Journal of Pediatric Nursing 66 (2022) e67–e73

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Journal of Pediatric Nursing

journal homepage: www.pediatricnursing.org

Beyond objective measurements: Danish nurses' identification

of hospitalized pediatric patients at risk of clinical
deterioration – A qualitative study
Josefine Tang Rørbech, MScN, RN a,⁎, Claus Sixtus Jensen, PhD, MHSc(Nurs), RN a,b,c,
Pia Dreyer, Professor, MScN., Ph.D. d, Sine Maria Herholdt-Lomholdt, Master in Educational Studies, Ph.d. e
a
Department of Paediatrics and Adolescent Medicine, Unit for Research and Development in Nursing for Children and Young People, Aarhus University Hospital,
Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
b
Research Centre for Emergency Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
c
Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
d
Professor in clinical nursing, Intensive care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
e
Faculty of Nursing and Health Sciences, Nord University, Universitetsalleen 11, 8026 Bodø, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: While the use of Pediatric Track and Trigger Tools as a standard to discriminate high level of urgency in
Received 23 November 2021 pediatric care has received considerable attention, less focus has been given to other important factors such as
Revised 15 May 2022 nurses' clinical observations and judgement. The purpose of this study was to explore nurses' observational prac-
Accepted 22 May 2022 tice and focus on which non-measurable signs and symptoms nurses find important when identifying inpatient
pediatric patients at risk of clinical deterioration.
Keywords:
Design and methods: This was an inductive qualitative study based on an interpretive description methodology.
Clinical deterioration
Pediatric track and trigger tools
Data were obtained through participant observation of experienced nurses working in a Danish pediatric unit
nurses' identification and focus group interviews with pediatric nurses. Field notes were taken, and focus group interviews were
Sign and symptoms audio taped and transcribed. A thematic text condensation method was used to analyse data.
Results: Findings revealed the following four main themes of non-measurable signs and symptoms that nurses
find important when identifying children at risk of clinical deterioration: Colour and skin tone; sounds; movement
patterns; behavioural signs.
Conclusions: This study suggest that pediatric patients show signs and symptoms that go beyond the objective
measurements integrated in Pediatric Track and Trigger Tools and they should not be ignored as they are highly
valuable to nurses who are responsible for observing inpatient pediatric patients at risk of clinical deterioration.
Implications: More empirical research on nurses' observational practice is recommended, especially research to
identify the signs and symptoms - both measurable and non-measurable – that are significant to nurses at the
bedside.
© 2022 Elsevier Inc. All rights reserved.

Introduction
Pediatric patients are often hospitalized with conditions that may
potentially deteriorate and become life-threatening if not identified in
⁎ Corresponding author at: Unit for Research and Development in Nursing for Children
and Young People, Department of Paediatrics and Adolescent Medicine, Aarhus University
Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
E-mail addresses: Josefine.tang.rorbech@rm.dk (J.T. Rørbech),
claus.sixtus@skejby.rm.dk (C.S. Jensen), piadreye@rm.dk (P. Dreyer),
sine.m.herholt-lomholdt@nord.no (S.M. Herholdt-Lomholdt).
a timely manner and correctly managed (Stotts et al., 2020). Early iden-
tification and treatment of the deteriorating condition of pediatric pa-
tients is highly important to their prognosis and survival (Hayden
et al., 2009). Although cardiopulmonary arrest is relatively rare among
inpatient children, only 15%–33% survive resuscitation. Among those
who do survive, approximately 35% experience poor neurological out-
comes (Jensen et al., 2019; Lambert et al., 2017; Robson et al., 2013). It
is therefore imperative to observe, identify, interpret and respond ap-
propriately to signs and symptoms of clinical deterioration. Within the
pediatric population, this is particularly challenging due to unique
age-specific physiological response patterns to illness and the children's

https://doi.org/10.1016/j.pedn.2022.05.016
0882-5963/© 2022 Elsevier Inc. All rights reserved.
J.T. Rørbech, C.S. Jensen, P. Dreyer et al.
predisposition to drastic and sudden deterioration(Mecham, 2006;
Murray et al., 2015).
Pediatric Track and Trigger Tools (PTTT) are widely used assessment
tools developed to support healthcare professionals in identifying pedi-
atric patients at risk of clinical deterioration through objective determi-
nation of the patient's clinical status (Chapman et al., 2016). A great
variety of PTTTs exist. Most PTTTs are based on systematic recording
of vital signs, which are then aggregated to form a weighted score. If
the measured values deviate from age-specific normal threshold, a
PTTT triggers a predetermined clinical intervention to prevent further
decline (Trubey et al., 2019). This process does not reflect the compli-
cated process required to identify hospitalized children at risk of clinical
deterioration(Lambert et al., 2017). Even though PTTTs are well estab-
lished in most healthcare settings, failure to recognise serious clinical
deterioration among hospitalized pediatric patients remains a signifi-
cant cause of unintended harm in healthcare (Carter, 2015; Pearson
et al., 2011; Teheux et al., 2019; Wolfe et al., 2014).
Nurses have the closest and most frequent contact with hospitalized
children and their families. Since they are typically the healthcare pro-
fessionals who first detect deterioration, their role is crucial(Massey
et al., 2017; Zachariasse et al., 2017). Nurses are responsible for syste-
matically performing routine measurements and for following the man-
datory algorithm linked to the PTTT, but poor adherence is an ongoing
issue (Almblad et al., 2018; Bunkenborg et al., 2016; Jensen et al.,
2018). Studies show that nurses do not always find the PTTT meaningful
and using PTTT has become more of a routine task which may impede
nursing clinical judgement and critical reflections (Cassidy et al., 2019;
Watson et al., 2014). Rather than performing routine measurements,
nurses place great emphasis on what they see, hear, smell and feel dur-
ing patient-centred care. This form of sensory observation allows nurses
to identify and respond to subtle cues and gradual qualitative changes
heralding a worsening of a patient's condition (Bowen et al., 2017;
Cioffi, 2000; Gawronski et al., 2018; Jensen et al., 2018). Such sensory
observation is highly dependent on decision-making skills, knowledge
and experience. In both the theoretical and empirical literature, sensory
observation is associated with a great variety of concepts such as clinical
judgement (Benner & Tanner, 1987), situational awareness (Endsley,
1995), tacit knowledge, intuition or gut feeling (Hams, 2000; Melin-
Johansson et al., 2017). In both pediatric and adult populations, these
concepts are considered to be among the primary factors in promoting
timely identification of clinical deterioration (Bonafide et al., 2013;
Douw et al., 2015; Raymond et al., 2019; Romero-Brufau et al., 2019).
While concerns have been raised that vital signs alone are inade-
quate to discriminate high levels of urgency in pediatric care (Hansen
et al., 2017; Lambert et al., 2017; Teheux et al., 2019; Trubey et al.,
2019), studies specifically request a way to integrate nurses' clinical ob-
servations with PTTTs in order to optimise the effects of PTTTs and im-
prove patient safety (Bonafide et al., 2013; Lambert et al., 2017;
Parshuram et al., 2018; Roland, 2013).Within surgical adult patients,
Douw et al. (2017) documented that nurses' awareness is triggered by
specific signs and symptoms prior to vital sign derangement. Douw
et al. systematically identified these signs and added them to an Early
Warning Score. This facilitated earlier recognition of clinical deteriora-
tion and improved patient outcome (Douw et al., 2015, 2016, 2018). De-
spite the obvious potential for improving care at an early stage of
deterioration, this potential has not yet been investigated within pediat-
rics. This is supported by a review that did not found any studies de-
scribing pediatric nurses' observational practice in the hours leading
up to clinical deterioration (Stotts et al., 2020). Furthermore, a recent
scoping review found that no study has specifically explored what
signs and symptoms - apart from vital signs - nurses use to identify chil-
dren at risk of clinical deterioration (Jensen et al., 2020, 2021). Thus, it
remains unknown what “non-measurable” signs and symptoms influ-
ence nurses' ability to recognise and respond to pediatric patients at
risk of deterioration at the bedside. Therefore, we find it important to
explore these non-measurable signs and symptoms and their
68
Journal of Pediatric Nursing 66 (2022) e67–e73
characteristics to enhance our understanding of how nurses identify pe-
diatric patients at risk of deterioration and hence improve nurses' obser-
vational practice and potentially improve patient outcomes (Odell et al.,
2009).
Aim
The aim was to explore nurses' observational practice and answer
the following research question: “Which non-measurable signs and
symptoms do nurses find important when identifying hospitalized pe-
diatric patients at risk of clinical deterioration?”
Design
This qualitative study had an exploratory and inductive approach in
accordance with the interpretive description (ID) methodology(Thorne,
2016).
Methods
Sample and participants
The study was conducted in two pediatric units at a Danish Univer-
sity Hospital. The units serve hospitalized patients from 0 to 18 years of
age with various diagnoses and clinical issues. No specific age or diag-
nostic groups were excluded as the participating nurses care for all pe-
diatric patients regardless of their age and illness. Through purposive
sampling, eight experienced nurses were recruited for participation
(Thorne, 2016). To explore their observational practice from different
angles thereby creating enriched data, a combination of two data
sources was chosen (Thorne, 2016; Thorne et al., 1997). Firstly, during
four days of fieldwork, participant observation was conducted. Sec-
ondly, two focus groups with experienced pediatric nurses were con-
ducted. For recruitment to the observation study, the participants
were contacted directly by members of the research team. For recruit-
ment to the focus group interviews, an invitation was placed in the
units' offices, and the head nurse mailed an invitation to all nurses
working in the units. As an inclusion criterion, the participants must
have experienced situations with deteriorating children. This require-
ment was highlighted in the invitation. Two of the nurses participated
in both the observational study and the focus group interviews. The
data material was collected from February to March 2020 by the first
and second authors. The demographic characteristics of the participants
are presented in Table 1.
Data collection
Participant observation
The first author made the observations. The observation sessions
lasted an average of four hours each and covered both day and night
shifts. In total, 16 h of observations were conducted. The aim was to ex-
plore nurses' observational practice in its natural context, including
their observations and patient-centred actions. The observations mainly
included specific care situations during which the nurses interacted
with hospitalized children and their relatives. The researcher had lim-
ited participation in the care and mostly engaged in unobtrusive obser-
vation from the back of the room. After having observed care situations,
informal dialogues with the participating nurses were conducted in a
private office in order to gain deeper insights and capture the nurses'
immediate reflections about the observed care situation as advised by
Roper & Saphira, 2000. Short impression notes were written down
along the way and field notes were written immediately after each ob-
servation day concluded. The field notes captured the researcher's ob-
servations along with incipient analytical reflections and personal
impressions arising during the observation sessions (Roper & Saphira,
2000).
J.T. Rørbech, C.S. Jensen, P. Dreyer et al.
Table 1
Demographic characteristics.
Total number of participants Years of nursing experience range (mean)
Observation Day 1–4 4 12–31 (20.5)
Focus Group 1 2 12–16 (14.0)
Focus Group 2 4 10–31 (20.5)
Focus group interviews
Focus group interviews were conducted to explore the participants'
shared perspectives and understandings, but also to inspire participants
to discuss different views on the same clinical topic (Morgan, 1997). The
goal was to extract as many different experiences and perceptions with
deteriorating children as possible. The setting was a meeting room lo-
cated near the units. A case describing a situation with a deteriorating
child was read out to catalyse discussion. The first author facilitated
the focus group using a semi-structured focus group guide (see
Table 2). The second author served as moderator but was located in
the background noting nonverbal and contextual details. At the end of
each interview, the moderator made a summary to ensure an overall
common understanding and agreement on the participants' statements
on the subject. The focus group interviews, each lasting approximately
one hour, were digitally audio recorded and transcribed verbatim.
Data analysis
After verbatim transcription of the focus group interviews, the tran-
scriptions were joined with the transcripts of the fieldnotes. A total of 36
full text pages constituted the data material. The data were analysed as
one coherent text in which the two datasets complemented and supple-
mented each other. In accordance with the analytic recommendations
associated with the ID methodology (Thorne et al., 2004), a systematic
thematic text condensation method was used to analyse the data
(Malterud, 2012). To condense textual data to create a coherent and
meaningful interpretation, the analysis method consisted of interpret-
ing the comparability and interrelationships of the overall data, devel-
oping initial codes for tagging meaning units and categories and
finally proposing saturated themes (Thorne, 2016).
Ethical considerations
Under Danish law, this qualitative research design required no for-
mal approval from the National Committee on Health Research Ethics.
The ethical principles recommended in the Declaration of Helsinki
were followed (WMA, 2013). All participants were informed in writing
and orally about the purpose of the study. Anonymity was ensured and
the participants were free to withdraw from the study at any time. The
Table 2
Focus group interview guide.
Introduction and welcome
The case is read aloud to catalyse discussion. “Please tell us about a similar
situation where you were concerned for your patient despite normal vital
parameters”.
Note what the participants find interesting and take this as a starting point.
If the discussion dies or does not flow, these examples questions may help to
prompt reflections:
• What do you think when you hear the word clinical deterioration?
• How do you identify whether a child is at risk of clinical deterioration?
• Which signs and symptoms can cause you to worry for an inpatient child?
• Please describe the characteristics of the signs and symptoms you highlighted.
• In which situations do you find it difficult to identify a deteriorating child?
• Can you describe the impression you get of the child when you become aware
that the child is at risk of becoming acutely ill?
Summary of the discussions by the co-moderator, including anything we need to
discuss further or have forgotten.
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Journal of Pediatric Nursing 66 (2022) e67–e73
Years of pediatric nurse experience range (mean) Gender
12–25 (18.5) Female
12–15 (13.5) Female
10–25 (18.25) Female
children and their relatives who were present during the observational
study were informed verbally and asked if they would be willing to par-
ticipate before the researcher entered the hospital room. The study
complied with the data regulations in Danish data law.
Validity, reliability and rigour
The combination of two data collection methods was used to
strengthen trustworthiness. The data generated through observations
was congruent with the data generated through focus group interviews
with clear similarities between the two data sets. The focus group ended
with a summing up of the main topics, and the participating nurses con-
firmed their interpretations of what has been said. The analysis was per-
formed by the first and last author, and a critical reflection and
interpretation of data was repeated several times to enhance the credi-
bility of the findings.
Findings
Hospitalized pediatric patients each have their own individual and
unique way of presenting signs and symptoms indicating potential clin-
ical deterioration. Findings revealed a wealth of nuances in the way the
signs and symptoms manifest in each patient and how nurses perceive
and describe them. The signs and symptoms reflect both physiological,
cognitive and behavioural clinical manifestations, and are interwoven
and have an effect on each other. Although a situation with clustering
signs and symptoms was prominent, in some situations the nurses
were alerted just by a single sign. Typically, their attention was triggered
by changes in the child's condition that were evident owing to a close re-
lation and frequent contact between the nurse and the child. If changes
in the state of disease were not observed, nurses described the signs and
symptoms as abnormalities in which the child's appearance differed
from the nurses' perception of an expected pattern of symptoms. A per-
vading element in the findings was the nurses' difficulties verbalising
and explaining the characteristics of the signs and symptoms, which
often resulted in unclear descriptions. Despite these linguistic limita-
tions, findings revealed the following four main themes of non-
measurable signs and symptoms that nurses find important when iden-
tifying children who are at risk of clinical deterioration: Colour and skin
tone; sounds; movement patterns and behaviour.
The Child's skin and colour
The child's colour and skin tone emerged as an important sign when
identifying children at risk of clinical deterioration. According to the
nurses, the colour assumes a different hue and apperance when the
child's condition worsens. It is not just a question of whether the child
becomes pale or cyanotic, which are two of the more well-known
signs of, e.g., circulatory decompensation. These signs and symptoms
described by the nurses, have a more non-specific and subtle character.
One participant described how the appearance of the child's skin trig-
gered her awareness of the child's condition:
“Like yellowish, greyish. Which the child may well be, although the cap-
illary response is normal... Or a glossy surface”. (FG1)
The child's skin texture and elasticity are also highlighted as impor-
tant. One nurse used the term “gloss” to describe the surface of the skin,
whereas another nurse used the term “wax pale” about a child with
impending circulatory collapse. The temperature of the patient's skin
J.T. Rørbech, C.S. Jensen, P. Dreyer et al.
was also important for the nurses to notice. Mostly, hands and feet were
mentioned, i.e. peripheral bodily areas, as areas that were important to
be aware of. To obtain a sense of colour, skin tone and temperature,
nurses would have to touch the child's skin. The feedback the nurses
get, from touching the child's skin was important in their assessments.
This tactile way of observing was evident during the fieldwork where
the nurses constantly sought to feel the child rather than observing
the child from a distance. It was a consistent finding that the nurses
were able to assess a child's clinical status if they touched it and prefer-
ably held the child (small children).
“I have a rule for myself - if it is a small child. I MUST feel it. I WANT it in
my hands. I'm not sure I'm going to wake the baby. They may be allowed to
sleep a little. But, then, they have to call when she needs to be changed. Be-
cause I WANT to hold her in my hands. Because I can feel. I can feel about a
child. A little child. Now we are talking maybe a child up to 2 years. I can
simply feel. It may well be that it's a claim, and probably I do not always
do it either, but I can simply feel. I imagine that when I get it in my hands,
I can feel if it's okay. So, this is a sick child. We are part of that. And it's in
the hospital. But is it an okay child? I use this a lot”. (FG1)
The child's sounds
The sound of the child was found to be an important sign of clinical
deterioration. Often sounds were related to highlighted respiratory
mechanisms, but silence could also be a warning sign. One nurse ex-
plained how a child hospitalized with asthma may sound “free” and ap-
pear clinically unaffected, but the respiratory sound indicates a
potentially deteriorating condition. Again, this was prominent with
young, preverbal children. Many variations were highlighted, ranging
from the child being quiet or making small whimpers through to
screaming. Particularly changes in the way the child cried, e.g., when
the child was going from crying to whining. A nurse described how a
change in children's way of crying warns her:
“The way they whine. The way they cry. That really changes, too. Grad-
ually, you learn to hear when a child is crying. Not because they want the
pacifier, but because…”. (FG2)
The importance of knowing the child was highlighted as a prerequi-
site for nurses to get a grasp of the child and establish their baseline in
order to be able to recognise and react to subtle changes in the child's
condition. Knowing the child and how the specific child usually re-
sponds and acts not only relates to changes in sounds but is central to
observing all qualitative differences and changes.
The child's movement pattern and tonus
Movements patterns and tonus are important signs when identify-
ing inpatient children at risk of deterioration. The child's bodily form
of expression relates to the way the body acts and reacts when their
condition is deteriorating. It is not just movement patterns or body po-
sition, but also body tonus and posture. Describing and observing spe-
cific movements was a difficult task because many of the non-
measurable signs related to movement patterns that only became evi-
dent when the child was stimulated to move. This was often noticed
during observations. Very often, nurses would stimulate the child to
move through holding to touching the child. When using technical mea-
surement equipment, nurses illustrated a proactive observational prac-
tice of seeking to access non-measurable and non-specific signs and
symptoms, in order to get a sense of the child's clinical status.
“Then you can notice if they move naturally during sleep. How do they
react when touched? It's also a feeling, I think. How is an infant? It sleeps so
peacefully...it could also be unconscious”. (FG2)
Again, touching the child was particularly important for the nurses'
ability to assess the clinical condition, especially with small children. A
pervasive finding was that nurses consistently reported how holding a
small child close to them was key to their assessment. By holding the
child, the child's tone and posture could be felt which allowed the
70
Journal of Pediatric Nursing 66 (2022) e67–e73
nurses to perceive the child's clinical condition. A nurse described how
she uses close bodily contact to the child, thereby helping her build an
impression of the child's condition:
“It is the way they hold their own body. The way the child feels when
you lift such a child up. The way the child can help to be undressed ... Just
holding the child. Just to be with it. If you hold it in your arms, the way
they fall into your own body. If they sit or the way they maintain their pos-
ture. It is very much their tone. I think it is very much about their tone…”.
(FG2)
The childs responsiveness and behavioural signs
This theme pertains to the way children express themselves and
their ability to engage with people. The nurses emphasized that when
assessing children's condition, it is particularly important to consider
their way of being. One important behavioural aspect is observing the
child's ability to interact and communicate with their family and care
providers. To make proper observations on behavioural signs, it is es-
sential that the nurse is familiar with the child's natural character in
order to be aware of changes that may occur in the child's clinical con-
dition. The nurses describes how deteriorating children can withdraw
from contact; disappering into their own inner world and refuse inter-
action with the nurse.
One nurse explained how a child's way of expression manifests itself
in a situation where the child is deteriorating due to a respiratory infec-
tion. She further described how the sick child whom she cared for be-
came less responsive to social contact; the child seems to shut itself
off from its surroundings.Upon observing this behavioural change, she
decided to remain with the child and initiate interventions to prevent
complete respiratory failure:
“It was something in the child's expression. It was something in his pres-
ence. It was something with the experience, the feeling that he was increas-
ingly unstable. It was the expression, the contact. Not that he was lethargic
and limp. He was there. But it was clearly my feeling that he was slipping
further towards the edge despite normal vital signs”.(FG2)
Behavioural signs and symptoms are described in various ways and
they often cluster with other clinical signs. According to the nurses,
these behavioural signs also reflect the child's degree of sensitivity and
responsiveness to its surrondings. For example, if the nurse observes
that a child has a strong reaction to a physical touch, this reflects the
child's mental condition of being overwhelmed. Being physically close
and in proximity with a child is needed for these signs and symptoms
to be apparent. For examble, holding the child against the nurse's
body was instrumental in detecting the child's behavioural signs and
symptoms.This requirement was confirmed in the field observations,
where it was evident that the nurses performed tactile and psysical ob-
servations of the child in order to be able to assess the non-measurable
signs and symptoms of potential clinical deterioration.
Discussion
To our knowledge, this is the first study that has specifically explored
which non-measurable signs and symptoms nurses report using to
identify pediatric patients at risk of clinical deterioration. The findings
are highly relevant for clinical practice because they illustrate some of
the key clinical characteristics on which nurses rely heavily when de-
tecting deterioration, and emphasise the importance, not just of mea-
suring vital signs, but of being sensitive to other types of changes and
abnormalities in the clinical and bodily status of pediatric patients. We
found that non-measurable signs and symptoms that relate to colour
and skin tone, sounds, movements pattern and behaviour are used by
nurses to identify hospitalized children at risk of clinical deterioration.
Interestingly, the findings of this study revealed new perspectives on
how pediatric nurses' observational practice is performed. Thus, we
found that to gain awareness of the non-measurable signs and symp-
toms, nurses performed an observational practice striving for a sensory
J.T. Rørbech, C.S. Jensen, P. Dreyer et al.
impression not solely obtained from visual perception and observation
from a distance. The observational practice performed by nurses in-
cluded sensory stimulation. When observing the children, they per-
formed proactive observations taking an embodied and tactile
approach e.g. by touching or holding the child. By stimulating the
child to move and respond, the nurses created ways to access many of
the non-measurable signs and symptoms indicating potential deteriora-
tion. These embodied observational skills where nurses used a judge-
ment touch were pervasive and found to be their preferred way of
performing observations.
Nurses' observations and clinical impressions have been explored in
some studies in relation to early identification of clinical deterioration
in pediatric patients (Bowen et al., 2017; Gawronski et al., 2018;
Zachariasse et al., 2017). However, how the observational practice is
performed by nurses seem relatively unexplored. This is supported by
a recent review that documented that no study has yet described spe-
cific actions and interventions by pediatric nurses when interacting
with deteriorating patients (Stotts et al., 2020). Since PTTT were intro-
duced, a strong focus has been on implementation and application of
PTTT as a standard in clinical practice (Bonafide et al., 2013; Teheux
et al., 2019). This focus may have hampered empirical explorations of
nurses'observations when identifying deteriorating children, resulting
in a rudimentary understanding of observational nursing practice
within the field of pediatrics (Draper, 2014).
This study adds to the literature that emphasises that performing ob-
servations and identifying deterioration is much more than relying on a
score. Thus, following the standard protocol is insufficient to ensure the
quality of patient safety in care (Lambert et al., 2017; Odell et al., 2009;
Watson et al., 2014). One explanation is that children's physiological re-
sponses to disease are dynamic and complex. A particularly important
physiological mechanism is children's ability to compensate for serious
conditions, which means that the trend of the patient's condition may
change rapidly (Mecham, 2003).This is illustrated in the results by the
nurse who explained how, despite recording normal vital signs, a
child was deteriorating. These “false negative” scores are not a rare phe-
nomenon. Similar situations were documented by Bowen et al. (2017)
and Jensen et al. (2018) and exemplify the importance of proactively
observing and reacting to the presence of signs and symptoms not evi-
dent in the PTTTs. In addition, vital signs are often affected by factors
such as crying, fever and anxiety (Hansen et al., 2017). Therefore, phys-
iological signs and symptoms in pediatrics must always be interpreted
in context (Roland, 2013; Roland & Snelson, 2019).
In addition to the fact that PTTT do not distinguish between diagno-
sis and unique patient characteristics, PTTT also do not leave much room
for nurses' individual clinical judgement. As this study showed, nurses'
subjective clinical judgement plays an important role in their early
problem identification process, as they are constantly sensing and per-
ceiving the child's non-measurable signs and symptoms. Studies have
stressed the need for clinical judgement and PTTT to complement one
another, with PTTT assisting but not replacing clinical judgement
(Brady & Goldenhar, n.d.; Bonafide et al., 2013; Cassidy et al., 2019;
Lambert et al., 2017 ; Murray et al., 2015). Since 2005, when the first
PTTT was introduced by Monaghan (2005) the PTTT has become an in-
tegrated part of everyday clinical practice (Chapman et al., 2016). De-
spite, uncertainties about the PTTTs effects on reducing mortality
among hospitalized pediatric patients (Parshuram et al., 2011, 2018;
Trubey et al., 2019), research has shown that the use of PTTTs has
clear benefits in clinical practice (Kaul et al., 2014). Studies argue that
PTTTs should not serve as a prediction tool to reduce mortality, but as
a communicative framework offering a precise and professional lan-
guage; used in this way, the PTTT helps voice nurses' concerns
(Andrews & Waterman, 2005; Jensen et al., 2018).
This study's findings revealed that some signs and symptoms are
characterized by being indefinable, nuanced and subtle. The partici-
pants were clearly having difficulties describing the characteristics of
the non-measurable signs and symptoms. In some cases, they related
71
Journal of Pediatric Nursing 66 (2022) e67–e73
these signs to an intuitive feeling or a gut feeling that something was
wrong with the child, even though no measurable vital signs supported
that impression. This finding is echoed in other studies where nurses'
clinical judgement and intuition are highlighted as important elements
in the ability to identify children whose condition worsen during hospi-
talization (Lambert et al., 2017; Murray et al., 2015). Clearly, signs and
symptoms not incorporated into PTTT are working as strong indicators
for nurses because they alert nurses of whether the child's clinical con-
dition is deteriorating (Bowen et al., 2017; Gawronski et al., 2018;
Jensen et al., 2018).
Even though various perspectives on the concept of intuition have
been presented in previous literature, intuition is believed to be an es-
sential component of clinical judgement (Hams, 2000; Melin-
Johansson et al., 2017). According to Benner and Tanner (1987), intui-
tion is often present when operating in subtleties, where situations
are characteristically uncertain and very often in critical situations
where time to analyse and deliberate information is limited (Benner &
Tanner, 1987). Often, this immediate sense that something is wrong
without having a specific answer to what, is referred to as a “gut feeling”
(Hams, 2000; Lise Holm & Severinsson, 2016). Apparently, intuition is
much more than just a gut feeling, as intuition is identified as a strong
indicator in early recognition of inpatient clinical deterioration (Douw
et al., 2016; Odell et al., 2009; Romero-Brufau et al., 2019; Teheux
et al., 2019). However, in opposition to rational and concrete calcula-
tions, intuition is often devalued and disbelieved due to lack of concrete
evidence (Andrews & Waterman, 2005; Hams, 2000). Unfortunately,
the use of intuition may be suppressed in clinical settings, as research
indicates that nurses fear criticism for escalating care without having
concrete evidence (Stotts et al., 2020). One explanation is that intuition
is well known for its tacit dimensions (Cioffi, 2000; Melin-Johansson
et al., 2017). This is also present in this study's findings that linguistic
limitations interfered with the participants' ability to make explicit the
specific features of non-measurable signs and symptoms.
Previous research reports combining nurses' clinical judgement with
PTTT positively influenced their response to deterioration (Brady &
Goldenhar, n.d.; Bonafide et al., 2013). In an adult surgical setting,
Douw et al. (2017) documented that applying specific nurse indicators
allows nurses to predict clinical deterioration before vital signs are devi-
ating. The application of these nurse indicators also improved patient
outcomes(Douw et al., 2017), again demonstrating that it is not only
vital signs that play an important role, as supported by the findings
the present study. Applying the non-measurable signs and symptoms
found in this present study to a PTTT may potentially have a similarly
positive effect, enabling nurses to identify pediatric patients at risk of
deterioration on signs and symptoms that are not yet reflected in the
PTTT and thereby contribute to better prediction of deteriorating pedi-
atric patients. Furthermore, the combination may provide a communi-
cative framework empowering nurses to react upon their intuition,
and also stimulate and facilitate a more sensory and embodied observa-
tional practice.
Strengths and limitations
This study has limitations that must be evaluated. It is a single-centre
study with only eight nurses included, thus limiting the scope of the
data and the generalizability of the findings. All participating nurses
were experienced which we perceive as beneficial to explore the aim
of this study. However, in many ward settings, many nurses will usually
not be as experienced as the participants in the present study. They may
not have acces to expert understanding, knowledge and intuition, and
they may be much less able to draw on the non-measurable signs and
symptoms highlighted in this paper. The observation time in the field
was limited, and only a few situations with deteriorated children oc-
curred. Therefore, the interviews conducted in the field turned out to
be a valuable method. By drawing on past clinical experiences, the par-
ticipants were able to recall and reproduce nuanced and in-depth
J.T. Rørbech, C.S. Jensen, P. Dreyer et al.
descriptions of previous situations with deteriorating children. This may
have affected the data, because the nurses descriptions was a retrospec-
tive of former experiences and not a capture of nurses immediate reflec-
tions. The focus groups represented few participants, and the interview
with only two participants had less group and discussion dynamics.
However, in this interview, conversations took on a more in-depth char-
acter indicating that individual interviews might be an effective method
to illuminate the research topic. As mainly young children were de-
scribed in the data, elements of the results may therefore be limited to
this specific age group.
Conclusion and perspectives
This study showed that pediatric nurses also identify hospitalized pe-
diatric patients at risk of clinical deterioration based on various non-
measurable signs and symptoms. Even though these signs and symptoms
are subtle and nuanced, they can be clustered into themes that relate to
colour and skin tone, sound, movement pattern and responsiveness/be-
havioural signs. These signs and symptoms go beyond the objective mea-
surements included in most PTTTs and they should not be ignored as they
are highly valuable to nurses who are responsible for observing inpatient
pediatric patients. Applying the non-measurable signs and symptoms
identified in this study to a PTTT may potentially allow nurses to detect
and react before vital signs are deviating, which holds potential for im-
proving care at an early stage of deterioration. Whether these signs and
symptoms may support today's observational practice with PTTT war-
rants exploration based on larger datasets in a multicentre study. More
empirical research on nurses' observational practice is recommended; es-
pecially research to identify the signs and symptoms - both measurable
and non-measurable – that are significant to nurses at the bedside. Finally,
the insights revealed by this study emphasise an important element in
understanding the performance of nurses' observational practice. Specifi-
cally, the study identified bodily observations and actions that are proac-
tively performed while nurses become aware of children at risk of
deterioration. A further exploration of this embodied observational prac-
tice will not only provide important knowledge about what to observe but
will - just as importantly – produce knowledge about how to observe hos-
pitalized pediatric patients at risk of clinical deterioration.
Funding source
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
Financial disclosure
The authors have no financial relationships relevant to this article to
disclose.
CRediT authorship contribution statement
Josefine Tang Rørbech: Conceptualization, Methodology, Project
administration, Investigation, Formal analysis, Writing – original draft.
Claus Sixtus Jensen: Investigation, Supervision, Writing – review &
editing. Pia Dreyer: Supervision, Writing – review & editing. R.N. Sine
Maria Herholdt-Lomholdt: Conceptualization, Formal analysis, Super-
vision, Writing – review & editing.
Declaration of Competing Interest
The authors have no conflicts of interests to declare.
Acknowledgments
The authors hereby express their gratitude to the participating
nurses and the pediatric unit who made this study possible. A special
72
Journal of Pediatric Nursing 66 (2022) e67–e73
thanks also to the children and their relatives who agreed to be
observed.
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