Silent Surveillance: Neonatal Nurses’ Recognition, Interpretation and Escalation of Early Clinical Deterioration-An Interpretive Description Study

AI Summary

Nurses detect subtle deviations from an infant's baseline before monitors, relying on clinical expertise and situation awareness.
Escalation requires building a credible case: testing signs, collecting evidence and legitimising concern prior to contacting physicians.
Organisational factors, including hierarchy, alarm burden, documentation and staffing variability, constrain surveillance and shape escalation decisions.

AI Summary

AIM: To explore how neonatal nurses in Level III (high-acuity) neonatal intensive care units recognise, interpret, and escalate early signs of clinical deterioration.

RESULTS: Four interrelated themes were identified: (1) 'the infant tells you before the monitor does', reflecting recognition of subtle deviation from the infant's baseline; (2) 'building the case', in which nurses tested and assembled evidence to make concern clinically credible before escalation; (3) 'the escalation calculus', describing how anticipated physician responses, hierarchy and previous dismissal shaped escalation and (4) 'the unit works against you', showing how alarm burden, documentation demands and staffing variability constrained vigilance.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Neonatal services should protect surveillance capacity through staffing and workload design, alarm reduction, simulation of ambiguous deterioration and constructive escalation feedback.

Basic summary

J Clin Nurs. 2026 Aug 5. doi: 10.1111/jocn.70492. Online ahead of print.

ABSTRACT

AIM: To explore how neonatal nurses in Level III (high-acuity) neonatal intensive care units recognise, interpret, and escalate early signs of clinical deterioration.

DESIGN: A qualitative interpretive description study underpinned by critical realism.

METHODS: Twenty-two registered nurses were purposively recruited from four Level III units in the Jouf Region of northern Saudi Arabia using criterion-based maximum-variation sampling. Semi-structured interviews were conducted in Arabic or English and analysed in their original language. Situation awareness and invisible work scholarship served as sensitising lenses. Rigour was supported through member reflection, negative-case analysis, peer debriefing and an audit trail.

RESULTS: Four interrelated themes were identified: (1) ‘the infant tells you before the monitor does’, reflecting recognition of subtle deviation from the infant’s baseline; (2) ‘building the case’, in which nurses tested and assembled evidence to make concern clinically credible before escalation; (3) ‘the escalation calculus’, describing how anticipated physician responses, hierarchy and previous dismissal shaped escalation and (4) ‘the unit works against you’, showing how alarm burden, documentation demands and staffing variability constrained vigilance. Recognition and escalation formed a cyclical, organisationally situated process rather than a single response to abnormal observations.

CONCLUSION: Escalation involved interpretive, relational and legitimising work before early concern became actionable. Participants’ accounts suggest that timely response depends on clinical expertise and environments that protect bedside attention and legitimise early escalation.

IMPACT: The study identifies case-building as a distinct stage between noticing deterioration and escalating concern and indicates how organisational conditions may constrain early nursing surveillance.

REPORTING METHOD: Consolidated Criteria for Reporting Qualitative Research.

NO PATIENT OR PUBLIC CONTRIBUTION: Patients and the public were not involved.

PMID:42554095 | DOI:10.1111/jocn.70492

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