Identifying patient deterioration: Using simulation and reflective interviewing to examine decision making skills in a rural hospital Ruth Endacott a,b, *, Julie Scholes c , Simon Cooper b , Tracy McConnell-Henry b , Jo Porter b , Karen Missen b , Leigh Kinsman d , Robert Champion e a Faculty of Health, Drake Circus, Plymouth PL4 8AA, UK b Monash University, School of Nursing (Gippsland), Churchill, Victoria 3842, Australia c Centre for Nursing and Midwifery Research, University of Brighton, Village Way, Falmer, Brighton BN1 9PH, UK d School of Rural Health, Monash University, P.O. Box 666, Bendigo, Victoria 3552, Australia e Department of Mathematics and Statistics, La Trobe University, P.O. Box 199, Bendigo, Victoria 3552, Australia What is already known about the topic?  Patients continue to deteriorate on acute medical and surgical wards, despite extensive work to improve early identification of disordered vital signs. Ward culture has been identified as an important component of clinical decision making for deteriorating patients.  Rural hospitals in Australia manage high acuity patients less frequently than metropolitan hospitals yet clinicians in these settings have to manage patients with fewer critical care resources.  Early identification and timely patient management have been demonstrated to improve patient outcomes. What this paper adds  Participants (Registered Nurses) in a single ward setting demonstrated widely different decision making International Journal of Nursing Studies 49 (2012) 710–717 A R T I C L E I N F O Article history: Received 28 June 2011 Received in revised form 27 November 2011 Accepted 28 November 2011 Keywords: Decision making Rural hospitals Safety management Nursing A B S T R A C T Objectives: The study aim was to examine how Registered Nurses identify and respond to deteriorating patients during in-hospital simulation exercises. Design: Mixed methods study using simulated actors. Setting: A rural hospital in Victoria, Australia. Participants: Thirty-four Registered Nurses each completed two simulation exercises. Methods: Data were obtained from the following sources: (a) Objective Structured Clinical Examination (OSCE) rating to assess performance of Registered Nurses during two simulation exercises (chest pain and respiratory distress); (b) video footage of the simulation exercises; (c) reflective interview during participants’ review of video footage. Qualitative thematic analysis of video and interview data was undertaken. Results: Themes generated from the data were: (1) exhausting autonomous decision- making; (2) misinterpreting the evidence; (3) conditioned response; and (4) missed cues. Assessment steps were more likely to be omitted in the chest pain simulation, for which there was a hospital protocol in place. Conclusions: Video review revealed additional insights into nurses’ decision-making that were not evident from OSCE scoring alone. Feedback during video review was a highly valued component of the simulation exercises. ß 2011 Elsevier Ltd. All rights reserved. * Corresponding author at: Monash University, School of Nursing (Gippsland), Churchill, Victoria 3842, Australia. E-mail addresses: ruth.endacott@plymouth.ac.uk, ruth.endacott@monash.edu (R. Endacott), J.Scholes@brighton.ac.uk (J. Scholes), simon.j.cooper@monash.edu.au (S. Cooper), tracy.mcconnell-henry@monash.edu.au (T. McConnell-Henry), Joanne.porter@monash.edu (J. Porter), Karen.Missen@monash.edu (K. Missen), Leigh.Kinsman@monash.edu (L. Kinsman), R.champion@latrobe.edu.au (R. Champion). Contents lists available at SciVerse ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.11.018