| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
 |
Abstract |
|---|
 Top Abstract Making Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
The increasing complexity of care delivery demands that nurses make rapid, complex decisions about the hemodynamic status of high-risk, critically ill patients. The potential for variability between nurses in the processes they use to make these decisions and in their choice and implementation of hemodynamic interventions is marked. Nurses’ decisions can vary because of knowledge, experience, and the complexity of the decision itself.1,2 Variability in decision making may also be due to environmental sources,3 because nurses make decisions in a clinical context. Variability may arise because nurses acquire, prioritize, and use hemodynamic cues differently.
We maintain that variability per se in how nurses make decisions about hemodynamic status should be neither encouraged nor discouraged. However, few studies have explored the multifactorial influences on decision making in critical care areas, resulting in a poor understanding of the extent, sources, and consequences of variability in decisions. We present an emerging model, naturalistic decision making (NDM), as a framework that can offer a richer perspective on the important and complex tasks involved in nurses’ decisions about patients’ hemodynamic status. We discuss current knowledge of specific practices in making decisions about hemodynamic status and the potential sources of variability in decisions among nurses by exploring the roles of nurses’ experience, the characteristics of the tasks involved, and the environment in which the decision is made. We focus on the methodological issues and limitations associated with previous research approaches that did not consider the multivariate relationships between the decisions, the nurses, and the environment.
 Data on the decision-making process related to hemodynamic stability are limited. Individual, task, and environmental factors may result in wide variations in critical care nurses’ decisions.
|
|
Making Decisions About Patients’ Hemodynamic Status After Cardiac Surgery |
|---|
|
TopAbstractMaking Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
However, little is known about how nurses make decisions about patients’ hemodynamic status in the immediate phase after cardiac surgery. No guidelines indicate what hemodynamic parameters are important or what assessment decisions and interventions should be prioritized to improve patients’ outcomes. This ambiguity can produce high levels of variability between nurses in decisions about assessment and interventions.
Aside from nurses’ years of experience, which has been studied in clinical and laboratory settings, our current understanding of factors that influence nurses’ decision making has been gained primarily through simulation studies. In order to accurately identify, explain, and include sources of variability in how nurses make decisions, research must account for, and be done in, the critical care environment. Fundamentally, the method used must reveal hemodynamic phenomena in terms of the way cues are used by nurses, the nurses’ response times, interpersonal interactions among nurses, interventional decisions made by nurses, and nurses’ reactions to environmental factors. NDM is a framework that offers methodological benefits in the way we study complex phenomena that can increase our understanding of how nurses make decisions about patients’ hemodynamic status.
|
Naturalistic Decision Making |
|---|
|
TopAbstractMaking Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
NDM emerged from traditional research on decision making in response to questions about the generalizability of laboratory-based research to real-world performance. In contrast to assessments of decision making in simulated settings, NDM-based research takes place in the domain of the decision maker, thereby providing information on events that occur before and after a decision is made.6 How a person uses experience and knowledge to make decisions is of great interest to researchers who use NDM,7 but not to the point that inexperienced persons are excluded from participating in the research.
Research on NDM focuses on decisions made in natural settings that incorporate specific characteristics6 (Table 1
). Nurses’ decisions about patients’ hemodynamic status in the immediate period after cardiac surgery have these characteristics.
|
| Rather than study the decision-making process through simulations, studies using naturalistic decision making occur in the natural (real), dynamic setting.
|
|
The Complexity of Making Decisions About Patients’ Hemodynamic Status |
|---|
|
TopAbstractMaking Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
Decisions are considered complex when numerous alternatives, each with numerous attributes, must be considered by the decision maker within a short time.2 Decisions about the hemodynamic status of typical patients in the intensive care unit (ICU) after cardiac surgery who have pulmonary artery and arterial catheters in place fit the aforementioned criteria. Nurses must acquire accurate data on hemodynamic parameters provided by these catheters by attending to the specific attributes of each parameter, for example, by ensuring that the monitoring system is zeroed. Before a decision is made about an intervention, the parameters must be interpreted in combination with laboratory and physical data. Nurses must rapidly assess hemodynamic data that may be ambiguous or conflicting, because prompt actions are required to maintain patients’ hemodynamic stability.
How do nurses assimilate complex, dynamic information to make accurate and rapid decisions about the hemodynamic status of patients who are at risk for life-threatening cardiovascular instability? Are certain cues considered more reliable or more important? If so, what are the cues, and what are the implications for management decisions? Studies in which NDM is used as a framework could help answer such questions (Table 2).
|
| Nurse experts base decisions on selective, most important patterns of information, whereas less experienced nurses may use a broader range of information, which results in greater variability in decisions.
|
Use and Prioritization of Cues
The effect of time restrictions on how nurses use and prioritize cues about patients’ hemodynamic status is not well understood. In an early, nonmedical simulation by Wright9 in which time restrictions were manipulated, decision makers under time pressure placed greater emphasis on different attributes of a problem than those not under time pressure. If time pressure affects the attributes that nurses consider relevant when making a decision about the cause of a patient’s hemodynamic changes (eg, attributes that do not support a hypothesized diagnosis of cardiac tamponade), a delay might occur in identifying the cause, which in turn might lead to a less than optimal outcome. Limitations of Wright’s study include its simulation basis and no inclusion of controls for experience.
Nurses make decisions in a dynamic environment where feedback from decisions influences subsequent processing of cues. Nurses who constantly make decisions in a time-pressured environment may adapt in important ways. Clinically based studies are needed to explore the effects of the clinical environment on decision making.
Because of the complexity of the decisions required in the acute postoperative phase, most likely nurses’ experiences with patients in the ICU after cardiac surgery positively influence the nurses’ decision making. Experience plays a pivotal role in how nurses make decisions. Specifically, it enhances their abilities to make rapid decisions,10 to distinguish important cues from unimportant cues, and to recognize and act on patterns of information.11 Because of this selectivity, the nurses pay less attention to irrelevant cues12 and use fewer information cues overall.13 A review14 of studies on experts indicated that the cues attended to by the experts are the most important, resulting in faster, more accurate decisions. The ability to recognize patterns of information is important, because cues viewed in isolation may not alert a nurse to an emerging problem. The need for rapid decision making in the context of complex hemodynamic assessment data means that nurses may also rely on shortcut mental strategies or heuristics.12
Substantial evidence indicates that experienced nurses perform well in the clinical setting. Benner et al11 made explicit some important aspects of clinical experience, such as the stages of skill acquisition in critical care practice and differences between novice and expert practitioners. Experienced nurses can assess and respond to episodes of cardiovascular instability rapidly and accurately. However, inexperienced nurses also care for acutely ill patients after cardiac surgery. Therefore, marked variations are possible in the way nurses with different levels of experience respond to clinical data. These variations can influence patients’ outcomes and warrant exploration.
The NDM framework can be used to study how experienced clinicians use important cues to make complex decisions in the clinical setting. An NDM-based study of experienced nurses in a neonatal ICU revealed assessment cues indicative of early sepsis in neonates that either had not been reported previously in the literature or conflicted with cues that had been reported.15 Significantly, the elicited cues were used to form a guide for assessment of sepsis in neonates. This guide enabled less experienced staff to apply expert knowledge in the detection of sepsis in their clinical practice to improve patients’ care.
Little is known of the cues important in assessing hemodynamic stability in cardiac surgical patients. Such knowledge would help nurses prioritize hemodynamic assessments and interventions to improve patients’ outcomes. The lack of guidelines for prioritizing and interpreting cues makes it highly likely that nurses base their decisions regarding the importance of information about patients on a combination of knowledge, experience, and unit protocols. In addition, likely variation exists between nurses in the way they combine information on patients.
For example, Shoemaker16 raised concerns about the common use of data provided by pulmonary artery catheters. Shoemaker argued that oxygen dynamics and circulatory performance are the most informative and useful data procurable via a pulmonary artery catheter but that these data either are not obtained or are measured but not used to guide or evaluate patients’ hemodynamic management. This view is supported by Ahrens,17 who proposed an assessment framework that aims to provide reliable information on hemodynamic stability by making the first step in assessment an examination of physical and associated diagnostic information. Ahrens suggested that certain cues provided by pulmonary artery catheter monitoring should be assessed in order of priority (Table 3). Having assessment of mixed venous oxygen saturation as the first item highlights that the purpose of using a pulmonary artery catheter, and the ultimate aim of hemodynamic monitoring, is to ensure adequate tissue oxygenation. This argument is a strong one that requires further validation.
|
In terms of what hemodynamic cues should be given priority, cues that have a relationship with an outcome such as length of stay are worth considering. In one study,19 hemodynamic instability (defined as systolic blood pressure <90 mm Hg or >140 mm Hg requiring either intravenous volume replacement or vasoactive pharmacological therapies, with the exception of dopamine at a dose of <5 µg/kg per minute) within the first 3 hours after admission to a cardiac surgical ICU, presence of arrhythmias, 12-hour fluid balance, and duration of intubation accounted for a high proportion of variance in ICU length of stay. Miller20 reported that low cardiac output syndrome and atrial dysrhythmias were associated with prolonged stays in the ICU. The aims of an NDM study would be to provide more specific information about the importance of cues and to reveal whether the cues discussed previously are currently used, prioritized, or documented by nurses, and if not, why not.
Assimilation and Integration of Conflicting Cues
In addition to the issues associated with use and prioritization of cues, how nurses incorporate complex and contradictory information is of interest. In the study by Aitken,18 not all nurses integrated the cues provided by pulmonary artery catheter monitoring with the cues provided by physical assessment of patients. How inexperienced nurses integrate technical and physical cues is not known. Aitken18 also found that experienced nurses did not use all of the available data. When the expense of hemodynamic devices is considered, the practice of either not using the devices to maximum advantage or not using information provided by the devices would be costly. Despite the proliferation of technology in critical care, the consequences of not using technology to its optimal level have not been explored.
Integrating cues provided by technological devices with data provided by physical assessment can be a further source of variation in nurses’ decisions about patients’ hemodynamic status. In a simulation study, Lewis21 found that nurses were more hesitant to attempt weaning a patient from mechanical ventilation when the case was complex than when the case was simple. She reported that conflicting cues made the decision significantly more complex.
Conflicting cues are an everyday part of hemodynamic monitoring. A field-based study could provide further understanding of nurses’ decisions and the influence of conflicting cues. The nurses in the study by Lewis were all experienced in weaning patients from respiratory support; how inexperienced nurses respond to conflicting cues is not known. Probably, nurses make judgments in these situations about which data sources are most accurate and intervene on that basis. This likelihood raises another issue for consideration: the importance of accessing accurate data.
Accuracy of Cues
Accurate measurement of hemodynamic parameters requires knowledge of the principles of hemodynamic monitoring. The highest mean score in several questionnaire-based studies22–24 in which investigators evaluated nurses’ knowledge of pulmonary artery pressure monitoring was only 65%. Disturbingly, areas associated with low scores were knowledge of, and ability to apply, information related to the assessment and collection of data provided by pulmonary artery catheter monitoring. Similarly, an inadequate knowledge of blood pressure monitoring practices was found in a questionnaire-based study25 of critical care nurses.
Knowledge deficits related to collection of data provided by technological devices could result in misinterpretation of data or inaccuracy in obtaining data. An NDM study could determine whether the reported knowledge deficits translate into poor hemodynamic practices in the clinical setting. Expert knowledge is specific to the expert’s practice domain,1 so nurses who have specific knowledge of pulmonary artery catheter monitoring may be skilled at accurately acquiring and interpreting data used to make decisions about interventions.
Environmental Factors
The critical care environment has unique characteristics that add to and are part of the complexity associated with how nurses make decisions about patients’ hemodynamic status. These characteristics include a high level of peer review, the irreversibility of the decisions, proliferation of technology, high patient acuity, and noise. The NDM framework is an ideal model for increasing our understanding of how the environment affects decisions. In particular, this framework can be used to study the role of social interactions in nurses’ decision making.
In noncritical care areas, the presence of colleagues can affect individual nurses’ decision making by influencing group decision-making processes.26 In an ethnographic study in critical care, Chase27 found that a hierarchy of nurses helped solve problems encountered in clinical practice and provided support for less experienced staff. After cardiac surgery, inexperienced nurses commonly call on more senior colleagues for help in making decisions about hemodynamic management. Remarkably, little research has focused on decisions about hemodynamic interventions during this crucial stage of patients’ recoveries.
In order to understand real-world decision making by nurses, research methods must reflect the totality of the task. To gain a greater understanding of how nurses use their knowledge and experience to perform complex tasks in realistic, dynamic situations, researchers have been encouraged to incorporate the NDM perspective.28 Research into the variability in how critical care nurses make decisions about patients’ hemodynamic status in the immediate phase after cardiac surgery is well suited to NDM studies.
| Naturalistic decision making may provide a comprehensive methodology to study all aspects of critical care nurses’ decisions about patients’ hemodynamic stability.
|
|
Conclusions |
|---|
|
TopAbstractMaking Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
|
REFERENCES |
|---|
|
TopAbstractMaking Decisions About...Naturalistic Decision MakingThe Complexity of Making...ConclusionsReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
