Using social judgement theory to model nurses' use of clinical information in critical care education

Delphi study to determine the key qualities consultant histopathologists look for in their trainees

AIMS

A Delphi study to triangulate and determine the relative importance of the key qualities of trainees identified from qualitative interviews that sought to understand how consultant histopathologists determine diagnostic competences in trainees.

METHODS

Twelve participants were purposively chosen for the Delphi to form an expert panel of relevant stakeholders. Participants were asked to score and rank the items presented to them.

RESULTS

A total of 22 out of 27 of the key qualities of trainees (items) reached 'consensus in' after round 2 suggesting participants were able to agree that the majority of the items identified in the qualitative interviews were important to diagnostic competence. Five items reached 'no consensus'. Participants did not suggest any additional items. Participants particularly valued qualities of reflection and professionalism and trainees who understood the process of reaching a diagnosis and how their pathological report could impact on patient care.

CONCLUSIONS

This study has triangulated findings from our qualitative interviews and show that consultants value a wide variety of qualities when determining diagnostic competence in their trainees. The judgement is complex and is therefore best assessed longitudinally and on a number of cases, so consultants can look for consistency of both approach to diagnosis and of trainee behaviour.

Pulmonary Artery Catheters: Impact of e-Learning on Hemodynamic Assessments

Pulmonary artery catheters (PACs) are invasive devices placed in critically ill patients to monitor hemodynamic data. They are a high-risk, and in some settings a low-volume, medical device due to the complex insertion procedure and potentially lethal complications. Smaller intensive care units (ICUs) have large variances in exposure to PACs, therefore strengthening ICU nurses' belief in their ability to manage these hemodynamic monitoring devices is of utmost importance. The design is a single-group, pre/posttest study conducted on a 15-bed ICU to survey nurses' self-efficacy, knowledge, and satisfaction of an e-learning educational module. Both PAC and noninvasive cardiac output monitor patient application data were collected prior to and following the intervention. Fifteen ICU nurses completed all components of the module. Confidence in ability to accurately interpret hemodynamic data increased from pre- to postintervention (P < .001), and knowledge also increased from pre- to postintervention, albeit not statistically significantly (P = .088). Overall, nurses reported satisfaction with the educational module. With increased self-efficacy, nurses can feel empowered and motivated to further improve patient care management. Thus, workplaces should continue to advocate for additional educational tools for high-risk, low-volume devices.

Cue acquisition: A feature of Malawian midwives decision making process to support normality during the first stage of labour

OBJECTIVE

to explore Malawian midwives decision making when caring for women during the first stage of labour in the hospital setting.

DESIGN AND METHODS

this focused ethnographic study examined the decision making process of 9 nurse-midwives with varying years of clinical experience in the real world setting of an urban and semi urban hospital from October 2013 to May 2014.This was done using 27 participant observations and 27 post-observation in-depth interviews over a period of six months. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation.

FINDINGS

analysis revealed a six-stage process of decision making that include a baseline for labour, deciding to admit a woman to labour ward, ascertaining the normal physiological progress of labour, supporting the normal physiological progress of labour, embracing uncertainty: the midwives' construction of unusual labour as normal, dealing with uncertainty and deciding to intervene in unusual labour. This six-stage process of decision making is conceptualised as the 'role of cue acquisition', illustrating the ways in which midwives utilise their assessment of labouring women to reason and make decisions on how to care for them in labour. Cue acquisition involved the midwives piecing together segments of information they obtained from the women to formulate an understanding of the woman's birthing progress and inform the midwives decision making process. This understanding of cue acquisition by midwives is significant for supporting safe care in the labour setting. When there was uncertainty in a woman's progress of labour, midwives used deductive reasoning, for example, by cross-checking and analysing the information obtained during the span of labour. Supporting normal labour physiological processes was identified as an underlying principle that shaped the midwives clinical judgement and decision making when they cared for women in labour.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the significance of this study is in the new understanding and insight into the process of midwifery decision making. Whilst the approach to decision making by the midwives requires further testing and refinement in order to explore implications for practice, the findings here provide new conceptual and practical clarity of midwifery decision making. The work contributes to the identified lack of knowledge of how midwives working clinically, in the 'real world setting. These findings therefore, contribute to this body of knowledge with regards to our understanding of decision making of midwives.

A measure of facilitators and barriers to rapid response team activation

PURPOSE

Poor patient outcomes and increased costs may be associated with underutilization of RRTs. The aim of this study was to develop and test an instrument that identifies specific facilitators and barriers to rapid response team (RRT) activation.

METHODS

Using an exploratory design, we surveyed a convenience sample of 250 registered nurses (RNs) employed in five Illinois hospitals. Participants completed the online RRT Facilitators and Barriers Survey (RRT-FBS), a 36 item survey developed by the researchers. The survey contains two sections, facilitators and barriers. Items in the facilitators subscales described nursing unit culture, RRT knowledge, and RRT member characteristics. Items in the barriers subscales described nursing unit culture, RRT education, and RRT member characteristics. Item analyses were conducted through exploratory factor analyses; internal consistency estimates were obtained. Descriptive statistics were conducted on the demographic data to describe sample and setting characteristics.

RESULTS

The final sample consisted of 202 nurses from four hospitals. We conducted an item analysis and were able to reduce the survey to 30 items with a secondary analysis. The full scale alpha was 0.752. Cronbach's alphas for subscales ranged from 0.770-0.897.

CONCLUSIONS

Facilitators and barriers may vary across institutions. This scale shows promise for identifying facilitators and barriers to nurses' use of rapid response teams and may provide a foundation for interventional studies promoting RRT utilization. In addition, more frequent education, emphasizing the RRT process, may be an effective method to maintain high rates of RRT activation and increase confidence.

Piloting the feasibility of head-mounted video technology to augment student feedback during simulated clinical decision-making: An observational design pilot study

BACKGROUND

Clinical decision-making is a complex activity that is critical to patient safety. Simulation, augmented by feedback, affords learners the opportunity to learn critical clinical decision-making skills. More detailed feedback following simulation exercises has the potential to further enhance student learning, particularly in relation to developing improved clinical decision-making skills.

OBJECTIVE

To investigate the feasibility of head-mounted video camera recordings, to augment feedback, following acute patient deterioration simulations.

DESIGN

Pilot study using an observational design.

METHODS

Ten final-year nursing students participated in three simulation exercises, each focussed on detection and management of patient deterioration. Two observers collected behavioural data using an adapted version of Gaba's Clinical Simulation Tool, to provide verbal feedback to each participant, following each simulation exercise. Participants wore a head-mounted video camera during the second simulation exercise only. Video recordings were replayed to participants to augment feedback, following the second simulation exercise. Data were collected on: participant performance (observed and perceived); participant perceptions of feedback methods; and head-mounted video camera recording feasibility and capability for detailed audio-visual feedback.

RESULTS

Management of patient deterioration improved for six participants (60%). Increased perceptions of confidence (70%) and competence (80%), were reported by the majority of participants. Few participants (20%) agreed that the video recording specifically enhanced their learning. The visual field of the head-mounted video camera was not always synchronised with the participant's field of vision, thus affecting the usefulness of some recordings.

CONCLUSION

The usefulness of the video recordings, to enhance verbal feedback to participants on detection and management of simulated patient deterioration, was inconclusive. Modification of the video camera glasses, to improve visual-field synchronisation with participants' actual visual field, is recommended to further explore this technology for enhancing student performance.

A Systematic Review of Quality of Life Measures in Pregnant and Postpartum Mothers

Quality of life has emerged as an essential health component that broadens the traditionally narrow concerns focused on only morbidity and life expectancy. Although a growing number of tools to measure quality of life are in circulation, there is a lack of guidelines as well as rigorous assessment for their use with pregnant and postpartum populations. It is also unclear whether these instruments could validly be employed to measure patient-reported outcomes in comparative effectiveness research of maternal care interventions. This paper reviews articles cited in CINAHL, COCHRANE, EMBASE, PSYCINFO, and PUBMED that addressed quality of life in pregnant and postpartum populations. Instruments used to measure quality of life in selected articles were assessed for their adherence to international guidelines for health outcomes instrument development and validation. The authors identified 129 articles that addressed quality of life in pregnant and/or postpartum women. Out of these, only 64 quality (generic and specific) scales were judged relevant to be included in this study. Analysis of measurement scales used in the pregnant and/or postpartum populations revealed important validity, reliability and psychometric inadequacies that negate their use in comparative effectiveness analysis in pregnant and post-partum populations. Valid, reliable, and responsive instruments to measure patient-reported outcomes in pregnant and postpartum populations are lacking. To demonstrate the effectiveness of various treatment and prevention programs, future research to develop and validate a robust and responsive quality of life measurement scale in pregnant and postpartum populations is needed.

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

Background

The importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making.

Methods

The study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds.

Results

When reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians.

Conclusions

Currently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making.

How nurse practitioners make decisions regarding coronary heart disease risk: a social judgment analysis

PURPOSE

Understanding how nurse practitioners use clinical decision skills in practice has the potential to guide education programs to ensure safe, competent, and high quality advanced nursing practice. This study used the lens of social judgment theory to examine the clinical decision making of 60 nurse practitioners.

METHODS

A three-group pretest-posttest comparison design was used to evaluate how much insight nurse practitioners had into their clinical decision-making process.

FINDINGS

Nurse practitioners had modest insight into their clinical decision-making process.

CONCLUSION

Self-insight has implications for enhancing nurses' decision making, improving education, and fostering agreement among advanced practice nurses.

IMPLICATIONS FOR NURSING PRACTICE

Self-insight has implications for developing professional decision making and promoting appropriate educational opportunities for advanced practice nurses.

Initiating artificial nutrition support: a clinical judgement analysis

BACKGROUND

Variations in the practice of artificial nutrition are partly a result of the judgements of clinicians. Little is known about these judgements, the decision processes used or the quality of the decisions that arise. The methodology of clinical judgement analysis describes and explains judgemental differences between clinicians and offers a window into why clinician choices sometimes fail to correspond with current best practice guidelines.

METHODS

A clinical judgement analysis with 27 clinicians using two judgement tasks was carried out. Clinicians expressed their 'likelihood of feeding' and 'whether or not they would initiate artificial nutrition support' in response to 54 patient scenarios. Measures of agreement between clinicians, the degree of linear reasoning employed, their judgemental consistency and concordance with National Institute for Health and Clinical Excellence (NICE) guidelines were assessed.

RESULTS

Clinicians' judgements varied substantially both in the amount of information employed and the weighting given to information. Clinicians had only moderate agreement with NICE recommendations and overestimated the need for artificial nutrition support. Suboptimal judgements were consistently applied by clinicians. When clinicians reasoned in more linear ways, their judgements and decisions improved.

CONCLUSIONS

Overestimating the need for artificial nutritional support may inflate health service costs and increase risks for patients unnecessarily. A better understanding by clinicians of the information needed (as well as how to use it) for artificial nutrition support initiation may help improve clinical decision-making.

Effectiveness of a decision-training aid on referral prioritization capacity: a randomized controlled trial

BACKGROUND

In the community mental health field, occupational therapy students lack the capacity to prioritize referrals effectively.

OBJECTIVE

The purpose of this study was to test the effectiveness of a clinical decision-training aid on referral prioritization capacity.

DESIGN

A double-blind, parallel-group, randomized controlled trial was conducted using a judgment analysis approach.

SETTING

Each participant used the World Wide Web to prioritize referral sets at baseline, immediate posttest, and 2-wk follow-up. The intervention group was provided with training after baseline testing; control group was purely given instructions to continue with the task.

PARTICIPANTS

One hundred sixty-five students were randomly allocated to intervention (n = 87) or control (n = 81). Intervention. Written and graphical descriptions were given of an expert consensus standard explaining how referral information should be used to prioritize referrals.

MEASUREMENTS

Participants' prioritization ratings were correlated with the experts' ratings of the same referrals at each stage of testing, as well as to examine the effect on mean group scores, regression weights, and the lens model indices.

RESULTS

At baseline, no differences were found between control and intervention on rating capacity or demographic characteristics. Comparison of the difference in mean correlation baseline scores of the control and intervention group compared with immediate posttest showed a statistically significant result that was maintained at 2-wk follow-up. The effect size was classified as large. At immediate posttest and follow-up, the intervention group improved rating capacity, whereas the control group's capacity remained poor. The results of this study indicate that the decision-training aid has a positive effect on referral prioritization capacity.

CONCLUSIONS

This freely available, Web-based decision-training aid will be a valuable adjunct to the education of these novice health professionals internationally.

Using the method of judgement analysis to address variations in diagnostic decision making

Background

Heart failure is not a clear-cut diagnosis but a complex clinical syndrome with consequent diagnostic uncertainty. Judgment analysis is a method to help clinical teams to understand how they make complex decisions. The method of judgment analysis was used to determine the factors that influence clinicians' diagnostic decisions about heart failure.

Methods

Three consultants, three middle grade doctors, and two junior doctors each evaluated 45 patient scenarios. The main outcomes were: clinicians' decisions whether or not to make a diagnosis of suspected heart failure; the relative importance of key factors within and between clinician groups in making these decisions, and the acceptability of the scenarios.

Results

The method was able to discriminate between important and unimportant factors in clinicians' diagnostic decisions. Junior and consultant physicians tended to use patient information similarly, although junior doctors placed particular weight on the chest X-Ray. Middle-grade doctors tended to use information differently but their diagnostic decisions agreed with consultants more frequently (k = 0.47) than junior doctors and consultants (k = 0.23), or middle grade and junior grade doctors (k = 0.10).

Conclusions

Judgment analysis is a potentially valuable method to assess influences upon diagnostic decisions, helping clinicians to manage the quality assurance process through evaluation of care and continuing professional development.

The effects of clinical experience on nurses' critical event risk assessment judgements in paper based and high fidelity simulated conditions: a comparative judgement analysis

BACKGROUND

Paper based simulated patients are widely used to analyse nurses' clinical judgements. However, developments in the physical simulation of clinical environments offer exciting, but relatively underexploited, opportunities for exploring nurses' judgements. Critical event risk assessment is an element of acute care practice which lends itself well to simulation and in which more clinical experience is often assumed to lead to better quality judgements.

OBJECTIVES

To model nurses' judgements of critical event risk using physical and paper simulation and to examine whether improving fidelity via physical clinical simulation impacts on the apparent benefits of clinical experience on nurses' judgement performance.

DESIGN

A comparative clinical judgement analysis.

SETTING

A university in Northern England.

METHODS

Sixty-three nursing students and 34 experienced nurses made dichotomous risk assessment judgements ("at risk" or "not at risk") in response to 25 paper and physical simulated scenarios. These were randomly generated from a dataset of real patient case records. Clinical outcomes (the judgement criteria) for a 'correct' judgement were derived from the same case records. Logistic regression models were constructed to derive statistics for each nurse representing various measures of judgement performance: achievement (r(a)), consistency (R(s)) and clinical information use (G). These statistics were known as Lens Model statistics (from the psychological theory of Brunswik's Lens Model of judgement). Performance measures for novice and experienced nurses were compared.

RESULTS

No significant differences in judgemental achievement (r(a)) between experienced nurses and students were observed in either paper or high fidelity clinical simulations. Similarly, there were no significant differences in the nurses' abilities to correctly match the ways they synthesised clinical information with the optimum synthesis required by the task (policy matching) (G). When faced with "paper patients" experienced nurses exercised more cognitive control/consistency (R(s)) than students (P=0.04). However, this heightened control in experienced nurses was absent when those same nurses made judgements in the higher fidelity clinical simulation environment.

CONCLUSION

Clinical experience made no difference to nurses' judgement achievement (accuracy) in either the lower fidelity paper scenarios or the higher fidelity setting of the clinical simulation unit. The significant impact of clinical experience on judgement consistency was negated by the increases in fidelity offered through clinical simulation.

Exploring decision making in intellectual disability nursing practice: a qualitative study

Due to the dearth of relevant research, intellectual disability nurses may have difficulty identifying sources of evidence on which they can base their clinical decisions. The aim of the present research was to explore how intellectual disability nurses make decisions and how their decisions are influenced by evidence. The method was guided by interpretative phenomenology and the analysis adopted an idiographic approach. Twelve National Health Service intellectual disability nurses in Wales participated in semi-structured interviews. Four key themes were identified: getting to know the person; working as a team; evidence to support decision making; and understanding of evidence-based practice. In the context of the myriad of other professionals involved in caregiving, the nurses conveyed a commitment towards ensuring that the person with intellectual disability is at the centre of decision making. Although using empirical evidence to support practice was acknowledged, these nurses considered person centred decision making to be paramount.

Exploring understanding of the term nursing assessment: a mixed method review of the literature

BACKGROUND

Much skilled nursing practice is described by words that at face value appear low-tech and self-explanatory. Despite being intrinsic to practice, the term "nursing assessment" has few operational definitions. Evidence-based practice and the quality agenda makes it imperative that this term is well understood.

OBJECTIVES

To contribute to the evidence base and facilitate a greater understanding of assessment of patients as carried out by nurses through exploring the research question: How is the term "nursing assessment" used in the current health care literature?

DESIGN

The review process, synthesised from the work of Greenhalgh et al. (2005), Clancy (2002), Egger et al. (2001), identified and assessed the quality of articles, text books, the grey literature, policy documents and databases. Glaser's Grounded Theory (GT) method was utilised to analyse the concept of "assessment" as exemplified within the included studies.

METHODS

The focus for this mixed-method review is the health care literature between 1990 and 2005. Studies were identified, screened and assessed for methodological quality and data were extracted and recorded. Analysis of the included studies was facilitated using a GT approach. Possible tensions when using a mixed-method research design are acknowledged and briefly discussed.

RESULTS

Of the 32,602 instances initially identified, 329 articles, policy documents and book extracts were closely read and after further screening, 120 articles and 12 policy documents and book extracts were analysed. Seven overlapping categories were identified, with "judicial" or "judgement making" identified as the core category.

CONCLUSIONS

Hierarchies of nursing practice, government policies and inter-professional agendas cause barriers to meaningful assessment. Informal and formal assessments and screening processes are often conflated, resulting in confusion regarding the scope and nature of the process. Differences between the rhetoric of placing the patient at the heart of the assessment process and practice have been identified.

Encounters with unemployment in occupational health care: Nurses' constructions of clients without work

This study explores occupational health nurses' encounters with unemployed clients in Finland. It involved setting up and evaluating a new service, Career Health Care, that resembled occupational health care, except that clients were recruited from among job seekers who were participating in one of three active labour market policy measures: vocational training, subsidised employment in the public sector, or participatory training for entering the labour market. Our main interest focused on nurses' perceptions of the unemployed and their professional practices in the context of Career Health Care. The analysis revealed four overlapping discourses with regard to clients: the client as a casualty of unemployment, the client as unemployed but active, the client as a deviant in the labour market, and the client as a skilled user of the system. Each discourse had implications for professional practice. The risk of negative stereotyping and consequent exclusion from services is discussed here. In conclusion, we stress the complexity of providing health services that can match the increasing diversity of contemporary labour market trajectories.

Using the discrete choice experimental design to investigate decision-making about pressure ulcer prevention by community nurses

This study investigates the preferences of senior community nurses who work as district nurse team leaders in selecting preventive care plans for elderly people at high risk of pressure ulcer formation. The discrete choice experiment (DCE) technique was used. Focus group work produced the following five attributes of nurse decision-making: 'ease of care plan management', 'impact of care plan on patient's lifestyle', 'speed of obtaining the equipment', 'affordability', 'evidence-based practice'. These were incorporated into a self-administered questionnaire, posted to 102 nurses from two integrated acute/community NHS Trusts in Wales. A response rate of 55% was achieved. Respondents were asked to rate the importance of the selected attributes on a 5-point scale. They rated 'evidence-based practice', 'impact of care plan on patient's lifestyle', 'ease of care plan management' and 'speed of obtaining the equipment' highly, whereas 'affordability' was of less importance. However, regression analysis, which is part of the DCE technique, produced a somewhat different picture, with 'impact' being least and 'affordability' most statistically significant. The reasons for this apparent anomaly are discussed and the paper concludes that the DCE approach is capable of yielding important information, which is not produced by simple rating exercises. Such information is potentially of value in the context of modernisation and service configuration.

Understanding how nurse practitioners estimate patients' risk for coronary heart disease: a judgment analysis

AIM

This paper is a report of a study to examine how nurse practitioners combine information when estimating patient risk of coronary heart disease.

BACKGROUND

In the United States of America and other countries, nurse practitioners are increasingly working alongside physicians in primary healthcare settings. Given this role, nurse practitioners represent an important resource in early detection of numerous diseases. Understanding how nurse practitioners use patient characteristics (cues) to form estimates of patient risk for disease may improve general disease prevention efforts.

METHOD

Social judgment theory and its lens model analysis are concerned with the correspondence between a person's judgments and the environment. This approach was applied to examine how 15 nurse practitioners weighted eight risk factors for coronary heart disease, how accurate practitioners were in assessing patient risk for coronary heart disease, and how much self-insight practitioners had into their own risk estimation processes. The data were collected in 2006.

RESULTS

Nurse practitioners showed moderate to high accuracy and evinced a variety of cue-weighting strategies. Insight into their own judgment policies was modest. The lens model analysis revealed that most practitioners had lower values on knowledge of the ecology than they did on cognitive control.

CONCLUSION

Educational efforts aimed at improving detection of patients at risk for diseases might do better to target increasing clinicians' understanding of cue-criteria relationships, than to stress themes of consistency in evaluating patients.

Clinical reasoning and its application to nursing: concepts and research studies

Clinical reasoning may be defined as "the process of applying knowledge and expertise to a clinical situation to develop a solution" [Carr, S., 2004. A framework for understanding clinical reasoning in community nursing. J. Clin. Nursing 13 (7), 850-857]. Several forms of reasoning exist each has its own merits and uses. Reasoning involves the processes of cognition or thinking and metacognition. In nursing, clinical reasoning skills are an expected component of expert and competent practise. Nurse research studies have identified concepts, processes and thinking strategies that might underpin the clinical reasoning used by pre-registration nurses and experienced nurses. Much of the available research on reasoning is based on the use of the think aloud approach. Although this is a useful method, it is dependent on ability to describe and verbalise the reasoning process. More nursing research is needed to explore the clinical reasoning process. Investment in teaching and learning methods is needed to enhance clinical reasoning skills in nurses.

Alternative futures for health economics: implications for nursing management

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.