Escalating Concerns and Speaking Up for Student Nurses
Recognising that a patient is becoming unwell is only part of safe nursing practice. Student nurses also need to know how to raise concerns clearly, promptly and persistently when something does not feel right.
Speaking up can be a patient-safety intervention
Deterioration may begin with small changes: a patient may seem more breathless, unusually sleepy, confused, clammy, restless or simply "not right". Sometimes these changes occur before there is a dramatic alteration in observations.
As a student nurse, you are not expected to diagnose the cause of deterioration independently. You are, however, expected to observe carefully, recognise concerning changes and communicate them to the registered professionals responsible for the patient's care.
Recognise
Notice changes in observations, behaviour, appearance, symptoms or clinical presentation.
Respond
Begin an appropriate assessment within your competence and seek supervision where required.
Report
Communicate concerns clearly to the registered nurse or other appropriate clinician.
Re-escalate
If the patient's condition remains concerning or worsens, raise the concern again using the local escalation pathway.
Do not wait for certainty before raising a concern
Escalation is appropriate whenever you identify a significant change, a potentially unsafe situation or a clinical concern that needs review. You do not need to know the diagnosis before speaking up.
- A patient's NEWS2 score has increased or reached a local escalation threshold.
- Respiratory rate, oxygen saturation, pulse, blood pressure, temperature or level of consciousness has changed significantly.
- The patient develops new breathlessness, chest pain, confusion, reduced responsiveness or severe weakness.
- You notice signs that may suggest sepsis, shock, respiratory compromise or neurological deterioration.
- The patient looks substantially different from earlier, even if observations appear relatively stable.
- The patient or their family expresses serious concern about deterioration.
- You believe care has been delayed, omitted or has become unsafe.
- You have already raised a concern but the patient's condition remains worrying.
What to do when you become concerned
Stay with the patient if necessary
If the patient appears acutely unwell, remain with them where safe to do so and obtain immediate assistance. Do not leave a seriously deteriorating patient alone simply to complete documentation or find equipment.
Call the registered nurse or supervisor
Inform the nurse responsible for the patient, your practice supervisor or another appropriate registered practitioner. State clearly that you are concerned and why.
Give specific information
Avoid vague messages such as "Can you come and have a look?" when the situation is urgent. Explain what has changed, give relevant observations and describe the patient's current condition.
Use SBAR where appropriate
SBAR can help you structure urgent communication: Situation, Background, Assessment and Recommendation. Keep the most important concern at the beginning.
Follow local escalation policy
Escalation pathways differ between organisations. Depending on the setting this may involve the nurse in charge, medical team, outreach or critical care team, emergency response team or another designated clinician.
Escalate again if needed
If your concern has not been addressed and the patient remains at risk, raise it again with a more senior practitioner in accordance with local policy. Persistent concern should not be quietly abandoned.
Use language that makes the urgency obvious
Students can sometimes soften their language because they are unsure of themselves. In an urgent clinical situation, clarity is safer than excessive politeness or vague wording.
| Less effective | Clearer escalation language |
|---|---|
| "Could you look at bed 4 when you have a minute?" | "I'm concerned about the patient in bed 4. Their respiratory rate has risen to 30 and they are more breathless." |
| "They don't seem quite right." | "They are newly confused, pale and difficult to rouse compared with an hour ago." |
| "The observations are a bit strange." | "Their blood pressure has fallen from 128/74 to 88/54 and their pulse is now 118." |
| "Sorry, I know you're busy..." | "I need you to review this patient now because I am worried they are deteriorating." |
Example of a concise escalation
A simple structure when you need to organise your thoughts
S — Situation
Identify yourself, the patient and the immediate concern.
Example: "I'm worried that Mr Jones is becoming acutely breathless."
B — Background
Give only the relevant clinical context, such as diagnosis, recent procedure or important history.
A — Assessment
State what you have observed, including relevant ABCDE findings, observations and NEWS2 where appropriate.
R — Recommendation
State what you need, for example an urgent review by the registered nurse or medical team.
Professional persistence is part of safe care
It can feel difficult to challenge or re-approach someone who is more experienced than you. However, hierarchy should never prevent appropriate escalation when patient safety is at risk.
If you have raised a concern and believe the patient still requires attention, explain again what is worrying you and state what has changed. If the concern remains unresolved, follow the next step in the organisation's escalation process.
Useful phrases
- "I am still concerned about this patient."
- "Their condition has changed since I first spoke to you."
- "I don't feel reassured by their current presentation."
- "Could we review them together now?"
- "Who should I escalate this to next?"
- "I think this needs urgent senior review."
Know when escalation needs to be immediate
Some situations require immediate emergency assistance rather than routine review. Examples may include severe respiratory distress, unresponsiveness, suspected cardiac arrest, rapidly worsening airway compromise or another life-threatening deterioration.
In these circumstances, activate the emergency response appropriate to your clinical area and organisation, obtain registered help immediately and perform only those actions you are trained, competent and authorised to perform.
Record observations and escalation accurately
Documentation should reflect what you observed, what was measured, who was informed and what action was taken, in line with your local documentation policy and level of responsibility.
Record facts rather than assumptions. Avoid retrospective alteration of records and seek guidance from your supervising registered nurse if you are uncertain about what should be documented.
- Record relevant observations and assessment findings accurately.
- Document the time of significant changes where appropriate.
- Record escalation and subsequent actions according to local policy.
- Report further deterioration rather than relying on documentation alone.
Speaking up does not mean working beyond your scope
Student nurses should participate actively in patient assessment and safety, but always within their competence, level of training and the supervision arrangements of the placement.
You should
- Report worrying changes promptly.
- Ask for help when uncertain.
- Use clinical observations and structured communication.
- Follow local deterioration and emergency policies.
- Re-escalate unresolved safety concerns.
You should not
- Delay escalation while trying to diagnose independently.
- Perform interventions you have not been trained or authorised to undertake.
- Ignore a concern because someone senior appears busy.
- Assume a normal-looking NEWS2 score means the patient cannot be deteriorating.
- Allow hierarchy to prevent appropriate patient-safety escalation.
Five things to find out early
- How does this clinical area summon emergency help?
- Who is the nurse in charge and who should you escalate concerns to?
- What NEWS2 or observation escalation policy is used locally?
- How do you contact the medical, outreach or emergency response team?
- What supervision is required for assessments and interventions at your stage of training?
A deterioration scenario
Scenario
You are caring for a patient who was comfortable earlier in the shift. They now appear restless and breathless. Their respiratory rate is 31, pulse 116 and oxygen saturation has fallen compared with previous observations.
Your priorities
- Recognise that the change is clinically significant.
- Remain with the patient if their condition appears unstable.
- Call the supervising registered nurse promptly.
- Communicate the changes clearly using ABCDE findings and SBAR where useful.
- Ensure local escalation procedures are followed.
- Continue observation and report any further deterioration.
You are not expected to independently determine the diagnosis. Safe student practice means recognising deterioration, obtaining appropriate help and contributing to the assessment under supervision.
Key takeaway
Speaking up is an essential clinical skill. If a patient appears to be deteriorating, communicate your concern promptly, use specific clinical information, follow local escalation procedures and raise the concern again if the situation remains unsafe.
As a student nurse, always work within your competence and scope of practice, use appropriate supervision and follow your university, placement provider and local organisational policies.
