The effects of clinical experience on nurses' critical event risk assessment judgements in paper based and high fidelity simulated conditions: a comparative judgement analysis.

摘要

BACKGROUND: Paper based simulated patients are widely used to analyse nurses' clinical judgements. However, developments in the physical simulation of clinical environments offer exciting, but relatively underexploited, opportunities for exploring nurses' judgements. Critical event risk assessment is an element of acute care practice which lends itself well to simulation and in which more clinical experience is often assumed to lead to better quality judgements. OBJECTIVES: To model nurses' judgements of critical event risk using physical and paper simulation and to examine whether improving fidelity via physical clinical simulation impacts on the apparent benefits of clinical experience on nurses' judgement performance. DESIGN: A comparative clinical judgement analysis. SETTING: A university in Northern England. METHODS: Sixty-three nursing students and 34 experienced nurses made dichotomous risk assessment judgements ("at risk" or "not at risk") in response to 25 paper and physical simulated scenarios. These were randomly generated from a dataset of real patient case records. Clinical outcomes (the judgement criteria) for a 'correct' judgement were derived from the same case records. Logistic regression models were constructed to derive statistics for each nurse representing various measures of judgement performance: achievement (r(a)), consistency (R(s)) and clinical information use (G). These statistics were known as Lens Model statistics (from the psychological theory of Brunswik's Lens Model of judgement). Performance measures for novice and experienced nurses were compared. RESULTS: No significant differences in judgemental achievement (r(a)) between experienced nurses and students were observed in either paper or high fidelity clinical simulations. Similarly, there were no significant differences in the nurses' abilities to correctly match the ways they synthesised clinical information with the optimum synthesis required by the task (policy matching) (G). When faced with "paper patients" experienced nurses exercised more cognitive control/consistency (R(s)) than students (P=0.04). However, this heightened control in experienced nurses was absent when those same nurses made judgements in the higher fidelity clinical simulation environment. CONCLUSION: Clinical experience made no difference to nurses' judgement achievement (accuracy) in either the lower fidelity paper scenarios or the higher fidelity setting of the clinical simulation unit. The significant impact of clinical experience on judgement consistency was negated by the increases in fidelity offered through clinical simulation.