Date of Award


Degree Name

Master of Nursing (Research)

Schools and Centres

Nursing and Midwifery

First Supervisor

Associate Professor Kylie Russell

Second Supervisor

Doctor Tracey Coventry


The Western Australia (WA) Country Health Service (WACHS) requires a ward or emergency department registered nurse (RN) to assume the responsibility of conducting inter-hospital nurse-led patient ambulance transfers. In WACHS, these nurses are usually generalist nurses with no specialised training. WACHS has various escalation policies, guidelines and support systems for nurses when they are located within the hospital and wards. However, despite these escalation protocols being clear in this setting, their relevance and practicality during patient transport is uncertain. This research explores how well equipped WACHS RNs in the Wheatbelt region of WA are in managing clinical deterioration of patients during inter-hospital nurse-led ambulance transfers.

The WACHS Wheatbelt has identified ‘failure to recognise the need to escalate clinical care’ as a clinical risk in the in-hospital setting. The risk outlines knowledge and skills deficits, lack of access to specialist advice, failure to recognise observations that fall into the parameters that require intervention, and failure by nurses to follow clinical deterioration policy as causes that result in treatment delay, increased morbidity and mortality, delay in transfer, and increased length of stay. It should be appreciated that during road transfer there are additional factors that will increase the risk of failure to adequately detect and manage acute clinical deterioration.

This study aims to

• explore nurses’ perceptions about caring for a patient during road ambulance transfer, acknowledgement of clinical deterioration, and its occurrence on patients being transferred, and how well equipped the nurse escort is in detecting and managing acute deterioration; and

• seek to support future policy formulation and decision-making with regard to nurses training, induction and ongoing education on inter-hospital transfer. This study employed a mixed methods descriptive design using quantitative and qualitative data obtained in two phases. In Phase One using an online survey, the study explored the self-reported skills level of the RNs, the support available during transport, their perceptions of their role and abilities during transport, and their confidence and knowledge to enact policies that govern their practice away from the hospital setting. In Phase Two, the nursing leaders and policy makers were interviewed on an individual face-to-face basis, where they were requested to clarify, elaborate or comment on the quantitative and qualitative data from Phase One.

Phase One respondents acknowleged that nursing a patient in an ambulance had associated risks that require advanced clinical skills and confidence that would not normally be as critical when working within a hospital and with a team. Ambulance transfer logistics and inherent challenges require a trained patient escort. Respondents highlighted different practices, use of different guiding tools, and processes that were not uniformly applied within the region. This variation was evidenced in the different documentation kept by nurses during transfer, different interpretation of available policies, escalation processes for deterioration, and general attitude towards conducting these transfers. Inter-hospital patient transfers were viewed as complicated with associated risks, most of which were expected and cannot be completely eliminated. However, there was an acknowledgement that some of the factors that negatively affect these transfers could be eliminated by clearer guidelines and support for the transferring nurse.

During Phase Two, a significant finding highlighted how the patient was in most instances safe, but the likely lack of support for the nurses due to ambiguity with inadequate backup was reaffirmed. Phase Two also confirmed that if strategies were to be put in place to guide, support and prioritise not only patient safety but also nurses’ welfare, then the model of using RNs to conduct inter-hospital nurse-led patient transfers would need to be sustainable and can be improved. This was important to note as it is unlikely that the RN will remain the most likely staff member to continue to meet the ever-growing demand to transfer patients intra-regionally and to metropolitan areas by road ambulance.

There was a general appreciation that inter-hospital transfers are complex and that the WA rural health setting is unique and challenging. The generalist RN was viewed as having vital transferrable skills to adequately care for patients being transferred. These RNs were reported to be skilful and resilient in a setting where there is limited support for their personal wellbeing or professional development. The policies relating to inter-hospital patient transfers were assessed as unfamiliar, irrelevant or impractical, leading to disparities between what the policy stipulates and the realities of practice. This study will be critical in supporting health service discussions about policy formation and decision-making with regard to nurses’ training, induction, ongoing education and support in the ever-growing nurses’ responsibility of transferring patients between hospitals.

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