Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

Diagnostic Reasoning Foundations: Theoretical and Scientific Background With Suggested Competencies for Nurse Practitioner Education

This article provides a comprehensive narrative review and explanation of the theory, science, and component processes of diagnostic reasoning, based on over 30 years of diagnostic reasoning literature. Building on this background information and the authors' nurse practitioner education and practice expertise, foundational diagnostic reasoning concepts and processes are applied to nurse practitioner education and practice. Foci are suggested for nurse practitioner education competencies in the diagnostic reasoning components of illness scripts and script activation, interaction and encounter management, hypothesis-directed patient evaluation, problem representation and differential diagnosis, value-based testing, identifying and communicating the working diagnosis, developing the management plan, and metacognition and documentation. The desired goals include highest quality practice, diagnostic safety, and improved health outcomes.

Critical care nurses' responses to clinical scenarios involving cardiopulmonary resuscitation for deceased inpatients without a Do Not Resuscitate order: A cross-sectional study

BACKGROUND

Current Australian resuscitation training focusses on the practical application of cardiopulmonary resuscitation but lacks clarity on when it is inappropriate. Nurses are often first responders to inpatient emergencies and may take different approaches to cardiopulmonary resuscitation due to their views about its benefit. There is a lack of literature on how the absence of Do Not Resuscitate orders affect nurses' decisions regarding resuscitation in hospital settings.

OBJECTIVE

The aim of this study was to explore nurse's views of initiating cardiopulmonary resuscitation on inpatients with unequivocal signs of death without a Do Not Resuscitate order, using hypothetical scenarios.

METHODS

The cross-sectional survey recruited nurses across five Australian hospitals between October 2023 and April 2024. Participants were provided two hypothetical clinical scenarios (scenario 1: Mr D, an 84-year-old man; scenario 2: Mr G, a 35-year-old man). In both scenarios, the patients had unequivocal signs of death and absent Do Not Resuscitate orders. Respondents were asked to indicate their actions. Responses from participants working in the intensive care unit, emergency department, or critical care are reported here. Results were analysed using descriptive statistics.

RESULTS

Eighty participants working in the intensive care unit, emergency department, or critical care completed the survey. Most nurses indicated they would call a Code Blue and initiate full resuscitation in both scenarios (scenario 1: 51.3% [n = 41] vs scenario 2: 92.5% [n = 74]). Fear and a misunderstanding of the law was a recurring reason for initiating resuscitation in both scenarios. Ethical judgement and family's expectations were predominant reasons for initiating resuscitation for the younger patient (scenario 2).

CONCLUSIONS

Most nurses working in the intensive care unit, emergency department, or critical care areas chose to call a Code Blue and initiate full resuscitation in both scenarios where patients showed unequivocal signs of death and an absent Do Not Resuscitate order. Nurses' decisions were influenced by multiple factors, including patient's age and misconception of the law.

Relationship between social identity and cultural competence among Mexican nursing professionals

INTRODUCTION

Cultural competence in nursing is crucial for providing effective health care. Social Identity is the degree to which they identify with their professional group. Identifying with the group of nursing professionals allows nurses to connect with norms and values that favor the development of cultural competence. The objective of this study is to analyze the relationship between social identity and the level of cultural competence of nursing professionals.

METHODOLOGY

This was a cross-sectional correlational study (n = 211). Sociodemographic data were measured, and Cameron's social identity scales and a cultural competence measurement scale were used. The data were analyzed using correlations and a structural equation model.

RESULTS

The structural equation model demonstrated good fit (CFI = 0.94, TLI = 0.928 WRMR = 0.952, RMSEA = 0.058). The model indicated positive and significant relationships between social identity, cultural skills, and knowledge. However, it also revealed a negative and significant relationship between social identity and cultural awareness.

CONCLUSIONS

The findings suggest that greater identification with the nursing profession by nursing professionals is associated not only with higher levels of cultural knowledge and skills but also with lower levels of cultural awareness. This finding may be due to the fact that individuals seek to reinforce their professional identities when they feel that acknowledging their own personal biases represents a threat.

CLINICAL RELEVANCE

This study contributes to the understanding of how social identity can be related in a different way to the components of cultural competence. This work recognizes the challenges in developing cultural awareness in nursing and suggests that its findings can inform interventions to improve patient care and relationships.

The Scope of Nurses' Assessment of Deteriorating Patients in Coronary Care Units: A Mixed Methods Study

BACKGROUND

Despite the high acuity of coronary care unit (CCU) patients and their risk of deterioration, little is known about how nurses assess them.

AIM

Increase understanding of the scope of nurses' assessments of deteriorating CCU patients.

DESIGN

Online mixed methods survey.

METHODS

The mRAPIDS (modified Rescuing a Patient in Deteriorating Situations) tool was used to measure assessment scope in responses to a patient vignette with a higher mRAPID score signalling broader scope (maximum score 24). Reflections on day-to-day practice were collected concurrently and thematically analysed. Themes were integrated with scores using a joint display table and organised into domains. Comparing 'fit' between data showed expansion (overlap with broader nonoverlapping findings) and disconcordance (contradictory findings).

RESULTS

Thirty-four nurses responded, and scope of assessment was found to be narrow (median mRAPIDS 5). Two domains were identified that helped explain this finding 'the act of assessment' and 'education and experience'. Participants emphasised the importance of education and experience, neither increased assessment scope.

CONCLUSION

This study showed that participant assessments were generally narrower than widely accepted best practice (ABCDE assessment).

IMPLICATIONS

Participant assessments did not reflect gold standard A-E assessment, which may partly reflect a need for assessment frameworks that are more compatible with real-world practice. Further research is required to understand the role of healthcare assistants in the care of deteriorating CCU patients. Clinical judgement is important, but not yet well understood in rapid response systems.

IMPACT

This study offers preliminary understanding of nurses' assessments of deteriorating patients in CCUs.

REPORTING METHOD

American Psychological Association, Mixed Methods Standards.

PATIENT OR PUBLIC CONTRIBUTION

Reviewed protocol, aided result interpretation and shared ideas for future research.

Intuitive knowing for student nurses

ABSTRACT

"Intuitive knowing" is the ability to understand a clinical case instinctively without the need for conscious reasoning. This article examines the critical role of intuitive knowing in clinical decision-making among nurses, particularly in the context of increasingly complex patient care. Furthermore, the article offers recommendations for nursing educators to cultivate this essential skill in nursing students, ensuring they are equipped to effectively navigate the challenges of modern healthcare environments.

Ethical and regulatory considerations in the use of AI and machine learning in nursing: A systematic review

AIM

This study systematically explores the ethical and regulatory considerations surrounding the integration of artificial intelligence (AI) and machine learning (ML) in nursing practice, with a focus on patient autonomy, data privacy, algorithmic bias, and accountability.

BACKGROUND

AI and ML are transforming nursing practice by enhancing clinical decision-making and operational efficiency. However, these technologies present significant ethical challenges related to ensuring patient autonomy, safeguarding data privacy, mitigating algorithmic bias, and ensuring transparency in decision-making processes. Current frameworks are not sufficiently tailored to nursing-specific contexts.

METHODS

A systematic review was conducted, adhering to PRISMA guidelines. Six major databases were searched for studies published between 2000 and 2024. Seventeen studies met the inclusion criteria and were included in the final analysis.

RESULTS

Five key themes emerged from the review: enhancement of clinical decision-making, promotion of ethical awareness, support for routine nursing tasks, challenges in algorithmic bias, and the importance of public engagement in regulatory frameworks. The review identified critical gaps in nursing-specific ethical guidelines and regulatory oversight for AI integration in practice.

DISCUSSION

AI technologies offer substantial benefits for nursing, particularly in decision-making and task efficiency. However, these advantages must be balanced against ethical concerns, including the protection of patient rights, algorithmic transparency, and bias mitigation. Current regulatory frameworks require adaptation to meet the ethical needs of nursing.

CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY

The findings emphasize the need for the development of nursing-specific ethical guidelines and robust regulatory frameworks to ensure the responsible integration of AI technologies into nursing practice. AI integration must uphold ethical principles while enhancing the quality of care.

Development of a Questionnaire Assessing Nurses' Situational Awareness to Missed Care

This study aimed to develop and validate the Situational Nursing Awareness Probe-Missed Nursing Care Edition (SNAP-MNC) questionnaire, a novel tool designed to assess nurses' situational awareness in the context of missed nursing care. Data were collected from March to October 2022, following a rigorous five-phase questionnaire development process. The five-item questionnaire was developed through literature review and expert evaluation, establishing face and content validity. It was tested with 190 nurses across three shifts. Construct validity was assessed via confirmatory factor analysis, reliability via Cronbach's alpha, and criterion validity by correlating with the MISSCARE survey. The final five-item questionnaire demonstrated suitability for assessing personal situational awareness. The findings established content, construct, criterion validity, and good internal reliability. Confirmatory factor analysis displayed suitable loadings and an excellent fit to a one-dimensional model. Nurses received, on average, low situational awareness scores. The SNAP-MNC effectively assesses nurses' situational awareness, focusing on missed nursing care. This tool evaluates the identification of relevant clinical factors, understanding their implications, and projecting strategies to address challenges, offering actionable insights for improving nursing care quality and outcomes.

Triage gap? Analysis of admission rates, service utilisation and mortality for First Nations patients compared to non-First Nations patients, stratified by ED triage category

BACKGROUND

First Nations patients often experience poorer health outcomes than non-First Nations patients. Despite emergency triage primarily focusing on severity, implying comparable outcomes for patients in the same triage group regardless of demographics, the precision of triage for First-Nations Australians may be undermined by multiple factors, although research in this area is scarce.

OBJECTIVE

To compare admission rates, service utilisation and mortality for First Nations and non-First Nations patients, based on their triage categories.

METHODS

This retrospective cohort study utilised data for all adults presenting between January 2016 and May 2021, to Alice Springs Hospital; totalling 175 199 presentations from 39 882 individual patients. Data were analysed for differences between First Nations and non-First nations patients for outcomes including 30-day mortality, admission to hospital and admission to ICU.

RESULTS

First Nations patients had significantly higher admission than non-First Nations patients across all triage categories (P < 0.001). First Nations patients in categories 3 and 4 had a significantly higher 30-day mortality (P = 0.039, P = 0.045, respectively). First Nations patients in categories 2 and 3 were significantly more likely to be admitted to ICU (P < 0.001).

CONCLUSION

First Nations patients appear to have worse outcomes than non-First Nations patients in the same triage category. Socio-economic factors and high discharge against advice rates from wards may explain the significantly higher admission rate. Under-recognition of serious illness at triage could be attributed to communication issues or a 'well bias'. The results raise many questions and further investigation is required.

Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: A factorial survey experiment

AIM

To test the influences of patient, safety event and nurse characteristics on nurse judgements of credibility, importance and intent to report patients' safety concerns.

DESIGN

Factorial survey experiment.

METHODS

A total of 240 nurses were recruited and completed an online survey including demographic information and responses to eight factorial vignettes consisting of unique combinations of eight patient and event factors. Hierarchical multivariate analysis was used to test influences of vignette factors and nurse characteristics on nurse judgements.

RESULTS

The intraclass coefficients for nurse judgements suggest that the variation among nurses exceeded the influence of contextual vignette factors. Several significant sources of nurse variation were identified, including race/ethnicity, suggesting a complex relationship between nurses' characteristics and their potential biases, and the influence of personal and patient factors on nurses' judgements, including the decision to report safety concerns.

CONCLUSION

Nurses are key players in the system to manage patient safety concerns. Variation among nurses and how they respond to scenarios of patient safety concerns highlight the need for nurse-level intervention.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Complex factors influence nurses' judgement, interpretation and reporting of patients' safety concerns.

IMPACT

Understanding nurse judgement regarding patient-expressed safety concerns is critical for designing processes and systems that promote reporting. Multiple event and patient characteristics (type of event and apparent harm, and patient gender, race/ethnicity, socioeconomic status, and communication approach) as well as participant characteristics (race/ethnicity, gender, years of experience and primary hospital area) impacted participants' judgements of credibility, degree of concern and intent to report. These findings will help guide patient safety nurse education and training.

REPORTING METHOD

STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Members of the public, including patient advocates, were involved in content validation of the vignette scenarios, norming photographs used in the factorial survey and testing the survey functionality.

Communication strategies to support people experiencing mental health issues

This article explores the use of effective communication for nurses when interacting with people experiencing mental health issues. Emphasis will be on the importance of nurses adopting person-centred communication styles that prioritise empathy, with the aim of developing a therapeutic rapport. The article underscores the role of the nurse in promoting positive mental health outcomes through the use of techniques such as active listening, empathy and validation. The author also details some of the barriers to effective communication and how nurses can address them.

Nursing students and role modeled behavior while caring for LGBTQ + people: a cross-sectional, descriptive study

BACKGROUND

While efforts to improve the educational preparedness of nurses to care for lesbian, gay, bisexual, transgender, and queer (LGBTQ +) people have increased, the influence of role-modeled behaviors by healthcare professionals working with nursing students and recent graduates is not well understood. The purpose of this study is to describe the role-modeled behaviors of healthcare professionals observed by nursing students and recent graduates caring for LGBTQ + patients in clinical settings.

METHODS

A cross-sectional, online survey was conducted. Recruitment of nursing students who had completed one or more clinical rotations or were recent graduates (≤ 2 years) was performed through university emails and social media. Items included measurement of stigmatizing attitudes, observed stigmatizing behaviors, and ability to provide inclusive/affirming care for LGBTQ + patients. Open-text items prompted participants to describe observed behaviors. Data were analyzed using descriptive statistics and Wilcoxon signed rank sum tests to evaluate differences between LGB (lesbian, gay, bisexual) and T + (transgender and gender diverse) subscales. Open-text responses were analyzed using thematic analysis to identify relevant themes.

RESULTS

Participants (N = 73) had a low level of stigmatizing attitudes toward LGBTQ + people (M = 1.8, SD = 0.4), although higher stigmatizing attitudes toward T + people were reported (M = 3.0, SD = 0.2; Z = -7.254, p < .001). Half of the participants reported that they observed LGBTQ + stigmatizing behaviors role-modeled by two + healthcare professional roles; approximately one-third of participants personally engaged in one + LGBTQ + stigmatizing behaviors, most commonly toward T + people. Themes from participants' examples of observed stigmatizing behaviors included: cis-heteronormative bias, non-affirmation of chosen name/pronouns, outing patients, and rejected competency.

CONCLUSIONS

The majority of participants described observing stigmatizing behaviors toward LGBTQ + people in clinical settings. Poorer attitudes and a higher frequency of stigmatizing behaviors observed towards T + people point to deficits in healthcare provided to T + people in particular. Efforts to address LGBTQ + stigma in healthcare should be expanded to include clinical settings to address role-modeled behaviors and socialization of nurses.

Implementation of Cultural Awareness and Cognitive Bias Training Within Graduate Nursing Programs

BACKGROUND

Cognitive bias negatively affects patient outcomes, resulting in medical errors, sentinel events, and legal claims. The brunt of bias-induced inequities and disparities has fallen on Black and Brown people, women, and the LGBTQ+ communities. Faculty training programs have rapidly increased in number, whereas student training has lagged.

METHOD

A three-part curricular series was developed for students seeking nurse practitioner (NP) training. The series addressed racial bias, microaggression, and gender bias using vignettes and guided pre- and debriefing.

RESULTS

The series was initially implemented to 70 students from four different specialty areas of study. Students resoundingly reported the content as valuable and challenging and the environment as a safe space to learn, be vulnerable, and be empathetic to the experiences of others.

CONCLUSION

This three-part series has been implemented across eight NP majors and has become a required component of the NP on-campus intensive experience. [J Nurs Educ. 2024;63(11):777-780.].

A Systemwide Strategy to Embed Equity into Patient Safety Event Analysis

BACKGROUND

There is a lack of framework to incorporate equity into event analysis. This quality improvement initiative involved the development of equity tools that were introduced in a two-hour interactive, case-based training across 11 acute care facilities at the largest municipal health care system in the United States. A pre and post survey (which included analysis of a clinical vignette) was also conducted to assess for knowledge and comfort embedding equity in patient safety event analysis, and to measure discomfort or distress during the training. A separate assessment was used to evaluate the tools.

EQUITY TOOLS

A visual aid, the Patient Equity Wheel, was created to facilitate more comprehensive and robust health equity discussions by compiling a comprehensive list of equity categories, including internal, external, and organizational dimensions of equity. The Wheel was designed for use during each phase of event analysis. An Embedding Equity in Root Cause Analysis Worksheet was developed to aid in assessing considerations of equitable care in the investigation process and includes questions to ask staff to further assess bias or equitable care factors.

INITIATIVE OUTCOME AND KEY INSIGHTS

Participant knowledge and level of comfort increased after training. The most commonly unrecognized categories of bias were Training/Competencies, Structural Workflow, and Culture/Norms. Most participants responded that they had no discomfort or distress during the training. Post-training feedback noted that the tools were being used across the system in various stages of event analysis and have been reported to improve health equity conversations.

Health professionals implicit bias of patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review

OBJECTIVES

Research indicates that people with lower socioeconomic status (SES) receive inferior healthcare and experience poorer health outcomes compared with those with higher SES, in part due to health professional (HP) bias. We conducted a scoping review of the impact of HP bias about SES on clinical decision-making and its effect on the care of adults with lower SES.

DESIGN

JBI scoping review methods were used to perform a systematic comprehensive search for literature. The scoping review protocol has been published in BMJ Open.

DATA SOURCES

Medline, Embase, ASSIA, Scopus and CINAHL were searched, from the first available start date of the individual database to March 2023. Two independent reviewers filtered and screened papers.

ELIGIBILITY CRITERIA

Studies of all designs were included in this review to provide a comprehensive map of the existing evidence of the impact of HP bias of SES on clinical decision-making and its effect on the care for people with lower SES.

DATA EXTRACTION AND SYNTHESIS

Data were gathered using an adapted JBI data extraction tool for systematic scoping reviews.

RESULTS

Sixty-seven papers were included from 1975 to 2023. 35 (73%) of the included primary research studies reported an association between HP SES bias and decision-making. Thirteen (27%) of the included primary research studies did not find an association between HP SES bias and decision-making. Stereotyping and bias can adversely affect decision-making when the HP is fatigued or has a high cognitive load. There is evidence of intersectionality which can have a powerful cumulative effect on HP assessment and subsequent decision-making. HP implicit bias may be mitigated through the assertiveness of the patient with low SES.

CONCLUSION

HP decision-making is at times influenced by non-medical factors for people of low SES, and assumptions are made based on implicit bias and stereotyping, which compound or exacerbate health inequalities. Research that focuses on decision-making when the HP has a high cognitive load, would help the health community to better understand this potential influence.

Moral Distress as Moral Heuristic Missing the Mark

I propose that moral distress may function as a moral heuristic, and one that misses its mark in signifying a fundamental source for nurses' moral suffering. Epistemic injustice is an insidious workplace wrongdoing that is glossed over or avoided in explicit explanations for nurse moral suffering and is substituted by an emphasis on the nurse's own wrongdoing. I discuss reasons and evidence for considering moral distress as a moral heuristic that obfuscates the role of epistemic injustice as a fundamental constraint on nurses' moral reasoning underlying moral suffering.

The relevance of the contribution of psychoneuroendocrinoimmunology and psychology of reasoning and decision making to nursing science: A discursive paper

AIM

Patients' death or adverse events appear to be associated with poor healthcare decision-making. This might be due to an inability to have an adequate representation of the problem or of the connections among problem-related elements. Changing how a problem is formulated can reduce biases in clinical reasoning. The purpose of this article is to explore the possible contributions of psychoneuroendocrinoimmunology (PNEI) and psychology of reasoning and decision-making (PRDM) to support a new nursing theoretical frame.

DESIGN

Discursive paper.

METHOD

This article discusses the main assumptions about nursing and nurses' ability to face patient's problems, suggesting a new approach that integrates knowledge from PNEI and PRDM. While PNEI explains the complexity of systems, highlighting the importance of systems connections in affecting health, PRDM underlines the importance of the informative context in creating a mental representation of the problem. Furthermore, PRDM suggests the need to pay attention to information that is not immediately explicit and its connections.

CONCLUSION

Nursing recognizes the patient-nurse relationship as the axiom that governs care. The integration of PNEI and PRDM in nursing theoretics allows the expansion of the axiom by providing essential elements to read a new type of relationship: the relationship among information. PNEI explains the relationships between biological systems and the psyche and between the whole individual and the environment; PRDM provides tools for the nurse's analytical thinking system to correctly process information and its connections.

IMPACT ON NURSING PRACTICE

A theoretical renewal is mandatory to improve nursing reasoning and nursing priority identification. Integrating PNEI and PRDM into nursing theoretics will modify the way professionals approach patients, reducing cognitive biases and medical errors.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or writing of this discursive article.

'You don't see what I see': Co-designing simulation to uncover and address cognitive bias in healthcare

EDUCATIONAL CHALLENGE

Each year, adverse events are reported in healthcare, of which many relate to healthcare workforce cognitive bias. The active involvement of workforce and consumers in the review and co-design of effective training for the healthcare workforce to recognise, monitor, and manage unconscious bias is required.

PROPOSED SOLUTION

We used participatory action research to co-design an innovative, interprofessional simulation based on 'real world' clinical incidents and lived experiences to improve the delivery of safe, high quality, consumer-focused healthcare. Following ethics approval, content analysis of serious adverse patient safety events involving cognitive bias was conducted. These data informed audio-recorded interviews with the healthcare workforce and consumers to explore their experiences of cognitive bias. Following thematic analysis, key themes of communication, stigma, diagnostic overshadowing, and fragmented systems were uncovered. Guided by consumers, these themes were interwoven into a simulation scenario that included real places, stories, and verbatim quotes delivered through mixed media artefacts. This heightened the immersive and experiential learning that aimed to uncover unconscious bias and help learners recognise its impact on clinical decisions and practice.

POTENTIAL BENEFITS AND NEXT STEPS

To our knowledge, this is the first interprofessional, co-designed simulation to specifically address cognitive bias in current and future healthcare workforce. Plans to translate this research into a practical framework on how to work with key stakeholders (including consumers) to identify 'real-world' health service risks and co-design targeted simulations to address these gaps are described, including lessons learned.

Towards evidence-based practice 2.0: leveraging artificial intelligence in healthcare

Background

Evidence-based practice (EBP) involves making clinical decisions based on three sources of information: evidence, clinical experience and patient preferences. Despite popularization of EBP, research has shown that there are many barriers to achieving the goals of the EBP model. The use of artificial intelligence (AI) in healthcare has been proposed as a means to improve clinical decision-making. The aim of this paper was to pinpoint key challenges pertaining to the three pillars of EBP and to investigate the potential of AI in surmounting these challenges and contributing to a more evidence-based healthcare practice. We conducted a selective review of the literature on EBP and the integration of AI in healthcare to achieve this.

Challenges with the three components of EBP

Clinical decision-making in line with the EBP model presents several challenges. The availability and existence of robust evidence sometimes pose limitations due to slow generation and dissemination processes, as well as the scarcity of high-quality evidence. Direct application of evidence is not always viable because studies often involve patient groups distinct from those encountered in routine healthcare. Clinicians need to rely on their clinical experience to interpret the relevance of evidence and contextualize it within the unique needs of their patients. Moreover, clinical decision-making might be influenced by cognitive and implicit biases. Achieving patient involvement and shared decision-making between clinicians and patients remains challenging in routine healthcare practice due to factors such as low levels of health literacy among patients and their reluctance to actively participate, barriers rooted in clinicians' attitudes, scepticism towards patient knowledge and ineffective communication strategies, busy healthcare environments and limited resources.

AI assistance for the three components of EBP

AI presents a promising solution to address several challenges inherent in the research process, from conducting studies, generating evidence, synthesizing findings, and disseminating crucial information to clinicians to implementing these findings into routine practice. AI systems have a distinct advantage over human clinicians in processing specific types of data and information. The use of AI has shown great promise in areas such as image analysis. AI presents promising avenues to enhance patient engagement by saving time for clinicians and has the potential to increase patient autonomy although there is a lack of research on this issue.

Conclusion

This review underscores AI's potential to augment evidence-based healthcare practices, potentially marking the emergence of EBP 2.0. However, there are also uncertainties regarding how AI will contribute to a more evidence-based healthcare. Hence, empirical research is essential to validate and substantiate various aspects of AI use in healthcare.

Home care for patients with opioid use disorders: A qualitative study of registered nurses' experiences of pain management

AIM

To explore registered nurses' experiences with pain management in patients with opioid use disorder (OUD) in home care.

DESIGN

Qualitative explorative-descriptive design.

METHODS

Data were collected via nine individual semi-structured interviews with registered nurses working in home care meeting patients with OUD. Data were analysed using systematic text condensation.

RESULTS

Three categories were identified: Reciprocity in relationships and a professional approach enhance pain management; Discrepancies between guidelines, patient-reported pain and RNs' observations challenge pain management; and Interprofessional collaboration makes or breaks pain management.

Investigating risk factors for medication errors during perioperative care: A retrospective cohort study

Medication errors during perioperative care significantly compromise patient safety and the quality of outcomes. It is crucial to identify and understand the factors that contribute to these errors to develop effective, targeted interventions. This study aims to explore the risk factors associated with medication errors during perioperative care in a tertiary hospital setting, focusing on patient demographics, medication types, administration routes, and nursing care characteristics. A retrospective cohort study was conducted, encompassing adult patients who underwent surgical procedures from January 2020 to January 2023. Data on medication administration, patient demographics, and surgical details were extracted from electronic health records. Medication errors were classified based on the harm caused to the patients. Logistic regression analyses were employed to identify significant risk factors. The study included 1723 patients, with a balanced gender distribution. The median patient age was 53 years. Medication errors were significantly associated with patient age, the type of medication administered, and specific administration routes. Higher education levels and advanced professional titles among nursing staff were inversely related to the occurrence of medication errors. The presence of a dedicated anesthesia nurse significantly reduced the likelihood of errors. Patient age, medication type, administration route, nursing education level, and the involvement of specialized anesthesia nurses emerged as significant factors influencing the risk of medication errors in perioperative care. These findings underscore the need for targeted educational and procedural interventions to mitigate such errors, enhancing patient safety in surgical settings.

Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a 'Best Fit' framework approach

BACKGROUND

Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision-making process. We aimed to describe the patient's decision-making behaviour and shared decision-making (SDM)-related barriers and facilitators in breast cancer surgical treatment.

METHODS

We searched eight databases for qualitative studies and mixed-method studies about breast cancer patients' surgical decision-making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a 'best fit framework approach' to analyze and synthesize the evidence.

RESULTS

Twenty-eight qualitative studies and three mixed-method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision-making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM.

CONCLUSIONS

Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual-level and system-level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice.

PATIENT AND PUBLIC CONTRIBUTION

This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.

Psychotherapeutic approaches: hopefully, globally effective

Many patients have lasting disorders due, for example, to excessive and chronic childhood stress. For these patients, certain psychotherapeutic approaches may be maximally effective, and this may be universally the case. This piece is intended to give providers optimal tools for reaching and helping these patients who, otherwise, may remain among those worst off. These interventions should enhance patients' trust, the quintessential precondition for enabling these patients to change. Specific interventions discussed include anticipating ambiguity and clarifying this before ambiguity occurs, therapists indicating that they will support patients' and families' wants over their own views, feeling and disclosing their emotions, validating patients' anger, laughing, going beyond usual limits, explaining why, asking before doing, discussing religion and ethics, and informing whenever this could be beneficial.

Barriers and Facilitators Experienced by Undergraduate Nursing Faculty Teaching Clinical Judgment: A Qualitative Study

Background

Clinical judgment is declining in new graduate nurses, which affects patient safety and is therefore tested on the Next Generation NCLEX. There is limited research describing barriers and facilitators impacting nursing faculty's experiences teaching clinical judgment.

Aims

The purpose of this study was to explore barriers and facilitators affecting undergraduate nursing faculty's clinical judgment teaching methods.

Methods

Sixteen qualitative interviews were conducted with full-time nursing faculty at seven universities in the Northeast and Southeast regions of the United States.

Results

The findings revealed program, student, and faculty factors affecting clinical judgment teaching methods. Subthemes included time, class size, students' class preparation, critical thinking, task orientation, professional development, and faculty resistance.

Conclusion

Minimizing barriers and strengthening facilitators based on participants' practices and previous research can support more effective clinical judgment pedagogy, which has the potential to achieve Next Generation NCLEX success and potentially increase patient safety.

Student Nurses' Perceptions of the Role of High-Fidelity Simulation in Developing Decision-Making Skills for Clinical Practice: A Qualitative Research Study

Introduction

The integration of high-fidelity simulation (HFS) in nursing education has increased, but its effect on students' clinical decision-making skills and their ability to transfer these skills to clinical practice remains unclear.

Aim

This qualitative study aimed to explore nursing students' perceptions of simulation's role in developing decision-making skills for clinical practice.

Methods

Twenty-three self-selected final-year nursing students participated in an HFS exercise in 2016. They engaged in "think-aloud" activities during the simulation, reviewed videos of their performance, and attended a structured debriefing session. Four to six weeks later, face-to-face semistructured interviews were conducted to gather their views on the application of learning from simulation into practice. Thematic analysis was used to analyze the interview data.

Results

Four themes emerged from the analysis: "enhancing clinical decision-making skills," "recognition of the types of clinical decision-making," "recognition of cognitive biases," and "transferability and integrating theory into practice." Simulation improved student self-awareness, decision-making skills, and recognition of cognitive biases applied in practice. Overall, students found that the simulation improved their ability to apply theoretical knowledge gained through simulation to practice. The students' perception of the authenticity of activities in relation to real-world scenarios played a crucial role in enhancing the transferability and application of acquired knowledge from simulation to clinical practice.

Conclusion

The findings provide valuable insights into how simulation optimizes learning and decision-making skills, ultimately promoting effective care in clinical settings.

Non-clinical intuitions and adaptive heuristics in emergency care: A scoping review

BACKGROUND

Across a range of fields, including healthcare, heuristics are typically conceived as a source of bias and systematic error. However, research across the psychological and management sciences shows that intuition and heuristics are also vital sources of adaptive decision strategies, especially in complex, uncertain environments. The complexity of the emergency care environment marks this environment as one in which non-clinical intuitions and heuristics are likely to emerge and function as adaptive decision strategies. The aim of this study was to map and contextualize what is known about leadership and non-clinical intuitions and heuristics in emergency care.

METHODS

Based on a systematic search of the Pubmed, Scopus, Web of Science, MEDLINE and CINAHL electronic databases, we conducted a scoping review to map what is known about leadership and non-clinical intuitions and adaptive heuristics in emergency care.

RESULTS

Of the 1219 articles retrieved, 9 met the inclusion criteria. Our review revealed four key findings. First, intuitions are used to make judgments about patients, caring for patients, and coordinating with colleagues. Second, although non-clinical intuitions are documented, non-clinical heuristics are rarely studied. Third, the literature is focused on nurses and silent on the use of non-clinical intuition and heuristics among medical doctors. Finally, professional cultures influence clinicians' use of intuitive sense- and decision-making.

CONCLUSION

This review highlights the dearth of research into non-clinical intuitions and heuristics in emergency care. Understood in the context of insights from the psychological and management sciences about intuitions and 'smart' heuristics as adaptive decision strategies, our findings point to new frontiers of research into leadership in emergency care.

Access to device-aided therapies in advanced Parkinson's disease: navigating clinician biases, patient preference, and prognostic uncertainty

Device-aided therapies (DAT), which include deep brain stimulation and pump-based continuous dopaminergic stimulation with either levodopa or apomorphine, are among the major advances in the clinical management of Parkinson's disease (PD). Although DAT are being increasingly offered earlier in the disease course, their classical indication remains advanced PD. Theoretically, every patient should be offered transition to DAT when faced with refractory motor and nonmotor fluctuations and functional decline. Worldwide clinical reality is far from these ideal, and, therefore, question the "real-world" equal opportunity of access to DAT for PD patients with advanced PD-even within a single health care system. Differences in access to care, referral pattern (timing and frequency), as well as physician biases (unconscious/implicit or conscious/explicit bias), and patients' preferences or health-seeking behaviour are to be considered. Compared to DBS, little information is available concerning infusion therapies, as well as neurologists' and patients' attitudes towards them. This viewpoint aims to be thought-provoking and to assist clinicians in moving through the process of DAT selection, by including in their decision algorithm their own biases, patient perspective, ethical concerns as well as the current unknowns surrounding PD prognosis and DAT-related long-term side effects for a given patient.

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review

BACKGROUND

An integral part of clinical practice is decision-making. Yet there is widespread acceptance that there is evidence of cognitive bias within clinical practice among nurses and physicians. However, how cognitive bias among emergency nurses and physicians' decision-making influences patient outcomes remains unclear.

AIM

The aim of this review was to systematically synthesise research exploring the emergency nurses' and physicians' cognitive bias in decision-making and its influence on patient outcomes.

METHODS

This scoping review was guided by the PRISMA Extension for Scoping Reviews. The databases searched included CINAHL, MEDLINE, Web of Science and PubMed. No date limits were applied. The Patterns, Advances, Gaps, Evidence for practice and Research recommendation (PAGER) framework was used to guide the discussion.

RESULTS

The review included 18 articles, consisting of 10 primary studies (nine quantitative and one qualitative) and eight literature reviews. Of the 18 articles, nine investigated physicians, five articles examined nurses, and four both physicians and nurses with sample sizes ranging from 13 to 3547. Six primary studies were cross-sectional and five used hypothetical scenarios, and one real-world assessment. Three were experimental studies. Twenty-nine cognitive biases were identified with Implicit bias (n = 12) most frequently explored, followed by outcome bias (n = 4). Results were inconclusive regarding the influence of biases on treatment decisions and patient outcomes. Four key themes were identified; (i) cognitive biases among emergency clinicians; (ii) measurement of cognitive bias; (iii) influence of cognitive bias on clinical decision-making; and (iv) association between emergency clinicians' cognitive bias and patient outcomes.

CONCLUSIONS

This review identified that cognitive biases were present among emergency nurses and physicians during clinical decision-making, but it remains unclear how cognitive bias influences patient outcomes. Further research examining emergency clinicians' cognitive bias is required.

RELEVANCE TO CLINICAL PRACTICE

Awareness of emergency clinicians' own cognitive biases may result to the provision of equity in care.

NO PATIENT OR PUBLIC CONTRIBUTION IN THIS REVIEW

We intend to disseminate the results through publication in a peer-reviewed journals and conference presentations.

Potential influence of nurses' implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.

Nursing's Critical Role in Driving Toward Health Equity: One Organization's Experience

In the last decade, there has been active discourse within nursing communities regarding healthcare disparities associated with racism. To address this critical problem, a multidisciplinary team at a pediatric healthcare setting identified 33 projects across 4 key drivers of health equity. The drivers of health equity include: 1) developing a diverse nursing workforce; 2) creating a nursing culture with a strong sense of belonging; 3) providing learning and growth opportunities; and 4) providing equitable nursing care. This article describes 1 organization's approach to addressing healthcare disparities associated with racism through a nursing program to address equity, diversity, inclusion, and antiracism.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases

BACKGROUND

Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted.

OBJECTIVE

To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs.

DESIGN

Experimental vignette research.

SETTING

Online experiment distributed via email between October and December 2020.

PARTICIPANTS

Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States.

METHODS

Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information.

RESULTS

Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis.

CONCLUSIONS

Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs.

TWEETABLE ABSTRACT

Simulated experimental study found that despite having received identical clinical information, emergency nurses believed that patients displaying irritable behaviours were less likely to return to work soon and were less likely to recover than patients who displayed calm behaviour.

Patient Safety Culture in Latin American Hospitals: A Systematic Review with Meta-Analysis

INTRODUCTION

Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with effective communication, leadership, teamwork, error reporting, continuous improvement, and organizational learning. Although hospitals regularly measure their patient safety culture for strengths and weaknesses, there have been no systematic reviews with meta-analyses reported from Latin America.

PURPOSE

Our systematic review aims to produce evidence about the status of patient safety culture in Latin American hospitals from studies using the Hospital Survey on Patient Safety Culture (HSOPSC).

METHODS

This systematic review was guided by the JBI guidelines for evidence synthesis. Four databases were systematically searched for studies from 2011 to 2021 originating in Latin America. Studies identified for inclusion were assessed for methodological quality and risk of bias. Descriptive and inferential statistics, including meta-analysis for professional subgroups and meta-regression for subgroup effect, were calculated.

RESULTS

In total, 30 studies from five countries-Argentina (1), Brazil (22), Colombia (3), Mexico (3), and Peru (1)-were included in the review, with 10,915 participants, consisting primarily of nursing staff (93%). The HSOPSC dimensions most positive for patient safety culture were "organizational learning: continuous improvement" and "teamwork within units", while the least positive were "nonpunitive response to error" and "staffing". Overall, there was a low positive perception (48%) of patient safety culture as a global measure (95% CI, 44.53-51.60), and a significant difference was observed for physicians who had a higher positive perception than nurses (59.84; 95% CI, 56.02-63.66).

CONCLUSIONS

Patient safety culture is a relatively unknown or unmeasured concept in most Latin American countries. Health professional programs need to build patient safety content into curriculums with an emphasis on developing skills in communication, leadership, and teamwork. Despite international accreditation penetration in the region, there were surprisingly few studies from countries with accredited hospitals. Patient safety culture needs to be a priority for hospitals in Latin America through health policies requiring annual assessments to identify weaknesses for quality improvement initiatives.