A comparison of decision-making by “expert” and “novice” nurses in the clinical setting, monitoring patient haemodynamic status post Abdominal Aortic Aneurysm surgery
- Publication Type:
- Thesis
- Issue Date:
- 2007
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Effective high-quality decision-making is important in nursing to ensure that nurses’
decisions positively affect patient care. This is particularly important in critically ill
patients such as those being managed and monitored in Intensive Care Units (ICU).
Increasing nursing shortages worldwide are leading to greater demands for new graduate
nurses to enter directly into areas such as ICU, and the education of graduates needs to
prepare them for the demands of this area, particularly in relation to the development of
cognitive skills such as decision-making. Examination of the cognitive processes of
nurses as they decide on care for patients in ICU can help in not only understanding how
nurses make decisions about care, but can also lead to improvements in educational
methods to develop such skills. Comparing the decision-making skills of novice and
expert nurses can help illuminate the differences between these two groups and lead to
methods to best assist novice nurses towards expertise.
Much of our reasoning is invisible and examination of it requires methods that can
illuminate our thinking. The information-processing framework seeks to explain the
unseen processes as they occur in the mind and envisages a model of the mind as a
processor. The think aloud (TA) method of data collection and the corresponding verbal
protocol analysis from this theoretical framework were chosen for this study and allow
for in-depth, rich descriptions of a participant’s cognitive processing as s/he reasons about
care. Collection of such data in the natural setting can expand the knowledge of cognitive
processing in decision-making and the real world of practice was used for this purpose.
Eight ICU nurses, four novice and four expert, comprised the sample. The nurses thought
aloud (TA) for two hours while caring for patients who had undergone an elective
Abdominal Aortic Aneurysm (AAA) repair. The patients were all cared for within the
first 24 hours post-operatively. The participants were subsequently interviewed as soon
as the transcripts of the data were available after the TA session. Transcripts were
analysed using Problem Behaviour Graphs (PBG) and content analysis, and the problem
space identified by describing the tasks attended, cues gathered and information sources
used. The cognitive operators and processes used were also identified.
There were differences in both cognitive operators and processes used by novice and
expert participants. Expert participants, in contrast with some previous studies, collected
a greater range of cues than did novice participants and had an extensive repertoire of
known cues, which they were able to relate together more often than were novice
participants. The difference in novice and expert nurses’ decision-making may be as
much due to the way expert nurses put pieces of information together as it is to how much
information they have. This study was completed in the real world of practice. Expert
participants appeared to be anticipating problems and collecting cues that may indicate
these problems. Expert participants also used the cognitive operators “match” and
“predict” more often than novice participants did and appeared to match current patient
situations to previous patients and experience. Expert participants used more forward
reasoning in hypothetico-deductive reasoning, possibly as they could anticipate problems,
whereas novice participants used more backward reasoning in hypothetico-deductive
reasoning, working back from problems they identified. Novice and expert participants
used if/then statements and novice participants reported they had been taught some of
these by more experienced nurses. This type of reasoning in decision-making, although
mentioned in the nursing literature, has not been identified as a process in nursing studies.
Understanding how novice and expert nurses’ reasoning during decision-making differs
can be used to further develop undergraduate education programmes. It can also help
those who mentor novice nurses better understand and model decision-making. Adoption
of teaching and learning methods within Problem Based Learning (PBL) programmes,
such as concept maps to plan care, may help students and novice nurses better understand
how to gather and relate cues and information to plan care.
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