients experiencing acute deterioration (APD) prior to the arrival of a RRT or CRT.
3. The nature and scope of how self-confidence effects APD is unclear.
4. c.   Based on the findings of this review of literature, it is recognized that perceived self-confidence
5.       and leadership abilities are major components of nursing and can be detrimental to nurse
6.       decision-making.
7.               d. Very few quantitative studies have been conducted examining nurses' recognition and response to
8.                    APD.

2.    Which of the choices below best reflects the purpose statement for the instructor assigned article?

1. Lack of self-confidence negatively affects the nature of the caring relationship and healing environment, interfering with the nurses' ability to observe, listen to, understand, and know the patient.

b.  To explore and understand medical-surgical nurses' perceived self-confidence and leadership

      abilities as first responders in recognizing and responding to patients experiencing acute

      deterioration (APD) prior to the arrival of a RRT or CRT.

1. The Tanner's Clinical Judgement Model was used as the theoretical framework for the study. It provides a testable model for understanding the clinical reasoning and judgement of experienced nurses in a clinical setting.
2. Based on the findings of this review of literature, it is recognized that perceived self-confidence and leadership abilities are major components of nursing and can be detrimental to nurse decision-making.

3. According to Grove, Gray, and Burns (2015), which of the following statements are important when considering the significance and relevance of a study's problem and purpose? (Select all that apply.)

1. Does it consider ethical principles in its design?
2. Does it predict the non-significant findings anticipated in the study?
3. Does it specifically influence nursing education in university settings?
4. Does it identify the future research to be generated by the study?
5. Does it promote theory testing or development?
6. Does it identify extraneous variables?

4. When considering the feasibility of a study's problem and purpose, Grove, Gray, and Burns (2015) suggest that several areas should be evaluated, including: researcher expertise, money commitment, ethical considerations, and availability of subjects, facilities, and equipment.  Which of the following statements accurately assesses the feasibility of this article? 

1. Funding sources for the study were clearly identified in the article.
2. The author's credentials to design and conduct research are described.
3. 100% of the eligible subjects contacted participated in the study.
4. Evidence of protection of the subjects' rights was mentioned in this article.

Questions 5 - 7: Review of the Literature. 

5.  According to Grove, Gray, and Burns (2015), which one of the following is NOT a major purpose of the review of literature (ROL):

1. Describing the current knowledge of the practice problem
2. Identifying gaps in the knowledge base of the practice problem
3. Explaining how the current study contributes to the knowledge being built
4. To explain the reasons behind the selection of the statistics used in the study.
5. 6.  Select three MAJOR topics covered in the review of literature (ROL) from the list below:
6. Early warning signs of acute deterioration are not always recognized and addressed in a timely manner.

b.   Organizational, cultural and individual factors influence nurses' help-seeking behaviors during APD events.

c.   A descriptive correlational design was used to examine the relationship of age, years licensed, education level, certification and their perceived self-confidence as a first responder among a sample of Medical-Surgical RNs.

d.   Several important factors influence the experiences of nurses caring for critically ill patients, including clinical environment, professional relationships, patient assessment, nurses' feelings, and education needs.

e.   Managers should increase their knowledge of APD.

f.   The researcher administered three instruments: the demographic tool, the Self-confidence Scale, and the Leadership Ability Questionnaire.

7. Current knowledge in the review of literature (ROL) (all information included before the "Methods") is considered to be articles that are within 5 years of the publication date of the article. This is often assessed by reviewing the citations that are used in the ROL and counting the number that meet this criterion.  Which number below most closely reflects the number of current citations in the ROL? (HINT-look for references in the ROL that are between 2014-2009.)

1. 1
2. 3
3. 7
4. 10
5. Questions 8 - 10: Study Framework. (For help with these questions, refer to chapters 7 & 12)
6. 8.  Which of these statements best describes this study's research framework?

            a. This study has an implicit framework, which is not fully developed.

            b. The Tanner's Clinical Judgement Model was used as the theoretical framework for the study. It

                  provides a testable model for understanding the clinical reasoning and judgement of experienced

                  nurses in a clinical setting.

            c.  The authors developed the study's theoretical framework based on Murphy and Fitzsimons (2004)

                   intervention study to determine nurses' skill performance of immediate life support (ILS).

9.  What are some of the key concepts in this study's theoretical framework?

1. This study does not have any clearly defined concepts within a framework because it has an implicit framework.
2. Manager's understanding of a medical-surgical nurses' leadership abilities will result in an improved nursing work environment.
3. The theoretical framework identifies four steps in recognizing and responding to APD events: noticing, interpreting, responding, and reflection.
4. 10.  Which one of the statements below is an example of a relational statement from the theoretical framework?
5. Stress is a major component of nursing and can be detrimental to nurse response in emergency situations.
6. This study does not have any clearly defined relational statements because it has an implicit framework.
7. Self-confidence is necessary to respond appropriately to APD events.

Questions 11 - 15: Research objectives, questions, or hypotheses and research variables. (For help with these questions, refer to chapters 5 & 12)

11.  The author states that the first research objective, question, or hypothesis was "What are the 

       perceived levels of self-confidence and leadership abilities of medical-surgical nurses as

      first responders in APD events prior to the arrival of a RRT or CRT?" on page 2771. This is best

       described as a

1. Research objective
2. Research question
3. Research hypothesis
4. None of the above

12.  Which of these are considered to be MAJOR study variables in this study. (Select all that apply)?

1. first responder
2. psychological empowerment
3. perceived self-confidence
4. leadership abilities
5. acute patient deterioration
6. 13.  What is the conceptual definition (as defined in the review of the literature) of the following study variable: acute patient deterioration
7. The conceptual definition of acute patient deterioration is the presence of physiologic abnormalities that require the initiation of basic life support interventions or activation of the rapid response team and may occur at any time during a hospitalization.
8. The factors that influence acute patient deterioration need to be better understood.
9. The conceptual definition of acute patient deterioration is not clearly provided in the review of the literature.
10. The theoretical framework for the study describes the clinical judgement process of noticing, interpreting, responding and reflection.

14.  What is the operational definition (as defined in the methods section) of the following study variable: Leadership Abilities

a.  The conceptual definition of leadership abilities is not clearly provided in the review of the literature.

b.  The Leadership Ability Questionnaire

c.   No studies have compared leadership abilities to perceived self-confidence in the medical-surgical nurses.

1. Multifactor Leadership Questionnaire (MLQ)
3. 15.  Which demographic variables were assessed by the author for this study? (Select all that apply.)
4. Age
5. Highest education level
6. Years practiced
7. Current Master's program enrollment
8. Gender
9. Ethnicity/Race
10. Current ACLS certification

Questions 16- 19: Research Design

16.  Which phrases best describe the research design of this study? (Select all that apply.)

1. Descriptive
2. Correlational
3. Quasi-experimental
4. Experimental
5. Mixed methods
6. 17.   Which phrase best describes the time element of the research design of this study?
7. a.    Cross-sectional design
8. b.   Longitudinal design
9. c.    None of the above
10. 18.  Does the study include a treatment or intervention described in the methods section?
11. a.  The Self-Confidence Scale used in the study may be considered a treatment or intervention.
12. b.  500 medical surgical nurses were invited to participate in the intervention.
13. c.  The relationship between perceived-confidence and leadership abilities was assessed.
14. d.  This study was not designed with a treatment or intervention.

19.  Does the author specifically mention that a pilot study was done prior to conducting this study? (Hint: look at the words "prior to this study".)

a. Yes

b. No

20.  The authors indicate on page 2772 of the article that the institutional review board (IRB) authorization was acquired. This indicates than an IRB gave approval to conduct the research. In addition, an informed consent was provided to each participant. Per Grove, Gray, and Burns (2015), which of the following would NOT be considered essential information for informed consent? (Select all that apply.)

a.  a statement of the research purpose and any long-term goals of the study

b.  a copy of the abstract of the article that will be used in the publishing journal.

c.  an explanation of the procedures to be followed in the study

d.  a complete list of references to be used in the study.

 

ARTICLE TO CRITIQUE

ORIGINAL ARTICLE

Medical-surgical nurses' perceived self-confidence and leadership

abilities as first responders in acute patient deterioration events

Patricia L Hart, LeeAnna Spiva, Pamela Baio, Barbara Huff, Denice Whitfield, Tammy Law,

Tiffany Wells and Inocenica G Mendoza

Aims and objectives. To explore and understand medical-surgical nurses' perceived

self-confidence and leadership abilities as first responders in recognising

and responding to clinical deterioration prior to the arrival of an emergency

response team.

Background. Patients are admitted to hospitals with multiple, complex health

issues who are more likely to experience clinical deterioration. The majority of

clinical deterioration events occur on medical-surgical units, and medical-surgical

nurses are frequently the first healthcare professionals to identify signs and symptoms

of clinical deterioration and initiate life-saving interventions.

Design. A prospective, cross-sectional, descriptive quantitative design using a survey

method was used.

Methods. Nurses were recruited from an integrated healthcare system located in

the south-east United States. Nurses completed a demographic, a self-confidence

and a leadership ability questionnaire.

Results. One hundred and forty-eight nurses participated in the study. Nurses felt

moderately self-confident in recognising, assessing and intervening during clinical

deterioration events. In addition, nurses felt moderately comfortable performing

leadership skills prior to the arrival of an emergency response team. A significant,

positive relationship was found between perceived self-confidence and leadership

abilities. Age and certification status were significant predictors of nurses' leadership

ability.

Conclusion. Although nurses felt moderately self-confident and comfortable with

executing leadership abilities, improvement is needed to ensure nurses are

competent in recognising patients' deterioration cues and making sound

decisions in taking appropriate, timely actions to rescue patients. Further

strategies need to be developed to increase nurses' self-confidence and execution

of leadership abilities in handling deterioration events for positive patient outcomes.

What does this paper contribute

to the wider global clinical

community?

• Patients are admitted to hospitals

with multiple, complex health

issues who are more likely to

experience clinical deterioration.

• Nurses were only moderately

self-confident in recognising,

assessing and intervening during

clinical deterioration events and

were only moderately comfortable

in performing leadership

skills prior to the arrival of an

emergency response team.

• To ensure best outcomes for

patients, healthcare organisations

need to conduct baseline assessments

of nurses to identify areas

needing improvement in assessment

skills, recognition, knowledge,

leadership abilities and

self-confidence in clinical deterioration

events on a routine basis.

Authors: Patricia L Hart, PhD, RN, Assistant Professor of Nursing,

Kennesaw State University, Kennesaw, GA; LeeAnna Spiva, PhD,

RN, Director of Nursing Research, WellStar Development Center,

Center for Nursing Excellence, Atlanta, GA; Pam Baio, MSN, RN,

CNL, Clinical Nurse Leader, WellStar Kennestone Hospital, Marietta,

GA; Barbara Huff, MSN, RN, CNL, Clinical Nurse Leader,

WellStar Paulding Hospital, Dallas, TX; Denice Whitfield, MSN,

RN, CNL, Clinical Nurse Leader, WellStar Cobb Hospital, Austell,

GA; Tammy Law, MSN, RN, CNL, Clinical Nurse Leader, Well-

Star Douglas Hospital, Douglasville, GA; Tiffany Wells, MSN,

RN-BC, RN Staff Nurse, WellStar Douglas Hospital, Douglasville,

GA; Inocenica G Mendoza, BSN, RN, Clinical Educator, WellStar

Windy Hill Hospital, Marietta, GA, USA

Correspondence: Patricia L Hart, Assistant Professor of Nursing,

Kennesaw State University, 1000 Chastain Road, Kennesaw, GA

30144, USA. Telephone: +1 678 797 2506.

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2769-2778, doi: 10.1111/jocn.12523 2769

Relevance to clinical practice. Educational provisions should focus on various

clinical deterioration events to build nurses' self-confidence and leadership abilities

in handling clinical deterioration. Nurses should obtain national certification

to increase their knowledge and clinical reasoning skills.

Key words: acute patient deterioration, leadership abilities, medical-surgical

nurses, self-confidence

Accepted for publication: 25 October 2013

Introduction

Patients enter healthcare organisations with the trust and

assumption that nurses are trained and competent to detect

early warning signs of acute clinical deterioration and have

the self-confidence and leadership abilities to respond and

intervene with appropriate actions. Nurses perform patient

care within a very complex and ever-changing practice environment

that at times can be unpredictable requiring the

effective use of critical thinking skills to make quick, appropriate

clinical decisions in crisis situations. Patients are

admitted to healthcare organisations with multiple, complex

health issues who are more likely to experience an

acute patient deterioration (APD) event during their hospitalisation

(Bright et al. 2004). Acute deterioration can happen

at any time during patients' hospitalisation. Patients

are especially vulnerable following emergent admissions,

after surgery or during recovery from critical illness (Beaumont

et al. 2008). The majority of APD events occur on

medical-surgical nursing units (Cohn et al. 2004, Peters &

Boyde 2007), and medical-surgical nurses are frequently the

first healthcare professionals to identify signs and symptoms

of clinical deterioration and initiate life-saving interventions

(Gombotz et al. 2006). Therefore, medical-surgical nurses

play a pivotal role in assessing, recognising, and intervening

in a timely manner to secure fast, efficient, and effective

resources and treatment for patients experiencing acute

deterioration. Although nurses recognise the presence of

physiological abnormalities indicating acute deterioration,

nurses are reluctant to initiate basic life support interventions

or activate rapid response teams (RRT) (Considine &

Botti 2004). Nurses' nonactions may be linked to fear of

making wrong decisions, initiating false alarms, or the

desire to handle the situation in the early phase (Cioffi

2000a, Cioffi et al. 2006).

Literature review (background)

Early warning signs often precede acute deterioration events

including cardiac arrest, unplanned admission to critical

care and unexpected death (Hillman et al. 2001, Buist et al.

2004, Kause et al. 2004, Fuhrmann et al. 2008), but

patients with early warning signs are not always identified,

and those who are identified are not always addressed in a

timely manner (Hillman et al. 2005, Thompson et al.

2008). Failure to recognise and manage deterioration of a

patient's condition in the early stages, such as changes in

vital signs, is a common theme throughout the literature

that leads to cardiac and respiratory arrest in hospitalised

patients [Laurens & Dwyer 2011, Institute for Healthcare

Improvement (IHI) (2012)]. Multiple, complex and overlapping

factors have been identified as reasons that healthcare

professionals fail to recognise and respond appropriately to

APD. These factors include but are not limited to nurses'

lack of knowledge and skills, inconsistent monitoring or

detecting vital signs changes, delays in notifying medical

staff of the signs of deterioration, failure to seek prompt

assistance, failure to communicate with other staff and lack

of clarity about roles and responsibilities (Hillman et al.

2001, Cioffi et al. 2006, Endacott et al. 2007, National

Patient Safety Agency 2007).

Organisational, cultural and individual factors influence

nurses' help-seeking behaviours during APD events. Several

qualitative studies have explored nurses' experiences of

decision-making, cue recognition, assessment and communication

during acute deterioration events (Cioffi 2000a,

Minick & Harvey 2003, Cioffi et al. 2006). Cioffi (2000a)

and Cioffi et al. (2006) found that nurses felt uncertain

about notifying the RRT for fear of making a wrong decision

and calling the RRT for a false alarm. Additionally,

nurses have a desire to deal initially with patient problems

in the early stages resulting in delayed treatment. Furthermore,

Cioffi (2000a) and Cioffi et al. 2006 found that

higher workload and complexity of the work environment

decreased time for nurses to think about and analyse

changes in vital signs resulting in delayed responses to deteriorating

patients. Minick and Harvey (2003) found three

themes describing ways of knowing that enable the early

recognition of acute deterioration by medical-surgical

nurses: knowing the patient directly, knowing the patient

© 2014 John Wiley & Sons Ltd

2770 Journal of Clinical Nursing, 23, 2769-2778

PL Hart et al.

through family and knowing something is not as expected.

Cioffi (2000a,b) identified four patient characteristics that

nurses used when calling the RRT for 'concerned about

patient' criteria: feeling 'not right', colour, agitation and

small or no changes in observations.

Cox et al. (2006) explored factors that influenced the

experiences of nurses on general wards caring for critically

ill patients. Five themes emerged from the data: clinical

environment, professional relationships, patient assessment,

nurses' feelings and education needs. Reliance on machines

and being distracted by other patients impacted nurses'

abilities to assess deteriorating patients. In addition, professional

relationships emerged as an important factor in

obtaining help to support acute deteriorating patients. Feelings

of panic and anxiety in handling acute deteriorating

patients varied among nurses with varying levels of selfconfidence

that influenced their reactions or inactions. The

importance of ongoing education was identified to assist

with skill acquisition and knowledge of body system

changes that would warrant nurses' immediate attention.

Endacott et al. (2007) found that nurses relied heavily on

vital signs to identify patient deterioration, followed by

changes in the patient's activity level. In addition, the

researchers found that assessment practices by nurses were

influenced by patient location, time of day, symptoms/condition

of patient and expertise of the nurse.

Very few quantitative studies have been conducted examining

nurses' recognition and response to APD (Murphy &

Fitzsimons 2004, Cooper et al. 2011). Cooper et al. (2011)

conducted a simulated study that examined rural nurses'

abilities to assess and manage patient deterioration using

measures of knowledge, situation awareness and skill performance.

The researchers found that knowledge levels varied

in range from 27-91% with a mean score of 67%,

situation awareness and skill scores were low with nurses

missing important observations and actions, and nurses did

not use a systematic approach to patient assessment.

Murphy and Fitzsimons (2004) conducted an intervention

study to determine the effectiveness of an immediate life

support course (ILS) on the skill performance of nurses in

future cardiac arrest events. The performance skills evaluated

were the use of a defibrillator and inserting a laryngeal

mask airway (LMA) during resuscitation. The authors

found that nurses' confidence levels waned over time and

that ILS training alone was not sufficient in improving

nurses' skill performance over time.

Based on the current research findings, further research is

needed to explore medical-surgical nurses' perceived selfconfidence

and leadership abilities as first responders during

APD events prior to the arrival of a RRT or a cardiac

resuscitation team (CRT). In addition, further research is

needed to understand medical-surgical nurses' experiences

of handling patients in acute deterioration events. Knowledge

gained from this study will provide strategies to assist

nurses to be more knowledgeable, self-confident and skilled

in leadership abilities in caring for deteriorating patients.

Purpose

The study purpose was to explore and understand medicalsurgical

nurses' perceived self-confidence and leadership

abilities as first responders in recognising and responding to

patients experiencing acute deterioration prior to the arrival

of a RRT or CRT. The research questions were as follows:

1 What are the perceived levels of self-confidence and leadership

abilities of medical-surgical nurses as first responders

in APD events prior to the arrival of a RRT or CRT?

2 What is the relationship between medical-surgical nurses'

demographic variables (age, years licensed, certification

status and highest nursing degree) and their perceived

self-confidence and leadership abilities as first responders

in APD events?

Theoretical framework

The theoretical framework for this study was Tanner's

Clinical Judgment Model (2006). The model offers a functional

way in understanding the clinical reasoning and judgment

of experienced nurses in a clinical setting and is

appropriate in describing their decision-making and actions

in recognising and responding to APD events. The model

consists of four steps: noticing, interpreting, responding and

reflection. In the first stage of the clinical judgment process

termed 'noticing', nurses grasp the situation at hand. Noticing

involves nurses making focused observations and

obtaining information from the situation. This step requires

nurses to use previous knowledge learned from other

sources such as textbooks, assessment protocols, clinical

practice guidelines and previous clinical experiences to recognise

change in patterns that exist within varying patient

situations. During the 'interpreting' step, nurses develop an

understanding of the situation based on data collected, prioritise

nursing actions to be taken and develop an intervention

plan to address the situation. The 'responding' step

involves nurses taking action and implementing their intervention

plan. To respond appropriate, nurse must feel confident

in using their clinical skills and leadership abilities to

execute appropriate actions. The final step, 'reflection', is

the step where nurses reflect on actions taken and patients'

responses to those actions and evaluate their choices and

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2769-2778 2771

Original article Acute patient deterioration

decisions. Through this evaluation process, nurses gain an

understanding of varying situations and determine what

works and does not work for application in future situations.

By reflecting on the outcomes of various situations

from actions taken, nurses develop a broader knowledge

base and increased self-confidence in their leadership abilities

to respond to future clinical situations.

Methods

Design

A prospective, cross-sectional, descriptive quantitative

design using a survey method was used.

Setting and sample

A convenience sample of nurses working in a five-hospital

integrated healthcare system located in the south-east

United States was recruited. Inclusion criteria included:

(1) a medical-surgical nurse who provided direct patient

care, (2) willingness to complete the study questionnaires

and (3) 18 years of age and older. With a power of 0!80,

an a value of 0!05 and a small effect of 0!25, a sample size

of 126 participants was needed for the study.

Instruments

A demographic questionnaire, self-confidence scale and a

leadership ability questionnaire comprised the study instruments.

Permissions to use the instruments were obtained.

Self-confidence scale

The 12-item self-confidence scale (Hicks 2006) measures

self-confidence in caring for patients in acute deterioration.

Four dimensions are measured: (1) accurately recognising a

change in patient's condition, (2) performing basic physical

assessments, (3) identifying basic nursing interventions and

(4) evaluating the effectiveness of interventions during acute

deterioration. The items are rated on a Likert response

scale ranging from 1 (not at all confident)-5 (very confident),

with higher scores indicating greater self-confidence.

Internal consistency reliability has been demonstrated by

the instrument's author with Cronbach's as of 0!93 and

0!96. The responses to all items on the questionnaire were

summed for a total score for each participant.

Leadership ability questionnaire

The eight-item leadership ability questionnaire was derived

from Gordon and Buckley's (2009) 14-item questionnaire

that measures technical and nontechnical skills of nurses

responding to a crisis situation. For this study, only the

nontechnical subscale items were used to measure nurses'

leadership abilities during APD events. The items are rated

on a Likert response scale ranging from 1 (not at all)-4 (a

great deal), with higher scores indicating greater perceived

leadership abilities. Internal consistency reliability has been

demonstrated by the instrument's author with Cronbach's

as of 0!94 and 0!91 for the instrument. The responses to all

items on the questionnaire were summed for a total score

for each participant.

Protection of human subjects

Prior to beginning data collection, approval for the study

was obtained from the healthcare system's nursing research

committee and an institutional review board (IRB). An

informed consent was provided to each participant.

Completion of the research questionnaires by participants

was acknowledged as their consent to participate in the

study.

Data collection procedure

The research team recruited medical-surgical nurses by

making rounds on nursing units and attending staff and

shared governance meetings. Questionnaires were distributed

to nurses face-to-face. The researchers reviewed in

detail information about the study provided on the

informed consent and answered questions to clarify any

information. Participants were informed that they would be

asked to complete three study questionnaires. Participants

were informed that the questionnaires would take approximately

15-30 minutes to complete. Participants were also

advised that questionnaires did not contain any identifying

information linking the questionnaire to the participant

and all information obtained was confidential. Completed

questionnaires were returned directly to the researchers.

Some participants were familiar with the researchers distributing

and collecting the questionnaires while others

were not.

Data analysis plan

Quantitative data were analysed with descriptive and inferential

statistics using SPSS for Windows Release, version 18.0,

version (SPSS Inc., Chicago, IL, USA). Preanalysis data

screening was conducted prior to statistical analysis.

Descriptive statistics including frequencies, percentages,

means, standard deviations and correlations were performed

© 2014 John Wiley & Sons Ltd

2772 Journal of Clinical Nursing, 23, 2769-2778

PL Hart et al.

and reported on demographic variables, perceived selfconfidence

and leadership ability scores. Inferential statistics,

including regression analysis, were conducted to determine

the relationship between independent variables (age, years

licensed, certification status and highest nursing degree) and

perceived self-confidence and leadership ability scores. A p

value of ≤0!05 was considered statistically significant.

Results

Sample

From the 500 questionnaires distributed, 148 medical-surgical

nurses completed questionnaires, representing a 29!6%

response rate (Table 1). The majority of nurses were female

(93!2%, n = 138) and Caucasian (70!8%, n = 105). Nurses

ranged in age from 22-63 years (M = 40!8, SD = 10!4) and

over half (65!4%, n = 97) held baccalaureate degrees in

nursing. Years practised as a nurse ranged from 1-41 years

with a mean of 13!8 years (SD = 10!8). Only a third

(32!4%, n = 48) held a national certification. Most of the

nurses worked full time (96!6%, n = 143) during the day

shift (66!9%, n = 99).

Self-confidence

Self-confidence scores ranged from 33-60 with a mean of

52!38 (SD = 6!75), indicating that nurses felt very confident

in handling APD events. Over half of the nurses felt very

confident in recognising signs and symptoms of a respiratory

(64!2%, n = 95) or cardiac (58!8%, n = 87) event

(Table 2). In contrast, only 33!1% (n = 49) felt very confident

in recognising signs and symptoms of a neurological

event, with 24!3% (n = 36) not confident or somewhat

confident. Less than three quarters of the nurses felt very

confident in accurately assessing patients with shortness of

breath (60!8%, n = 90), while just over half (50!7%,

n = 75) felt very confident in accurately assessing patients

with chest pain. Only 40!5% (n = 60) felt very confident in

their ability to accurately assess patients with a mental status

change. Nurses felt more confident (very confident category)

in evaluating the effectiveness of their interventions

when responding to a patient with shortness of breath

(60!1%, n = 89), compared with patients experiencing chest

pain (53!4%, n = 79) or a change in mental status (36!5%,

n = 54).

Reliability of the self-confidence scale was assessed resulting

in a Cronbach's a reliability coefficient of 0!95. The a

score indicated a high degree of internal consistency.

Leadership ability

Leadership ability scores ranged from 10-32 with a mean

of 26!97 (SD = 5!12), indicating that nurses felt moderately

comfortable in their leadership abilities during APD situations.

Only 35!1% (n = 52) were comfortable a great deal

with being identified as a leader until the emergency team

arrived with 19!6% (n = 29) not at all or a little comfortable

with being identified as a leader (Table 3). Less than

half (45!9%, n = 68) of the nurses were comfortable a

great deal in coordinating immediate responders from their

unit. Only half (52!0%, n = 77) were comfortable a great

deal in performing the handover procedure to the emergency

team leader, while 55!4% (n = 82) were comfortable

a great deal in supporting the emergency team leader. Over

half (57!4%, n = 85) felt comfortable a great deal with

sharing information and keeping others informed during an

emergency and voicing concerns to others during an emer-

Table 1 Demographic characteristics of the participants (n = 148)

Characteristic M SD

Age 40!8 10!4

Years practised 13!8 10!8

n %

Gender

Male 10 6!8

Female 138 93!2

Ethnicity/Race

White/Caucasian 105 70!8

Black/African American 26 17!6

Hispanic/Latino 4 2!7

Native American 2 1!4

Asian/Pacific Islander 8 5!4

Other 1 0!7

Missing 2 1!4

Degree

Diploma LPN 2 1!4

Diploma RN 6 4!1

Associate degree 41 27!7

Baccalaureate degree 97 65!4

Master's degree 2 1!4

Employment status

Fulltime 143 96!6

Part-time 3 2

PRN 2 1!4

Primary shift

Day 99 66!9

Night 49 33!1

Certification status

No 100 67!6

Yes 48 32!4

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2769-2778 2773

Original article Acute patient deterioration

gency (52!0%, n = 77), while 62!8% (n = 93) were comfortable

a great deal with listening and responding to others'

concerns during an emergency.

Reliability of the leadership ability questionnaire was

assessed. Cronbach's a reliability coefficient was 0!94. The

a score indicated a high degree of internal consistency.

Relationship between perceived self-confidence and

leadership abilities

A Pearson's correlation coefficient was calculated for the

relationship between participants' perceived self-confidence

and leadership abilities. A moderate, positive correlation

was found (r148 = 0!553, p < 0!001), indicating a

significant linear relationship between the two variables. As

perceived self-confidence increased, perceived leadership

abilities in handling APD events increased.

Regression

To determine the multiple regression model with the best

fit to predict participants' perceived self-confidence and

leadership abilities based on their age, years licensed, highest

nursing degree and certification status (predictor variables),

the researchers in consultation with a statistician

conducted 15 different regression models, which included

all possible combinations of the four predictor variables.

Based on these analyses, age and certification status were

identified as the best variables to predict participants' perceived

self-confidence and leadership abilities. Both regres-

Table 2 Percentages and frequencies of self-confidence scale (n = 148)

Item

Somewhat not confident Somewhat confident Moderately confident Very confident

% (n) %(n) %(n) %(n)

Recognition signs/Symptoms

Cardiac arrest 0!7 (1) 7!4 (11) 33!1 (49) 58!8 (87)

Respiratory event 0!7 (1) 5!4 (8) 29!7 (44) 64!2 (95)

Neurological event 5!4 (8) 18!9 (28) 42!6 (63) 33!1 (49)

Assessment

Chest pain 2!0 (3) 11!5 (17) 35!1 (52) 51!4 (76)

Shortness of breath 1!4 (2) 6!1 (9) 32!4 (48) 60!1 (89)

Mental status change 1!4 (2) 13!5 (20) 43!9 (65) 41!2 (61)

Intervention

Chest pain 1!4 (2) 12!8 (19) 31!1 (46) 54!7 (81)

Shortness of breath 2!0 (3) 3!4 (5) 38!5 (57) 56!1 (83)

Mental status change 3!4 (5) 20!2 (30) 39!9 (59) 36!5 (54)

Evaluate effectiveness

Chest pain 2!0 (3) 11!5 (17) 33!1 (49) 53!4 (79)

Shortness of breath 1!4 (2) 8!1 (12) 30!4 (45) 60!1 (89)

Mental status change 4!1 (6) 15!5 (23) 43!9 (65) 36!5 (54)

The category 'not at all confident' was not added to the table as nurses did not choose this category as a response on the questionnaire.

Table 3 Percentages and frequencies of leadership abilities scale (n = 148)

Item

Not at all A little To some extent A great deal

% (n) %(n) %(n) %(n)

Be identified as a leader 7!4 (11) 12!2 (18) 45!3 (67) 35!1 (52)

Coordinate immediate responders 2!0 (3) 14!3 (21) 37!8 (56) 45!9 (68)

Perform handover to emergency team leader 2!7 (4) 15!6 (23) 29!7 (44) 52!0 (77)

Support emergency team leader 2!0 (3) 12!2 (18) 30!4 (45) 55!4 (82)

Share information and keep others informed 0!0 (0) 8!1 (12) 34!5 (51) 57!4 (85)

Voice concerns to others 2!0 (3) 9!5 (14) 36!5 (54) 52!0 (77)

Listen and respond to others' concerns 1!4 (2) 5!4 (8) 30!4 (45) 62!8 (93)

Use resources and external experts 1!4 (2) 7!4 (11) 34!5 (51) 56!7 (84)

© 2014 John Wiley & Sons Ltd

2774 Journal of Clinical Nursing, 23, 2769-2778

PL Hart et al.

sion models were statistically significant (Table 4). The

first overall model significantly predicted the dependent

variable, self-confidence, R2 = 0!08, R2 adj = 0!07,

F2,139 = 5!948, p = 0!003. This model accounted for 7%

of the variance in the dependent variable, self-confidence.

Review of the b-weights specified that the two predictor

variables, age, b = 0!122, t139 = 2!23, p = 0!027, and certification

status, b = 2!65, t139 = 2!20, p = 0!030, significantly

contributed to the model, with greater age and

having a national certification predicting greater perceived

self-confidence in managing as a first responder in an

acute deterioration event.

The second overall model significantly predicted the

dependent variable, leadership abilities, R2 = 0!10, R2

adj = 0!08, F2,139 = 7!406, p < 0!01. This model accounted

for 8% of the variance in the dependent variable, leadership

ability. Review of the b-weights specified that the two

predictor variables, age, b = 0!108, t139 = 2!66, p = 0!009,

and certification status, b = 2!06, t139 = 2!28, p = 0!024,

significantly contributed to the model, with greater age and

having a national certification predicting greater perceived

leadership ability in managing as a first responder in an

acute deterioration event.

Discussion

In this research study, we aimed to explore and understand

medical-surgical nurses' perceived self-confidence and leadership

abilities as first responders in recognising and

responding to patients experiencing acute deterioration

prior to the arrival of a RRT or CRT. The 148 participants

were typical of nurses working within healthcare organisations

in that the majority was female and Caucasian with

varying years of work experiences (U.S. Department of

Health & Human Services, Health Resources & Services

Administration 2010). A significant, positive, moderate

relationship was found between nurses' perceived self-confidence

and leadership abilities in handling APD events.

Nurses who are more self-confident in handling APD events

felt more comfortable in executing leadership abilities during

APD events. Failure to rescue, or inability to successfully

intervene after complications have developed, affects

cost and mortality/morbidity rates and has been determined

to be the most frequently reported cause of preventable

hospital deaths and intensive care unit (ICU) transfers (Hatler

et al. 2009). Nurses who are more self-confident, execute

leadership abilities and use strong clinical reasoning

skills may impact patient outcomes by identifying early

warning signs of clinical deterioration and by initiating

early interventions to reduce failure to rescue events and

patient mortality (Clarke 2004, Brunt 2005, Bobay et al.

2008).

Nurses in this study were more confident in recognising,

assessing and evaluating the effectiveness of their interventions

with patients experiencing respiratory and cardiac

clinical deterioration, than patients experiencing neurological

clinical deterioration. To our knowledge, this is the first

study that has delineated between various patient types and

nurses' perceived self-confidence in handling patient deterioration

events. This information is significant in aligning best

practice strategies directed at nurses in handling a variety

of APD events. Healthcare organisations routinely focus on

respiratory and cardiac events by educating nurses on cardiopulmonary

resuscitation, but may neglect to educate

nurses on other types of clinical deterioration. Andrews and

Waterman (2005) stress the importance of educating nurses

in the use of a systematic approach for conducting patient

assessments and developing nurses' knowledge of pathophysiology

associated with varying signs of clinical deterioration

to enhance nurses' interpretation of assessment

findings to improve patient outcomes.

In this study, age and certification status were found to

influence nurses' perceived self-confidence and leadership

abilities in handling APD events. Increase in age and

obtaining a national certification were associated with

higher levels of perceived self-confidence and leadership

Table 4 Multiple regression for variables associated with perceived self-confidence and leadership abilities (n = 148)

Regression variables

Self-confidence Leadership ability

B SE B b B SE B b

Age (in years) 0!122 0!054 0!186* 0!108 0!041 0!219**

Certification status 2!65 1!21 0!183* 2!06 0!903 0!188*

R2 0!08 0!10

Adjusted R2 0!07 0!08

F (p-value for model) 5!948 (p = 0!003) 7!406 (p = 0!001)

*p < 0!05, **p < 0!01.

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2769-2778 2775

Original article Acute patient deterioration

abilities. Interestingly, only about 50% or less of nurses

felt comfortable a great deal of the time in being identified

as a leader, coordinating immediate responders from

their unit, performing handover procedures to the emergency

response team, supporting the emergency response

team, sharing information and keeping others informed,

and listening and responding to others' concerns during

an emergency. These findings not only highlight the significance

of experience and certification as important factors

in developing clinical reasoning skills and self-confidence

in nurses, but also identify the impact a lack of self-confidence

and leadership skills may have on patient outcomes.

Patients experiencing clinical deterioration require staff

within a nursing unit to respond promptly and perform in

a coordinated, efficient manner in order to provide the

best opportunity for patient survival (Kilday et al. 2013).

Nurses caring for patients must have self-confidence and

leadership skills to direct other team members in resuscitation

efforts within the first few minutes prior to the

arrival of the RRT or CRT as well as being a proficient

and contributing team member to assist response teams

throughout the resuscitation period.

Limitations

Although the research study was carefully prepared, there

were some limitations. These limitations include the use of

a convenience sample of nurses within a five-hospital integrated

healthcare organisation located in the south-east

United States, which may limit the ability to generalise the

findings to other nurses and geographical locations. Using a

convenience sample may introduce sampling bias; therefore,

caution is warranted when making inferences about the

study findings. Future studies should focus on using random

samples of nurses to further support the study findings.

Additionally, nurses completed the questionnaires during

work hours on their nursing units. This may have allowed

nurses to interact with each other when completing the

questionnaires.

Another limitation was the length of the questionnaires.

This may have resulted in instrument fatigue for some

nurses completing the questionnaires as well as being a

deterrent to recruiting other nurses for the study.

The final limitation was an education intervention that

occurred at one of the five hospitals. The RRT at one of

the hospitals conducted education on acute signs of deterioration

on medical-surgical nursing floors during the data

collection phase. This may have influenced the response

results on the questionnaires by nurses who obtained the

training.

Conclusions

Although nurses felt very confident and comfortable with

leadership abilities, there is a need for improvement to

ensure nurses are competent in recognising patients'

deterioration cues and making sound decisions in taking

appropriate, timely actions to rescue patients. Further

strategies need to be developed to increase nurses' selfconfidence

and execution of leadership abilities in handling

deterioration events for positive patient outcomes.

Medical-surgical nurses are the front-line defence in

assessing and trending patient data for potential indicators

of acute clinical deterioration, and nurses must be knowledgeable

and confident to be leaders in directing and initiating

early interventions to improve patients' survival

during APD events.

Relevance to clinical practice

To ensure best outcomes for patients, healthcare organisations

need to conduct baseline assessments of nurses to

identify areas requiring improvement in assessment skills,

recognition, knowledge, leadership abilities and self-confidence

in clinical deterioration events on a routine basis.

Fox (2007) stated that nurses should abide by the National

Institute of Health and Care Excellence guideline (National

Institute for Health & Clinical Excellence 2007) that recommends

that all nurses have an adequate competency in

assessing and recording physiological signs, interpreting

physiological signs and responding to abnormal physiological

signs promptly and correctly. To achieve this level of

accountability, the development of educational programmes

addressing various types of clinical deterioration scenarios

such as the Acute Life-Threatening Events: Recognition and

Treatment programme (ALERT 2013) needs to be implemented

within healthcare organisations.

Additionally, team training using an evidence-based curriculum,

TeamSTEPPs! (Team Strategies and Tools to

Enhance Performance and Patient Safety) (Agency for

Healthcare Research & Quality 2006), needs to be implemented

to optimise leadership abilities of medical-surgical

nurses prior to the arrival of the RRT or CRT. Furthermore,

team training is needed to enhance medical-surgical

nurses' abilities to communicate effectively and optimise

team performance when working with rapid response and

CRT members. During a clinical deterioration event, medical-

surgical nurses are instrumental in conveying pertinent

information leading up to the deterioration event that

guides the emergency response team in differentiating

causes of the event.

© 2014 John Wiley & Sons Ltd

2776 Journal of Clinical Nursing, 23, 2769-2778

PL Hart et al.

To promote optimal patient outcomes, nurses within

healthcare organisations should be encouraged to obtain

and maintain national certification to increase knowledge

and clinical reasoning skills. Becoming nationally certified

recognises nurses' specialised knowledge, skills and experience

in meeting national standards in promoting optimal

patient outcomes (American Board of Specialty Nursing

2005). Although controversial, some research supports a

link between certification status and improved patient outcomes

(Coleman et al. 2009, Kendall-Gallagher et al. 2011).

Disclosure

The authors have confirmed that all authors meet the

ICMJE criteria for authorship credit (www.icmje.org/

ethical_1author.html), as follows: (1) substantial contributions

to conception and design of, or acquisition of data

or analysis and interpretation of data, (2) drafting the

article or revising it critically for important intellectual

content, and (3) final approval of the version to be

published.

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