To explore and describe nurses’ assessment and management decisions to recognize and respond to patient deterioration not meeting rapid response system (RRS) activation criteria.

Nurses’ decision-making in response to deterioration that meets RRS activation criteria is well documented. RRSs are activated when deterioration meets pre-defined criteria or from clinicians’ concern, escalating care to teams of suitably qualified clinicians. Most deterioration is expected from illness and treatment and is managed within nurses’ clinical role. Safe healthcare relies on nurses’ surveillance for patient changes to prevent deterioration progressing towards RRS activation criteria. Evidence does not examine nurses’ safety role in response to expected deterioration occurring from acute illness and treatment. Studies examining nurses’ decision making in response to patient changes have limitations in designs that rely on self-report and retrospective audits.

Informed by Tanner’s Clinical Judgment Model, a qualitative descriptive study was conducted using non-participant observations of nurse-patient interactions followed by semistructured interviews between January and May 2021. Twenty nurses participated. Verbatim transcripts were analyzed using reflexive thematic analysis. First, nurses make targeted assessment decisions based on their prediction of patients’ risk of deterioration. Second, subjective assessment was perceived by nurses as highly sensitive in identifying early signs of deterioration. Third, nurses’ concern for patients prompted further assessment to inform safety-related judgments.

This study reaffirms nurses’ essential safety role for patients who experience deterioration during their hospitalization. Further research should evaluate nurses’ concern and subjective assessment to recognize deterioration to contribute to the evidence-based approach to patient assessment.

Nurse

Acute care

Decision making

Deterioration

Patient assessment

Clinical judgment

© 2025 The Authors. Published by Elsevier Inc.