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Title: Decision-making in acute care nursing with deteriorating patients
Author: Smith, Sally Ann
Awarding Body: University of Brighton
Current Institution: University of Brighton
Date of Award: 2013
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Concerns have been well documented about deteriorating patients being missed and that care has not been of a sufficient standard to maintain their safety. This 'failure to rescue' remains despite changes in training and critical care experts working with ward staff. little is known about what influences decision-making at the point a patient deteriorates and prior to referring on to an expert. The aim of this study was to understand how nurses reach their clinical decisions while caring for a deteriorating patient and to identify the contextual factors that influence that decision-making process. Using grounded theory methodology the study comprised fieldwork, semi-structured interviews and a focus group; participants were 22 nurses and 2 physiotherapists working in general medical and surgical wards. A pragmatist philosophical tradition informing symbolic interaction guided the interpretive analytical framework of the study. The simultaneous collection, memoing, dimensional analysis of the data and constant comparison of the findings with the body of literature, built an emerging theory of clinical reasoning in acute care situations. Findings suggested that acute care nurses practice in one of 3 modes. They are: • 'Ward routine', where normal ward work takes place and nurses use protocols to deliver care. • 'Crescendo of care' where searching, information gathering, checking findings and efforts to gain control over the clinical situation took place. Nurses' reasoning in this mode was abductive and focused on building a believable case prior to referral. • 'Management of crisis' where the nurse was sure of their concerns, made the referral and continues to seek to confirm concerns. Through the three modes nurses reasoned and made sense of the clinical information they picked up. They spent lime marshalling this data until it served them a believable credible case with which to refer to another professional. This involved negotiating and bargaining to elicit action. The goals in these actions and interactions were to keep the patient and themselves safe. This was underpinned and motivated by their personal and professional beliefs. Throughout the whole decision-making process nurses accounted for every decision and judgement they made until they were convinced and confident in what they believed was happening. Then they made a referral to a more senior professional. This was conceptualised as the theory of mind accounting in clinical reasoning 'Which emerged as the explanation for how nurses clinically reason and make decisions when caring for a patient whose condition is declining. The emerging theory offers an alternative explanation of the way nurses assess and intervene when concerned about a patient. This is significant because timely accurate decision-making is fundamental to providing quality care.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: B000 Health Professions