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THE CLINICAL REASONING of EXPERT ACUTE CARE REGISTERED NURSES in PRE-CARDIOPULMONARY ARREST EVENTS Approved by Dissertation Comm

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THE CLINICAL REASONING of EXPERT ACUTE CARE REGISTERED NURSES in PRE-CARDIOPULMONARY ARREST EVENTS Approved by Dissertation Comm THE CLINICAL REASONING OF EXPERT ACUTE CARE REGISTERED NURSES IN PRE-CARDIOPULMONARY ARREST EVENTS Approved by Dissertation Committee: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. THE CLINICAL REASONING OF EXPERT ACUTE CARE REGISTERED NURSES IN PRE-CARDIOPULMONARY ARREST EVENTS by Alyce Louise Smithson Ashcraft, B.S.N., M.S.N. Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin May 2001 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. To my Father who gave me life and To my family who sustains life Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Acknowledgments This has been a long journey and one which I could not have made alone. To my husband, Glen, and son, Donovan, thank you for allowing me to fulfill a dream. To my mother Elise, thank you for telling me that I can do anything then making me believe it. To my father Wiley, thank you for acknowledging my special place in your heart. To everyone at work who listened to the bright spots and low spots in this arduous journey, thank you. To Dr. Susan Grobe, you are a very special person, teacher, and mentor to work with novice researchers. Thank you for your patience. To Dr. Angela Clark, thank you for your inspiration. To Dr. Claire Ellen Weinstein, you weave a special magic with students. To Drs. Kuipers and McDougall, thank you for your additional words of wisdom that enhanced the final product. One last word(s). Donovan, you too, can do anything which you desire. Dream, imagine, play. This journey has ended, but another is about to begin. May 1, 2001 v Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. THE CLINICAL REASONING OF EXPERT ACUTE CARE REGISTERED NURSES IN PRE-CARDIOPULMONARY ARREST EVENTS Publication N o. __________ Alyce Louise Smithson Ashcraft, Ph.D. The University of Texas at Austin, 2001 Supervisor: Susan J. Grobe The purposes of this study were to (a) identify the clinical reasoning processes of expert acute care Registered Nurses (RNs) in pre- cardiopulmonary arrest events using empiric indicators and to (b) make inferences about the expert acute care RN’s reasoning processes during pre-cardiopulmonary arrest events. Data were collected from 15 subjects using think aloud (TA) as they verbalized their thoughts concerning how their presence and attention prevented a patient from experiencing cardiopulmonary arrest. Protocol analysis (PA) provided a description and structure for the information attended to while reasoning about the care to prevent cardiopulmonary arrest. The data that expert acute care attend to when reasoning about the care required by a patient thought to be in danger of experiencing a cardiopulmonary arrest cluster around the operators scenario set, intervene, decision/rationale, and outcome. In addition, the experts used five type of assertions in the transcripts to determine relationships between the operators: observational, indicative, conditional, decisional/action, and vi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. interpretive. Detailed analysis of these relationships revealed the following implications: 1. Experts predominately used the operator Scenario Set. This is indicative of their searching for an evolving pre-cardiopulmonary arrest pattern. 2. The operator decision/rational is important because it reflects that a decision was made and/or a rational supplied concerning delivery of care. 3. Experts predominately used indicative assertions to link the largest amount of data within the operator Scenario Set. Indicative assertions represent the nurses’ search for a pattern that can link all other operators. 4. Expertise takes time to develop within an specific area of practice and is nontransferable despite similarities in the work environment. 5. The definition of expert acute care Registered Nurse may need to be limited to individuals who maintain a full time practice providing direct patient care in the critical care environment. 6. Expertise may be attained by through continual refinement of clinical reasoning processes in the practice environment or by constant exposure to different situations in the practice environment. 7. Self perception of expertise may be one indicator that expertise in a nursing has been attained. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table of Contents D edication .................................................................................................. iv Acknowledgments .....................................................................................v Abstract ........................................................................................................vi Table of Contents ..................................................................................... v iii List of Tables .............................................................................................. xv Chapter 1—Introduction .............................................................................1 Purpose of the Study ...................................................................... 2 Background and Significance ...................................................... 2 Statement of the Problem .............................................................. 7 Research Questions ....................................................................... 7 Theoretical Framework...................................................................7 Antecedents .................................................................................. 11 Clinical Reasoning ........................................................................11 C o n clu sio n .................................................................................... 12 Patient/Client Outcome ................................................................ 12 Clinical Reasoning........................................................................12 C o n clu sio n .....................................................................................12 Patient/Client Outcome .................................................................12 Metacognition ................................................................................ 13 Definitions of Terms ...................................................................... 13 Assumptions .................................................................................. 15 Limitations ......................................................................................16 S um m ary ........................................................................................17 v iii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 2—Review of the Literature .......................................................18 Clinical Reasoning as a Concept. .............................................. 19 Clinical Reasoning Studies ........................................................ 23 Presence (multiple cue acquisition) .......................................... 23 Multiple Hypothesis Generation (the deriving of meaning from observed data) ............................................................................. 31 Cue Interpretation (the confirming or refuting of cues) ........... 33 Methods for Examining Clinical Reasoning ............................. 35 Quantitative I nstruments ............................................................. 3 7 Verbal Reports ..............................................................................42 Protocol Analysis ..........................................................................46 Expertise as a Concept ............................................................... 51 Nursing Expertise .........................................................................53 Pre-cardiopulmonary Arrest as a Concept ............................... 58 Morbidity Scoring Tools .............................................................. 59 Cardiopulmonary Arrest Studies ................................................65 Variables Predicting Outcome/Survival .................................... 65 Variables Predicting Arrest ......................................................... 75 Sum m ary .......................................................................................80 Chapter 3—Methods .................................................................................86 Qualitative Research ................................................................... 86 Pilot Study ..................................................................................... 87 Data analysis: Referring Phrase Analysis ................................88 Data Analysis: Assertional Analysis ......................................... 88 ix Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Data Analysis: Script Analysis ................................................... 9 2 Results ............................................................................................ 94 Main Study ................................- ..................................................
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