As a student you may feel unsure about raising concerns, but doing so could save a life

After a lecture highlighted the number of preventable deaths every year in the UK, it scared me to think I could be involved in the care of a patient whose deteriorating condition I could have spotted earlier.

I was in the second year of my adult nursing degree, and wanted to learn more about how nursing students can help identify and manage patient deterioration. As a result, I carried out some research on the subject, which I then presented at a Health Education England learner engagement event.

What the data reveals about avoidable deaths

Data from the Office for National Statistics show that in 2018, around 22% of all deaths in the UK were considered avoidable. Research from the British Heart Foundation shows that around 30,000 people a year experience an out-of-hospital cardiac arrest in the UK, but just one in ten survive.

Equally alarming is a 2012 report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which found that 38% of in-hospital cardiac arrests in the UK could have been prevented. The report revealed that despite 75% of patients having clear warning signs before cardiac arrest, 56% of those cases were not adequately acted on.

More recently, the latest National Cardiac Arrest Audit shows that of the 12,682 people who had a cardiac arrest in hospital between April 2019 and March 2020 in the UK and Ireland, only 24% survived to discharge.

Students may be first to notice changes in a patient

The Nursing and Midwifery Council (NMC) Standards of Proficiency for registered nurses say that at the point of registration, nurses must be able to ‘demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration… and use this knowledge to make sound clinical decisions’.

‘Even if you lack the clinical experience to know exactly what is wrong with the patient, if you notice changes or feel that something isn’t right, speak up straight away’

Our supernumerary status as nursing students means we are able to spend more time with our patients. We may be the first to notice changes in a patient’s condition, which we can then flag up to registered nurses or other clinicians.

Even if you lack the clinical experience to know exactly what is wrong with the patient, if you notice changes or feel that something isn’t right, it is important to speak up straight away and report any concerns to a more senior member of staff.

We work in busy clinical areas that may be short-staffed, with nurses and other healthcare professionals also under immense pressure due to COVID-19. One way we can support nursing staff in identifying acutely ill patients is by carrying out vital observations and using the National Early Warning Score (NEWS) system.

Assessing the patient

Although NEWS is a useful tool in helping to identify deteriorating patients, it should not be relied on alone, but rather to support your clinical judgement.

The ABCDE approach is a well-established way to carry out patient assessments. It stands for:

• Airway.
• Breathing.
• Circulation.
• Disability.
• Exposure.

The ‘look, listen and feel’ approach relies on using your senses and clinical skills to assess the patient, for example, manually monitoring a patient’s pulse, measuring peripheral capillary refill time, and checking for signs of respiratory distress. Even when we are all extremely busy, a simple patient assessment can be carried out while you are helping patients with personal care, such as washing and dressing.

Establishing a good understanding of the patient’s baseline presentation will also help you detect small changes, and you should familiarise yourself with the patient’s history.

• RELATED: Interactive read: What is ABCDE and why is it important?

Pathways and tools that can help you

NICE pathways cover a huge range of different conditions and are great learning tools for students. The pathways on acutely ill patients in hospital and sepsis can teach us how to recognise deteriorating patients and know when to call for assistance.

A patient’s condition can deteriorate for many reasons, including infection, so you must always ask yourself ‘could it be sepsis?’ The Sepsis Trust has developed a screening and management tool – the Sepsis Six – which sets out the six actions that should be taken within one hour in suspected sepsis cases (see box below).

The trust has adapted the screening tool for a variety of care settings, including general practice and community services, out-of-hours services and acute hospital inpatients.

• RELATED: Use of the ABCDE approach to assess a patient post-operatively: a case study

Putting what I’ve learned into practice

My research into deteriorating patients has helped improve my practice, increasing my confidence in identifying patients who are deteriorating and raising my concerns with more senior staff.

While on placement on a surgical ward, I was concerned about a patient who didn’t seem to be improving after abdominal surgery. He had spent an unusually extended time in recovery, and when he returned to the ward he didn't seem right – his skin was clammy, he was restless and his peripheral oxygen saturation level was 91%.

I reported this to a staff nurse on three separate occasions, but she told me he was being assessed using the chronic respiratory early warning score (CREWS) system – a variant of NEWS for patients with chronic hypoxaemia – and not to worry.

‘If you are having trouble being heard when raising concerns, talk to your practice supervisors or assessor, or another senior member of the nursing team’

However, I was becoming increasingly concerned, and when I spoke to a different nurse, she called the critical care outreach team, who immediately contacted the doctor. The patient’s observation recording system had been changed from NEWS to CREWS, but he didn’t have chronic respiratory disease, so should have stayed on NEWS.

Had I checked the patient’s history, I would have noticed this and been able to raise it as an issue from the start. This taught me a valuable lesson about checking patients’ histories and not just relying on what has been communicated in handover.

Speaking up is scary – but saying nothing could put your patient at risk

The NMC code says we must make the care and safety of patients our main concern. Although it is not easy to speak out, it is important to be brave and prioritise the needs of your patient. Had I not ensured my concerns about the patient were listened to, his condition could have deteriorated further.

As nursing students, the hierarchy within healthcare organisations can feel intimidating and there is also the fear of retribution if we make a mistake. However, I would rather report concerns and be wrong than not tell anyone and put a patient at risk.

• RELATED: Raising concerns: it’s rarely easy, but be brave, because it’s the right thing to do

It is essential that nursing students have a voice and are able to contribute meaningfully to patient care. If you are having trouble being heard when raising concerns, talk to your practice supervisors or assessor, or another senior member of the nursing team. You can also contact your university lecturers for advice and support, and all NHS trusts now have Freedom to Speak up Guardians who you can talk to in confidence.

As students, we have broad experiences across a variety of acute and community settings, with more opportunities to learn about the latest evidence-based interventions across different specialty areas.

Evidence-based practice is the cornerstone of good nursing care, so always use the evidence – this is what gives us a voice.

• RELATED: Could it be sepsis? The question all nursing students should learn to ask

RCNi’s sepsis resource collection

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Fiona Fitch is a third-year adult nursing student at the University of Suffolk