Gibbs Reflective Account — Deteriorating Patient Escalation

Description

During a late shift on a busy medical admissions unit at a large NHS acute trust, I was assigned to a bay of six patients. One patient, whom I will refer to as Mr A in accordance with the NMC Code (2018) requirement to respect confidentiality, had been admitted the previous evening with a community-acquired pneumonia. At approximately 17:00 his National Early Warning Score 2 (NEWS2) rose from 3 to 6, driven principally by a respiratory rate of 24 and new confusion recorded on the ACVPU scale.

I escalated to the nurse in charge, who was at that moment managing a separate admission. She acknowledged my concern and asked me to repeat the observations in fifteen minutes. I did so; the score had risen to 7. At this point I contacted the on-call doctor directly rather than waiting for the nurse in charge to become available.

Feelings

I felt considerable anxiety about escalating past the nurse in charge, which in retrospect reveals more about my perception of hierarchy than about any real procedural barrier. I was conscious of being a student and of the possibility that I had misread the situation. I also felt a competing and stronger concern that delay carried a clinical risk that my discomfort did not justify.

Analysis

The literature on escalation failure consistently identifies hierarchy as a principal barrier rather than knowledge deficit. Johnston et al. (2014) found that student and junior nurses frequently recognised deterioration correctly but delayed escalation because of perceived social cost. This maps directly onto my experience: my clinical judgement was accurate and timely, and the delay arose entirely from my reluctance to bypass a senior colleague.

NEWS2 exists precisely to remove that ambiguity by converting judgement into a threshold-triggered response (Royal College of Physicians, 2017). A score of 7 mandates urgent clinical review irrespective of who is available to authorise it. Framed that way, my escalation was not a breach of hierarchy but compliance with a protocol that supersedes it — an interpretation supported by the NMC Code (2018), which places a positive duty on registrants to act without delay where safety is compromised.