The clinical reasoning of expert acute care registered nurses in pre-cardiopulmonary arrest events

Abstract

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 interpretive. Detailed analysis of these relationships revealed the following implications: (a) experts predominately used the operator Scenario Set. This is indicative of their searching for an evolving pre-cardiopulmonary arrest pattern; (b) the operator decision/rational is important because it reflects that a decision was made and/or a rational supplied concerning delivery of care; (c) 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; (d) expertise takes time to develop within an specific area of practice and is nontransferable despite similarities in the work environment; (e) 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; (f) 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; and (g) self perception of expertise may be one indicator that expertise in a nursing has been attained.