A Realist‐Informed Evaluation of a Rapid Response System for Mental State Deterioration in Acute Hospitals: Testing Program Theories Through Interviews

ABSTRACT

Effective management of patient mental state deterioration in acute hospital settings is crucial due to its significant impact on both patients and staff. However, inconsistencies in management strategies highlight the need for standardised approaches. We adopted a realist evaluation approach to gain insights into staff perceptions and experiences, exploring how, for whom and under what circumstances the DIvERT (De‐escalation, Intervention, Early, Response, Team) system, a rapid response system functions in practice. We conducted 23 semi‐structured interviews with clinical staff from two pilot acute hospital settings. The qualitative data were analysed to identify key themes and contextual factors that influence the system's functioning, providing insights into the mechanisms through which DIvERT facilitates proactive intervention. Findings indicated that ward staff valued a structured approach and benefited from interdisciplinary collaboration with mental health experts, which improved their clinical knowledge and confidence. A supportive ward culture, characterised by teamwork and open communication, facilitated collaboration and response effectiveness. However, bedside nurses often deferred escalation decisions to senior staff, have to balance prioritising immediate medical needs over proactive risk management. Inconsistent training, unclear escalation pathways and knowledge gaps, particularly among new graduates, limited system efficiency. Resource shortages and scheduling conflicts further constrained timely responses. Addressing these barriers through structured training, clear escalation pathways and proactive risk management is essential to improving mental state deterioration management. A ward culture that promotes communication, teamwork and effective resource allocation can strengthen the implementation and effectiveness of rapid response systems in acute hospital settings.

1. Background

Managing patients' mental state deterioration (MSD) in acute hospital settings is important because of its profound impact on patient well‐being, their families and healthcare staff. Ensuring safe, high‐quality and comprehensive MSD care is a top priority for healthcare organisations (Garrubba and Joseph 2019; Gaskin and Dagley 2018). MSD, which involves a decline in a person's mental, emotional and psychological well‐being, requires timely intervention to mitigate risks, such as clinical aggression, worsening medical conditions and extended hospital stays (Granek et al. 2019; Mento et al. 2020). However, MSD interventions can inadvertently exacerbate trauma in patients and their families (Duxbury et al. 2019; Tomagová et al. 2016; Udo 2019). Despite the significance, gaps persist between the support patients' need and the care they receive in acute settings, emphasising the urgency for tailored proactive approaches (Alexander et al. 2016; Kaul et al. 2017).

The aetiology of MSD in patients is complex and multifactorial, encompassing factors such as worsening of existing mental illnesses, medical complications and reaction to medical treatments or illicit substances (ACSQHC 2017; NICE 2015). Managing patient MSD in acute hospital settings is challenging, requiring healthcare professionals to tailor treatment plans that address patients' physical and mental health needs while considering the complex interplay of contributing factors (ACSQHC 2021; Granek et al. 2019; White et al. 2017).

Previous discussions on MSD highlight that patients with long‐term mental health diagnoses are at increased risk of developing a wide range of chronic physical conditions, leading to higher rates of admission to acute hospital settings and poorer physical health outcomes (Fok et al. 2019; Roberts 2019; Rodrigues et al. 2021). The complex interconnected nature of mental and physical health underscores the MSD risks for patients when their clinical needs are not proactively managed (ACSQH 2021; Lamont et al. 2025). This complexity challenges healthcare organisations and staff in promptly recognising and responding to mental state changes, emphasising the need for integrated care approaches (ACSQHC 2017; Lamont et al. 2025).

A key challenge in the context of MSD is the effective recognition and management of delirium, particularly among the elderly cohort, vulnerable patient groups and the strain on healthcare resources (Nitchingham and Caplan 2021; Pezzullo et al. 2019). Despite being the most common complication among elderly patients admitted to acute hospitals, it is often overlooked, poorly recognised and inadequately managed (Johansson et al. 2018; McCoy et al. 2017). Effective management of delirium requires interdisciplinary collaboration and the integration of structured screening and responsive care practices to ensure timely and accurate diagnosis and intervention (ACSQH 2021). Addressing these challenges is crucial to effectively managing MSD within clinical environments.

Previous evidence indicates that healthcare organisations lack robust, integrated systems to timely respond to indicators of clinical deterioration, leading to inconsistencies in patient care (Department of Health and Human Services 2014; Victorian Auditor‐General 2015). However, strengthening collaboration with specialist mental health teams can provide essential support and expertise to ensure comprehensive care tailored to mental health needs (Davids et al. 2021; Lamont and Brunero 2018). This multidisciplinary approach is important for improving service delivery and patient outcomes (Griffiths et al. 2014; Somani et al. 2021).

In particular, the role of rapid response systems (RRS) for MSD has not been adequately studied and warrants additional research. RSS are hospital‐wide systems designed to promptly identify and respond to patient deterioration, providing additional clinical expertise and decision‐making support through timely interventions in clinical settings where rapid escalation of care is needed (Jones et al. 2015). RRS typically follow a four‐arm structure: an administrative arm that provides oversight and resources; an afferent arm, where bedside clinicians identify patient deterioration and notify the response team (efferent arm); and a quality assurance arm that monitors compliance and outcomes, ensuring continuous updates to policies and procedures (Jones et al. 2015; Vandegrift et al. 2021). To improve patient outcomes and care standards, organisations must bridge the identified gaps and build on existing knowledge to address the challenges associated with patient MSD (ACSQHC 2017; WorkSafe Victoria 2017).

1.1. DIvERT (De‐Scalation, Intervention, Early, Response, Team) System

The DIvERT system, piloted in a trauma unit and an acute surgical ward within an Academic Health Science Centre of an Australian metropolitan teaching hospital, is a tailored response system designed to initiate early intervention for patients presenting with MSD and provide timely, comprehensive care plans. DIvERT was piloted on the background on increasing rates of patient MSD. The system aimed to support healthcare teams in medical wards to manage MSD risks and prevent escalation to crisis levels by facilitating thorough MSD assessments and recommending tailored trauma informed care plans.

As illustrated in Figure 1, DIvERT is part of a four‐level escalation process: initial management by ward staff, DIvERT, Code Grey and Code Black. Further details on the comparison of MSD escalation levels in acute hospital settings are provided in a table in the Supporting Information section. While DIvERT focuses on timely intervention for managing patient MSD, Code Grey and Code Black serve as distinct emergency response protocols. Code Grey is typically activated in response to incidents of aggression or behavioural disturbances that pose a health and safety risk to staff, patients, or others within the healthcare setting (Department of Health and Human Services 2017). In contrast, Code Black is an emergency response to severe threats, including actual violence or situations involving weapons or armed individuals (Department of Health and Human Services 2017). DIvERT emphasises collaborative intervention planning, involving nursing staff, mental health specialists, medical personnel and allied health team members. On the other hand, Code Grey requires immediate action to manage increased risks, while Code Black necessitates critical emergency response to ensure safety during violent or armed incidents. Further details on these distinctions have been previously discussed in (Dziruni et al. 2024a).

FIGURE 1.

Four‐level escalation process for mental state deterioration in acute hospital settings: Figure outlines the four levels of escalation for managing MSD in acute hospital settings. Each level represents a progressive response tailored to the severity and nature of the risks. DIvERT aims to serve as an early intervention mechanism focused on collaborative assessment and care planning, distinguishing it from the immediate safety‐oriented responses of Code Grey and Code Black.

1.2. Study Aim

Based on a realist evaluation methodology, the aim of this research was to build, support and refine program theories underlying the DIvERT system effective functioning by evaluating the contextual factors and mechanisms that led to its outcomes.

2. Methods

This study adopted a realist evaluation approach to build, validate and refine the program theories underpinning the DIvERT system through in‐depth, semi‐structured interviews. Realist evaluation is a theory‐driven way of thinking that seeks to understand not only whether an intervention works, but also how, why, for whom and under what circumstances it works (Pawson and Tilley 1997). The methodology is rooted in a realist philosophy of science, which acknowledges that interventions function differently depending on the context and the mechanisms they trigger (Pawson and Tilley 1997; Sayer 2000). By exploring the interaction between context, mechanism and outcome configurations (CMOCs), realist evaluation provides nuanced insights into the effectiveness, functioning and adaptability of complex interventions. The CMOC framework specifically examines how contextual factors influence the activation of mechanisms, ultimately shaping the outcomes of interventions (Pawson and Tilley 1997; Wong et al. 2016). Realist evaluation was chosen as it offers the analytical framework needed to understand the complex multifaceted nature of the DIvERT system, particularly how contextual factors influence the mechanisms that lead to specific outcomes.

We conducted realist interviews, guided by initial program theories (IPTs), to uncover the contextual factors, mechanisms and outcomes that influence DIvERT's functioning (Manzano 2016; Pawson 1996). The tentative IPTs were initially formulated during the synthesis protocol (Dziruni et al. 2024b), drawing on scoping the literature and stakeholder insights to hypothesise how DIvERT might function in managing patient MSD within acute hospital settings. IPTs as seen in Table 1 were further developed and refined as reported in our synthesis (Dziruni et al. 2024).

TABLE 1.

Initial program theories.

IPT	Context	Mechanism	Outcome
Theory 1 Nurses' Clinical Skills	If staff are trained to assess MSD early warning signs and are provided with the necessary systems to effectively identify, assess and communicate MSD signs	Then, staff will gain the clinical skills, confidence and experience to empower them to escalate risks to DIvERT in a timely manner	Leading to effectively escalating MSD to the response team, ensuring timely intervention and appropriate management and a positive working environment Unintended outcome: Staff may experience heightened pressure and responsibility to identify and respond to MSD risks promptly, leading to increased stress levels, burnout and feelings of inadequacy or overwhelm among staff members
Theory 2 MSD Timely Assessment	If nurses follow a structured framework together with clinical judgement to trigger when to activate DIvERT	Then, this will facilitate early recognition and escalation of patients at risk of MSD	Leading to escalation for rapid response without delays, resulting in timely interventions and appropriate support for patients at MSD risk Unintended outcome: Overreliance on assessment tools can lead to a reduction in the use of clinical judgement. As staff become accustomed to using structured assessment tools, there is a risk that they may rely solely on these tools without adequately considering the broader clinical context or using their clinical judgement. This could lead to missed opportunities for identifying patients at risk of MSD who may not meet the criteria outlined in assessment tools, resulting in delays in activating DIvERT.
Theory 3 Timely Escalation	If DIvERT is engaged promptly by the ward staff	Then the comprehensive assessment DIvERT conducted with their specialist knowledge facilitates tailored and integrated interventions to manage MSD risks and recommend treatment plans.	Leading to timely intervention, improvement in patient outcomes and MSD care standards. Unintended outcome: Over time, ward staff may become overly reliant on DIvERT to manage MSD, potentially limiting nurses' capacity to proactively recognise and manage MSD. This reliance could strain the DIvERT system resources and delay timely interventions for patients, emphasising the importance of maintaining a balanced approach to managing MSD
Theory 4 Timely Response	If the DIvERT is engaged promptly by the ward staff	Then, with their specialist knowledge, DIvERT can complete a comprehensive, thorough and focused assessment of the patients' MSD risks and needs	This will facilitate tailored interventions for managing MSD risks, recommending treatment plans based on individual needs and optimising integrated care Unintended outcome: Over time, ward staff may become overly reliant on DIvERT to manage MSD, potentially limiting nurses' capacity to proactively recognise and manage MSD. This reliance could strain DIvERT resources and delay timely interventions for patients, emphasising the importance of maintaining a balanced approach to managing MSD
Theory 5 MSD Incident Reporting	If staff consistently report and document MSD incidents in a timely manner based on user‐friendly reporting systems	Then, data accuracy and availability will improve	Resulting in accurate, high‐quality and reliable data for clinical governance purposes, improvement in MSD documentation and an increase in incident reporting rates Unintended outcome: Changing reporting systems may increase staff's workload, requiring more learning, navigation and data entry time. The additional administrative tasks may detract from the responsibilities related to patient care
Theory 6 Organisational Support	If the organisation provides resources to proactively address MSD risks, including staffing levels based on patient acuity and clinical workload demands	Then, patients experiencing MSD will receive appropriate and high standards of care, allowing staff to allocate sufficient time and resources to meet MSD patient needs	Leading to increased efficiency and effectiveness of DIvERT and MSD care delivery, resulting in improved patient safety, reduced staff burnout, a supportive work environment and enhanced organisational performance and culture Negative outcome: If certain departments receive more resources or staffing support to address MSD challenges compared to others, it could lead to disparities in resource allocation for other organisational priorities

This realist interview study is part of a mixed‐methods approach that included a nursing staff survey (Dziruni et al. 2025), field observations and an audit of electronic medical records and MSD incident reports to test, validate and refine the program theories in real‐world settings. This iterative process of testing and refinement ensured that the theories remained evidence‐based and contextually relevant.

The survey results highlighted key factors influencing the management of MSD, including lack of tailored training, confidence in assessing and managing MSD, gaps in MSD incident reporting and the need for improved teamwork, communication and organisational support. These findings informed the refinement of the program theories to better address staff skills, collaboration and organisational processes. To further test and validate these theories, it is essential to engage staff through interviews, as they provide deeper insights into contextual factors and practical challenges that influence the DIvERT system's functioning.

Building on the work of Westhorp and Manzano (2017), we developed an interview guide (see Appendix 1) focusing on theory testing, validation and refinement. The interviews followed a teacher–learner cycle approach, where participant feedback and experience informed the iterative refinement of theories (Mukumbang et al. 2020; Westhorp and Manzano 2017). Semi‐structured interviews, guided by exploratory questions aligned with the initial CMOCs, elicited participants' insights and feedback to test initial theories (Manzano 2016). The guide evolved over data collection and became more tailored to participants' expertise and preliminary findings. Interviewees' responses were used to confirm, refute, or contribute new theoretical insights, facilitating the refinement of CMOCs.

2.1. Setting

The study was conducted at an Academic Health Science Centre of an Australian metropolitan teaching hospital. The DIvERT system was piloted in two selected clinical settings: a trauma unit and an acute surgical ward specialising in burn services, plastics, reconstructive surgery, and ear, nose and throat surgery. Ethics was approved by the university and healthcare ethics committees.

2.2. Recruitment Process

To recruit interviewees, we used a combination of convenience sampling and snowball sampling. Convenience sampling was chosen because it allowed us to access staff who were readily available within the piloting clinical units, maximising participation during busy clinical shifts. Snowball sampling was also used to improve recruitment by asking participants to recommend colleagues who might be interested, leveraging existing professional networks to reach a broader range of staff members.

We accessed the email list for the participating wards through the Nurse Unit Managers (NUMs), while the email list for the Consultation‐Liaison (CL) psychiatry team was obtained from the CL psychiatry team manager. Email invitations were sent exclusively to staff within the participating wards and the CL psychiatry team to ensure relevance and efficiency.

To increase visibility and participation, TBD attended the piloting clinical units during afternoon handover shifts to inform staff directly about the research and invite participation. Additionally, we displayed posters within the clinical units providing details about the study. This multi‐pronged recruitment strategy aimed to maximise staff engagement while ensuring a representative sample of those directly involved in the DIvERT pilot.

2.3. Data Collection

Participants were provided with a participant information sheet detailing the study's purpose, procedures, potential risks and benefits, and their rights, including the voluntary nature of participation and the option to withdraw at any time. After receiving this information, participants provided verbal informed consent before proceeding with the interviews. The interviews were completed in private by TBD, lasted between 20 and 30 min, with a mean duration of 25 min. All interviews were recorded using a handheld recorder. Interviews were transcribed using Microsoft Word and coded in NVivo 14.23.0 by TBD. Data collection was conducted iteratively to ensure the comprehensive refinement of program theories, guided by the RAMESIS Realist Evaluation Reporting Standards (Wong et al. 2017).

2.4. Data Coding

We adopted reflexive thematic analysis to systematically code the data and iteratively identify CMO components and themes (Braun et al. 2019). To improve the validity and relevance of the analysis, we coded the data as interconnected dyads (context‐mechanism or mechanism‐outcome) and triads (context‐mechanism‐outcome) (adopted from Jackson and Kolla (2012)). This approach allowed us to capture nuanced relationships between CMOs, ensuring a deeper understanding of how mechanisms operate within specific contexts.

In RTA Phases 1 and 2, we coded general CMO configurations and patterns, identifying key factors such as staff clinical skills, MSD training, assessment and response. We adopted open and selective coding methods to ensure comprehensive and flexible data categorisation. In Phases 3 and 4, we refined the codes, grouping them into specific categories to accurately reflect emerging themes. In Phase 5, we further refined the codes within each theme and generated clear definitions and names, ensuring that the final thematic structure accurately represented the data.

This systematic and iterative coding process improved the validity by continually cross‐referencing emerging themes with the initial program theories, while relevance was improved by ensuring that identified themes closely aligned with the real‐world contexts of DIvERT functioning.

2.5. Data Analysis

Data analysis was completed by TBD with regular input from the research team (AH, SKA and TB) through fortnightly reflection sessions. Reflection sessions provided an opportunity to critically review emerging themes, discuss interpretations and ensure consistent coding. We used a confirmatory theory refinement approach to link key components and formulate causal pathways, focusing on building and refining theories. Triangulating analytical techniques helped uncover the contexts and mechanisms driving the DIvERT outcomes. For example, after initial coding, the team reflected on how identified mechanisms aligned with context‐specific outcomes, allowing for further refinement of the programme theories.

A key technique used was retroduction, combining inductive and deductive reasoning to theorise the underlying mechanisms (Gilmore et al. 2019; Mukumbang et al. 2021). Retroduction is a reasoning process used in realist research to identify the underlying mechanisms that explain observed events by moving from an observed outcome to hypothesise the deeper causal factors that could have generated them (Jagosh 2020; Mukumbang 2023). Retroduction is fundamental for theorising and uncovering latent causal mechanisms, particularly when investigating complex healthcare interventions, allowing researchers to move beyond surface observations and uncover latent factors that, when activated, influence outcomes in specific contexts (Jagosh 2020; Mukumbang 2023).

We identified and categorised the mechanisms (clinical skills, MSD assessment and DIvERT activation) and analysed their correlations with contextual factors. Configurational mapping explored outcomes from specific context–mechanism combinations and analysed dyad and triad relationships to identify patterns. We constructed CMO configurations to illustrate the contextual relationships and mechanisms. The analysis of theory confirmation and refinement, accompanied by illustrative examples of supporting quotes from participants, is presented in the Supporting Information section.

3. Findings

As summarised in Table 2, the participant demographics included 23 participants, distributed across trauma and acute surgical units, with varying educational backgrounds, professional roles and years of experience. The majority held a Bachelor of Science in Nursing, with a smaller proportion having postgraduate qualifications. Most participants had between one and five years of experience in healthcare, with fewer reporting longer tenures.

TABLE 2.

Participant demographics: Clinical units, educational qualifications, roles and healthcare experience.

Units	n (%)	Educational qualifications	n (%)
Trauma	13 (57)	Bachelor of Science in Nursing	16 (70)
Acute surgical	10 (43)	Master of Science in Nursing	6 (26)
		Psychology Degree	1 (4)
Totals	23 (100)	Totals	23 (100)

Roles	n (%)	Healthcare experience (years)	n (%)
Nurse Unit Manager	1 (4)	0–1	7 (30%)
Associate Nurse Unit Manager	9 (39)	1–5	10 (43%)
Bedside Nurse	8 (35)	5–10	2 (9%)
Clinical Support Development Nurse	2 (9)	10–15	2 (9%)
Clinical Liaison Psychiatry	2 (9)	15–20	1 (4%)
Neuropsychologist	1 (4)	20+	1 (4%)
Totals	23 (100)	Totals	23 (100)

The findings are presented thematically and aligned with the program theories. For example, Theory 1 focuses on the context of clinical skills. This thematic approach offers a structured outline to explore the contexts, mechanisms and outcomes that contribute to the effective functioning of DIvERT.

3.1. Theory 1: Nurses' Clinical Skills

Nurses, particularly junior and newly graduated staff, play a pivotal role in recognising and escalating patient MSD indicators. However, interviewees highlighted challenges related to confidence, awareness and understanding of the DIvERT system. These challenges were exacerbated by limited clinical experience in managing to complex MSD presentations, leaving new graduates feeling unprepared. As one interviewee reflected, “Because patients may have a past history of mental health, ….… that alone is a big shock for a young grad who just hasn't had those life experiences. So, you know, lack of confidence…” (ANUM #12).

Raising awareness and providing DIvERT training were identified as key mechanisms for improving staff competence and confidence in MSD management. Effective multidisciplinary communication and collaboration also emerged as essential to fostering shared understanding and role clarity. One Senior Nurse remarked, “Probably even like a 30 to 45‐minute to about an hour session during the GNP's (Graduate Nurse Program) orientation. Or say we have this program DIvERT, this is what it is, this is what you need to do. This is what we would like to see and giving them some scenarios on how a DIvERT would look like…. Having it ingrained from day one so GNPs are aware that there is DIvERT, that there is a blanket there to support you guys” (CDSN #11). Noting that skills development and training in MSD‐assessment, escalation and multidisciplinary collaboration are important for bedside nurses. Multidisciplinary collaboration was highlighted as important in ensuring bedside nurses actively participated in MSD discussions rather than relying on senior staff. As one nurse noted, “I feel like at the moment with more junior staff, it does more often come from nurse in charge saying, this patient had a Code Grey yesterday, are we going to do the DIvERT” (ANUM #12).

While these mechanisms aim to improve clinical skills, confidence and collaboration, unintended outcomes included increased reliance on senior nurses, adding to their workload. These findings refine the initial programme theory by emphasising the importance of comprehensive training and collaborative environments for improving MSD management and patient outcomes. Table 3 provides an exemplary illustration of the CMO configurations for Theme 1, with additional supporting CMO configurations for the other themes available in Appendix 2.

TABLE 3.

Theory 1 CMO configuration: Nurses' clinical skills.

Contexts	Mechanisms	Outcomes
Staff composition: High proportion of junior nurses with limited experience in MSD, affecting awareness, understanding and confidence in using DIvERT	Awareness and education: Raising awareness and embedding structured DIvERT training to improve staff competence	Improved clinical skills for assessing, escalating and managing MSD
Experience and skill level: Limited exposure to MSD and complex behavioural presentations, leading to uncertainty and hesitation	Simulation‐based learning and mentorship: Providing scenario‐based training and peer learning to strengthen recognition and response skills	Increased confidence and competence among nurses in managing MSD
Competing clinical demands: High workload and fast‐paced environments create time scarcity, making it difficult to complete comprehensive assessments	Task integration and time reallocation: Embedding MSD assessments into workflows, automating reminders and allocating protected time for assessments	Improved clinical judgement, confidence, efficiency and communication, leading to higher standards of care
Organisational culture and team dynamics: Junior nurses defer responsibility to senior staff, leading to a lack of participation in MSD discussions	Multidisciplinary communication and role clarification: Encouraging bedside nurse participation in DIvERT meetings and fostering shared responsibility	More proactive involvement of bedside nurses in MSD escalation and intervention
		Unintended outcomes: Increased reliance on experienced nurses and workload burdens on senior staff, limiting junior nurse participation in MSD discussions

3.2. Theory 2: MSD Timely Assessment

The staff reported inconsistent use of the Mental State Monitoring (MSM) tool for assessing patient MSD. Nurses often prioritised physical health needs over mental health assessments, contributing to incomplete, delayed and reactive MSM assessments. One interviewee noted, “It's not that people are not aware that it needs to be done. I think it's other contributing factors like you know acuity, our patients will always take priority…… If a patient needs something attended to, often, times just goes by fast, it's hard. So it's not that they don't know that they need to do it, it's often that there's a time constraint that it's just not done” (ANUM #14). Staff emphasised the importance of completing MSM assessments promptly, particularly within the first eight hours of admission or following patient transfers.

While nurses acknowledged that structured assessment tools provide a standardised framework for documenting changes in a patient's mental state and improve consistency and reliability in clinical evaluations, bedside nurses reported frequently relying on situational awareness and clinical judgement. One staff highlighted, “MSM is useful for gauging change…… over time, you can pick these things up quicker just with experience” (ANUM #7). Training and awareness initiatives were identified as mechanisms for effectively promoting the use of MSM and the DIvERT system. Documentation and communication improvements, including the integration of MSM into electronic medical records (EMR), were also recommended.

The highlighted outcomes included improved recognition and escalation of patient MSD risks, enabling timely interventions and improving patient safety. However, overreliance on MSM without a comprehensive understanding of the MSD context led to missed opportunities for escalation. Additionally, inconsistencies in adherence to protocols resulted in delays, with escalations sometimes occurring post‐incidents. Staff emphasised the need to balance structured frameworks, such as the MSM tool with clinical judgement to improve consistency in identifying and managing MSD risks. Additional supporting CMO configuration data are provided in the Supporting Information.

3.3. Theory 3: Timely Escalation

The hierarchical structure of wards influenced DIvERT activation, with responsibility typically falling on senior nurses or leadership teams as one participant noted, “DIvERTs are led by the leadership team…… we will always proactively DIvERT on arrival or the following day” (ANUM #14). Junior nurses often deferred escalation decisions to the nurse in charge, leading to delayed escalation. One staff highlighted, “There seemed to be a lot of post‐Code Grey DIvERTs… I cannot remember the last time I attended DIvERT for pre‐empting something” (CLP #23).

Participants emphasised the need for shared responsibility across healthcare teams, including allied health and medical staff, to facilitate timely and proactive escalations. One interviewee emphasised, “Empowering the bedside nurses, allied health and medical teams to actually initiate that DIvERT” (CSDN #11). The findings suggest that repeated exposure to MSD risks can lead to cognitive desensitisation (mechanism), reducing nurses' awareness and sensitivity to early signs of deterioration as highlighted by one nurse, “I think it's because like of our patient cohort, like it becomes very normalised and in a way like, oftentimes I do feel like a bit desensitised, like the things that happen” (Bedside Nurse #16). This normalisation of risks may impact clinical judgement, leading nurses to unconsciously downplay the urgency of escalation.

While proactive DIvERT activations, informed by thorough handover communication, demonstrated potential for improved outcomes, delays in recognising changes in patient MSD often led to Code Grey escalations. Nurses noted the challenges of balancing attending to acutely unwell patients, high patient turnover and resource constraints with MSD escalation responsibilities may contribute to missed opportunities for timely intervention. One staff member highlighted, “The ward is getting heavier, our patients are more complex, not only in medical terms but also social and psychological terms” (CSDN #11). Interviews underscore the importance of empowering all team members to take ownership of escalation decisions. Additionally, supporting bedside nurses in managing patient acuity, protected time for assessments and streamlined escalation pathways to ensure timely detection and response to MSD deterioration.

3.4. Theory 4: Timely Response, Emerging Theory

Organisational structures and workflows created challenges in scheduling and conducting DIvERT meetings. Staff reported difficulties in coordinating meeting times due to competing priorities, particularly during morning ward rounds, which limited the participation of key personnel, such as clinical psychiatric liaison and medical staff. One participant noted, “Psychiatry sometimes is not finishing their ward rounds until 10:30am, and so they cannot make it” (Neuropsychologist #22). Resource constraints and staffing shortages further compounded these issues, leading to delays, cancellations, or low attendance. Another nurse highlighted, “Sometimes you are left there, and no one comes, and you are left to manage things by yourself” (ANUM #2).

Despite barriers, the staff emphasised the importance of multidisciplinary collaboration in DIvERT meetings to manage MSD risks effectively. Mechanisms for improvement included involving bedside nurses, who provide valuable insights into the context of MSD, and integrating DIvERT discussions into existing multidisciplinary meetings. One nurse proposed, “We have a multidisciplinary meeting at 8:30am and another one again at 2:30pm… they do not have to stay for the whole half hour” (ANUM #10). Flexible meeting formats, including remote participation, are also recommended to improve attendance and efficiency.

Effective communication and coordination were identified as essential mechanisms for improving the DIvERT meetings. Proactive involvement of all team members, including psychiatry, allied health and nursing staff, was seen as central to enabling timely interventions and preventing escalation to critical incidents, such as Code Grey events.

3.5. Theory 5: MSD Incident Reporting

As DIvERT was in its pilot phase, staff are not required to formally report DIvERT episodes, and reporting processes were based on Code Grey reporting. Bedside nurses, often first responders to incidents, were responsible for completing the RiskMan forms. One participant explained, “If it is a Code Grey, I actually get the bedside staff to do it because often they're the ones witnessing it” (ANUM #14). However, challenges such as workload, knowledge gaps and unclear protocols affect reporting rates. A bedside nurse remarked, “We are never really taught properly how to fill out a RiskMan” (Staff Nurse #20).

Despite the importance of RiskMan documentation for understanding incidents and informing management, completion rates were low. One nurse noted, “Last month, we had 26 Code Greys but only six RiskMan reports; the completion rate is really poor” (CSDN #11). Time constraints, lengthy forms and unclear categories contributed to this underreporting. However, when completed, RiskMan reports provided valuable insights for identifying trends and areas for improvement, as highlighted: “Most RiskMan reports I have read are very descriptive and give us a better picture of what happened” (CSDN #11).

To improve incident reporting, the staff emphasised the need for streamlined protocols, user‐friendly reporting systems and targeted training. Supportive leadership and fostering a culture that prioritises reporting were also identified as key mechanisms. However, concerns remain regarding increased administrative duties that directly impact patient care responsibilities.

3.6. Theory 6: Organisational Support

A supportive organisational culture and teamwork were highlighted as essential for improving patient MSD management. The staff emphasised the value of collaboration and camaraderie, which facilitated knowledge sharing and strengthened multidisciplinary approaches to holistic care. One nurse underscored, “There is a really wonderful relationship…… we learn things we might not see because we are not exposed to that” (Bedside Nurse #14). Open communication and involving bedside nurses in DIvERT meetings were seen as priorities for fostering understanding and engagement in patient MSD management. An ANUM remarked, “I always get bedside nurses to attend DIvERT…… there's huge value in seeing the process and being involved” (ANUM #7).

However, challenges related to resource constraints and workload prioritisation emerged as significant barriers. The staff reported that high acuity patients, heavy workloads and limited staffing hindered their ability to attend DIvERT meetings or provide adequate care. Nurses relied on peer support and delegation of their patients to other nurses, with one commenting, “If you need to attend a DIvERT, ask your colleagues to look after your patients for 10–15 minutes” (CSDN #11). Despite this, the lack of formal training particularly for new graduates, posed gaps in standardising practice.

Organisational support mechanisms, such as fostering a culture of open communication and providing updated training and resources, were viewed as essential for addressing workload challenges and improving patient MSD risk management. While encouraging teamwork was beneficial, concerns about over‐reliance of junior nurses on senior nurses were identified as unintended outcomes.

4. Demi‐Regularities in MSD Management

The analysis identified several semi‐predictable patterns (demi‐regularities) that underpin the effective functioning of the DIvERT system in acute hospital settings, as shown in Table 4. Demi‐regularity is semi‐predictable patterns or pathways of program functioning, indicating recurring but not universal trends that help identify how contexts and mechanisms influence outcomes (adapted from Vareilles et al. (2017)). A central theme was resource allocation and workload management, where high patient acuity and limited staffing consistently challenged the ability of the staff to attend DIvERT meetings or complete incident reporting. Mechanisms such as peer support, task delegation and flexible scheduling are essential for mitigating barriers, resulting in improved collaboration and task prioritisation.

TABLE 4.

Demi‐regularities underpinning DIvERT effective functioning.

Demi‐regularity	Examples or evidence	Activated mechanisms	Outcomes
Resource allocation and workload management	High workload acuity (Themes 3, 5, 6) Limited staffing levels (Themes 4, 5). Time constraints for reporting (Theme 6)	Peer support and task delegation Flexible scheduling of DIvERTmeetings	Improved workload management and team collaboration Enhanced staff participation in DIvERT processes
Training and knowledge gaps	Lack of training in RiskMan (Theme 6) Limited understanding of MSM tools (Theme 2) Outdated guidelines (Theme 5)	Formal training programs and updated guidelines	Increased confidence and competence in MSD management Standardised use of protocols and tools
Collaborative culture and communication	Multidisciplinary teamwork barriers (Themes 4, 5) Poor communication in escalation (Theme 3)	Open communication channels Multidisciplinary involvement in decision‐making	Proactive risk management and timely interventions Improved patient outcomes and team coordination

Another key pattern was training and knowledge gaps, particularly in using assessment tools, such as Mental State Monitoring and completing RiskMan reports. MSD‐timely assessment, organisational support and incident reporting themes highlighted how formal training programs, updated guidelines and ongoing education may improve staff confidence, competence and adherence to MSD protocols. Finally, collaborative culture and communication emerged as important mechanisms. Timely escalation, response and organisational themes emphasised the importance of multidisciplinary collaboration, shared responsibility and open communication channels in fostering proactive risk management and timely escalation of MSD risks. These demi‐regularities provide actionable insights for improving the functioning of DIvERT, emphasising the need for targeted training, efficient resource management and a culture of collaboration and communication.

5. Refined Program Theories

Building on the identified demi‐regularities, these findings further explain the mechanisms underlying effective MSD management in acute hospital settings. Comprehensive, structured training programs were emphasised as essential for addressing knowledge gaps, particularly among junior staff, and ensuring consistent application of protocols such as RiskMan reporting and Mental State Monitoring. Simplified, user‐friendly incident reporting systems with clear feedback loops were identified as essential for improving reporting rates and system performance. Resource allocation challenges, including high workload acuity and limited staffing, emphasised the need for flexible staffing models and resource prioritisation to support timely responses. Collaborative ward cultures that promote open communication and reduce hierarchical barriers facilitate better teamwork and decision‐making. The consistent application of standardised escalation pathways is pivotal for improving proactive risk management and timely interventions.

Table 5 provides a detailed illustration of the refined program theories and demonstrates how specific contexts, mechanisms and outcomes are connected through causal pathways. For example, if healthcare organisations provide comprehensive training and foster a supportive learning environment, staff develop the skills, confidence and resources necessary to manage MSD effectively. However, unintended outcomes such as increased reliance on experienced nurses and limited participation by junior staff were also noted, highlighting areas for targeted improvement.

TABLE 5.

Refined program theories.

Theory 1: Staff clinical skills	Context: If healthcare organisations provide comprehensive training, facilitate multidisciplinary collaboration and foster a supportive learning environment Mechanism: Staff will develop improved patient MSD clinical skills, confidence and experience (resource) and utilise the DIvERT system effectively (response) Outcome: This will lead to improved management of mental state deterioration and better patient outcomes in acute hospital settings Unintended outcome: Increased reliance on experienced nurses for managing MSD. Limited participation by junior nurses in the DIvERT discussions due to work acuity managing patient MSD Because: The training programs and systems shape the mechanism by providing the necessary knowledge and tools, enabling staff to confidently and effectively respond to patient MSD. Without these resources, the mechanism would be disabled and the desired response would not occur
Theory 2: MSD assessments	Context: If nurses are empowered through training and provided with clear guidelines on the use of structured frameworks, such as MSM (Mental State Monitoring) tools, along with their clinical judgement to recognise early signs of patient MSD Mechanism: Nurses will be more confident and proactive (resource) in triggering the DIvERT system escalation when it is clinically indicated (response) Outcome: Leading to timely interventions and support for patients presenting with patient MSD risks, thereby improving patient safety and well‐being Unintended outcomes: Probable overreliance on tools like MSM without comprehensive understanding or completion, leading to missed opportunities for escalation. Development of skills and intuition over time leading to timely recognition of patient MSD, potentially reducing reliance on structured tools and protocols. Instances where escalations occur post‐incident (e.g., Code Grey) due to delayed recognition or response to patient MSD changes. Inconsistencies in escalating patient MSD by bedside nurses, potentially resulting in missed escalations Because: The structured framework and assessment tools shape the mechanism by offering clear guidelines and support, enabling nurses to make informed decisions. Without these resources, the mechanism would be less effective and the response would be uncertain and inconsistent
Theory 3: Timely escalation	Context: If ward staff, including allied health, are empowered to share the responsibility for proactively identifying and escalating risks when patients present with early indicators of MSD Mechanism: With DIvERT specialist mental health knowledge and through multidisciplinary collaboration (resource), the DIvERT model/system can facilitate comprehensive, thorough and focused assessment of the patients' MSD risks and needs (response) Outcome: Timely engagement of the DIvERT to manage risks and prevent escalations to critical incidents, such as Code Grey events, is crucial. Early recognition and intervention minimise the likelihood of adverse outcomes, thereby improving patient safety and well‐being Unintended outcomes: Over time, ward staff may become overly reliant on DIvERT to manage MSD, potentially limiting nurses' capacity to proactively recognise and manage MSD. This reliance could strain the DIvERT model/system resources and delay timely interventions for patients, emphasising the importance of maintaining a balanced approach to managing patient MSD Because: The involvement of ward staff and allied health enhances the mechanism by leveraging their specialist knowledge and multidisciplinary collaboration. This ensures early recognition and timely intervention, which are crucial for preventing critical incidents and minimising adverse outcomes
Theory 4: Timely response	Context: If there is timely engagement with the DIvERT, adequate staffing levels and resources to support timely response to patient MSD, and clear, standardised protocols for identifying, assessing and escalating patient MSD Mechanism: The DIvERT promptly responds to MSD escalations (resource). Efficient communication systems facilitate rapid communication between ward staff and response teams (response) Outcome: Comprehensive evaluation of patient MSD risks and needs allows for tailored interventions and treatment plans to address patient MSD effectively, leading to improved patient safety and well‐being Unintended outcomes: The delay or rescheduling of the DIvERT meetings due to scheduling conflicts or staff availability challenges. These delays can result in missed opportunities for early intervention and may contribute to the escalation of patient MSD risks Limited participation from DIvERT team members, such as bedside nurses, medical staff and clinical psychiatry, can impact the effectiveness of the DIvERT meetings Because: The presence of the DIvERT specialist knowledge shapes the mechanism by ensuring that comprehensive and expert assessments are conducted. This enables tailored interventions that would not be possible without such specialised input
Theory 5: MSD incident reporting	Context: If staff receive clear guidance and training on the importance and process of reporting MSD incidents Mechanism: They will be more likely to accurately report patient MSD incidents (response), in a timely manner using user‐friendly reporting systems (resource) Outcome: This will improve their understanding of the incidents and ensure proper monitoring and resource allocation, leading to improved patient safety and quality of care Unintended outcomes: This may result in underreporting of incidents, leading to gaps in understanding and response to MSD. Additionally, complex and time‐consuming reporting processes can hinder staff compliance with reporting requirements, while challenges in navigating and completing RiskMan reports may lead to delays or inconsistencies in reporting incidents Because: The user‐friendly reporting systems shape the mechanism by making it easier for staff to document incidents accurately and efficiently. Without these systems, the mechanism would be hindered and the response would be less reliable and comprehensive
Theory 6: Organisational support	Context: If the organisation provides comprehensive resources (e.g., staffing, training, infrastructure) to proactively address MSD risks, dynamically adjusted based on patient acuity and clinical workload demands Mechanism: Allowing staff to allocate sufficient time (reasoning) and resources (response) to meet MSD patient needs through workload redistribution (response) and targeted interventions (reasoning) Outcome: Leading improvements in the efficiency and effectiveness of DIvERT and MSD care delivery, improved patient safety and hospital care, reduced staff burnout, the creation of a supportive and collaborative work environment, and overall improved organisational performance and culture Unintended outcomes: While encouraging colleagues to support each other is beneficial, there may be a risk of staff becoming overly dependent on others to attend DIvERT meetings or manage workload, potentially leading to decreased individual accountability or opportunity to improve clinical skills Despite efforts to promote a culture shift, some staff members may resist or feel apprehensive about embracing new practices or communication norms, leading to resistance and challenges in implementing new interventions Because: The allocation of resources shapes the mechanism by providing the necessary support to staff, enabling them to effectively manage patient MSD. Without adequate resources, the mechanism would be disabled and the response would be insufficient to meet patient needs

6. Discussion

Following a realist evaluation methodology, this study evaluated the effective functioning of the DIvERT system, a tailored rapid response system for managing patients' MSD in acute hospital settings. The evaluation found that DIvERT's functioning is based on multilevel organisational integration, encompassing clear role definitions, MSD training tailored to staff roles, proactive workflow embedding and multidisciplinary collaboration, broadly aligning with findings from other studies in this area (Craze et al. 2014; Lamont et al. 2025; McGaughey et al. 2017). Key causal mechanisms identified included empowering bedside nurses and allied health staff to recognise and escalate MSD based on validated tools, fostering a responsive multidisciplinary team to manage MSD risks and ensuring organisational support through adequate staffing, resources and standardised clinical practices. These factors collectively contribute to improving clinical skills, timely escalation and intervention, and support better patient outcomes and staff confidence (Adams 2017; Chua et al. 2017; Jones et al. 2015).

Previous RRS studies have highlighted challenges in integrating RRS into acute healthcare settings, identifying mechanisms such as the lack of structured protocols, limited interprofessional collaboration due to hierarchical communication, and inconsistent training on non‐technical skills such as communication, teamwork and de‐escalation often leading to variability in care practices (Allen et al. 2017; Baig et al. 2020).

The (ACSQHC 2017) National Consensus Statement on MSD emphasised the need for integrated and holistic approaches when addressing MSD, highlighting the importance of coordinated care, timely escalation processes, structured training and interprofessional collaboration to ensure consistent and effective management of MSD in healthcare settings. Our findings align with this perspective, underlining the importance of addressing contextual factors that shape the implementation and functioning of DIvERT. By focusing on improving clinical skills, fostering multidisciplinary collaboration and establishing clear escalation pathways, the DIvERT system addresses the contextual and mechanistic gaps identified in previous studies, contributing to the evidence on proactive strategies for managing patient MSD in acute healthcare settings.

Interview findings showed that new graduate nurses often lack the experience and confidence in managing patient MSD, impacting their ability to recognise, respond and escalate deterioration. Furthermore, we found that some nurses are task‐oriented, focusing on routine tasks, such as vital sign assessments and venipuncture, impacting the timely assessment of MSD indicators. The literature highlights challenges for nurses in recognising early patient deterioration, including subtle symptoms, reliance on objective data, communication barriers, varying experience levels and organisational factors, such as skill mix, hierarchical structures, workload demands and workplace culture (Bucknall et al. 2024; Donnelly et al. 2024; McGaughey et al. 2017). This aligns with our results, highlighting the importance of tailored training, which has been shown to improve nurses' knowledge, skills and confidence, enabling proactive assessment and management of patients' MSD risks. Continuous training is essential to bridge the gap between theoretical knowledge and practical applications, ensuring that nurses can confidently and effectively use the RRS (Foley and Dowling 2019; Jones et al. 2015). Interviews with staff exploring the causal mechanisms of training indicated that training primarily focused on improving environmental awareness, which is synonymous with breakaway and de‐escalation techniques for managing aggression, rather than specifically improving MSD knowledge (Ferrara et al. 2017; Krull et al. 2019; NICE 2015).

Drawing from the literature and aligned with our findings, the RRS provides ward nurses with opportunities to collaborate and improve their clinical skills in managing patient MSD (Chalwin et al. 2020; Department of Health and Human Services 2014). By proactively leveraging the mental health expertise of the DIvERT team, ward nurses can improve their competency in skills, knowledge and confidence (Adams 2017; Sethi and Chalwin 2018).

Interactions between DIvERT and ward nurses are pivotal, serving as dynamic channels for team learning, knowledge exchange and experiential learning (Griffiths et al. 2014; Martland et al. 2016). Therefore, DIvERT members can explain the rationale behind interventions and educate ward nurses on improved care pathways for patients experiencing MSD. This exchange fosters growth in knowledge and understanding while improving nurses' ability to apply concepts confidently in clinical settings. Furthermore, positive relationships among healthcare staff, built on trust, guidance and effective communication, facilitate the timely escalation of care (Chalwin et al. 2020; O'Neill et al. 2021).

The DIvERT system relies on nurses' timely escalation of MSD risks using evidence‐based assessment tools and clinical judgement (Gaskin 2019). Our findings highlight the critical interplay between the use of assessment tools and clinical judgement in the decision‐making process in clinical settings. Assessment tools, which are often structured and standardised, provide a quantitative measure of a patient's status and offer objective data that can guide initial evaluations (Gaskin and Dagley 2018; NICE 2015). However, tools are most effective when used in conjunction with clinical judgement and nurses' subjective evaluations based on experience, knowledge, awareness of the underlying causes of deterioration and understanding of the patient's context (ACSQHC 2017; Burke and Conway 2022; Gottlieb et al. 2018).

Evidence from staff interviews highlighted how assessment tools and clinical judgement influenced nurses' decision‐making in escalating patient MSD risks to DIvERT. Similar to Padilla et al. (2018), we found that bedside nurses often delayed the decision to escalate, contributing to missed opportunities for timely intervention. Evidence suggests that junior nurses may need encouragement from experienced staff to escalate deterioration (Astroth et al. 2017). Consequently, we found that the nurse in charge often drove decisions to trigger DIvERT. The factors that impede nurses' decision‐making processes include balancing clinical judgement with assessment scores, confidence in communication and escalation, and differentiating subtle changes in patient deterioration (Ede et al. 2021; McGaughey et al. 2017). Staff are often reluctant to breach the traditional patient management system due to fear of criticism and being reprimanded if they bypass attending medical doctors, especially among less experienced nurses (Astroth et al. 2017; Chua et al. 2017; O'Neill et al. 2021). Furthermore, the decision to activate rapid response is often moderated by seeking affirmation from peers and gathering more clinical indicators to avoid unnecessary activation or to justify the need for escalation (Chua et al. 2017).

An analysis of the DIvERT pathways activated by staff, both in identifying and addressing challenges, underscored the importance of collaboration in achieving timely responses and interventions, consistent with findings from previous studies (Lyons et al. 2018; Olsen et al. 2019; Padilla et al. 2018). This cycle of prompt assessment and rapid response is important for the effective operation of DIvERT, as it facilitates timely intervention, improves patient safety and ensures efficient resource utilisation (Dziruni, Hutchinson, Coomer, et al. 2024; Martland et al. 2016). Additionally, a reliable system that supports timely responses can increase staff confidence and strengthen the overall organisational culture, leading to improved patient care (Astroth et al. 2017; Jensen et al. 2018; O'Neill et al. 2021).

Consistent with the literature, we found that effective communication and collaboration between DIvERT and ward staff emerged as vital mechanisms for the functioning of the DIvERT system (Chalwin et al. 2020; Department of Health and Human Services 2014; Hamilton et al. 2016; Martland et al. 2016). Mental health specialists, ward nurses, allied health professionals and doctors must work cohesively and share information and strategies to effectively manage MSD (Donnelly et al. 2024; Sethi and Chalwin 2018; Somani et al. 2021). The involvement of bedside nurses during the DIvERT response, along with improving nurses' confidence in assessing and escalating MSD risks, is crucial for the effectiveness of the response system (Chua et al. 2017; Sethi and Chalwin 2018). Furthermore, effective rapid responses depend on the clear acknowledgement of care plans between the ward team and the responding team as well as on evaluating whether the ward team can safely and effectively manage the patient's ongoing needs (Chalwin et al. 2020; Chua et al. 2017). Unresolved clinical concerns may result in unease and lead to repeated response activation (Chalwin et al. 2020).

Interviews highlighted that a practical challenge with DIvERT is its limited operational hours, typically functioning only at a set time in the morning, with responses deferred outside of these hours until the following day. This scheduling contradicts the principles of rapid response systems, which aim for immediate intervention upon patient deterioration indications (Jones et al. 2015; Lyons et al. 2018; Padilla et al. 2018). Sebat et al. (2014) underlined that the primary goal of RRS should be the identification and treatment of patients within the “golden hour” when interventions have the greatest chance of improving outcomes.

While the pre‐existing Code Grey response allows for escalation at any time, expanding DIvERT's operational hours to 24‐h coverage could improve its effectiveness because it would ensure continuous access to specialised mental health support, facilitate timely interventions during off‐peak hours and reduce reliance on crisis‐driven responses. However, this extension would require careful consideration of resource allocation, potential staff fatigue and cost implications to balance benefits with operational sustainability. Feedforward and feedback mechanisms, implemented through regular response protocol reviews, incorporation of staff feedback and adjustment of staffing models tailored to peak times of patient deterioration, are recommended to optimise resource allocation and enhance system functionality (Chua et al. 2017; Victorian Auditor‐General 2015).

Interviews revealed challenges in triggering DIvERT after Code Grey responses and with repeated activations for the same patients on consecutive days. The staff questioned the utility of immediate DIvERT activation following a Code Grey and the value of repeated activations without time for interventions to take effect. A triaging system to review DIvERT escalations was suggested to ensure appropriate justification and to reduce unnecessary repeat activations. This evaluation highlights some of the challenges associated with implementing an RRS and the priorities that must be addressed to improve its effectiveness.

7. Strengths and Limitations

The strength of realist evaluation is rooted in uncovering the contexts and mechanisms through which interventions produce outcomes, rather than merely assessing their effectiveness. Our study provides practical insights for policymakers and organisations to consider when designing and implementing response systems for managing MSD, helping to better meet the needs of both patients and healthcare providers. However, the study was conducted in two acute hospital settings within one hospital, which may limit transferability. Further research across diverse settings is needed to strengthen our understanding and applicability. While we interviewed nurses, neuropsychologists and clinical liaison psychiatry staff, including doctors who care for acute patients would have enriched the multidisciplinary perspective on managing MSD.

8. Conclusion

This realist evaluation of a rapid response system for MSD in acute hospital settings highlights the complexity of implementing effective integrated mental health care. Multiple factors, including timely assessment, escalation, response, interdisciplinary collaboration, policies and organisational executive support, influence the effective functioning of the response system. Addressing barriers such as resource constraints, organisational culture and training gaps is important for improving patient outcomes and staff confidence. By incorporating these findings into practice and policy, hospitals can improve their capacity to deliver timely and effective mental healthcare. This collaborative approach ensures that evidence‐based interventions are directly applied to improve the well‐being of patients presenting with MSD and foster a more responsive healthcare environment.

9. Relevance for Clinical Practice

Effective management of mental state deterioration in acute hospitals requires structured, timely approaches. This study highlights the benefits of interdisciplinary collaboration, clear escalation pathways and structured training in improving staff confidence and response effectiveness. Addressing resource challenges and improving ward culture through teamwork and communication can strengthen rapid response systems. Implementing these strategies can improve patient safety, reduce reliance on restrictive interventions and improve clinical decision‐making in acute hospital settings.

Author Contributions

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors agree with the manuscript.

Disclosure

The authors have nothing to report.

Ethics Statement

The research was approved by the ethics committees of both the Deakin University Human Research Ethics Committee (Ref: 2024‐105) and the Alfred Health Ethics Committee (Ref: 176/22).

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Appendix 1. DIvERT Interview Guide

Basic Information about the interview DIvERT Realist Evaluation: Speakers (identified by pseudonyms): Date and time of the interview: Setting: Audio file name or number:

Introduction The healthcare organisation evaluating the DIvERT intervention to better understand how it works to improve mental state deterioration in acute hospital settings. This interview is part of the evaluation to gain a better understanding of the intervention. The knowledge and experience you have gained about mental state deterioration and how the DIvERT intervention works are valuable to the evaluation. If you agree to participate, we will ask you general questions about your experience about the DIvERT program and how it is working on the ward. Participation is voluntary and will not affect your routine care, your relationship with professional staff, or your relationship with Alfred Health. The information you provide will be kept confidential and we will ask for your personal details.

Opening questions How long have you worked in healthcare and with the organisation. What are your qualifications? Can you tell me what your role and your involvement with DIvERT?

Perceived Outcomes of DIvERT What do you consider the outcomes of DIvERT to be for patients on the ward? What outcomes do you perceive for the staff due to the implementation of DIvERT? Do you believe the outcomes have been consistent for all patients presenting with mental state deterioration (MSD)? In what ways have they been different? Have the outcomes been the same for patients presenting with aggression, delirium, or self‐harm? In what ways have they been different? Can you describe a specific incident involving DIvERT and its impact on managing mental state deterioration? Understanding causality and perceived changes How do you perceive the role and effectiveness of DIvERT in addressing mental state deterioration incidents? How do you believe DIvERT has influenced the identified outcomes? In your opinion, has DIvERT changed the way you think or feel about MSD? If so, how? Mechanisms and implementation How do you think DIvERT has enhanced the clinical skills and resilience of staff? Can you provide an example? Has DIvERT functioned effectively as an early intervention to prevent escalation of risks? Can you share examples from your experience? How does DIvERT align with broader general nursing duties, especially concerning MSD? In your view, what aspects of the implementation of DIvERT have affected its effectiveness positively or negatively? What specific factors contribute to the variations in how DIvERT functions on your ward? Learning and training What is the relationship between DIvERT team and the ward team? Do you feel it provides learning opportunities? If so how. Aside from the response team model, do you attend any other training to improve your clinical skills for MSD? Recommendations and reflections If you could enhance DIvERT to make it more effective, what changes would you propose and why? Looking back, what could have been done differently to improve the effectiveness of DIvERT? Based on your experience, how do you think DIvERT could be adapted or applied in different clinical settings? What recommendations do you have for enhancing training and preparedness of staff in managing mental state deterioration on the ward? Are there any additional resources or support systems you believe would enhance the effectiveness of DIvERT? Is there anything else you'd like to share or any additional insights you believe are crucial for understanding how DIvERT has worked here?

Probes to be used to elicit more information “Tell me more.” “I need more detail.” “Could you explain a bit more about what you said” “What is about that” “Can we focus here a bit longer”

Closing instructions Thank the interviewee for their time and answer any questions.

Appendix 2. CMO Configurations Across Themes

Theme	Contexts	Mechanisms	Outcomes
Nurses' Clinical Skills	Predominance of junior nurses with high turnover rates impacting MSD awareness and confidence Task‐oriented approach focused on routine duties rather than holistic patient care	Training and skill development programs to improve MSD assessment and escalation Multidisciplinary collaboration to build confidence and competence	Enhanced clinical skills for MSD management Increased staff confidence in escalation processes Improved patient outcomes through timely responses
MSD Timely Assessment	Reliance on intuition for identifying MSD risks Challenges integrating MSM tools into workflows Limited training on tools like MSM	Raising awareness and training for MSM tool usage Improving documentation through EMR integration	Timely and consistent MSM assessments Enhanced identification of patient MSD risks Reduced ambiguity in decision‐making
Timely Escalation	Hierarchical ward structures influencing escalation roles Junior nurses deferring decisions to senior staff. Reactive rather than proactive escalation practices	Empowering all healthcare team members to share escalation responsibilities Leadership involvement and structured protocols for proactive risk assessment	Timely DIvERT activation Proactive risk management Multidisciplinary collaboration reducing critical incidents
Timely Response	Scheduling conflicts for DIvERT meetings due to workload pressures and ward rounds Limited availability of key personnel like psychiatrists and medical staff	Flexible scheduling of DIvERT meetings Integration of DIvERT into existing multidisciplinary handovers Encouraging remote participation for wider inclusion	Increased participation in DIvERT meetings Early interventions ensuring patient safety More effective risk assessments
Organisational Support	Collaborative culture prioritising safety and teamwork Limited formal training for new staff. Outdated protocols impacting staff confidence and competence	Open communication and peer support to handle workload challenges Regular training and updated guidelines for standardisation	Improved collaboration and transparency Enhanced confidence in MSD management Increased attendance in DIvERT processes
MSD Incident Reporting	Low RiskMan reporting rates due to unclear protocols, time constraints and knowledge gaps Complexity of forms discouraging completion	Simplified reporting protocols and user‐friendly systems Training staff on efficient documentation practices	Higher reporting rates and improved documentation quality Quality data for clinical governance and incident trend analysis

Dziruni, T. B. , Hutchinson A. M., Keppich‐Arnold S., and Bucknall T.. 2025. “A Realist‐Informed Evaluation of a Rapid Response System for Mental State Deterioration in Acute Hospitals: Testing Program Theories Through Interviews.” International Journal of Mental Health Nursing 34, no. 3: e70083. 10.1111/inm.70083.

Data Availability Statement

The data that supports the findings of this study are available in the Supporting Information of this article.