Abstract
-
Purpose
This study aimed to explore the roles, facilitators, barriers, and future directions of rapid response teams (RRTs) in Korean hospitals from the perspectives of both RRT and ward nurses.
-
Methods
Focus group interviews were conducted with 10 RRT nurses and 10 ward nurses across three hospitals that employed RRTs in Korea from August 2021 to February 2022. The interviews were recorded, transcribed, and analyzed using qualitative content analysis to identify themes relevant to RRT operations.
-
Results
The analysis yielded 10 subtopics and 4 main themes: the exploration of RRT's essential roles, the facilitators and barriers impacting RRT operations, and the construction of a blueprint for future systems. Notable barriers included unclear job assignments without legal safeguards, conflict arising from hierarchical structures, and insufficient organizational support. The following facilitators were identified: transformed perceptions through collaborative efforts, organizational recognition and support, and self-reinforcement by demonstrating expertise.
-
Conclusion
This study highlights the challenges and opportunities associated with implementing RRTs in Korean hospitals, including the need for clear role definitions, effective interprofessional collaboration, and organizational support. Based on these findings, future efforts should focus on establishing legal frameworks that define the scope of practice for RRT nurses.
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Key Words: Focus groups; Hospital rapid response team; Nursing services; Patient safety; Qualitative research
INTRODUCTION
Approximately 10% of patients admitted to hospitals face unexpected emergencies during their stay, including severe conditions (cardiac arrest), unplanned admissions to intensive care units (ICUs), and mortality [
1]. Research on unexpected hospital death patterns has revealed that 60~80% of patients exhibit signs of physiological instability-such as tachypnea, tachycardia, hypotension, reduced oxygen saturation, and altered consciousness-before these critical events [
2-
4]. Rapid response teams (RRTs) are strategically developed to identify these early warning signs, aiming to prevent the escalation of a patient's condition and enhance overall hospital safety [
5,
6]. Evidence suggests that the implementation of RRTs significantly decreases the incidence of cardiopulmonary resuscitation (CPR) outside ICUs by 33.8% and reduces in-hospital mortality rates from 49.6% to 32.6% [
7].
The adoption of RRT systems is a global phenomenon aimed at maintaining a secure hospital environment. In the US, the initiation of the "100,000 Lives Campaign" facilitated the widespread adoption of RRTs across the nation [
8]. Similarly, the UK and Australia established critical care outreach teams (CCOTs) and medical emergency teams (METs), respectively. Despite having different names, these systems all share the unified goal of preventing severe emergencies to safeguard patient well-being [
9]. In Korea, a pilot project for a rapid response system was launched in May 2019 to increase the safety of general ward patients and improve the quality of medical care. This pilot project was terminated early in December 2023 and subsequently converted into a main project [
10,
11].
RRTs in healthcare settings have diverse team members, including doctors, respiratory therapists, nurses, and pharmacists, with nurses often comprising the majority of the team [
8,
12]. In Korea, the composition of RRTs varies significantly based on team operational hours, ranging from one doctor and ≥9 nurses in 24/7 operations to 2~5 nurses in teams operating for 8 or 16 hours daily [
10]. RRT activation is typically triggered by early warning signs or direct calls from ward medical staff in response to acute changes in patient conditions, with nurses frequently initiating these calls [
12,
13]. This underscores the pivotal role of nursing personnel not only within the RRT but also as primary responders in ward settings, highlighting the necessity of examining RRT operations from the nursing perspective [
12,
13].
While many studies have examined the clinical outcomes of RRTs, such as reduced mortality and fewer ICU admissions [
1,
5-
7], there is a notable gap in the literature regarding the nuanced experiences of the nurses who are fundamental to RRT activation and operation. Unlike in many Western countries, where RRTs are well established [
8,
9,
12], the implementation of RRTs in Korea is still in its early stages, underscoring a critical need for foundational evidence specific to this context. Given that ward nurses provide the majority of direct nursing care to critically ill patients and that nurses constitute most of the RRT members responsible for detecting and responding to patient deterioration, an in-depth understanding of RRT operations from a nursing perspective is essential. Previous Korean studies have primarily focused on delineating tasks within RRTs or adapting critical care screening tools from other countries [
11,
14,
15]; however, few have conducted comprehensive qualitative analyses that examine the roles, facilitators, barriers, and potential directions for developing RRTs in Korean hospitals [
16]. This study addresses these gaps by exploring the experiences of RRT and ward nurses, whose roles are crucial to the effective functioning of RRTs in Korea. Therefore, the research question of this study is: "What are the perceived facilitators and barriers to the implementation of RRTs in Korean hospitals from the perspectives of both RRT and ward nurses?" Accordingly, this study aimed to explore these facilitators and barriers to provide a comprehensive understanding from the nursing perspective, using a qualitative approach that reflects the critical role of nurses in this emerging field.
METHODS
1. Study Design
This study employed qualitative content analysis to describe the roles, facilitators, barriers, and future directions of RRTs from the nursing perspective in Korea.
2. Participants and Setting
The study focused on the role of RRTs from a nursing perspective, targeting both dedicated RRT nurses and ward nurses with experience in patient care alongside RRT nurses. We purposively sampled three hospitals participating in the Korean RRT pilot project. These hospitals were selected based on their willingness to participate and their diverse characteristics, including varying RRT operating hours and geographical locations. Data were collected from Chonnam National University Hospital (1,092 beds, 24-hour RRT) in Gwangju, Korea; Korea University Anam Hospital (1,091 beds, 10-hour RRT) in Seoul; and Boramae Medical Center (786 beds, 8-hour RRT) in Seoul. Gwangju and Seoul are geographically diverse, being approximately 300 km apart. This selection strategy allowed us to explore the potential influences of different RRT operational models and regional contexts on nurses' experiences.
Among the study participants, RRT nurses had >3 years of clinical experience and >3 months of experience working on an RRT. The criterion for selecting a dedicated RRT nurse was based on the pilot project's requirement in Korea: a dedicated nurse must have >3 years of clinical work experience, including experience in the ICU or emergency department [
10]. Additionally, research suggests that it typically takes 3 to 6 months for new nurses to adapt to ward nursing roles [
17]. Given that RRT nurses are experienced professionals with a background in critical care, a minimum of 3 months of RRT-specific experience was deemed sufficient for effective role adaptation. In this study, the criteria for selecting ward nurses were: (1) having more than 1e year of ward experience and (2) having experience in emergency patient nursing in cooperation with the RRT within the last 3 months. We included ward nurses with >1 year of experience to ensure they had sufficient time to adapt to their roles and engage in meaningful collaborations with the RRT. The requirement of 3 months of cooperative experience with the RRT was set based on evidence suggesting that memory fades over time and that information should be reinforced within 3 months [
18].
Participants were recruited through recommendations by the nursing department, ensuring that each nurse met the selection criteria and could describe RRT facilitators and barriers from a nursing perspective. Additionally, interviewees were encouraged to recommend other potential participants for the study.
Data collection and analysis were performed simultaneously. A research meeting was held after each focus group interview. Recruitment was stopped when the research team judged that saturation had been reached, as no new information emerged from the interviews. Thus, 20 nurses -10 dedicated RRT nurses and 10 ward nurses-participated in this study.
3. Data Collection
Focus group interviews (FGIs) were conducted following guidelines established in previous studies [
19,
20]. The FGI process included: (1) preparing the interview guide, (2) selecting and recruiting participants, (3) conducting the FGIs, and (4) analyzing the data [
19,
20]. The interview guide was developed based on a review of relevant literature and the research team's expertise in RRT operations. The questions were designed to elicit participants' experiences, perceptions, and insights regarding the facilitators and barriers impacting RRT operations. A semi-structured questionnaire was used, with questions arranged in the following order: introductory, transition, key, and ending questions (
Table 1).
FGIs were conducted separately for RRT nurses and ward nurses to facilitate open discussion. Although minifocus groups are typically composed of 4~5 participants for detailed exchanges [
20], each focus group in this study consisted of 2~4 participants due to Corona Virus Disease-2019 (COVID-19) restrictions during data collection. In total, interviews were conducted with seven focus groups: four groups of dedicated RRT nurses and three groups of ward nurses.
Data were collected from September 2021 to February 2022. The FGIs were led by a nursing professor experienced in qualitative research, assisted by a doctoral student in nursing who took field notes. Interviews were held in a private, comfortable setting, such as a quiet university seminar room, and lasted an average of 58.29±13.20 minutes. All interviews were audio-recorded using two recorders and transcribed verbatim for analysis.
4. Data Analysis
This study employed a qualitative content analysis approach, following the inductive method outlined by Elo and Kyngas (2008) [
21], to analyze the transcribed interviews and field notes. NVivo 12.0 software was used to manage and analyze the data, which were collected until saturation was reached. The analysis involved several key stages: first, researchers immersed themselves in the data to gain a comprehensive understanding of the participants' experiences and context. Next, meaningful units of text (words, phrases, sentences, paragraphs) were identified and assigned initial codes based on their relevance to the research aim, richness of information, frequency, and potential for new insights. This stage was guided by the aim of exploring the roles, facilitators, barriers, and future directions of RRTs. Codes were then compared and grouped based on similarities and differences to create a hierarchical structure of categories and subcategories. A constant comparative method was employed to refine the coding framework as new insights emerged. Finally, overarching themes were identified that captured the essence of the participants' experiences and perspectives regarding RRTs. These themes were analyzed and interpreted within the broader context of RRT implementation. The entire data analysis process, including the development of categories and overarching themes, was conducted collaboratively by the research team to ensure rigor and consistency.
The study aimed to secure validity by addressing the four criteria proposed by Lincoln and Guba [
22]: credibility, transferability, dependability, and confirmability. To ensure credibility, a member check was conducted in which participants reviewed the final research report to confirm that the findings accurately reflected their experiences. Additionally, researcher bias was minimized by avoiding leading questions and fostering an open interview environment where participants could share their experiences freely. Transferability was enhanced by selecting participants from diverse organizations and collecting data until saturation was reached, thereby capturing a wide range of perspectives. Detailed descriptions of the participants and research context further aid in assessing the transferability of the findings. Dependability and confirmability were established through meticulous review and refinement of the analysis, ensuring that interpretations were grounded in the data rather than influenced by researcher bias. A reflexive approach was maintained throughout, with researchers continuously reflecting on their own perspectives to ensure neutrality. The member check process further strengthened dependability and confirmability by allowing participants to verify the accuracy and representation of their perspectives in the findings.
The Institutional Review Boards Committee of Chonnam National University Hospital approved the study (IRB no. CNUH-2021-192). For participant selection, voluntary consent was first obtained verbally, followed by written consent after participants had sufficient time to consider their involvement prior to the interview.
RESULTS
Table 2 presents the general characteristics of the 20 participants, which included 10 RRT nurses and 10 ward nurses. RRT nurses had work experiences ranging from 7 to 29 months (average: 19.4 months) and reported an average of 4.4 dispatches to wards. A total of 594 codes were generated from the meticulous examination of interview transcripts, encapsulating key participants' statements. These codes facilitated the creation of categories, resulting in 10 subtopics and 4 main themes (
Table 3;
Supplement 1).
1. Exploring the Essential Role of the RRT
The essential role of the RRT was categorized into two sub-themes: "safety net for critical patients" and "coordinator of medical staff," highlighting the multifaceted contributions of the team. These sub-themes underscore the RRT's vital role in safeguarding patient well-being and facilitating seamless interprofessional collaboration in critical situations.
1) Safety net for critical patients
The RRT serves as a crucial safety net for critically ill patients-a sentiment echoed by both RRT and ward nurses. Through their specialized expertise and proactive approach, RRT nurses play a vital role in assessing patients' critical health status, identifying deteriorating patients, and initiating timely interventions. Ward nurses, particularly those working in facilities with 24-hour RRT coverage, emphasized the invaluable support provided by RRTs, especially during night shifts when contacting on-call physicians can be challenging.
In hospitals without 24-hour RRT support, ward nurses expressed a strong need for such teams, noting the difficulties they face in managing emergencies during night shifts. According to ward nurse 5, the consensus was to maintain patients' conditions overnight and call the RRT at the earliest opportunity in the morning. This perspective emphasizes the importance of RRT availability and the collaborative efforts between RRT and ward nurses in ensuring round-the-clock patient safety. Echoing the need for nighttime support, ward nurse 5 stated, "The idea of having RRT support at night is widely supported. Night shifts are understaffed, yet emergencies and patient deterioration predominantly occur during these hours."
2) Coordinator of medical staff
The RRT also serves as a coordinator, enhancing the synergy within the medical team and providing substantial support to both doctors and ward nurses. Both RRT and ward nurses recognized the RRT's crucial role in directly enhancing patient care by providing expert assessments, executing essential treatments, operating complex medical equipment, and communicating patient conditions to doctors. The RRT's support extends to assisting doctors with arterial line placement, arterial blood gas analysis, and ICU arrangements. Its advisory role in medication prescription, blood transfusion, inter-departmental consultation, and faculty contact further underscores its function as a coordinator and facilitator within the medical team.
In emergency situations where ward nurses encounter difficulties communicating with doctors, the RRT acts as a mediator, ensuring timely treatment for patients. Given their expertise and experience in emergency patient care, RRT nurses occasionally assume leadership roles, guiding novice doctors and nurses in patient management. As a result, the RRT streamlines communication among medical staff and leads patient care initiatives. Ward nurse 2 shared a positive experience with the RRT, noting, "During a critical moment when a patient's condition did not improve despite suction, the RRT intervened. They performed phlegm suction, which significantly stabilized the patient's condition. The RRT nurse's keen observation led to the recommendation of NPO due to worsening aspiration pneumonia, a suggestion promptly accepted by the attending physician."
The integrated perspectives of both RRT and ward nurses highlight the multifaceted role of RRTs in providing critical patient care-both as a safety net that identifies and manages deteriorating patients and as a coordinator that enhances communication and collaboration among medical staff.
2. Barriers to RRT Operations
The barriers hindering RRT operations were identified as "unclear job assignments without legal safeguards," "conflict arising from hierarchical structures," and "insufficient support from the organization." These challenges collectively impede the RRT's ability to function optimally, underscoring the urgent need for interventions to address these systemic and organizational constraints.
1) Unclear job assignments without legal safeguards
Both RRT and ward nurses reported that the lack of clear job standards and resulting role ambiguity is a significant challenge for RRTs. As a novel entity, the RRT's primary function is to support both nurses and doctors; however, because it does not formally belong to either group, confusion regarding its identity arises. RRT nurse 2 shared this dilemma, "When doctors were unable to insert an arterial line, they requested our assistance, acknowledging our expertise despite the legal constraints. I was torn between the legal implications and the urgent need to assist a critically ill patient." This quote highlights the discrepancy between the RRT's capabilities and the legal permissions governing their practice, creating a conflict between their expected roles and responsibilities. Ward nurse 2 echoed the concerns regarding the RRT's unclear job assignments, mentioning, "I wish RRTs were given at least the right to prescribe prescriptions in urgent emergency situations. Currently, the RRT checks the level of temporary POCT... Strictly speaking, ordering authority is not within RRT's scope. Since their orders are not official, the data cannot be viewed by uploading it to the EMR, and only results printed on a piece of paper are exchanged."
The integrated perspectives of RRT and ward nurses underscore the challenges posed by the lack of clear job standards and the legal gray area in which RRTs operate. The discrepancy between their capabilities and legal permissions creates a conflict between their expected roles and responsibilities, causing dilemmas and hesitation in critical situations.
2) Conflict arising from hierarchical structures
Conflicts frequently emerged when RRT recommendations diverged from physicians' treatment plans, underscoring the pervasive influence of hierarchical structures within the hospital. RRT nurses perceived that resistance to their recommendations often stemmed from deeply ingrained cultural and hierarchical differences. As RRT nurse 1 reflected, "We gently recommend treatments based on the patient's condition, but there's a reluctance from doctors to consider our advice, which I believe stems from cultural and hierarchical differences within the hospital."
In addition to conflicts with physicians, ward nurses also expressed hesitancy in accepting advice from RRT nurses-even when the latter possessed extensive experience in managing critically ill patients. This hesitancy exacerbated tensions, particularly when RRT recommendations conflicted with physicians' decisions. For example, ward nurse 10 described a conflict over the recommendation for arterial line placement: "There was a conflict when the RRT suggested an arterial line and the doctor disagreed. Personally, I believed the patient would benefit from it. The disagreement hindered the patient's treatment progress."
These insights suggest that such conflicts arise not only from a lack of understanding of the RRT's role but also from deeper institutional issues such as shifting responsibilities and ambiguous role boundaries. Hierarchical and cultural structures further compound these issues, creating resistance to collaborative decision-making. These factors, collectively, contribute to the tension between RRT and ward nurses, as well as with physicians, ultimately hindering seamless patient care and delaying treatment interventions.
3) Insufficient support from the organization
Both RRT and ward nurses reported challenges related to insufficient organizational support for RRT operations. The RRT relies on an EMR-based Early Warning Score (EWS) system-such as the Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS)-to assess patient severity in wards. However, ward nurses encountered difficulties updating the EMR with real-time patient data during emergencies, prompting calls for a more accessible system to summon the RRT.
RRT nurse 6 shared their experience with system limitations, saying, "I proposed adding a quick-alert icon in the EMR for emergencies, which would send an SMS to the RRT. However, the request was denied due to space and cost constraints. Simply pressing a button would be more efficient than a phone call in critical situations."
This example highlights the need for organizational support to implement technological solutions that improve the efficiency of alerting the RRT. Ward nurse 9 added, "We often struggle to update the EMR during emergencies, which can delay the activation of the RRT. Having a more streamlined system would greatly improve our ability to respond to critical situations promptly."
3. Facilitators of RRT Operations
The facilitators enhancing RRT operations were identified as "transformed perceptions through collaborative efforts," "organizational recognition and support," and "self-reinforcement by demonstrating expertise." These facilitators underscore the importance of fostering a collaborative environment, providing robust organizational support, and recognizing the RRT's expertise to ensure effective operations.
1) Transformed perceptions through collaborative efforts
Despite initial skepticism-especially from first-year residents-both RRT members and ward medical staff experienced a notable shift in their perceptions of the RRT's role and value. RRT nurses shared stories of how their expertise and efficiency in managing emergencies gradually gained recognition, leading to increased reliance on their services.
RRT nurse 4 recounted a transformative experience, saying, "Initially, first-year residents were wary of our presence, wondering about our role. However, as we demonstrated our skill and speed in responding to emergencies, I observed a significant change in their attitude. They began to rely on us, calling us immediately when an emergency arose."
Ward nurse 3 corroborated this shift in perceptions, stating, "Over time, we witnessed the incredible impact of the RRT on patient outcomes. Their expertise and quick response have become invaluable to us, and we now work closely with them to ensure the best possible care for our patients."
2) Organizational recognition and support
The hospital's logistical support, as exemplified by the strategic location of the RRT office and special elevator access, demonstrates the organization's recognition of the RRT's critical role in emergency response. RRT nurses acknowledged that such support enhances their operational efficiency. RRT nurse 5 emphasized the significance of organizational support, stating, "The location of the RRT office is crucial for quickly reaching all wards. Before the office relocation, RRT nurses had to assign different wards to each other to reduce dispatch time. The decision to move the RRT office to the center of the hospital signifies the organization's awareness and appreciation of the RRT's role."
3) Self-reinforcement by demonstrating expertise
RRT nurses derive a profound sense of fulfillment and pride from effectively managing emergencies. Through regular rounds and assessments of critically ill patients using early warning scores, they can preemptively intervene in potentially fatal situations. RRT nurse 1 stated, "There are moments when we preemptively assess and intervene in a deteriorating patient condition, averting the worst possible outcomes. It's in these moments that I feel a deep sense of pride in our team's ability to make a difference." Ward nurse 6 acknowledged the RRT's expertise, noting, "The RRT's proactive approach and ability to identify and manage deteriorating patients have been truly impressive. Their skills and knowledge have prevented many critical situations from escalating."
The integrated perspectives of RRT and ward nurses highlight a complex interplay between barriers and facilitators-while challenges such as insufficient organizational support and initial skepticism persist, the RRT's expertise, collaborative efforts, and gradual recognition by both the organization and ward staff serve as key facilitators of effective RRT operations.
4. Constructing a Blueprint for Future Systems
The blueprint for future RRT systems was constructed around two sub-themes: "clarification of RRT's role and legal authority" and "pioneers building the infrastructure." These sub-themes emphasize the need for clear role definitions, legal clarity, and continuous improvement efforts to establish a robust and sustainable RRT system.
1) Clarification of RRT's role and legal authority
Both RRT and ward nurses emphasized the importance of clarifying the RRT's role and legal authority in future protocols. RRT nurses reported that they often extend their duties beyond traditional boundaries-performing tasks typically reserved for ward doctors, such as transporting critically ill patients to the computed tomography (CT) room and monitoring sedated patients. This blurring of role boundaries not only increases the RRT's workload but also creates confusion among ward nurses. RRT nurse 5 commented, "The lack of legal authority for RRT nurses to issue medical orders is a significant barrier. In emergencies, every second counts, and having to wait for a doctor's approval can delay critical interventions."
Both groups of nurses called for granting RRT nurses-especially those with advanced degrees-limited prescriptive authority to streamline patient care. Ward nurse 2 elaborated, "If RRT nurses, particularly those with a master's degree, were granted prescriptive rights, it would greatly expedite care for emergency patients. Currently, the lack of such authority means duplicated efforts and complications in sharing test results with the medical team."
2) Pioneers building the infrastructure
RRT nurses perceived themselves as pioneers striving to increase operational effectiveness. Their efforts include analyzing CPR events, tailoring EWS systems to better suit clinical situations, and standardizing RRT call protocols. RRT nurse 3 reflected, "We see ourselves as pioneers, tasked with not just managing emergencies but also creating and establishing the systems needed to do so effectively. It often feels like we're laying the groundwork for a system that's still in its infancy here."
Despite ongoing challenges in raising awareness within the hospital community, there is a strong commitment to further establishing and promoting the RRT's role. Additionally, many ward nurses expressed hope for the RRT to be available 24/7, which would necessitate increased staffing.
The integrated perspectives of RRT and ward nurses underscore the importance of constructing a blueprint for future RRT systems that address role clarification, legal authority, expertise development, and the pioneering efforts needed to build the necessary infrastructure. By incorporating these insights, healthcare organizations can work toward creating a more effective and sustainable RRT system that optimizes patient care and supports the professional growth of its members.
DISCUSSION
The research aimed to illuminate the complexities surrounding the implementation and integration of RRTs-especially in regions where such teams are in the nascent stages of development-by adopting a dual perspective that integrated insights from both RRT members and ward nurses. The study sheds light on the specific challenges nurses face in the context of RRT operations, such as role ambiguity, interprofessional conflicts, and the need for clearer protocols and support systems. These insights provide a foundation for refining nursing practices, protocols, and educational initiatives to optimize RRT performance, ultimately enhancing patient safety and outcomes.
In the United States and the United Kingdom, RRTs and CCOTs have well-defined roles and responsibilities in providing emergency care [
8,
9,
23]. These teams, comprising physicians, nurses, respiratory therapists, and other healthcare professionals, are responsible for assessing and stabilizing patients with acute deterioration, providing critical care interventions, facilitating transfers to higher levels of care, and educating ward staff [
8,
9,
23]. Nurses in RRTs in the US and CCOTs in the UK play a crucial role in these teams. In the US, RRT nurses are typically Critical Care Registered Nurses with Advanced Cardiac Life Support certification [
24]. Their responsibilities include conducting patient assessments and monitoring, initiating and titrating critical care interventions, collaborating with physicians and other team members, and providing education and support to ward nurses [
23-
25]. Likewise, CCOT nurses in the UK are experienced critical care nurses with advanced qualifications, such as those outlined in the National Outreach Forum Competency Framework [
26]. They are responsible for assessing and managing critically ill patients, offering expert advice and support to ward staff, facilitating the implementation of evidence-based guidelines, and educating and training ward staff in critical care skills [
26]. In contrast, the Korean RRT system-currently implemented as a pilot project-includes guidelines on the role, composition, and scope of the team [
10]. However, these guidelines incorporate practices that are not legally sanctioned for nurse-led RRTs, causing confusion in hospitals. Despite lacking legal authority for certain invasive procedures, these tasks are performed in practice, highlighting a discrepancy between legal standards and clinical realities. This discrepancy can lead to compromised patient safety, reduced job satisfaction among RRT nurses, and increased professional liability [
16,
25,
27]. A recent study on the nurse -led Korean RRT model developed a framework emphasizing the roles of coordinator, educator, and emergency expert for RRT nurses [
16]. In addition to developing such a model, clarifying legal authority is essential for effective RRT implementation. By learning from the experiences and best practices of countries such as the US and UK and adapting them to the Korean healthcare context, Korea can overcome current ambiguities in RRT roles and create a sustainable, effective system that ultimately improves patient care and saves lives.
This study also illuminated interprofessional friction as an obstacle encountered by RRTs, particularly between RRT nurses and some doctors during field operations. This tension-attributed to either a lack of familiarity with the RRT nurses' role or deeply ingrained cultural hierarchies that elevate doctors above nurses-is not unique to the Korean healthcare context. Institutional constraints, such as insufficient reimbursement rates, lack of staffing standards, and inadequate education and training systems, can further contribute to these challenges. Environmental factors, including hospital size and structure, a shortage of medical equipment and facilities, and insufficient collaboration among medical staff, can also exacerbate these issues. Moreover, nurses face challenges such as high workloads, role conflict, and a sense of burden due to a lack of expertise, all of which can further impede effective interprofessional collaboration within the RRT. These challenges, combined with the aforementioned cultural and hierarchical factors, create a complex landscape for RRT implementation.
The Korean effort to embed the RRT system as a safety net underscores the urgent need to address these interprofessional issues, advocating for a paradigm shift toward improved RRT recognition and interdisciplinary collaboration. Interviews with RRT nurses in this study further highlighted teamwork as a fundamental strategy for effectively navigating and overcoming emergency situations. Such experiences underscore the need for ongoing education and shared experiences, ensuring that all members of the RRT understand and value the importance of collaboration.
The efficacy of the RRT depends on its dispatch pathways, which are initiated either by direct calls from medical staff or guardians who recognize an emergency or through alerts generated by the EWS [
23,
25]. Direct calls by ward medical staff typically occur in anticipation of acute patient deterioration, signaling the need for swift RRT intervention [
13,
28]. Delays in calling the RRT persist due to factors such as unnecessary information exchange during calls, hesitancy in communication, and misrecognition of emergencies-despite ongoing research aimed at refining call protocols to facilitate easier access to RRT support [
28]. Ardlianawati et al. [
29] highlighted that simplifying RRT calling through the implementation of a call bell system significantly reduced patient death rates, underscoring the importance of streamlined communication in emergency response. This study further suggested that integrating a direct call button within the EMR system could mitigate these barriers, although such proposals have yet to be adopted-reflecting a gap in organizational support for RRT optimization. Furthermore, the rapid response system relies on EWS indicators such as MEWS and NEWS to trigger automated alerts for potential patient deterioration [
30]. In Korea, adaptations to these scoring systems-including additional parameters like lactate levels-aim to enhance their sensitivity in the Korean medical context [
12,
13]. However, the challenge of real-time data entry into the EMR system, particularly for vital signs and levels of consciousness, impedes the seamless operation of EWS-based RRT dispatch [
31]. While the direct integration of bedside monitor data into the EMR could offer a solution [
31], the prevalent use of multi-occupancy rooms in Korean hospitals limits its feasibility. Consequently, a hybrid model employing both single parameters and EWS has emerged as a necessary adaptation, with ongoing research efforts focused on developing EWS models tailored to Korean healthcare [
12,
13]. These findings highlight critical areas for improvement in RRT dispatch, emphasizing the need for policies that lower the threshold for RRT activation by ward staff and for technological advancements that enable more effective utilization of EWS [
13,
28,
29,
31].
CONCLUSION
This study highlights key challenges and opportunities for RRTs in Korean hospitals, particularly the discrepancy between guidelines and their practical application due to legal limitations on nurse-led RRTs. To increase the effectiveness of RRTs, it is essential to establish a legal framework for RRT nurses, promote interprofessional collaboration, and adapt best practices from established RRT systems to the Korean context. These steps will support improved teamwork and better patient outcomes in the Korean healthcare environment.
However, because this study focused on a specific group of nurses in a particular region of Korea, further research with a larger and more diverse sample is needed to confirm the broader applicability of these findings.
-
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
-
AUTHORSHIP
Conceptualization, Methodology, Software,Validation, Formal analysis, Investigation, Resources, Data curation, Project administration, Funding acquisition, Writing - original draft - MS-H; Methodology, Software,Validation, Formal analysis, Investigation, Resources, Data curation, Writing - original draft - JH; Investigation, Resources, Data curation - JD.
-
ACKNOWLEDGEMENT
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Supplementary Material
Table 1.Focus Group Interview Questions according to the Moderator's Role and Focus Group Interview Process
|
FGI stage |
Moderator's role |
Interview questions |
|
Opening |
∙ Introduce the purpose of the study |
∙ Please briefly introduce yourself and tell us about your clinical experience. |
|
∙ Obtain informed consent |
|
∙ Establish ground rules |
|
Introductory questions |
∙ Encourage participation |
∙ What is the composition of the RRT in your hospital, and what are typical dispatch situations for RRT nurses? |
|
∙ Set the tone for the discussion |
∙ (For ward nurses) What are the typical situations where you collaborate with the RRT? |
|
Transition questions |
∙ Move the discussion toward the key topics |
∙ What kind of help is generally provided by RRT nurses, and what kind of help is received by ward nurses in emergency situations? |
|
∙ Probe for more in-depth responses |
∙ Can you describe a specific case where the RRT's activities had a positive or negative impact on patient care? |
|
Key questions |
∙ Focus on the main research questions |
∙ What are the main facilitators that contribute to the effective operation of the RRT? |
|
∙ Encourage participants to share their experiences and insights |
∙ What are the primary barriers that hinder the optimal functioning of the RRT? |
|
∙ How do you think RRT operations can be improved in the future? |
|
Ending questions |
∙ Summarize the main points of the discussion |
∙ Is there anything else you would like to add regarding the facilitators and barriers impacting RRT operations? |
|
∙ Provide an opportunity for final thoughts and comments |
∙ Do you have any questions or concerns about the study? |
Table 2.The Characteristics of Participants (N=20)
|
Characteristics |
Categories |
RRT nurses (n=10) |
Ward nurses (n=10) |
Total (n=20) |
|
n (%) or Mean (min/max) |
n (%) or Mean (min/max) |
n (%) or Mean (min/max) |
|
Gender |
Men |
0 (0.0) |
2 (20.0) |
2 (10.0) |
|
Women |
10 (100.0) |
8 (80.0) |
18 (90.0) |
|
Average age (year) |
|
32 (27/44) |
27 (24/31) |
30 (24/41) |
|
Total clinical career (months) |
|
112 (47/228) |
49 (13/108) |
81 (13/228) |
|
Education level |
Bachelor's degree |
9 (90.0) |
10 (100.0) |
19 (95.0) |
|
Master's degree |
1 (10.0) |
0 (0.0) |
1 (5.0) |
|
RRT operation (per day) |
24 hours |
6 (60.0) |
3 (30.0) |
9 (45.0) |
|
10 hours |
2 (20.0) |
0 (0.0) |
2 (10.0) |
|
8 hours |
2 (20.0) |
7 (70.0) |
9 (45.0) |
|
RRT's previous place of work |
Internal medicine |
0 (0.0) |
7 (70.0) |
7 (35.0) |
|
Surgery ward |
2 (20.0) |
3 (30.0) |
5 (25.0) |
|
Emergency department |
2 (20.0) |
0 (0.0) |
2 (10.0) |
|
Intensive care unit |
6 (60.0) |
0 (0.0) |
6 (30.0) |
Table 3.Themes and Subthemes of Focus Group Interviews with RRT Nurses and Ward Nurses
|
Themes |
Subthemes |
|
Exploring the essential role of the RRT |
∙ Safety net for critical patients |
|
∙ Coordinator of medical staff |
|
Barriers to RRT operations |
∙ Unclear job assignments without legal safeguards |
|
∙ Conflict arising from hierarchical structures |
|
∙ Insufficient support from the organization |
|
Facilitators of RRT operations |
∙ Transformed perceptions through collaborative efforts |
|
∙ Organizational recognition and support |
|
∙ Self-reinforcement by demonstrating expertise |
|
Constructing a blueprint for future systems |
∙ Clarification of RRT's role and legal authority |
|
∙ Pioneers building the infrastructure |
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