Factors influencing escalation of care of deteriorating children

An overview of a qualitative study aimed for paediatricians and paediatric nurses.

Recognising when a child is deteriorating—and knowing what to do next—is rarely straightforward. It’s a dynamic process that relies on more than clinical acumen. It involves teamwork, communication, and navigating complex systems involving healthcare professionals and families.

Hospitals, including those within the NHS, have introduced a range of safety nets to support early recognition and timely escalation—think Paediatric Early Warning Scores (PEWS), dedicated resuscitation teams, and clear escalation protocols. These tools help us act fast when a child’s condition worsens.

But as anyone working on the shop floor knows, having these systems in place doesn’t always make things easy. The reality is that recognising deterioration and escalating appropriately can still be tricky. Factors like clinical experience, team dynamics, and the work environment all play a role—and sometimes, they can get in the way.

In this post, we dive into a qualitative study from a tertiary paediatric hospital in Italy that explores just what those barriers look like. What makes it harder for healthcare professionals to spot and escalate care for an unwell child? And how can understanding these challenges help us do better?

Along the way, we’ll also take the opportunity to unpack what qualitative research looks like in practice—how it’s done, and why it can offer valuable insights into the ‘how’ and ‘why’ behind clinical decisions.

Gawronski O, Parshuram C, Cecchetti C, Tiozzo E, Ciofi degli Atti ML, Dall’Oglio I, et al. Qualitative study exploring factors influencing escalation of care of deteriorating children in a children’s hospital. BMJ Paediatrics Open. 2018 May;2(1):e000241.

What was the timeframe of the study?

April-October 2015.

What were the objectives of the study?

The study aimed to explore HCPs and parents’ experiences of in-hospital deteriorating children’s events to ascertain factors associated with recognition and escalation of care.By identifying these contributing factors, the researchers hoped to shine a light on the barriers to timely escalation—and, where possible, offer recommendations to improve clinical outcomes for children. The goal wasn’t just to describe the problem, but to provide insights that could lead to safer, more effective care.

What was the study’s design, and who were the participants?

The study was designed to obtain information (data) from focus groups,

To explore these issues, the researchers conducted six focus groups involving a total of 32 participants. Four of the groups were made up of healthcare professionals, and the remaining two involved parents. Each group had between four and seven participants, representing a range of voices and perspectives from across the hospital.

Importantly, participants came from nine different clinical areas, ensuring a broad snapshot of experiences—both from those delivering care and those receiving it. This approach allowed the researchers to dig into the realities of escalation from multiple angles: the clinical, the organisational, and the deeply personal.

The HCP groups were structured to include HCPs according to their professional roles. There were groups for ward nurses, ward nurse managers, ward physicians, and PICU physicians. The researchers deliberately grouped participants by role—separating healthcare professionals from parents, and avoiding mixing different staff hierarchies (like ward nurses and PICU consultants) within the same group. Why? Because they recognised that power dynamics and perceived hierarchy can sometimes stifle honest conversation.

By creating more comfortable and equal environments for discussion, the team hoped to encourage open, authentic dialogue—giving participants the space to speak freely about their experiences, concerns, and frustrations around escalation of care.

How were the participants selected? 

All of the healthcare professionals involved had cared for a deteriorating child within the past 12 months, bringing fresh and relevant experiences to the table. Likewise, the parents who took part had all had a child admitted to the hospital in the previous year, during which their child’s condition worsened and required escalation of care.

A two-step enrolment strategy selected HCPs and parents for enrolment. The first step was the nomination of suitable HCPs and parents by the ward nurse managers. Subsequently, a research nurse validated the suitability of potential enrollees.

The research nurse provided each participant with a comprehensive briefing on the study’s objectives and method. Informed consent was obtained from all participants.

What happened during the focus group sessions?

Each healthcare professional focus group was presented with the same two clinical scenarios involving deteriorating children. These case-based discussions were used to prompt reflection, spark conversation, and ground the discussion in realistic situations. By keeping the scenarios consistent across all four groups, the researchers could better compare themes and responses, highlighting commonalities and variations in how different staff members viewed and approached escalation. The scenarios were written by a group of experts from the research team and aligned with the hospital’s escalation guidelines.

The scenarios were of a 3-month-old infant brought into the emergency department with gastroenteritis and deteriorated after a few hours. The second scenario was of a 5-year-old child with chronic kidney disease who was discharged from PICU to the ward but deteriorated and had to be readmitted to PICU.

The clinical scenarios were used to prompt HCPs’ recollection and reflection on their personal experience of similar clinical events and expression of opinions on factors triggering or preventing escalation of care.

The scenarios for the parents’ focus groups were modified to ensure they were understood by non-HCPS. They included symptoms of a deteriorating child, which parents could recognise. Parents were asked to reflect on their personal experience of whether escalation of care was required and describe the response of HCPs. Parents were also asked about their suggestions for improvements.

The research nurse led each focus group session, and a second research nurse acted as an observer to ensure the focus group was conducted in accordance with the study’s requisitions.  

Focus groups were audio-recorded and transcribed. All obtained information was anonymised.

How were the results analysed?

The research team performed two independent thematic analyses on the information obtained from the focus groups, using the qualitative data analysis software NVivo V.8 to analyse the data.

What were the results?

Four themes, extracted from several subthemes, were identified as adversely influencing the recognition and escalation of deteriorating children.

Impact of processes of identification and responding to escalation  

• Under-or-over reliance on monitoring systems such as PEW
• Preconceived, fixated clinical judgement 
• Lack of situational awareness
• Not physically reviewing the patient
• Non adherence to escalation processes
• Not inviting parental opinions and thoughts 

What were the conclusions?

So, what did the researchers find?

Escalating care for a deteriorating child isn’t blocked by a single issue—it’s a complex web of challenges. The study identified a range of contributing factors that made timely escalation and response more difficult. These included:

• Gaps in staff knowledge and training – especially around recognising subtle signs of deterioration.
• Workload and service pressures – high patient volumes and staffing constraints that stretched teams thin.
• Workplace culture and interprofessional trust – where poor communication or siloed thinking got in the way of shared decision-making.
• Hierarchy – where junior staff felt hesitant to speak up or question senior colleagues.
• Disempowerment of parents – where families felt their concerns weren’t always heard or acted on.

In short, these were systemic issues—not just individual oversights. The researchers didn’t stop at highlighting the problems; they also offered some constructive solutions. Their recommendations included:

• Strengthening staff training and mentoring, particularly around early recognition and communication.
• Ensuring appropriate staffing models to reduce the burden on overstretched teams.
• Creating a more supportive, open culture, where all voices—regardless of role or rank—are valued.
• And crucially, involving parents as partners in recognising and responding to deterioration.

The message was clear: improving escalation isn’t just about refining tools like PEWS—it’s about changing the culture and systems that surround them.

Now that we have read the study’s summary, what do we think? Was it a good study? 

Was there a clear statement of the study’s objectives?

Yes.

Was a qualitative methodology appropriate?

Yes, it was. Qualitative research in this context was both practical and useful. The qualitative method, with its use of phenomenology and ethnography, explored participants’ experiences, processes, cultures, and behaviours and led to the identification of key barriers to escalation.

Was the study design appropriate to address its objectives?

Yes, to a certain extent but not fully. The qualitative design was appropriate; however, the researchers relied exclusively on the focus groups’ findings. It would have probably enriched this study if the researcher had observed the MDTs and Parents’ day-to-day activity in the clinical areas, as this may have also provided valuable insights.

Was the recruitment strategy appropriate?

Yes, to a certain extent but not fully. The participating HPCs were initially chosen by ward nurse managers, and so were the participating parents. The eligibility of the participants was subsequently validated by the research nurse. Despite a 2-step recruitment strategy, there is still a possibility of selection bias as the initial nomination of participants may have been influenced by personal opinions and affinity. Additionally, only nurses with two years’ experience or more were included in the focus groups. This may also represent selection bias.  

Was the data collected in a way that addressed the study’s objectives?

Yes, to a large extent, but not fully. The inclusion of only experienced staff and the researchers not observing the day-to-day clinical activities in real time may have affected the breadth of the collected data.  

Has the relationship between the researcher and participants been adequately considered?

It is not possible to determine this aspect fully based on reading the research article. The researcher nurse met and briefed the participants prior to their enrolment; however, it is not clear as to the breadth and depth of the research team’s direct engagement with participants.  

Have ethical issues been taken into consideration?

Yes, to a large extent, such as obtaining informed consent from participants, the presence of an observer research nurse during the focus groups’ sessions, and the anonymisation of data. Also, not enrolling parents whose children are currently admitted to the hospital reflects empathy by the research team so as not to increase the emotional burden on parents.

It would have been useful if participants were offered psychological support during and after the study, as it may have been needed considering the topic of the study.  

Was the data analysis sufficiently rigorous?

Yes, it was. 2 independent thematic analyses were performed, and a third independent researcher undertook a global assessment of findings to confirm validity. Additionally, the appropriate software was used to analyse the data.

Was there a clear statement of findings?

Yes.

How valuable is the study?

The study is valuable as it identified several themes and barriers to escalation of deteriorating children in the research’s hospital. Addressing the identified themes would undoubtedly improve patients’ outcomes and experiences. Additionally, the findings of the study may also be applicable and beneficial to many organisations and teams.

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