Factors That Influence Nurses' Clinical Judgment During Episodes of Acute Physiologic Patient Deterioration

Abstract Each day in hospitals across the United States patients experience serious adverse events such as a cardiopulmonary arrest, unexpected admission to the intensive care unit, or unanticipated death. Many of these events occur on medical and surgical units and are preceded by a period of demonstrated warning signs of physiologic deterioration. Acute physiologic deterioration is characterized by abnormalities in one or more physiological measures such as blood pressure, heart rate, respiratory rate or level of consciousness. Unfortunately, the clinical warning signs indicating deterioration are sometimes missed, unrecognized, or mismanaged. Despite widespread efforts to improve early detection and management of acute physiological deterioration, substantial problems persist in hospitals across the United States. Noticing that a patient problem exists is the basis on which nurses’ clinical reasoning, clinical judgment and decision-making rest according to the Clinical Judgment Model by Christine Tanner. Failing to notice, interpret, or respond appropriately to deterioration can have serious consequences for patients. Little is known, however, about the factors that influence the registered nurse’s ability to notice, interpret, and respond to the clinical signs of deterioration. The purpose of this qualitative descriptive study was to identify nurses’ descriptions of factors that influence their ability to notice, interpret, respond and reflect on situations of acute physiologic patient deterioration. Twenty medical-surgical RNs from an academic medical center in the South Central region of the United States volunteered to participate in semi-structured telephone interviews about their experiences with acute patient deterioration. Eight themes and 18 subthemes emerged during data analysis as being important to nurses’ clinical judgments. An overarching theme that cut across all components of clinical judgment (i.e., noticing, interpreting, responding and reflecting) also was revealed: Nurses’ Keen Sense of Responsibility. Within the component of noticing three themes were identified: knowing the patient, experience matters, and lots of small points where the system can fail. Two themes were identified in the clinical judgment component of interpreting: making sense of the data and, something doesn’t go together. Within the component of responding three themes were identified: caught in the middle, culture of teamwork, and increased nursing workload. Two themes were identified that showed participants’ reflections on situations of acute deterioration: I always remember, and lessons learned. Participant recommendations for improving the response to a deteriorating patient were grouped into three themes: know your patient, be prepared, and trust your gut. Findings of this study revealed mixed support for Tanner’s Clinical Judgment model during situations of acute physiologic patient deterioration. An underlying premise of the model is that clinical judgments are influenced by individual characteristics and pre-established perspectives of the nurse. These perspectives are informed by various types of knowledge, including the nurse-patient relationship. These perspectives influence nurses’ “initial grasp” of a situation, or what is noticed. The results of the present study support the influence of the nurse’s background knowledge on clinical judgments. The results of this study also support the model’s proposal that nurses who have a stronger nurse-patient relationship are likely to notice changes of deterioration earlier. The second underlying premise of the model is that clinical judgments are influenced by the context in which the situation occurs, and the culture of the nursing unit. This premise was also supported by the findings of the present study. According to the model, clinical judgment situations trigger nurses to use one or more reasoning strategies to interpret the meaning of data. The findings of this study revealed that nurses used different reasoning strategies such as intuition, recognizing similar situations, and hypothesis testing in order to understand the situation. A finding that did not support the clinical judgment model was in the area of reflection. Nurses in the present study did not demonstrate reflection-in-action. Reflection-on-action was observed through the stories that demonstrated looking back on the experience and gaining knowledge for future situations. The findings of the current study indicate that nurses’ clinical judgments (noticing, interpreting, responding, and reflecting) are much more iterative than is depicted by the description of the model. This finding suggests the need for refinement in the model. A significant new finding from this study was the role that nurses’ sense of responsibility played in influencing clinical judgment. This theme demonstrates how participants’ professional and personal values regarding caring and patient responsibility affected how they performed during their experience of caring for a patient who was deteriorating. Nursing hand-off report at transitions of care also was identified as a key opportunity for improving nurses’ ability to notice early signs of deterioration. Findings from this study revealed important considerations for future research in the areas of transitions of care and patient hand-off, nurses’ perspectives on and practice of conducting patient assessments, nurse’ autonomy and relationship with physicians, and the practice of taking vital signs