City Research Online

Abstract

Background
Rapid response systems aim to reduce preventable harm through early recognition and response to clinical deterioration. While most interventions target knowledge and skills, limited attention has been paid to the role of non-reflective cognitive processes, including habit and automaticity, in shaping nurses' recognition and escalation of care behaviours.

Objectives
To explore automaticity in recognition and escalation of care behaviours and to examine individual and contextual factors associated with behavioural automaticity.

Design
International, multicentre cross-sectional survey.

Setting
Four acute hospitals in the United Kingdom (n = 2), Singapore (n = 1), and Finland (n = 1), where the National Early Warning Score 2 (NEWS2) was implemented as part of the rapid response system.

Participants
Two hundred and twenty nursing staff working in adult acute wards including registered nurses, enrolled nurses, and healthcare assistants.

Methods
A questionnaire incorporating 22 recognition and response behaviours anchored on the Self-Report Behavioural Automaticity Index was administered. Behaviour enactment in the form of self-rated performance of each behaviour was examined descriptively and compared between countries using chi-square tests. Differences in automaticity were analysed using analysis of variance and general linear models.

Results
Most behaviours were widely enacted (70%–99%), although family-focused communication behaviours were reported less frequently. Mean automaticity scores ranged from 3.5 to 4.0 out of 5, indicating moderate to high automaticity. Automaticity was highest for assessing conscious level and recording vital signs in the health record, and lowest for asking family members how the patient appeared and speaking with family members about clinical deterioration. In general linear models, significant associations were identified for 12 of the 22 behaviours. Country was most consistently associated with automaticity, with participants from Singapore generally reporting lower automaticity than those from the United Kingdom. Job role was associated with measuring vital signs and assessing conscious level, with healthcare assistants reporting lower automaticity than registered nurses. Clinical area was associated with measuring respiratory rate and dialling the emergency number. Time in current role and highest nursing qualification were not significantly associated with automaticity across behaviours.

Conclusions
Recognition and escalation of care behaviours are shaped not only by knowledge and protocol adherence, but also by habitual processes embedded in routine practice. Variation across behaviours and contexts suggests that implementation interventions to improve recognition and response to clinical deterioration should combine educational strategies with approaches that strengthen adaptive practice habits, while preserving reflective clinical judgement when patient presentations are complex or uncertain.

Publication Type:	Article
Additional Information:	© 2026 The Author(s). Published by Elsevier Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Publisher Keywords:	Habits; Patient deterioration; Decision making; Early warning score; Nurses; Rapid response systems
Subjects:	B Philosophy. Psychology. Religion > BF Psychology H Social Sciences > HN Social history and conditions. Social problems. Social reform R Medicine > RT Nursing
Departments:	School of Health & Medical Sciences School of Health & Medical Sciences > Department of Nursing & Midwifery
SWORD Depositor:	Symplectic Administrator

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