A comparison of decision-making by “expert” and “novice” nurses in the clinical setting, monitoring patient haemodynamic status post Abdominal Aortic Aneurysm surgery

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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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