Corcoran-Perry S A, Narayan S M, Cochrane S
School of Nursing, University of Minnesota, Minneapolis 55455, USA.
Nurs Health Sci. 1999 Mar;1(1):49-61. doi: 10.1046/j.1442-2018.1999.00008.x.
Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses' decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be incorporated into knowledge-system design. One implication of the variability in subjects' line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects' performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.
心脏病住院患者病情日益加重，这对护士的决策能力提出了很高要求。然而，由于对护士如何运用知识进行决策的理解有限，护理领域在基于知识的系统开发方面滞后。本研究的两个研究问题是：在一组具有代表性的假设患者案例样本中，经验丰富的冠心病护理护士所采用的推理思路与新入职的冠心病护理护士所采用的推理思路相比如何？以及冠心病护理护士在假设情境中使用的主要推理思路与临床实践中类似可比情境所使用的推理思路是否相似？推理思路被定义为一组论据，其中知识嵌入在导致结论的决策过程中。来自美国明尼苏达州一家大型私立教学医院冠心病护理病房和冠心病降级护理病房的16名受试者（8名经验丰富的护士和8名新护士），在对六个假设案例和可比实际案例进行临床决策时被要求大声说出想法。一个发现是，两组中的大多数受试者每个案例都使用了多种推理思路；但他们只主要使用一种。这一发现突出了临床决策的非线性性质。受试者使用了25种主要推理思路，其中六种存在组间差异。存在差异的地方，经验丰富的护士使用的推理思路质量低于新受试者。推理思路的类型变异性表明，知识系统设计应纳入多种途径。受试者推理思路质量的变异性的一个影响是，各级专业水平的护士都可能犯错，并且可以从决策支持中受益。受试者倾向于在可比的假设案例和实际案例中使用相似推理思路这一发现，适度验证了受试者在假设案例中的表现代表了他们在实践中的决策。因此，支持在临床决策教学和研究中使用模拟和案例研究。
