Perceived and actual decision making by novice baccalaureate students

Second Life and Classroom Environments: Comparing Small Group Teaching and Learning in Developing Clinical Reasoning Process Skills

Medical education and clinical practice support the development of clinical reasoning competency. Traditionally, the process of clinical reasoning is taught through small group discussions in pre-clinical and clinical medical training, and the need exists to explore further teaching and learning approaches that develop clinical reasoning. This study compared teaching and learning the clinical reasoning process through the virtual platform of Second Life (SL) with the traditional classroom setting. Participants were first semester veterinary students; 34 participated virtually through SL, and 41 experienced traditional classroom interactions. Students and one facilitator engaged in three small group meetings to process a clinical case. A seven-item clinical reasoning rubric guided the teaching, learning, and assessment. Clinical reasoning assignments were scored on a grading scale from 0 to 4 with a maximum result of 28. Descriptive statistics for clinical reasoning assignment scores were (m = 14.0; SD = 2.6) and (m = 12.2; SD = 2.6) in SL and classroom interaction, respectively. Results indicated positive associations for all participants between the rubric item score of gathering historical information with (1) gathering physical examination information (p < 0.01) and (2) prioritizing patient's problems (p = 0.003). Additionally, the rubric item score of gathering physical examination information was positively associated with the rubric item score for prioritizing patient's problems (p = 0.02). Specifically for the SL cohort, results demonstrated that rubric item scores were significantly higher for gathering historical information (p = 0.03), gathering physical examination information (p < 0.01), and prioritizing patient's problems (p = 0.02). Small group interaction using SL and traditional classroom environments offers a comparable educational platform for developing clinical reasoning process skills.

Clinical Reasoning in Experienced Nurses

As an essential component of nursing practice, clinical reasoning is used to assimilate information, analyze data, and make decisions regarding patient care. Little is known about the reasoning strategies of experienced nurses who are not yet experts. This qualitative descriptive study explored the cognitive strategies used by experienced nurses as they considered assessment findings of assigned patients. To date, few studies of nurses' clinical reasoning have been conducted in a practice setting during actual patient care. A small group research design was employed using the think-aloud (TA) method with protocol analysis. A total of 15 experienced nurses were asked to “think aloud” about patient assessment findings. Data were audiotaped, transcribed, and analyzed using the three steps of protocol analysis. The results suggest that experienced nurses used a conceptual language to reason about assessment findings and used heuristics to reason more quickly and efficiently.

Microethical decision making among baccalaureate nursing students: a qualitative investigation

Nursing students frequently encounter microethical nursing practice problems during their clinical experience. The purpose of this study was to understand the lived experiences of senior-level baccalaureate students faced with making microethical clinical decisions in practice settings. A descriptive qualitative design was used, and five central themes emerged. A dominant finding was the experience of unapplied and forgotten ethics education revealing a mismatch between what faculty perceived was taught and students' experiences of that education. When faced with microethical decisions, participants trusted and deferred to staff nurse recommendations, even if the advice contradicted best-practice standards. Contextual naivete was brought out of concealment, contributing to the experience of moral disequilibrium (i.e., students felt conflicted about what they learned in school as best practice and what they observed being role modeled in the clinical environment). This study resulted in theory-guided implications for nursing education and recommendations for future study.

A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students

Simulation is increasingly referred to in the nursing literature and its use in healthcare has developed dramatically over the past decade. Whilst the concept of simulation is not new, there is now a greater emphasis on its use in nurse education (Murray et al., 2008). The purpose of this article is to develop understanding and define the concept of simulated learning as a strategy used in the education of undergraduate nursing students. The analysis outlined in this paper was guided by a systematic process of studying a concept presented by Walker and Avant (2005). The analysis sought to identify how the concept of simulation is interpreted in the existing literature printed in English and retrieved from databases (Medline, CINAHL, PubMed, and Cochrane Library), internet search engines (GoogleScholar) and hand searches. The definition offered is a work in progress and presents a theoretically grounded understanding of what simulated learning currently represents. The identified antecedents, critical attributes and consequences are presented as a basis to stimulate further research, development and understanding.

Second-Year Baccalaureate Nursing Students’ Decision Making in the Clinical Setting

This qualitative, intrinsic case study explored the decision-making activities of baccalaureate nursing students in the second year of a 4-year program. It sought to discover how second-year students determine the need to make a clinical decision, how they respond to a pending clinical decision, the types of decisions made in the clinical setting, and the factors that enhance or impede decision making. The study involved 12 students, all of whom were enrolled in their first clinical rotation on an inpatient unit and completed journals and interviews. Inductive analysis revealed three key encounters that demonstrated students' decision making: encounters with the patient, nursing staff, and clinical tutor. Each encounter revealed an emotion-based and knowledge-based response to various clinical situations. Decisions were evident within each of the three encounters. Implications for curriculum development and clinical tutors are described.

Implementing objective structured clinical skills evaluation (OSCE) in nurse registration programmes in a centre in Ireland: a utilisation focused evaluation

This paper presents findings from a research study of two objective structured clinical skills evaluation (OSCE) processes that were used in the new BSc. in General and Psychiatric Nursing Registration programmes offered in an Institute of Technology in the south west of Ireland. OSCEs, which have gained widespread acceptance throughout the western world as valid academic measures of nursing competence has yet to be established in this country. This research aimed to evaluate the process and outcomes of OSCE from the perspective of the major stakeholder groups: first and second year nursing students, lecturers, clinical placement coordinators and assessors. A utilisation focussed evaluation approach was adopted which values the opinions and experiences of stakeholders. It is intended to use the findings to develop the validity and quality of the OSCE assessment. The OSCE process was found to have a positive impact on all stakeholders. OSCEs were perceived to be a meaningful and fair form of assessment. Students identified that they felt more prepared for and more confident about forthcoming placements. The OSCE process was, however, perceived to be a stressful experience and requires considerable preparation effort by students and academic staff. Mature students claimed that more practice effort was required but also felt more prepared for placements and achieved higher OSCE scores.

A Pilot Study to Investigate the Effect of a Simulation Strategy on the Clinical Decision Making of Midwifery Students

The actual effect of the use of simulations on clinical decision making is inconclusive. This pilot study used a posttest design to determine the effect of a simulation strategy on the clinical decision-making process of midwifery students. Thirty-six graduate diploma students volunteered and were randomly assigned to two groups, with the experimental group receiving two simulation sessions (normal labor and physiological jaundice), and the control group receiving the two usual lectures. The main findings were that students who received the simulation strategy collected more clinical information, revisited collected clinical information less, made fewer formative inferences, reported higher confidence levels, and for the posttest normal labor simulation, reached a final decision more quickly. Such effects are reasonable for this type of intervention with the existent variability in each group. Further research with a larger sample size and more rigorous data collection strategies is required.

Decision-making in clinical nursing: investigating contributing factors

BACKGROUND

This article describes the results of a study which investigated the contextual factors influencing clinical decision-making. Education and experience have been suggested by some as having a positive effect on clinical decision-making, and have been listed as being of high importance. Values, knowledge, clinical setting and stress have also been identified as being important to decision-making, with various rankings given by different researchers.

AIM

The study was undertaken to determine relationships between occupational orientation (value to role), educational level, experience, area of practice, level of appointment, age and clinical decision-making in Australian nurses. The predictive ability of each factor on clinical decision-making was determined.

METHOD

This correlational study examined Australian nurses' decision-making about some common nursing interventions and 'occupational orientation', educational level, experience, level of appointment, area of clinical speciality and age. A model was constructed using stepwise selection regression to predict the 'weight' of each variable in clinical decision-making.

RESULTS

Education and experience were not significantly related to decision-making. The factor that accounted for the greatest variability to clinical decision-making was holding a professional occupational orientation, followed by level of appointment, area of clinical speciality, and age in that order.

CONCLUSION

In contrast to other studies, experience and educational level were not found to influence decision-making strongly, the value of role was the most significant predictor. The model developed, however, only accounted for a low amount of variability in decision-making. The findings indicate that there are other factors affecting clinical decision-making that still require identification.

Nephrology nursing: blurring the boundaries: the reality of expert practice

BACKGROUND

Expertise in nursing has been widely studied; there have been no previous studies into what constitute expertise in nephrology (renal) nursing. This paper describes a 'real-world' characteristic of expert nephrology nursing practice.

AIMS AND OBJECTIVES

This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept blurring the boundaries.

DESIGN

The study utilized grounded theory methodology and symbolic interactionism.

METHODS

The study took place in one renal unit in New South Wales. Sampling was purposive then theoretical; the sample consisting of six non-expert and eleven expert nurses. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semi-structured interviews was undertaken.

RESULTS

The study revealed that only expert nephrology nurses 'blurred the boundaries' of professional nursing practice. They did this by moving intermittently and purposefully, for the benefit of particular patients, into medical domains in the areas of prescribing, dispensing and ordering of pathology tests. Non-expert nurses did not cross these professional boundaries.

CONCLUSIONS

Blurring the boundaries was a significant feature of expert nursing practice, and this study was the first to describe explicitly nursing boundaries as two distinct entities; that is, formal and informal.

RELEVANCE TO CLINICAL PRACTICE

There are some nephrology nurses who have sufficient knowledge and experience to prescribe some medications and to order certain investigations.

Role of knowledge and ability in student nurses' clinical decision-making

Little is known about the acquisition of decision-making skills in nursing students as a function of experience and academic ability. Knowing how experience and academic skills interact may help inform clinical education programs and formulate ways of assessing students' progress. The aims of the present study were to develop a problem-solving task capable of measuring clinical decision-making skills in novice nurses at different levels of domain-specific knowledge; and to establish the relative impact on decision-making of domain-specific knowledge and general ability as determinants of the acquisition of decision-making skills. Three types of clinical problems of increasing complexity were developed. Sixty second-year and third-year student nurses with high and low academic scores were studied in terms of their ability to generate hypotheses for a hypothetical case, recognize disconfirming information and the need to access additional information, and diagnostic accuracy. The results showed that general academic ability and knowledge function partly independently in the acquisition of expertise in nursing. Academic ability affects decision-making in low complexity tasks, but as case complexity increases, domain-specific knowledge and experience determines decision-making skills. There are important differences in the way novices with different levels of knowledge and ability make clinical decisions and these can be studied by systematically increasing the complexity of the decision task. These results have implications for the way in which clinical education is structured and evaluated.

Clinical Decision Making Among Fourth-Year Nursing Students: An Interpretive Study

This study investigated how fourth-year nursing students learned clinical decision making. Seventeen fourth-year nursing students between ages 21 and 37, who were completing their last semester of a baccalaureate nursing program, were interviewed. A research team using a modified seven-step process developed by Diekelmann and Allen analyzed the data. Five themes or essential components associated with learning clinical decision making were identified, including gaining confidence in their skills, building relationships with staff, connecting with patients, gaining comfort in self as a nurse, and understanding the clinical picture.

Thinking Processes Used by Nurses in Clinical Decision Making

Clinical decision making forms the basis of expert clinical practice. The purpose of this study was to investigate and document the thinking processes used by nurses in clinical decision making situations so the processes could guide educational practice. Clinical data was analyzed to reveal that clinical decision making is complex and requires a variety of thinking processes. Medical and surgical nurses used different thinking processes, showing the importance of context in clinical decision making. The nursing exemplars and working vocabulary developed in this study to describe the thinking processes used in clinical decision making can be used in nursing education.

Nurses' decision-making in collecting information for the assessment of patients' nursing problems

1. The paper addresses two questions: Firstly, what kind of information do nurses acquire from cancer patients for purposes of judging their patients' problems and preparing a care plan? Secondly, how systematically do nurses proceed in the decision-making process from the formulation of initial assumptions about the patient's situation to the final definition of problems? 2. The instrument used for data collection was a computer-simulated case description compiled by a team of four nursing researchers and one medical researcher. The case description was based on a real patient history. 3. The sample consisted of 107 Registered Nurses on four oncology, two internal medicine and five surgical wards of two central university hospitals in Finland. Data were collected in autumn 1998 and spring 1999 using a laptop computer and a tape recorder. 4. The four most important problems identified by nurses at baseline were pain (85%), pain medication (59%), family situation (66%) and spread of cancer (49%). Presented with a list of 23 options, they obtained additional information on average on 13 areas. Almost one-third collected information from 16 to 22 areas. On average nurses identified 12 of the 28 nursing problems specified. A statistically significant association was observed between information acquisition and problem definition in seven different variables. These had to do with pain, general condition and prognosis. 5. Nurses adequately prioritized their patients' problems and systematically collected data on those problems. On the other hand they also identified a number of problems that were not relevant to the situation.

Developing an instrument to measure and describe clinical decision making in different nursing fields

The purpose of this study was to develop and test a decision-making instrument for nursing, to consider the nursing decision-making models in different nursing fields, and to create a scoring system for the instrument. A 56-item instrument was developed on the basis of different decision-making theories and earlier studies about nursing decision making. The instrument was evaluated by using several different convenience samples of nurses from seven different countries (N = 1,460). Statistical analysis used were correlation coefficients, factor analysis, factor scores, and factor reliability coefficients. The results indicated that nurses from different countries and working in different fields of nursing respond similarly. The results of the studies using the 56-item instrument showed that nurses use four kinds of decision-making models (analytical, analytical-intuitive, intuitive-analytical, and intuitive). The factor reliability scores were high (alpha = 0.85-0.91). According to the results, 60 per cent of the nurses used the analytical-intuitive and intuitive-analytical decision-making models, 14 per cent used the analytical model, and 26 per cent used the intuitive model. However, these models vary both between and within different fields of nursing.

Clinical simulations: development and validation

Simulations used as an educational strategy can mimic clinical reality bringing real life activity into the learning environment. This paper presents a conceptual approach to simulation development and validation that is applied to develop assessment simulations for both childbirth and triage situations. A process-based method of presenting information to the learner in the assessment phase is incorporated in simulations developed from actual clinical cases. The uncertain conditions of assessment are recognized as mirroring practice reality and validation of this construct and that of expertise are considered. Use of these simulations has the potential to provide learners with the opportunity to experience dimensions of simulated practice reality and educators with an experiential strategy that can be used to prepare students and also clinicians who are unfamiliar with new clinical practice areas.

Gender and age bias in triage decisions

INTRODUCTION

Recently it has been recognized that women are less likely than men to be diagnosed with a myocardial infarction (MI) or to receive early or aggressive treatment and are more likely than men to die of an MI. The purpose of this qualitative study was to examine the triage decisions made by ED nurses for persons with symptoms suggestive of MI. The theoretical framework for this investigation was Hammond's lens model for clinical inference and Evan's two-stage reasoning model.

METHOD

Four focus group sessions were conducted. The participant's oral descriptions were tape-recorded, transcribed verbatim, and analyzed using the Krueger method.

RESULTS

Content analysis revealed several important issues influencing triage decisions: patient presentation, nursing knowledge and experience, practice environment, intuition, the fear of liability, and gender-specific behaviors. ED nurses held different perceptions regarding the significance and likelihood of MI for male and female patients seeking evaluation and treatment. In addition, ED nurses admitted that MI is not the first diagnosis considered for middle-aged women.

DISCUSSION

The inability of ED nurses to associate middle-aged women's presenting symptoms with MI may contribute to the increased morbidity and mortality experienced by this population. The findings of this study have implications for nursing research, education, and practice.

Triage decision making: educational strategies

Patient triage in Accident and Emergency departments requires emergency nurses to make rapid decisions based on their knowledge and experiences. The development of triage decision-making skills can be addressed through the use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced emergency nurses. Clinical educators and experienced emergency nurse mentors are encouraged to recognize that skill acquisition in triage decision making requires practice before registered nurses can engage fully in the process of triaging patients in the emergency department. It is essential to experience the process of triage decision making in order to develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information leading to a decision on the triage category for each patient. By using triage simulations developed from 'real triage cases' the process of decision making can be experienced by nurses. Further, if these simulations are accompanied by the collection of verbal protocols, nurses have opportunities retrospectively to explore their decision making with reflection. In addition, the presentation and use of decision rules used by experienced triage nurses can enhance the development of skills in novice triage nurses.

Education for clinical decision making in midwifery practice

OBJECTIVE

To present an approach to developing clinical decision-making skills in midwifery students.

DESCRIPTION

Use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced midwives are proposed for developing clinical-reasoning skills and acquiring skilled clinical knowledge.

IMPLICATIONS

Educators are encouraged to recognise that skill acquisition in clinical decision making requires practise before students engage fully in the clinical setting. The process of decision making is emphasised as essential for students to experience so they develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information to reach clinical judgements. By using clinical simulations developed from 'real cases' the process of decision making is able to be experienced by students. Further, if these simulations are accompanied by the collection of verbal protocols, students have opportunities to retrospectively explore their decision making with reflection. In addition, the presentation and use of decision rules of experienced midwives has the potential to enhance the development of skills in students.

Organizing context: nurses' assessments of older people in an acute medical unit

The paper presents findings from a study of how older people are assessed and cared for in an acute medical unit. The aim of the study was to reconsider nurses' assessment practices in relation to organisational context. Drawing together ethnographic methods with discourse analysis, the study develops an approach to studying nurses' assessment practices and aims to demonstrate that nurses go beyond entering their relationships with patients as individuals. Rather, nurses' assessments of patients can be considered as processes of alignment that help nurses accomplish complicit managerial and medical objectives, and shape their own identities.

The perception and judgment of senior baccalaureate student nurses in clinical decision making

This descriptive, exploratory study sought to validate Brooks's theory of intrapersonal perceptual awareness, a middle-range theory derived from King's interacting systems framework and to extend King's work by making perception (sensory and intuitive), judgment (cognitive and affective), and decision making explicit concepts in the personal system. The results supported the theory's central premise and clarified the interaction between perception and judgment but did not support bringing perception, judgment, and decision making into the personal system as proposed. Self emerged as the core concept, and the results are used to recommend a proposed reconceptualization of King's personal system as self.

Phenomenography: an alternative approach to researching the clinical decision-making of nurses

In this paper, the limitations associated with current research approaches to the study of clinical decision-making are discussed. Research examining the clinical decision-making of nurses and doctors, and associated work in information procession, is reviewed. It is concluded that although the research is valuable in furthering the understanding of clinical decision-making, there are limitations associated with the current research approaches. The limitations are primarily related to the research approaches employed and the concentration on experienced nurses. The research fails to examine the development of clinical decision-making ability and the learning that occurs in practice. Phenomenography is proposed as an alternative approach. The aim of phenomenography is to describe an individual's perception of a phenomenon. Phenomenography is relevant to the study of clinical decision-making as it is concerned with variation in experience. When applied to the study of new graduate nurses, phenomenography can provide valuable information in relation to individual differences in learning that arise from experience, what factors influence learning and how they affect clinical decision-making ability.

Clinical decision making of experienced and novice nurses

Decision making is an important daily nursing activity. Given contradictory past findings concerning the ease of use cognitive schema for reaching decisions among experts and novices, we chose to examine consistency of information as a parameter that may clarify the process of decision making. Ninety-two experienced nurses and 65 nursing students rated their decisional difficulty and levels of certainty in reaching a diagnosis for two scenarios: one including consistent information and one providing information that was partly inconsistent with the given diagnosis. For the consistent information, students showed more difficulty and less certainty in the given diagnosis than the experienced nurses. The inconsistent scenario was perceived as more difficult by nurses in comparison to students. The cognitive processes responsible for these results are discussed.

Decision-making models of Finnish nurses and public health nurses

This study described nursing decision-making models and variables related to these models. For this purpose a 56-item Likert-type questionnaire was constructed according to the Dreyfus model of skill acquisition as applied to nursing by Benner and information processing theory. The target group consisted of 100 registered nurses working in inpatient clinics and 100 public health nurses working in preventive health care. The decision-making variables explored were nurses' experience, education and knowledge as well as the nature of the nursing task and context. The results revealed four different types of decision-making: (a) unquestioning/questioning decision-making, (b) creative-diversive decision-making, (c) patient/nurse-oriented decision-making, and (d) rule- and situation-based decision-making. The most important factors related to decision-making were experience and the nature of the nursing task and context.

The Clinical Decision-Making Processes of Student Nurses

This descriptive study examined the clinical decision-making processes used by 19 female senior diploma nursing students in a simulated client situation. The subjects were divided into two groups, with either an internal or external locus of control, as measured by the Rotter Internal-External Locus of Control Scale. From a content analysis of the data, six decision-making elements and eight decision-making processes were identified. The frequency and pattern of use of the decision-making processes differed between internally and externally oriented subjects. Internal subjects used a significantly higher proportion of complex decision-making processes than the external subjects (z = 3.48; p < .01). All subjects were found to use decision-making elements and processes in a manner that reflected novice characteristics and supported the theoretical framework of information-processing theory. These findings have implications for nurse educators in relation to teaching strategies that facilitate clinical decision-making ability and internalization strategies for students with an external locus of control.

Metacognitive skills in diagnostic reasoning: making the implicit explicit

The metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, regulating, and revising frame the nursing process and support clinical reasoning. Nurse educators who encourage metacognitive skill acquisition are likely to accelerate student comprehension, understanding, and mastery of nursing diagnosis, nursing process, and clinical reasoning. The models presented in this article have implications for teaching and learning clinical/diagnostic reasoning.