• acute care;
  • decision making;
  • judgment;
  • judgment analysis

Aims.  To explore and explain nurses’ use of readily available clinical information when deciding whether a patient is at risk of a critical event.

Background.  Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge ‘basics’ such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses’ responses to abnormal signs result in delays of between one and three hours.

Methods.  A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, ‘at-risk’ status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

Results.  Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as ‘at risk’ and deciding to intervene. Nurses’ weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (Ra) statistics suggests that nurses’ assessments of risk were largely inaccurate; these assessments were applied consistently among ‘patients’ (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

Conclusion.  Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

Relevance to clinical practice.  Practice developers and educators need to pay attention to the quality of nurses’ clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes’ rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of ‘holism’ and ‘expertise’ from the science of predictive validity, accuracy and competence in judgement and decision making.