Saudi Critical Care Journal

: 2022  |  Volume : 6  |  Issue : 3  |  Page : 68--74

Factors influencing nurses' decision to activate critical care response team: The nursing perspective

Mustafa Ibrahim AlDhoon1, Diana Selvamony Lalithabai2, Nizar AbuSahyoun2,  
1 Nurse Educator, King Fahad Medical City, Riyadh, KSA
2 Nurse Manager, Executive Administration of Nursing Affairs, King Fahad Medical City, Riyadh, KSA

Correspondence Address:
Mustafa Ibrahim AlDhoon
King Fahad Medical City, P.O Box 59046, Riyadh 11525


Background: Critical care response team (CCRT) intervenes quickly in life-threatening situations to reduce adverse outcomes and improve patient safety. Nurses play an essential role in CCRT activation. Despite clearly satisfied criteria, there have been instances where nurses have failed to activate CCRT. Objective: This study examined the factors that influence nurses' CCRT activation. Methodology: The proposed study was done in an acute health-care setting using a cross-sectional survey approach. The study participants included 206 nurses working in inpatient care units. Nursing staff in intensive care units, pediatric intensive care units, operating rooms, outpatient departments, and main emergency rooms were excluded from the study. Results: Moreover, half of the majority (54.4%) of the 206 responders are knowledgeable about CCRT activation. Nearly 83 (40.3%) choose not to activate CCRT due to fear of being chastised. Nurses were more reliant on physicians to trigger CCRT. The activation score significantly correlated with the nurse participants' job title and working unit. Conclusions: Nursing staff avoided using the CCRT for fear of being blamed despite having a positive impression. They are primarily reliant on physicians to initiate CCRT. In addition to education and training that engages all health-care workers, hospitals should empower nurses to reduce barriers and improve CCRT activation.

How to cite this article:
AlDhoon MI, Lalithabai DS, AbuSahyoun N. Factors influencing nurses' decision to activate critical care response team: The nursing perspective.Saudi Crit Care J 2022;6:68-74

How to cite this URL:
AlDhoon MI, Lalithabai DS, AbuSahyoun N. Factors influencing nurses' decision to activate critical care response team: The nursing perspective. Saudi Crit Care J [serial online] 2022 [cited 2023 Feb 8 ];6:68-74
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Full Text


Health-care facilities strive to deliver high-quality care and favorable patient outcomes. There may be adverse events that require emergency treatment or admission to the intensive care unit (ICU) for patients, visitors, employees, and other facility staff. Approximately 1–5 cardiac arrest happens in hospitals per thousand admissions, or 0.175 per bed annually.[1] In multisite observational research involving 207 institutions, cardiac arrest incidence was reported.[2] In any emergency, antecedents are typical before death, cardiac arrest, and hospitalization.[3] In most cases of potentially life-threatening abnormalities, the patient had at least one potentially deadly antecedent within the previous 8 h.[4] It is hard to believe hospitals could have avoided most in-hospital cardiac arrests.[5]

An emergency response team is a formally recognized multidisciplinary critical care team that assesses and manages high-risk patients who show early signs of clinical deterioration before it becomes irreversible. Critical care and emergency care providers will be part of the teams to support quick intervention in a life-threatening crisis.[6] The medical emergency team (MET), rapid response team (RRT), rapid assessment team, and critical care response team (CCRT) are all names for this emergency response team. The term CCRT is used in this study and the research setting. It is evident from several study findings that activation of rapid reaction teams decreases unexpected deaths and saves lives.[7],[8],[9] Delay in calling METs is associated with a higher mortality rate[10] and longer ICU stays, and more extended hospital stays.[11] Hospitals equipped with RRT had a lower in-hospital mortality rate.[12],[13],[14]

RRT is activated by the medical team working with the patient. Health-care professionals' decisions to activate or not activate an RRT were affected by many factors, including the perceptions and clinical experiences of ward nurses and physicians, availability of multiple strategies, specificity of the activation criteria, lack of human resources, and informal hierarchical norms in the hospital culture affected. Still, the most important factor was the need to justify RRT activation.[15],[16] The nurses activated RRT based on predetermined criteria and played a major role in the CCRT activation[17] In emergencies, bedside nurses must recognize and appropriately manage rapid patient deterioration.[18] Nurses were more likely to activate when they were familiar with the activation process and saw the value of the RRT.[19]

Despite an abundance of literature on this topic in the Western world, Saudi Arabia has a shortage of studies investigating the factors that influence RRT activation from the perspective of nurses. To minimize the risk of major avoidable outcomes, the setting implemented the CCRT program. The program was created with specific policies and guidelines developed as part of the program to help staff manage the activation, which allowed them to seek assistance if patients deteriorated outside the critical care unit. The nurses are an essential part of CCRTs implementation, and they are given a no-harm policy. However, despite meeting all requirements, the CCRT was not activated in some instances. Consequently, it is crucial to determine what factors influence a nurse's decision to use CCRT. This study examined ward nurses' beliefs and behaviors that impact their decision to activate the critical response team in a multicultural health-care system.


Study design

The surveys were presented to nurses in a multicultural tertiary health-care setting, and the study used a cross-sectional approach.

Data collection

Questionnaires adapted from prior studies were used to collect data.[20],[21] There were two components to the instrument. The demographic data in Section A comprised age, gender, nationality, educational status, job title, and work experience. Section B consisted of a 17-item Likert Scale on the elements influencing activation. The research team first got approval from the Institutional Review Board, then from the heads of the hospitals and centers in the area. The researchers then obtained a list of nurses working in the units and contacted those who were eligible based on their shift patterns. The study's goal was explicitly described to the participants, and they were asked to participate. The research team collected the questionnaires after they were distributed in their spare time. The data collection took 2 months. A total of 206 questionnaires were delivered proportionately to nurses in the hospital units, with a 100% response rate.

Sample estimation

The population for the study included all nurses who worked directly with patients or were involved in direct care and nurses who worked in inpatient care units. Nurses who agreed to participate in the study worked in inpatient care units and had at least 6 months of experience in the field were all eligible. ICU, pediatric, OR, OPD, and main ER nurses were excluded from the study. A convenience sampling method was used in this investigation. Using a two-sided F-test with a significance threshold of 0.05, a sample of 195 participants, each responding to 17 questions, obtains 90% power to detect the difference between the coefficient alpha under the null hypothesis of 0.65 and the coefficient alpha under the alternative hypothesis of 0.75. To cater to the nonresponse rate, the sample size was increased to 206 [Table 1].{Table 1}

Data analysis

The data were analyzed and interpreted in accordance with the study's objectives. Average, mean scores, and percentages were used to characterize the Demographic variables of the participants. Cronbach's alpha (value=0.913) was used to determine the tool's internal consistency. The data were analyzed using SPSS version 20.0, IBM Corp., Armonk, New York, USA.

In this study, Structural Equation Model analysis (23) resulted in a model depicted in [Figure 1], and the following characteristics, i.e. Chi-square = 2.567, P = 0.002 (<0.05), were reported to find significant (Chi-square goodness of fit). Therefore, it is concluded that the proposed model used in this study fits the sample data influencing nurses' decision to activate critical care response. While reviewing the relationship between the 17 items and the proposed overall item, the path coefficient between each item and the proposed overall item was positive and significant (P value <0.05). In this study, the Goodness-of-fit index (GFI) =0.946, Adjusted GFI (AGFI) = 0.891, Normed Fit Index (NFI) = 0.925, Relative Fit Indices (RFI) = 0.781, Tucker-Lewis Index (TLI) = 0.729, and Comparative Fit Index (CFI) = 0.932, respectively, are highly consistent, suggesting the proposed model represented an adequate fit to the data [Table 3]. The Root Mean Square Error of Approximation for the proposed model is equal to 0.041 (<0.05) [Table 3], which indicates the model is a good fit. This finding is supported by a study,[22] which stated that the value of GFI, AGFI, NFI, RFI, TLI, and CFI ranges from 0 to 1, with values closer to 1 indicative of a good fit. The standard root mean square residual = 0.021 (<0.05) in [Table 3] indicates a good fit. In conclusion, SEM analysis showed that the items observed under the proposed overall item are acceptable to measure influencing nurses' decision to activate critical care response.{Figure 1}{Table 3}


[Table 2] shows the nurses' perspectives on the critical response system's activation. A significant number of participants, 126 (61.2%), agree that CCRT can be used to prevent a minor problem from becoming a major problem (Agreed or Strongly Agreed).{Table 2}

When a patient is unwell, almost half of the participants, 101 (49%), agreed or strongly agreed to call the covering doctor before calling a CCRT. Simultaneously, 85 (41.3%) agreed that if I can't reach the covering doctor regarding my sick patient, I'll phone the CCRT. Almost half of the participants, 102 (49.5%), strongly disagreed or disagreed that they do not like calling CCRT because of criticism for not properly caring for their patients. Nearly half of the participants (43.2%) strongly disagreed or disagreed that if my patient met the CCRT requirements but did not appear to be in distress, I would not initiate a CCRT call.

[Table 4] shows the association between the activation score and nurses' demographic variables. Among the demographic variables, the nationality of the nurses, job title of the nurses, and working unit of the nurses have a significant association with their activation score. Considering nationality, Saudi nationality nurses have more activation scores 56 (50–67) than non-Saudi nationality nurses 50 (45–57). Considering the job title of the nurses, the activation score is high 63 (47–85) among head nurses than registered nurses at 51 (45–58) and the charge nurses at 50 (43–55). Similarly, nurses working in specialty units have a higher activation score of 53 (45–62) than nurses working in medical unit 51 (46–55) and surgical unit 50 (45–55).{Table 4}


This study provides an initial step in understanding the factors influencing the activation of CCRT by nurses, which, if not examined and managed by an organization, might have a negative consequence. It can affect the ability of the health care Team to act efficiently during an emergency, consequently leading to higher morbidity and mortality rates.

In the present study, more than half of the nurses reported that CCRT helps decrease the risk of cardiac and respiratory arrest among unwell patients. This is written in a study finding that demonstrates how an effective MET system will minimize the risk by reducing the occurrence of critical deterioration among patients admitted to the hospitals.[23] A number of studies have also confirmed this finding and found that implementation of the RRT project resulted in a dramatic reduction in the number of ICU admissions, the average ICU occupancy rate, and the total ICU mortality.[13],[24] In this study, more than half of the participants in the survey agreed that the CCRT is overused in the management of hospital patients. According to a study, the overuse of medical services has been identified as a contributing factor to poor quality care and high cost.[25] Nearly half of the participants in the current study disagreed that the doctor and nurse have handled the patient's care in an inadequate manner. At the same time, the majority of nurses were not positive about their confidence of nurses in themselves and the physicians. The results of this study are inconsistent with those of a prior study that described nursing challenges in managing emergency care[26] as well as a lack of a holistic approach to nursing care.[27]

A significant portion of the participants in the present study called the covering doctor before calling CCRTs when a patient was ill and only activated a CCRT call if they could not reach the doctor. According to previous studies[20],[21],[28],[29] conducted in Western countries, nurses were unable to activate CCRT when they were relying on physician direction. A study conducted in Finland found that nurses did not perceive doctors' disagreement with activating the rapid response system as a solid barrier to activating the quick response system.[30]

In this study, nearly half of the participants were hesitant to initiate a CCRT call for fear of criticism if the patient is not that ill. There was also disagreement over whether fear of criticism for not taking care of the patient well enough was the reason for not activating CCRT. Researchers have found that bedside nurses may refrain from appropriately activating RRT due to fear of reprimand,[31] anxiety about making the wrong decision,[32] and negative emotional reactions.[33] In addition, negative past experiences with RRTs, and an unsupportive unit culture, were among the barriers to not activating RRT.[34],[35],[36],[37]

As vital signs monitoring is a vital nursing assessment, many of the participants disagreed or strongly disagreed that they make a CCRT call on a patient if they are concerned, even if the vital signs are normal. Another study identified nurses performed vital signs as part of a routine, overlooking their significance in detecting patient deterioration[38] and failed to activate MET if vital signs were not documented adequately[39] Most participants disagreed that if the patient meets the CCRT criteria but does not appear ill, they would not activate a CCRT call. Literature supports the finding that the nurses' decision to activate CCRT was influenced by many factors, including the patient's condition.[40]

The present study results showed that the activation had a significant association with the job title of nurses and that head nurses had a higher activation score than other nurses. A study in the USA supported this finding that clinical ladder rank is significant for calling RRS.[41] Interestingly, the level of education had no significant association with the activation of CCRT. According to a study, activation of the MET is influenced by the level of education.[42] A previous study[43] found that the nurses working unit had an association with the activation, especially those in the surgical team who were less likely to consult the attending physician. Our study results showed that the unit of work affected the activation, and nurses in the specialty unit had a higher activation score than the nurses in medical and surgical units.

This could be explained by the fact that nurses in specialty units are better trained to identify early deterioration in the patient, respond promptly to the deterioration, and initiate CCRT.

The findings of this study motivate the health care leaders to examine appropriate strategies for nurses' empowerment and active participation in decision-making. By empowering nurses and encouraging their involvement in CCRT activation, adverse events within healthcare can be avoided. This can improve the quality of care and nursing satisfaction.

The study is a cross-sectional study that collected data from nurses in a particular setting with a specific instrument. However, it suggests further studies with more objective tools to focus on the most common barriers. It would be beneficial to conduct a qualitative study is needed to explore the factors involved in CCRT activation as well as strategies to enhance it.


Due to its cross-sectional nature and a particular health-care setting, it is not generalizable. Study findings provide insights into nurses' perception of CCRT, why nurses fail to activate it, and how to develop strategies to improve nurse activation of CCRT.


Nurses remain a large majority of those who activate the CCRT in health-care settings and help manage emergencies as well as improve health-care outcomes. Nurses' perceptions and factors that influence CCRT activation are examined in this study. Study findings point to the need for organizational culture change that enables effective communication, collaboration, and support among health-care teams. Education training and commitment from all the health-care personnel are also essential for activating and better utilizing the CCRT. In addition to guiding the process of education and training involving all health-care providers, addressing barriers, and enhancing the activation of CCRT.


We acknowledge the research center at the study setting for the grant and scientific editing services.

Financial support and sponsorship

The study received grant from research center at King Fahad Medical City/Riyadh under IRF 021-021.

Conflicts of interest

There are no conflicts of interest.


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