Nursing judgement and decision-making using the Sedation Withdrawal Score (SWS) in children

Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review

OBJECTIVE

The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice.

INTRODUCTION

Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning.

INCLUSION CRITERIA

Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion.

METHODS

Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary.

RESULTS

The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review.

CONCLUSIONS

The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.

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

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Parent's experiences of their child's withdrawal syndrome: a driver for reciprocal nurse-parent partnership in withdrawal assessment

Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours.

OBJECTIVE AND RESEARCH METHODOLOGY

This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis.

SETTING

A large children's hospital in the Northwest of England.

FINDINGS

Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment.

CONCLUSION

Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome.