Coronary care nurses’ clinical decision making

Abstract

Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses' decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be incorporated into knowledge-system design. One implication of the variability in subjects' line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects' performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.

Critical care cardiovascular nurse expert and novice diagnostic cue utilization

“…To develop effective and efficient knowledge‐based systems for supporting diagnosis (e.g. expert systems) in the practice setting, it is important to understand the nature of diagnostic expertise (Woolery 1990, Corcoran‐Perry et al . 1999, Montani et al .…”

Judgments of Critical Care Nurses About Risk for Secondary Brain Injury

“…[30][31][32][33][34][35][36][37][38][39][40] The types of judgments typically made by nurses can vary, depending on the shift worked and whether or not a nurse is performing an initial assessment on a patient or has provided care for that patient before.…”

Intensive Care Unit Nurse Characteristics Impacting Judgments About Secondary Brain Injury

“…The individual characteristics of the ICU nurse, such as age, years of experience, education, and nursing shift have been shown in other studies to influence judgments and decisions of ICU nurses in general. [17][18][19][20] Because care of the critically ill TBI patient can be especially complex, and because nursing interventions for these patients can prevent fluctuations in physiological parameters, thereby preventing secondary brain injury, 11 this study sought to explore how individual nurse characteristics influenced judgments when caring for this specific patient population.…”

“…18 As a result, skilled ICU nurses rely on previous judgments and use different reasoning processes, particularly when detecting subtle changes in a patient's condition that may signal an acute deterioration. [19][20][21][22] Intensive care unit nurses are adept in making appropriate judgments and decisions in a crisis situation, and a significant number of decisions are made for patients before contacting a physician. 23 …”