The determinants of nursing staff escalating clinical deterioration out-of-hours: A mixed methods systematic review

‘Failure to rescue’ remains as a critical challenge in acute care globally. Despite the implementation of rapid response systems and early warning scoring tools, adverse outcomes persist especially out-of-hours - defined as night and weekends - when patient morbidity and mortality is higher. The underlying causes of this disparity remain poorly understood. Timely recognition and escalation of clinical deterioration are essential to prevent harm, with nursing staff playing a vital role. However, significant gaps persist in understanding the determinants to escalation out-of-hours. To synthesise existing literature addressing the question: What are the determinants of nursing staff escalating care for clinically deteriorating patients out-of-hours? Embase, Medline, PsycINFO and CINAHL. A systematic mixed-methods review was conducted, covering studies published up to May 2025. Eligible studies examined nursing staff recognition and response to clinical deterioration out-of-hours in adult inpatient wards. Quality appraisal used Critical Appraisal Skills Programme, Newcastle-Ottawa Scale, and the Mixed Methods Appraisal Tools. Data synthesis followed the Joanna Briggs Institute Convergent Integrated Approach. Of 3085 records screened, 26 studies met inclusion criteria (n = 18 quantitative, n = 7 qualitative, n = 1 mixed methods). Most were of moderate to high quality, though limitations in recruitment and reporting were noted. No study exclusively examined the determinants of nursing staff behaviour in escalating care out-of-hours, making this the first comprehensive review on the subject. Five key determinants of behaviour were identified: (1) The unique challenges and workarounds of the ‘hospital at night’ , (2) Workforce composition and team dynamics out-of-hours , (3) Organisational oversight and adaptive strategies , (4) Clinical nursing workflow and supporting resources , (5) Individual determinants of behaviour, strengths and limitations . This review underscores the complex interplay of determinants influencing nursing staff escalation out-of-hours, highlighting the urgent need for targeted interventions to enhance patient safety. Increasing psychological safety, integrating automated vital signs monitoring technologies, and redesigning communication pathways may strengthen clinical decision-making and teamwork. Staffing models and skill-mix require reassessment to reflect out-of-hours challenges. Future research should prioritise feasible, context-sensitive interventions informed by behavioural and human factors science. By advancing these strategies, healthcare organisations can mitigate out-of-hours risks and deliver safer, more effective patient care. https://www.crd.york.ac.uk/PROSPERO/ CRD42024500837, registered 10/January/2024.