Now we know why respiratory rates are poorly recorded: Let’s do something about it!

Mrs Tracy Flenady1, Associate Professor  Trudy Dwyer1, Doctor Judity  Applegarth1

1Central Queensland University, Rockyview, Australia

The Australian Commission on Safety and Quality in Health Care explain that two main factors that contribute to undetected patient deterioration are inconsistent monitoring of vital sign observations and a lack of understanding regarding the significance of physiological changes patients’ exhibit preceding clinical decline. Despite abnormal respiratory rates being recognised as accurate indicators of clinical deterioration, it has been established that this vital sign is the least accurately recorded observation. Little is known about the behaviours of emergency department (ED) nurses when they collect and record respiratory rates.

The aim of this study was to understand this cohorts’ reasons for perpetuating the phenomenon of inaccurate respiratory rate observations. Using grounded theory methodology, 79 ED nurses from across Australia participated in the study. The resulting theory comprises three main categories and associated properties which explain how this cohort rationalise erroneous reporting methods. Compensating (category) occurs when ED RNs feel they are compensating for erroneous reporting methods by adding value to the outcome. This is achieved when RNs believe their time is better spent doing ‘more important’ tasks than counting respiratory rates. Minimalizing (category) occurs when RNs consider the importance of assessing respiratory rates for each patient’s health outcomes, and if the task is seen as less important for that patient, errant behaviour can be rationalised. Trivialising (category) is employed when ED RNs sanction negligent behaviour, and/or negate the importance of organisational requirements by adjusting the deficit between organisational requirements and personal beliefs/ values to virtually nil.

Understanding the reasons for this erroneous reporting provides insight and direction for changing behaviour. Findings from research such as this inform the development of education packages aimed at delivering information to ED nurses that permeate their understanding of the relationship between accurate respiratory rate observations for the broader patient population and optimal patient safety outcomes.


Tracy Flenady is a registered nurse with emergency nursing expertise, a nurse researcher and a PhD Candidate. The focus of her PhD is to develop a theory explaining how nurses rationalise transgression when measuring and recording respiratory rate observations. Her research interests include, Classic grounded theory, emergency nursing, human behaviour in the context of patient safety and the science of knowledge implementation. She is establishing a track record in these areas with publications in book-chapters, peer-reviewed journals and international conference presentations. Tracy is the project manager of a Category I OLT Research grant titled “Preparing undergraduate nurses for the workforce in the context of patient safety through innovative simulation.”