C, Thompson 1 , L, Dalgleish 2 , T, Bucknall 3 , C, Estabrookes 4 ,
description
Transcript of C, Thompson 1 , L, Dalgleish 2 , T, Bucknall 3 , C, Estabrookes 4 ,
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The effects of time and experience on nurses’ risk assessment
decisions: a signal detection analysis
C, Thompson1, L, Dalgleish2, T, Bucknall3, C, Estabrookes4, R, De Vos5, A, Hutchinson4, K, Fraser4, J, Binnekade5, G, Barrett6,
J, Saunders6
1University of York, UK;2University of Stirling, UK; 3 Deakin University, Australia; 4University of Alberta, Canada; 5University of Amsterdam, Netherlands; 6Bradford Hospitals NHS Trust, UK
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Backgroundo 60% of cardiac arrests preventable1 o 50% of arrests have documented but
not-acted-on changes in “basic” data: heart rate, BP, urine output, conscious level etc. 2
o Nurses key link in preventing “failure to rescue”o 98% of calls to METs nurse-initiated3
o Transforming changes in status to MET call in only 2.8% of cases4
1Hodgetts et al 2002; 2Goldhill 2001; 3Cioffi 2000; 4Daffurn et al 1994
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Background o Expertise and experience often
“confused”1
o “epidemiological” benefits of experience not easily seen in individual judgements and decisions2
o Intuitive judgement is modus operandi for nurses3
o Time pressure4 and irreducible uncertainty5 important clinical contexts
1Anders Ericsson 2007; 2Aiken et al. 2003; 3Thompson et al. 2005; 4Thompson 2001, 2004, Bucknall 2000; 5Eddy 1994
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questions
o Does “generic” clinical experience improve the ability to detect the need to take action?
o Does “specialist” clinical experience improve the ability to detect the need to take action?
o How does time pressure impact on nurses’ decision making performance?
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methodsSignal detection analysis1
risk No risk
Yes TP+ FP-
no FN- TN+
1Stanislaw & Todorov 1999 Calculation of signal detection theory Measures, Behaviour research measures, instruments and computers 31(1), 137-149
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methods
Thompson C, Dalgleish L et al. The effects of time pressure and experience on nurses' risk assessment decisions: a signal detection analysis. Nursing Research, 2008; 57(12): 302-311
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methodso 50 clinical
scenarios via power point in wards/units
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Methodso “Signal”
o MEWs (Modified Early Warning Score) clinical prediction rule1
o MEWS ≥5 = “at risk”o Thus 18 “signals” and 32 “no signals” from 50 scenarioso Scenario values randomly selected from 1 years MEWs
assessments in 1 UK acute Trust (n=1350)
o Time pressure = 10 seconds and a visual cue (clock symbol).o Time pressure = 26 scenarios; no time pressure = 24. o Cases mixed randomly to prevent primacy and recency effects
o Judgement = “would you intervene by contacting a senior nurse or doctor?” o nb: as per protocol in each site
1Subbe et al. 2001
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analysiso N and proportions of hits and false
alarms calculatedo SDT indices d’ and ln(β) calculated1
o Experience made ordinalo 2 x mixed model ANOVA with d’ and ln(β)
as dependents and clinical experience (between subjects 4 levels) and time pressure (within subjects 2 levels)
o Country as a factor in all analysis
o Separate analysis looked at critical care experience and time pressure
1Stanislaw & Todorov 1999
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participantso 245 acute or critical care nurses
o UK 95; Netherlands 50; Australia 50; Canada 50
o Sampled randomly in UK; convenience elsewhere
o Mean years registered 11.6 (SD 8.8)o Mean years in current specialty 8.8 (SD 6.7)o Mean age 34 years (SD 8.1) o 64% had more than a year’s critical care
experienceo Graduates:
o UK 6%; Canada 77%; Netherlands 40%; Australia 100%
o nb: assessing critical event risk was a common judgement for all the nurses
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Results: time pressure
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results: experience under pressureo All nurses performed better with no time
pressureo No significant interaction between
experience and time pressure on the d’ (signal detection ability) measure.
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discussiono More time = greater accuracy and less
unwarranted (costly) interventiono Less time = more “failure to rescue” (14%
to 32%)o Dangers of spreading expertise too thinly
(critical care, METs, rapid response)o Variation in performance ?due to variations
in organisational contexto “Good enough” fast-and-frugal heuristics
used by nurses may (in the absence of feedback) may not be quite as good when analysed systematically.
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conclusiono Time pressure masks nursing expertiseo Quantity of clinical experience ≠
expertiseo Quality of clinical experience =
expertiseo Nurses need to be taught the value of
clinical information, combating cognitive caution: clinical epidemiological ways of thinking
o We need to know more about the “signals” and “noise” that surrounds nursing judgement calls and decisions
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Reference and contactThompson C et al. The effects of time pressure and experience on nurses' risk assessment decisions: a signal detection analysis. Nursing Research, 2008; 57(12): 302-311
Dr Carl Thompson Centre for Evidence Based NursingDepartment of Health SciencesArea 2, Seebohm Rowntree BuildingUniversity of YorkYork YO10 5DDUnited Kingdome: [email protected] t: +44 1904 321350