NUR 608 Module 1 Foundations of a Qualitative Study Example

Deciding Alone at Night: Foundations for a Qualitative Study of How Rural Nurses Escalate Care for Deteriorating Patients

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

NUR 608: Qualitative Research Design and Methods

Instructor Name

Month Day, Year

Deciding Alone at Night: Foundations for a Qualitative Study of How Rural Nurses Escalate Care for Deteriorating Patients

Introduction

At 2 a.m. in a 20-bed critical access hospital, the nurse caring for a patient whose breathing is worsening may be the most experienced clinician in the building. The physician or advanced practice provider may be on call from home, and the nearest intensive care unit may be two hours away by ground. In my years in such a hospital, I watched experienced nurses make high-stakes decisions about when to call, what to say and when to push for transfer. This paper identifies that decision as a research problem, reviews what is known about how nurses recognize and respond to deterioration, describes the gap in rural settings and argues that a qualitative approach, interpretive description, is suited to address it.

The Research Problem

Failure to recognize and respond to clinical deterioration in hospitalized patients contributes to avoidable cardiac arrests, intensive care admissions and deaths. Nurses are central to detection because they spend the most time with patients. The problem in rural critical access hospitals is not only recognition but escalation: deciding whether and how to seek help when help is far away and when transfer carries its own risks.

What Is Known

Research on deterioration has focused largely on urban and academic hospitals. A systematic review of nurses' role in detecting deterioration on hospital wards found that nurses often notice early, subtle changes, sometimes described as intuition or "worry," before vital signs cross thresholds, and that they validate their concerns with colleagues and tools before acting (Odell et al., 2009). An integrative review of factors that influence recognition and response found that nurses' knowledge, workload, confidence, relationships with physicians and organizational support for escalation all shape whether a concern becomes action (Massey et al., 2017). Rapid response systems and early warning scores were developed to reduce reliance on individual judgment, but both assume that a responding team is on site.

Rural hospitals operate under different conditions. Many critical access hospitals have small nursing staffs, limited on-site physician presence at night and no intensive care unit, and rural hospital closures have increased pressure on those that remain (Kaufman et al., 2016). Transfer decisions involve weather, distance and the availability of air transport.

The Gap

Little research describes how nurses in rural critical access hospitals experience and make escalation decisions when the people they would escalate to are not in the building. Existing studies explain recognition in settings with rapid response teams; they do not explain the reasoning, negotiation and moral weight of escalating from a distance. This gap matters because interventions designed for urban hospitals, such as escalation algorithms tied to an on-site team, may not fit rural practice.

Background and Significance

About one in five Americans lives in a rural area, and rural residents are older and carry more chronic illness on average than urban residents. When a patient deteriorates in a small hospital, delays in escalation or transfer can be fatal, while unnecessary transfers strain families and regional intensive care capacity. Understanding how rural nurses make these decisions could inform rural-specific escalation tools, telehealth support such as tele-ICU consultation and education for nurses entering rural practice. The study also contributes to nursing knowledge about clinical judgment under conditions of isolation and limited resources.

Why a Qualitative Approach

The question is not how often nurses escalate or which vital sign thresholds predict escalation, which quantitative methods could address. It is how nurses understand situations, what they weigh and how context shapes their actions. Qualitative research is suited to questions about meaning, process and context in naturally occurring settings (Green & Thorogood, 2018).

Methodological Approach: Interpretive Description

I propose interpretive description, a qualitative methodology developed in nursing to generate knowledge that is useful for practice (Thorne, 2016). Interpretive description draws on the techniques of established traditions, such as constant comparison and thematic analysis, but it is not bound to their full theoretical apparatus. It begins from the clinician's knowledge of the field, which suits my position as a former rural nurse, and it aims for findings that clinicians and educators can apply.

Philosophical Assumptions

Interpretive description rests on a constructivist and naturalistic foundation (Thorne, 2016; Lincoln & Guba, 1985). Ontologically, it assumes that reality as experienced is multiple and constructed by people in context: the deteriorating patient means something different to a new graduate and a 30-year rural nurse. Epistemologically, it assumes that knowledge is created through interaction between researcher and participant, so the researcher's clinical experience is a resource to be examined reflexively rather than a bias to be eliminated. These assumptions point to methods that capture participants' accounts in their own words, such as in-depth interviews built around specific recent escalation events, and to analysis that seeks patterns across accounts while preserving variation.

Research Question

Consistent with these assumptions, the research question asks about experience and meaning rather than causes or frequencies:

How do registered nurses in rural critical access hospitals describe their experience of recognizing patient deterioration and deciding whether, when and how to escalate care when no physician is on site?

A secondary question asks: What individual, relational and organizational factors do these nurses describe as shaping their escalation decisions?

Conclusion

Escalation in rural hospitals is a high-stakes decision that existing research, built in urban settings, does not explain. An interpretive description study grounded in constructivist assumptions can describe how rural nurses make these decisions in their own terms and produce knowledge that could shape rural escalation tools and education. The next step, in the final paper, is to develop the design, sample and analysis.

References

Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). SAGE.

Kaufman, B. G., Thomas, S. R., Randolph, R. K., Perry, J. R., Thompson, K. W., Holmes, G. M., & Pink, G. H. (2016). The rising rate of rural hospital closures. The Journal of Rural Health, 32(1), 35-43. https://doi.org/10.1111/jrh.12128

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23. https://doi.org/10.1002/nop2.53

Odell, M., Victor, C., & Oliver, D. (2009). Nurses' role in detecting deterioration in ward patients: Systematic literature review. Journal of Advanced Nursing, 65(10), 1992-2006. https://doi.org/10.1111/j.1365-2648.2009.05109.x

Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.). Routledge.