Table 2

Themes, subthemes and dimensions

Themes/subthemes	Dimensions
Impact of staff competencies and skills
Differences in staff training and knowledge.	Paediatric training.
	Specialty clinical skills.
Individual self-perceived ability in identifying clinical deterioration.	Past experiences increasing the belief about self-perceived capability of escalating care.
	Interdisciplinary credibility based on competence and personal assurance of own abilities.
Peer-to-peer mentoring.	Coaching less expert nurses.
Belief on ward responsibility for severely deteriorated patients: keeping high-risk patients on the ward.	Advanced skills to treat the deteriorating child.
Relationships and leadership in care
Teamwork.	Integrated handover and care planning processes.
	Interdisciplinary rounding and huddles.
	Trust among staff members.
Communication.	Interprofessional and intraprofessional communication.
Knowing the patient and colleagues.	Knowing the team.
	Knowing the patient.
Family empowerment.	Recognising and accepting parent’s competences of child’s illness.
	Listening to parent’s concerns.
	Family-centred needs and support.
Leadership: defining priorities.	Prioritising tasks.
	Unclear accountability in escalation processes.
Interprofessional hierarchies.	Empowerment in initiating escalation of care.
Processes identifying and responding to clinical deterioration
Clinical observation and patient assessment practices.	Intuition—the gut feeling.
	Observing the patient and monitoring.
Tools supporting the identification of patient risk and decision making.	Influence of early warning scores/standardised processes.
	Adherence to BedsidePEWS score matched recommendations and clinical judgement.
Ward rounding.	Bedside rounding practices.
	Nursing and family involvement in rounds.
Situational awareness.	Interpreting clinical deterioration through the BedsidePEWS.
	Tunnel vision of reasons for clinical deterioration.
RRT role.	Calling RRT only in extreme clinical deterioration.
	Proactive patient rounding of RRT members in support of escalation processes.
Hospital management: organisational factors
Staffing and workload.	Discrepancy between staffing levels and workload.
	Balancing nursing seniority on shift.
	Reduced senior staffing present on site during nights, weekends and public holidays.
	Clinical record documentation workload.
Production pressure.	Organisational demands on clinicians competing with patient care needs.
Management and relational continuity of care.	Service physician availability 24 hours a day.
	Nursing primary care.
	Shift structure.
Patient pathway.	Mismatch between severity of illness and level of care.
	Discrepancy between the children’s illness and the specialty of the ward where they are located (specialty patients outlying on non-specialty wards).
	Availability of PICU beds.

BedsidePEWS, Bedside Paediatric Early Warning System; PICU, paediatric intensive care unit; RRT, rapid response team.