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C, Thompson 1 , L, Dalgleish 2 , T, Bucknall 3 , C, Estabrookes 4 ,

The effects of time and experience on nurses’ risk assessment decisions: a signal detection analysis. C, Thompson 1 , L, Dalgleish 2 , T, Bucknall 3 , C, Estabrookes 4 , R, De Vos 5 , A, Hutchinson 4 , K, Fraser 4 , J, Binnekade 5 , G, Barrett 6 , J, Saunders 6.

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C, Thompson 1 , L, Dalgleish 2 , T, Bucknall 3 , C, Estabrookes 4 ,

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  1. 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

  2. Background • 60% of cardiac arrests preventable1 • 50% of arrests have documented but not-acted-on changes in “basic” data: heart rate, BP, urine output, conscious level etc. 2 • Nurses key link in preventing “failure to rescue” • 98% of calls to METs nurse-initiated3 • 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

  3. Background • Expertise and experience often “confused”1 • “epidemiological” benefits of experience not easily seen in individual judgements and decisions2 • Intuitive judgement is modus operandi for nurses3 • 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

  4. questions • Does “generic” clinical experience improve the ability to detect the need to take action? • Does “specialist” clinical experience improve the ability to detect the need to take action? • How does time pressure impact on nurses’ decision making performance?

  5. methods Signal detection analysis1 1Stanislaw & Todorov 1999 Calculation of signal detection theory Measures, Behaviour research measures, instruments and computers 31(1), 137-149

  6. 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

  7. methods • 50 clinical scenarios via power point in wards/units

  8. Methods • “Signal” • MEWs (Modified Early Warning Score) clinical prediction rule1 • MEWS ≥5 = “at risk” • Thus 18 “signals” and 32 “no signals” from 50 scenarios • Scenario values randomly selected from 1 years MEWs assessments in 1 UK acute Trust (n=1350) • Time pressure = 10 seconds and a visual cue (clock symbol). • Time pressure = 26 scenarios; no time pressure = 24. • Cases mixed randomly to prevent primacy and recency effects • Judgement = “would you intervene by contacting a senior nurse or doctor?” • nb: as per protocol in each site 1Subbe et al. 2001

  9. analysis • N and proportions of hits and false alarms calculated • SDT indices d’ and ln(β) calculated1 • Experience made ordinal • 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) • Country as a factor in all analysis • Separate analysis looked at critical care experience and time pressure 1Stanislaw & Todorov 1999

  10. participants • 245 acute or critical care nurses • UK 95; Netherlands 50; Australia 50; Canada 50 • Sampled randomly in UK; convenience elsewhere • Mean years registered 11.6 (SD 8.8) • Mean years in current specialty 8.8 (SD 6.7) • Mean age 34 years (SD 8.1) • 64% had more than a year’s critical care experience • Graduates: • UK 6%; Canada 77%; Netherlands 40%; Australia 100% • nb: assessing critical event risk was a common judgement for all the nurses

  11. Results: time pressure

  12. results: experience under pressure • All nurses performed better with no time pressure • No significant interaction between experience and time pressure on the d’ (signal detection ability) measure.

  13. discussion • More time = greater accuracy and less unwarranted (costly) intervention • Less time = more “failure to rescue” (14% to 32%) • Dangers of spreading expertise too thinly (critical care, METs, rapid response) • Variation in performance ?due to variations in organisational context • “Good enough” fast-and-frugal heuristics used by nurses may (in the absence of feedback) may not be quite as good when analysed systematically.

  14. conclusion • Time pressure masks nursing expertise • Quantity of clinical experience ≠ expertise • Quality of clinical experience = expertise • Nurses need to be taught the value of clinical information, combating cognitive caution: clinical epidemiological ways of thinking • We need to know more about the “signals” and “noise” that surrounds nursing judgement calls and decisions

  15. Reference and contact Thompson 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 Nursing Department of Health Sciences Area 2, Seebohm Rowntree Building University of York York YO10 5DD United Kingdom e: cat4@york.ac.uk t: +44 1904 321350

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