ORIGINAL RESEARCH: EMPIRICAL RESEARCH –
QUALITATIVE
An analysis of nursing students’ decision-making in teams during
simulations of acute patient deterioration
Tracey K. Bucknall, Helen Forbes, Nicole M. Phillips, Nicky A. Hewitt, Simon Cooper & Fiona
Bogossian FIRST2ACT Investigators
Accepted for publication 1 March 2016
Correspondence to T.K. Bucknall:
e-mail: tracey.bucknall@deakin.edu.au
Tracey K. Bucknall PhD RN
Professor
Deakin University Centre for Quality and
Patient Safety, School of Nursing and
Midwifery, Geelong, Victoria,
AustraliaAlfred Health, Victoria, Australia
Helen Forbes PhD RN
Associate Professor
Deakin University Centre for Quality and
Patient Safety, School of Nursing and
Midwifery, Geelong, Victoria, Australia
Nicole M. Phillips PhD RN
Associate Professor
Deakin University Centre for Quality and
Patient Safety, School of Nursing and
Midwifery, Geelong, Victoria, Australia
Nicky A. Hewitt MN RN
Research Fellow
Alfred Health, Victoria, Australia
Simon Cooper PhD RN
Professor
School of Nursing, Midwifery and
Paramedicine, Federation University
Australia, Victoria, Australia
Fiona Bogossian PhD RM RN
Associate Professor
School of Nursing, Midwifery and Social
Work, The University of Queensland,
Queensland, Australia
© 2016 John Wiley & Sons Ltd
BUCKNALL T.K., FORBES H., PHILLIPS N.M., HEWITT N.A., COOPER S. &
B O G O S S I A N F . F I R S T 2 A C T I N V E S T I G A T O R S ( 2 0 1 6 ) An analysis of nursing
students’ decision-making in teams during simulations of acute patient deteriora-
tion. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.13009
Abstract
Aim. The aim of this study was to examine the decision-making of nursing
students during team based simulations on patient deterioration to determine the
sources of information, the types of decisions made and the influences
underpinning their decisions.
Background. Missed, misinterpreted or mismanaged physiological signs of
deterioration in hospitalized patients lead to costly serious adverse events. Not
surprisingly, an increased focus on clinical education and graduate nurse work
readiness has resulted.
Design. A descriptive exploratory design.
Methods. Clinical simulation laboratories in three Australian universities were
used to run team based simulations with a patient actor. A convenience sample of
97 final-year nursing students completed simulations, with three students forming
a team. Four teams from each university were randomly selected for detailed
analysis. Cued recall during video review of team based simulation exercises to
elicit descriptions of individual and team based decision-making and reflections
on performance were audio-recorded post simulation (2012) and transcribed.
Results. Students recalled 11 types of decisions, including: information seeking;
patient assessment; diagnostic; intervention/treatment; evaluation; escalation;
prediction; planning; collaboration; communication and reflective. Patient distress,
uncertainty and a lack of knowledge were frequently recalled influences on decisions.
Conclusions. Incomplete information, premature diagnosis and a failure to
consider alternatives when caring for patients is likely to lead to poor quality
decisions. All health professionals have a responsibility in recognizing and
responding to clinical deterioration within their scope of practice. A typology of
nursing students’ decision-making in teams, in this context, highlights the
importance of individual knowledge, leadership and communication.
1
T.K. Bucknall et al.
Keywords: clinical decision-making, clinical judgement, education, nursing,
patient deterioration, patient safety, problem-solving, simulation, team work,
think aloud
Why is this research needed?
• Professional standards require that undergraduate nursing
programmes prepare students to respond to unexpected or
rapidly changing situations, whether as individuals or in
the healthcare team.
• Knowledge and experience underpin clinical decision-making
ability. However, novice nurses lack skills in cue selection,
data search strategies, proactivity, timely information assess-
ment and tend to fixate on technology and tasks, neglect
important cues and follow rules regardless of context.
• Our understanding of optimal approaches in clinical deci-
sion-making education is limited and examination of team
based decision-making of nursing students during simula-
tions may enhance future education strategies.
What are the key findings?
• Descriptive analysis of thirty-five transcripts revealed 11
decision types evident in student nurses’ clinical decision-
making. These decision types were mostly consistent with
studies of RN and nurse practitioners, although there was
limited depth in decisions and absent or inadequate leader-
ship and team communication.
• Influences on decisions included three broad categories:
patient characteristics; individual students and team; and
context. Patient safety was prioritized but patient distress,
uncertainty, lack of knowledge and the absence of experi-
enced support staff influenced decision-making.
How should the findings be used to influence policy/
practice/research/education?
• A typology of nursing students’ decision-making in teams,
in this context of recognizing and responding to clinical
deterioration, highlights the importance of individual
knowledge, leadership and communication. The typology
can be used as an educational framework to guide student
learning and evaluate outcomes of educational strategies.
• The next step is to test the effectiveness of educational
interventions designed to improve recognition and response
to clinical deterioration in acute care settings.
Introduction
Clinical decision-making is a fundamental skill for all
nurses. It involves the comparison and evaluation of infor-
mation to form a judgement about future actions (Bucknall
et al. 2008). Patients and families are heavily reliant on a
nurse’s ability to identify, interpret, analyse and evaluate
data (Bucknall 2000, Beckie et al. 2001, Hicks et al. 2003,
Lyons 2008, Cranley et al. 2012). However, clinical deci-
sions are not isolated cognitive events, instead they occur in
2 © 2016 John Wiley & Sons Ltd
and are influenced by, the social, ethical, economic, legal
and political structure of clinical practice (Dowie & Elstein
1988). In an increasingly dynamic hospital environment,
there is evidence linking nurses’ decision-making to both
the production and prevention of iatrogenic harm (Thomp-
son et al. 2008).
Detecting changes that indicate a deteriorating health sta-
tus is one of the most commonly made clinical decisions in
hospital. With nurses usually being the first responders to
patient deterioration, their ability to assess, analyse and res-
cue patients using appropriate interventions is critical for
patient outcomes. Prior to taking responsibility for patients
in hospital, education providers worldwide are charged with
adequately preparing graduates for safe, high quality care in
complex clinical environments. However, an Australian
study revealed that only half of final-year nursing students
have experienced caring for a rapidly deteriorating patient
and of those only 5% were first responders (Bogossian et al.
2014). Thus, simulation techniques have been used to repli-
cate real world experiences of patient deterioration.
The aim of this study was to examine the decision-mak-
ing of nursing students during team based simulations on
patient deterioration to determine the sources of informa-
tion, the types of decisions made and the influences under-
pinning their decisions. The study was part of a larger
project designed to enhance undergraduate nursing stu-
dents’ competence in managing rapid patient deterioration
(Cooper et al. 2012, Bogossian et al. 2014, McKenna et al.
2014). This paper presents the qualitative findings of third
year nursing students’ decision-making in a team during
simulations of acute patient deterioration.
Background
Clinical decision-making is a dynamic process and essential
for effective selection of interventions and management of
patient care regardless of patient status (Bucknall 2007).
However, when a patient’s condition deteriorates, it is cru-
cial that decisions made are both accurate and timely.
Knowledge and experience underpin a nurse’s clinical deci-
sion-making ability (Tanner 2006, Bucknall et al. 2008).
Although there is evidence identifying differences between
novice and expert nurses (Benner 2001, Tanner 2006), our
understanding of the optimal approaches for educating
novices in clinical decision-making remains limited. Little is
known about skill acquisition at different time points in
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Students’ decision-making during acute deterioration simulation
students’ education and the impact on clinical reasoning
and problem-solving skills as knowledge develops and
exposure to clinical experiences is increased (Botti & Reeve
2003, Thompson & Stapely 2011).
Research has highlighted novice nurses as being; less
focused in cue selection (Lamond & Farnell 1998), limited
in their data searching strategies (White et al. 1992), reac-
tive rather than proactive (Hoffman et al. 2009), fixated on
technology and tasks (Hardy et al. 2002), neglectful of
important cues (Arbon 2004), with a tendency to follow
rules without paying attention to the context of decisions
(Benner 2001). Bucknall (2000) also reported that novice
nurses take more time to collect assessment information
slowing decision-making and delaying problem manage-
ment. Students’ academic ability has been shown to affect
low complexity tasks, while domain specific knowledge and
experience affected decision-making in higher complexity
tasks (Botti & Reeve 2003).
In acute care settings, nurses are required to function
effectively in teams to optimize patient outcomes. The com-
position of which can vary on any given day. Endacott
et al. (2015) found that when teamwork skills are deficient
this impacts negatively on patient outcomes and has been
associated with increased adverse events. The elements of
an effective team include proficiency in communication, sit-
uational awareness, decision-making and leadership ability
(Todd et al. 2008, Cooper et al. 2010). Professional stan-
dards require that undergraduate nursing programmes pre-
pare students to respond to unexpected or rapidly changing
situations, be competent in knowledge and skills during
emergencies and collaborate with team members to provide
comprehensive care (Nursing and Midwifery Board of Aus-
tralia 2013). Teaching and learning strategies that facilitate
development of decision-making skills individually and in
teams include; interacting and learning with students from
other health disciplines, scenario based activities, targeted
clinical placement experiences and simulation.
Simulation provides undergraduate students with oppor-
tunities to practice decision-making and develop team skills
in a safe non-threatening environment. Simulation can facil-
itate the development of knowledge, technical and non-
technical skills including communication, decision-making,
teamwork and leadership. Simulation experiences can be
designed to address situations that may not be readily avail-
able to all students during clinical placements, such as man-
agement of a deteriorating patient (Cato 2012). Simulation
scenarios involve assigning students to active roles whereby
they are required to achieve specific learning outcomes (Jef-
fries & Rogers 2012). Typically students are required to
provide care for a ‘patient’. The ‘patient’ can be a training
© 2016 John Wiley & Sons Ltd
model, mannequin, high fidelity responsive human simula-
tor or a trained actor. After simulation, student learning
may be followed by a reflective activity, such as a struc-
tured group debrief conducted by a simulation facilitator.
Debriefing involves deconstructing and analysing the sce-
nario and includes provision of feedback on student perfor-
mance (Cato 2012). Participation in simulation scenarios
with structured feedback facilitates student development of
knowledge and skill in a stable and supportive environ-
ment. Importantly, simulation allows students to make and
learn from their mistakes.
The study
Aim
The aim of this study was to: examine the decision-making
of nursing students during team based simulations of
patient deterioration; to determine the sources of informa-
tion; the types of decisions made; and the influences under-
pinning their decisions.
Design
A descriptive exploratory design was used to examine stu-
dents’ decision-making. The study of decision-making can
be addressed with either prescriptive or descriptive
approaches. Prescriptive approaches are concerned with
prescribing how decisions ought to be made, with a focus
on the outcomes; while descriptive models are concerned
with describing how the decisions are actually made and
focus on the process of decision-making (Thomas et al.
1991). Descriptive approaches focus on the sequence of the
intervening steps between the input (information cues) and
outcomes (decision responses) and the strategies used by the
decision maker.
In this study, cued recall during video review of team
based simulation exercises was used to elicit descriptions of
team-based decision-making and reflections on their perfor-
mance. Cued recall describes the situation when an interac-
tion is recorded and played back to the clinician who is
asked to explain that happening at particular points during
the interaction. Clinicians are asked to record reasoning
processes and decision outcomes (Thomas et al. 1991).
Three characteristics of process methods, such as cued
recall, include: the mediation involved in observing vari-
ables between input and output; the sequence of events
from the initial search to detailed processing; and the con-
tent of short-term memory in determining what the deci-
sion maker knows (Carroll & Johnson 1990). Analysis of
3
T.K. Bucknall et al.
these characteristics was used to address the aims of this
study.
Participants
The clinical simulation laboratories in three Australian uni-
versities, two in Victoria and one in Queensland, were used
to conduct the team based simulations with a patient actor.
All participants were third year nursing students studying a
Bachelor of Nursing or combined Bachelor of Nursing
degree. All students had completed coursework on and had
at least two clinical placements in acute care, prior to com-
pleting the simulation. A convenience sample of 97 students
completed the simulations. Individual students were allo-
cated to groups of three and a scheduled simulation time,
so just as in real life they may or may not have had prior
knowledge of the capabilities of the other members of their
team.
Data collection
Students were recruited via a short presentation and email.
If students expressed interest in participation they were con-
sented and given a scheduled time in March 2012. Teams
of three students were conveniently formed on a sequential
basis. Each team of students completed three 8 minute sce-
narios with an actor simulating deterioration during a car-
diac case, a shock case and a respiratory case in the
simulation laboratory. The same actor, a white Caucasian
male aged in his 70s, was used across all sites in a stan-
dardized format, commencing with subtle deterioration and
progressing to more obvious deterioration at the four min-
ute mark. Prior to commencement of each scenario, a group
team leader was randomly selected and given a brief outline
of the clinical context sufficient for a first responder role.
Each student was allocated team leadership once with the
same members involved in each scenario. Videoing began
when the team leader entered the room. The team leader
was instructed to respond to the situation and to call for
assistance at any time from the other team members
(Cooper et al. 2012).
At the completion of the scenarios, the student team went
into another room to participate in video review and recall,
as well as performance feedback led by a member of the
research team. Students were shown the team video and
asked to recall their decision-making during each scenario.
Each student gave an account of their reasoning, any
sources of information and their decisions. Team leaders
led the recall and then when other team members did some-
thing on the video they were asked to explain their
4 © 2016 John Wiley & Sons Ltd
decision-making and how the information influenced the
team’s decisions and behaviour. Video reviews were audio-
recorded and 12 teams were randomly selected for detailed
analysis of decision-making. Four teams from each univer-
sity had audio recordings transcribed verbatim.
Ethical considerations
Research Ethics Committee approval was obtained at each
of the three universities.
Data analysis
The Framework Analysis approach was used to extract and
synthesize data (Ritchie & Spencer 1994). This process
involved a systematic approach to the analysis around a
thematic framework, comprising sifting, charting and sort-
ing material according to key issues and themes. The five
analytical stages in the framework approach include:
1 Familiarization – becoming familiar with content of data.
2 Identification of a thematic framework – identifying key
issues, concepts and themes.
3 Indexing – systematically applying the thematic frame-
work to the data.
4 Charting – rearranging the data according to the appro-
priate thematic reference.
5 Mapping and interpretation – identifying the key charac-
teristics of the data.
Rigour
Video reviews were conducted according to pre-determined
trigger questions and by the same two researchers regard-
less of the site. Prompts for cued recall such as ‘what were
you thinking’ and ‘what did you think next’ were brief to
ensure student–researcher interactions were minimal. Ver-
balization required explanation and discussion of thought
processes by drawing from their short-term memories (Eric-
sson & Simon 1993). In this context, the think aloud tech-
nique conducted after task completion is not devoid of
recall error. Nonetheless, student thinking and decision-
making is likely to be elicited without researcher influence.
In addition, an advantage of retrospective think aloud tech-
niques is that verbalization and recall of decision-making
after the event does not interfere with usual task processes
(Guan et al. 2006). A key component of the simulation
activity was to record student actions and verbalization ‘as
it happened’ to enable them to later reflect on their perfor-
mance. Field notes were kept of each video review. Each
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Students’ decision-making during acute deterioration simulation
audio recording was transcribed and the authenticity of the
transcriptions confirmed. Three researchers from different
practice backgrounds independently coded the data (TB,
HF, NH), with comparisons made prior to agreement on
categories to minimize an individual’s impact on findings.
Data analysis began with multiple readings of the tran-
scripts and was followed by an initial analysis where data
were grouped broadly; by types of decisions and influences
on decisions. The former included 11 types of decisions
where data were categorized according to a decision typol-
ogy, while the latter revealed data in three broad categories.
To establish a greater trustworthiness and dependability of
the analysis of the video review, the data were analysed
independently by two researchers (TB, HF). Subsequently
researchers, experienced in qualitative research, discussed
excerpts from transcripts, leading to a consensus on the
main groupings and the categories.
Results
Demographics
Four groups of three students, from each of the three uni-
versities, were randomly selected for detailed decision-mak-
ing analysis. Yielding a total of 35 student transcripts (one
team consisted of only two students) and representing
36
1% of the students who participated in the simulations.
The students whose transcripts were included were aged
between 18-50 years with an average age of 22
9 years,
88
6% were females, 91
4% were enrolled in a Bachelor of
Nursing and 8
6% were enrolled in a dual degree which
included nursing. More than half had cared for a deterio-
rating patient in their experience with only two having
experienced the role of first responder.
Sources of information
The first source of information nurses used was patient
behaviour on entry to the room. Students usually started
collecting information using patient assessment, such as
vital signs, but often taking an incomplete set focussed on
the area of concern. This was followed by a review of
patient charts, commonly medication and observation
charts, trying to determine what was happening to the
patient. Notably, they were less likely to ask the patient for
information, reflecting on the patient’s distress and trying
to overcome it as quickly as possible. Students would ask
their team members for ideas and assistance when they felt
out of control and uncertain about what to do next. They
reported that they would have asked a more experienced
© 2016 John Wiley & Sons Ltd
nurse if they were available in a hospital context but with-
out this support in the simulation they escalated the prob-
lem to the junior doctor, who was available to be called as
part of the simulation:
For me, it was starting at the top and just assessing vital signs and
then pain and then what can we do next as a nurse? Group 3 Par-
ticipant
I looked at him pretty much. Straight at the patient. Group 3 Par-
ticipant
Try and do like – ask the patient, obviously and then maybe just
try and do some kind of assessment and prioritize what’s urgent.
Group 5 Participant
Types of decisions
Analysis of video review transcripts revealed 11 types of
decisions recalled by students. These decisions were: infor-
mation seeking; patient assessment; diagnostic; intervention/
treatment; evaluation; escalation; prediction; planning; col-
laboration; communication and reflective. Students demon-
strated most of these decisions in each simulation.
Decisions types with illustrative quotes are reported in
Table 1.
The occurrence of the decision type depended on the
scenario, the students involved, the leadership of the group
and the communication with the patient. Patient assess-
ment was the most frequent decision noted; centring on
collecting vital signs to obtain a baseline assessment. Sin-
gle vital signs were often collected with a focus on the
exhibited symptom such as shortness of breath, rather
than the collection of a complete set of vital signs. Patient
assessments lacked depth and were inclined to be minimal-
ist in that the students tended to perform opportunistic
assessment and be reactive to the situation as it unfolded.
Students often recalled that they missed interventions once
they reviewed the video. Reflective decisions were evident
in the recall of the situation rather than during the simula-
tion. Intervention decisions were frequently preceded by a
diagnosis and usually after collection of a single patient
assessment cue. For example, oxygen saturation levels if
evaluated as low resulted in a diagnosis of hypoxia with
the response being to intervene with administering oxygen.
Furthermore, there was a tendency for students to employ
similar behaviour, making diagnostic conclusions during
scenarios two and three, based on experiences in scenarios
one and two respectively. For example, if the first scenario
related to a cardiac condition, students would tend to
5
T.K. Bucknall et al.

Table 1 Decision typology.

Decision type Examples

Patient assessment Chest pain “I just asked him have you felt like this before, and if so, what makes you feel better” Group 5
Participant.
Chest auscultation “He said it was hard to take a deep breath, so I just wanted to listen whether he’d had a wheeze
or whether he wasn’t breathing down to his base. I just wanted to have something to tell the doctor when they
came in basically. Yeah, he had a wheeze” Group 6 Participant.
Information seeking “. . .I was going to check his file and check whether they have any medication for his pain. . .” Group 5 Participant.
“Just tried to get as much information as possible. You know just treat like the main problems like straight away,
like prioritise – so was he in cardiac or respiratory. . .pain” Group 7 Participant.
Diagnosis “The chest pain, the angina, because he’s got a past history, . . .wanted to make sure it is ischemia or something and
not other causes. So I did an ECG.” Group 5 Participant.
“So we know now that he’s smoked all his life, that he’s probably got COPD, maybe even chest infection,
bronchitis, something like that. That’s why the neb’s probably been written up to help relieve and help him breathe
better. . .” Group 11 Participant.
Intervention Student asked for a Hudson mask 6 Litres “Because he seemed really short of breath and I think he needs more than
the nasal prongs. . .” Group 5 Participant.
Student asked for ordered fluids “. . .he’s in hypovolemic shock. His heart rate’s gone up, he’s got low blood
pressure so his compensatory mechanisms have already kicked in and he’s on the way down pretty quick. I didn’t
take his blood pressure at the start, which I should have. We need some fluids to fill in that intravascular space again
and get his blood pressure up. . .” Group 11 Participant.
Evaluation “I was looking at the picture, I suppose, seeing if I could find an abnormality. I can’t read an ECG off the top of my
head. To be honest, I don’t remember if there was anything, but I was just looking for something abnormal”
Group 10 Participant.
Reason for anxiety and confusion “Lack of oxygen. . .His sats would have come up pretty quickly if it was just
anxiety – putting oxygen on him. It wouldn’t have stayed down at 82 for so long, as it did, because he was on 10
litres for a good couple of minutes before it started increasing” Group 6 Participant.
BP interpretation “I thought it was quite normal, quite plausible. I didn’t really have anything to compare it to, so I
thought for someone his age that it was fine” Group 11 Participant.
Escalation “It looked irregular. . . Which is when we next called the doctor in to review it” Group 6 Participant.
“But the thing is, I stopped halfway through doing my observations because he was in such severe pain and vomited
that I found – I got the doctor to get the Maxolon and the morphine straightaway because you can’t really do the
obs when they’re in that much pain because they’re like help me” Group 6 Participant.
Predictive “I thought with an ABG, maybe you could see – if he’s been nil by mouth and he’s vomiting – if he’s in alkalosis or
acidosis. . .” Group 11 Participant.
Raised the head of bed “Just then. Yeah, we raised it only just then. Just because he was nauseous, I didn’t want him
to – he’s lying down – I didn’t want him to choke on anything” Group 11 Participant.
Planning “I was asking for an IV. . . I was starting to think that maybe we were going into a scenario where he’s going to arrest
on us.” Group 3 Participant
Shortness of breath “Well, I didn’t think that lying him down would help his lung expansion, so I just thought that
sitting up would be better” Group 5 Participant
“Just sometimes positioning helps with different pain. I know for myself I crunch up in a ball if I’ve got stomach
pain and that helps me, so I thought maybe it would help him” Group 5 Participant.
Collaboration “I think that if someone said something, they listened to everyone else’s opinion before they went with that” Group 5
Participant.
“Because I can’t give the medication and continue on with the observations and things like that. So having someone
else there to assist just makes it a little bit easier on yourself. I went out to get them . . ..” Group 6 Participant.
Communication “I think when we got the Ventolin, we were reminding him, take deep breaths. Relax a bit, because we weren’t sure.”
Group 12 Participant
“Well I think when I started to hear the reasons why [student name] wanted to give it, then I understood. Compared
to if someone just said I’m going to give pain medication, I wouldn’t understand why she wanted to do it and
therefore I wouldn’t agree. Whereas at least if she explained why she wanted to give it. . .” Group 11 Participant.
Reflective “I just should of asked him that-would have made sense” Group 7 Participant.
“I definitely should have been checking more his oxygen and stuff. I probably would have put him on oxygen if I
could go back” Group 6 Participant.

6 © 2016 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Students’ decision-making during acute deterioration simulation

Table 1 (Continued).
Decision type Examples

How much oxygen therapy “Probably just – it depends on his oxygen [sats] were but just to ease his pain and
agitation. Maybe just four litres on nasal prongs – if it was low, obviously, then more – just to get him comfortable.
I would have checked the med chart” Group 6 Participant.
“In the middle scenario it was probably the worse because he like fully had the shakes and everything. Yeah, I was
thinking afterwards maybe I didn’t look at his chart so I wonder if he was a diabetic?” Group 7 Participant.

follow a cardiac hypothesis in the subsequent scenario,
regardless of cues to the contrary. Evaluation of the inter-
vention response depended on the context of the situation
and this influenced the student’s thinking. Collaboration
decisions occurred when the lead student had typically
exhausted their own knowledge and they sought informa-
tion and ideas from other students. An active exchange
took place between team members to decide on what to
do next. However some groups demonstrated little verbal
communication in their team or with the patient actor,
trying to problem solve on their own. Communication
with the patient actor was minimal and directive rather
than engaging with the patient and sharing information.
Escalation occurred when students had decided they
needed medical intervention outside of their scope of prac-
tice or they considered patient safety to be at risk. Plan-
ning decisions were less common, sometimes they involved
the students preparing equipment, such as suction devices
or an intravenous line, in case of an emergency require-
ment. Few students demonstrated predictive decisions.
Those who did may have had previous experience as a
first responder with deteriorating patients in their clinical
placement or work.
Influences on decision-making
The students cited many examples that demonstrated the
impact on decision-making in a controlled simulated envi-
ronment. Influences were grouped into the following three
broad categories: patient characteristics; individual students
and team and context.
Patient characteristics
Students reported that they felt uncertain how to proceed in
the beginning of the scenarios because they were unfamiliar
with the patient. They spoke about the importance of obtain-
ing baseline information to make a diagnosis or work out
how to manage the patient. Overt patient behaviour such as
moaning with pain acted as a distraction from patient assess-
ment and potential interventions. At the 4 minute mark, the
patient demonstrated pre-planned overt behaviours such as
increased pain or shortness of breath. The response reported
by students to the change in patient behaviour tended to be
panic, stress or information overload, resulting in them being
unable to process confounders or collate information system-
atically. Patient distress was the most frequently cited influ-
ence for blocking their thinking, distracting them,
interrupting their assessments or interventions. It also
prompted students to communicate with the patient, collabo-
rate with their colleagues, or escalate care once they identi-
fied that a referral was required. At times the patient offered
important cues for the students, but they failed to listen and
continued on with the incorrect diagnosis:
I should have probably gone straight to taking his obs. . .Like I
haven’t even taken his temperature. I’m just thinking like there’s
still more assessment to do, but I’m just so like distracted and
stressed . . . Group 7 Participant.
. . . I need to calm him down a bit, because he seemed a bit worked
up. I don’t know if that’s the right thing or not, I just didn’t know
what else to do Group 5 Participant.
Individual students and team
The individual student characteristics and the combined
team members were both influential on decision-making.
Individuals’ knowledge, skills and personality traits
impacted on the decisions and outcomes of the scenarios.
Lack of knowledge was the most common influence cited
by students. Lack of knowledge generally meant that at
times the wrong rules were enacted for the patient situa-
tion. Similarly, there was superficial patient assessment per-
formed by most teams which hampered their decision-
making by limiting it to the most common conditions
encountered by them in clinical placement without consid-
eration of differential diagnoses. The students demonstrated
limited knowledge of medications, exhibiting confusion and
uncertainty with their knowledge and an inability to inter-
vene appropriately. Collaboration between students
depended on the group of individuals, some leaders would
act quickly to consult with the other students about patient
information and potential treatments or to determine if

© 2016 John Wiley & Sons Ltd 7

T.K. Bucknall et al.
escalation of care was indicated in the circumstances. When
team members were seen as supportive in decision-making,
it increased the time available by sharing the activities; both
assessment and interventions. Some team leaders failed to
lead and when reviewing the video replay identified how
they could have done things differently such as directing
team members to do other activities. Other leaders were
able to delegate roles and responsibilities. Team members
took passive roles when not leading, sometimes failing to
speak up although they believed the wrong action was
being taken. They reflected this was due to uncertainty
about their knowledge and not knowing the capability of
other team members sufficiently before the simulation.
Hard on us coming in, because we didn’t really know much about
the patient’s history. I suppose if you come on at 7
00 in the morn-
ing and this was happening to you, you wouldn’t really know
because you’ve just had handover anyway. So it’s a frazzling situa-
tion Group 5 Participant.
. . .I was rattled when I couldn’t find his anginine spray [glycerine
trinitrate], because that’s what I would have done first and then sat
him up, put the mask on and then that rattled me. Then, when it
was tablets, not the spray, it was like, oh, yeah. So, it goes down-
hill from there. . ..I was way out of depth Group 1 Participant.
As a student, they train you to watch out for these things and what
you can do. But in my amount knowledge, once you get to that
point – you’ve checked everything, you’ve given the meds, you’ve
assessed the patient and the patient starts to deteriorate – besides
continuing to monitor them, after you’ve called the MET [Medical
Emergency Team], I don’t know what else I would do at that
point, to be honest Group 6 Participant.
Blood pressure ‘It’s low, yeah. I – when he vomited, I panic. I don’t
know why, because probably I was very nervous at the time. . . I
think I didn’t even finish taking the obs, because I called for help
and then I’m not sure what happened next. Group 12 Participant.
Context
Students reported feeling unfamiliar with the patient charts
and unable to find information at times. Hunting for infor-
mation tended to slow their decision-making and/or distract
them from the task. Lack of familiarity with and availability
of equipment were reported by some students. Other students
noted the benefit of checklists and guidelines for assisting
their decision-making, prompting them when there was so
much happening around them. Many students reflected on
the value of having experienced staff around when they
didn’t know what to do next. In the scenarios, the presence
8 © 2016 John Wiley & Sons Ltd
of a ‘junior doctor’ – who was instructed not to direct care –
was available for escalation but there were no experienced
nursing staff to call for assistance. So despite consulting with
the other students in the team, if the knowledge levels in the
team were inadequate and the team leader did not lead, then
much time was wasted and the patient was put at risk.
Because – I didn’t know there was any medication on the chart. I
would have done what you did, but I was like okay, there’s no
meds. I don’t think I – did I ask for oxygen? I don’t think I did,
which I probably – talking back with them after, I was like I prob-
ably would have put him on oxygen but his oxygen saturation –
but then if there was no medication written up, I suppose – I called
you guys, but I suppose, looking back, I might have called a doctor
to give him something for the pain or write up something because
there’s not a hell of a lot more to do. I suppose I could have kept
assessing him, but as far as what a nurse can do without a doctor
writing up meds Group 6 Participant.
Yeah, we needed someone a little bit more senior in there, because
I know the policy is, like, you go for 15 minutes and you do – and
then you do another ECG and you can give anginine three times
five. . .Then, you call and – if it doesn’t resolve and get it looked at
again, so that’s probably – and I mean, obviously, it was only eight
minutes, not 15 minutes, but that’s probably when we would have
looked at, maybe, getting someone else in Group 9 Participant.
Just wondering what the pain could be. I haven’t dealt with abdo
pain on the ward so I was going through my primary assessment to
see what the body was doing regardless with the pain and just in
general Group 2 Participant.
Discussion
This study reveals a typology of nursing students’ decisions,
sources of information and influences on decisions during
simulations involving acute patient deterioration in hospital.
There were 11 categories of decisions made, which are con-
sistent with other research that demonstrated nurses’ deci-
sions in clinical practice. Although the categories were
similar, the depth of decisions in categories was limited in
student decisions. Leadership and team communication were
noticeably absent or inadequate. Patient safety was an impor-
tant focus but patient distress, uncertainty, lack of knowledge
and the absence of experienced support staff were frequently
recalled influences on their decision-making.
Several studies have developed typologies of nurses’ deci-
sion-making in varying contexts including critical care
(Bucknall 2000, Aitken et al. 2009), general practice
(McCaughan et al. 2005) and acute care (Thompson &
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Students’ decision-making during acute deterioration simulation
Dowding 2001). Similar to other studies on nurses’ deci-
sion-making, this study demonstrated the types of decisions
made by RN and nurse practitioners were consistent with
nursing students’ decisions. Given that simulations are
developed to mimic real life situations the similarity of deci-
sion types is not surprising. The various types of decisions
were comprehensively captured in this simulation. There-
fore, the types of nursing decisions made appear to be con-
sistent regardless of the level of experience, the practice
domain and the environment.
There is limited research regarding the depth of nursing
students’ decision-making in simulated environments. How-
ever, the research examining novice and expert decision-
making reflects some differences, one of which is cue acqui-
sition (Hoffman et al. 2009). Similar to Tanner et al.
(1987) and Taylor (1997) who described novice nurses use
of cues as being minimalist, with single cues forming the
basis of hypotheses, this study highlighted the same prema-
ture closure of information search during assessment.
Indeed Tanner (2006) has argued that clinical judgements
are influenced more by what a nurse brings to the situation
in knowledge and experience than the specific cues avail-
able in a given patient situation. In laboratory-based simu-
lations, students may or may not have opportunities for
developing their understanding and depth of assessment
required; with single cues usually being insufficient in for-
mulating accurate hypotheses. Therefore, opportunities to
develop such depth need to be factored into simulations;
online simulation offers one contemporary option for repet-
itive learning. New technologies have the ability to trans-
form student learning to be increasingly interactive and
varied, and measure the effectiveness of learning outcomes.
In a review of educational strategies to improve a nurse’s role
in recognition and response to patient deterioration, Liaw
et al. (2011) concluded that the use of decision-making mod-
els could guide nurses learning and provide an education
framework for developing interventions. Such a framework
would appear needed given Thompson and Stapely’s (2011)
systematic review on the effectiveness of educational inter-
ventions which identified a lack of robust evidence in measur-
ing nurses’ decision-making. Nevertheless, simulations of
complex, uncertain, clinical contexts offer significant poten-
tial to enhance work readiness for graduates. Primarily focus-
ing on specific skill development and filtering extraneous
information (Thompson et al. 2012).
This study highlights several barriers to decision-making
that influence student learning outcomes. Individual barriers
to decision-making in this laboratory-based simulation
included: lack of knowledge, lack of experience, limited
leadership skills, uncertainty with decisions and anxiety.
© 2016 John Wiley & Sons Ltd
Environmental barriers to decision-making included: the
limited experienced clinical support roles, the patient dis-
tress and the changing situation.
The context where clinical decisions are made strongly
influences nurses’ decisions (Bucknall 2003, Tanner 2006).
This study incorporated a changing context that included
realistic patient situations, patient interactions, collabora-
tion among team members and escalation of care. Realistic
decision tasks are fundamental to the construction of valid
simulations (Brehmer & Joyce 1988). The presentation of
the information and the decision-making context should
underpin the development of authentic simulations (Buck-
nall 2000, Gerdtz & Bucknall 2007). Findings from this
study highlighted the need to expose nursing students to
variable decision tasks and situations. A key skill in clinical
practice is the ability to filter relevant from irrelevant infor-
mation to manage uncertainty.
Internationally, the patient safety movement has
increased the focus on preventing adverse events that occur
in acute care (Leape et al. 1991, Vincent et al. 2001, Davis
et al. 2002, Baker et al. 2004). In Australia, the National
Safety and Quality Health Service (NSQHS) Standards have
been developed to guide policy makers, organizations and
health professionals in care that is evidence-based to
decrease clinical risk for patients (Australian Commission
on Safety and Quality in Health Care (ACSQHC) (2011b).
The Quality of Australian Health Care study of 14,000
patients across 28 hospitals analysed the causes of 2353
adverse events as: ‘the failure to synthesize, decide or act
on available information’ (15
8%) (Wilson et al. 1995,
1999, p.1). Organizations have initiated numerous strate-
gies to identify and treat deteriorating patients. Some strate-
gies designed to assist decision-making include evidence-
based checklists and clinical guidelines (ACSQHC 2010,
2011a). However the effectiveness of these decision-making
supports mostly remain untested.
Implications of the study
This study provides insight into nursing students’ decision-
making in teams during simulations of acute patient deteri-
oration. A typology of decisions was presented that demon-
strated a concordance with RN, nurse practitioner and
physician decision-making typologies that were empirically
derived. This study offers the foundation for educational
institutions to test the typology in other simulated contexts
and settings. Using the typology to frame simulation tasks
for students allows manipulation and measurement of cog-
nitive skills requisite for nurses in dealing with uncertainty
in changing clinical contexts. On graduation, students of all
9
T.K. Bucknall et al.
health professions need to be able respond to: poorly
defined problems; uncertain, time pressured environments
with competing goals; and, interactions with multiple team
members from different disciplines. Feedback loops need to
offer responses that include random, positive, negative and
delayed information to simulate real world clinical practice
and continuous evaluation. Arguably curricula need to not
only build domain competence but also decision-making
competence (Hammond 1996).
Unique to this study is the functional role of team mem-
bers on the decision-making process. Not surprisingly it
highlighted the importance of communication and the role
of leadership in time pressured events. Verbalizing reason-
ing is one approach that could be developed and tested as
an educational intervention for effectiveness on decisions.
The approach provides an opportunity in a safe environ-
ment to identify and correct inaccurate or flawed decision-
making processes and decisions.
While decision-making research has been increasing, a sig-
nificant amount of it has been descriptive in nature. It is now
time to further our understanding and test the effectiveness of
interventions to improve nurses’ decisions and more impor-
tantly impact positively on patient outcomes in practice.
Limitations of the study
This qualitative study, randomly selected 12 teams consisting
of 35 students from a larger cohort to study their decision-
making. As with all the samples, this study may not represent
all nursing students’ decision-making. However, the study
was conducted across three Universities with different facili-
tators and the data analysed independently by two research-
ers. To ensure consistency throughout the study, all charts
were the same across study sites and therefore students may
not have been familiar with the location of information. The
results also offered concordance with RN and nurse practi-
tioners decisions published previously. Students were asked
to recall their thinking during the simulation and therefore
the transcripts offer a retrospective interpretation of their
behaviour. This approach is strengthened by the use of video
recordings to assist students’ visualize their actions and the
video review immediately following the simulation.
Conclusion
Patient safety and the identification and management of
patients at risk of serious deterioration is a priority internation-
ally. Incomplete information, premature diagnosis and a failure
to consider alternatives leads to suboptimal decisions and
10
serious adverse events for patients. All health professionals
have a responsibility in knowing what to look for and how to
respond within their scope of practice. With one in seven
patients fulfilling medical emergency team calling criteria (Gui-
nane et al. 2013), nurse graduates are expected to know how
to manage a deteriorating patient situation. If we are to pre-
pare nurses on how to react during uncertainty and changing
patient contexts, then it is critical we understand the different
types of decisions, when and under what conditions they are
made. A typology of nursing students’ decision-making in
teams in this context highlighted the importance of individual
knowledge, leadership and communication. The next step is to
design and test the effectiveness of educational interventions
with the aim of improving students’ cognitive, technical and
social skills to benefit patient outcomes.
Acknowledgements
The research team is appreciative of the students who par-
ticipated in the study. The authors would like to acknowl-
edge the contributions of other members of the FIRST2ACT
research team: Alison Beauchamp, Robyn Cant, Ruth Enda-
cott, Leigh Kinsman, Victoria Kain, Lisa McKenna, Jo Por-
ter, and Susan Young.
Funding
This study was part of a larger project funded by the Aus-
tralian Government, Office for Learning and Teaching
August 2011 (ID11-1914).
Conflict of interest
No conflicts of interest have been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
References
Aitken L., Marshall A.P., Elliot R. & McKinley S. (2009) Critical
care nurses’ decision making: sedation assessment and
management in intensive care. Journal of Clinical Nursing 18(1),
36–45. doi:10.1111/j.1365-2702.2008.02318.
© 2016 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Students’ decision-making during acute deterioration simulation
Arbon P. (2004) Understanding experience in nursing. Journal of
Clinical Nursing 13(2), 150–157. doi:10.1046/j.1365-
2702.2003.00861.x.
Australian Commission on Safety and Quality in Health Care
(ACSQHC) (2010) National Consensus Statement: Essential
Elements for Recognising and Responding to Clinical
Deterioration. ACSQHC, Sydney.
Australian Commission on Safety and Quality in Health Care
(ACSQHC) (2011a) A Guide to Support Implementation of the
National Consensus Statement: Essential Elements for
Recognising and Responding to Clinical Deterioration.
ACSQHC, Sydney.
Australian Commission on Safety and Quality in Health Care
(ACSQHC) (2011b) National Safety and Quality Health Service
(NSQHS) Standards. ACSQHC, Sydney.
Baker G.R., Norton P.G., Flintoft V., Blais R., Brown A., Cox J.,
Etchells E., Ghali W.A., Hebert P., Majumdar S.R., O’Beirne M.,
Palacios-Derflingher L., Reid R.J., Sheps S. & Tamblyn R.
(2004) The Canadian Adverse Events Study: the incidence of
adverse events among hospital patients in Canada. Canadian
Medical Association Journal 170(11), 1678–1686. doi:10.1503/
cmaj.1040498.
Beckie T.M., Lowry L.W. & Barnett S. (2001) Assessing critical
thinking in baccalaureate nursing students: a longitudinal study.
Holistic Nursing Practice 15(3), 18–26. doi:10.1097/00004650-
200104000-00006.
Benner P.E. (2001) From Novice to Expert: Excellence and Power
in Clinical Nursing Practice. Prentice Hall, Upper Saddle River,
NJ.
Bogossian F., Cooper S., Cant R., Beauchamp A., Porter J., Kain
V., Bucknall T. & Phillips N.M. (2014) Undergraduate nursing
students’ performance in recognising and responding to sudden
patient deterioration in high psychological fidelity simulated
environments: an Australian multi-centre study. Nurse
Education Today 34(5), 691–696. doi:10.1016/j.nedt.2013.
09.015.
Botti M. & Reeve R. (2003) Role of knowledge and ability in
student nurses’ clinical decision-making. Nursing and Health
Sciences 5(1), 39–49. doi:10.1046/j.1442-2018.2003.00133.x.
Brehmer B. & Joyce C.R.B., eds. (1988) Human Judgment: The
SJT View. Elsevier, Amsterdam.
Bucknall T.K. (2000) Critical care nurses’ decision-making
activities in the natural clinical setting. Journal of Clinical
Nursing 9(1), 25–35. doi:10.1046/j.1365-2702.2000.00333.x.
Bucknall T.K. (2003) The clinical landscape of critical care: nurses’
decision making. Journal of Advanced Nursing 43(3), 310–319.
doi:10.1046/j.1365-2648.2003.02714.x.
Bucknall T. (2007) A gaze through the lens of decision theory
toward knowledge translation science. Nursing Research 56(4
Suppl), S60–S66. doi:10.1097/01.NNR.0000280630.40784.0f.
Bucknall T.K., Kent B. & Manley K. (2008) Evidence use and
evidence generation in practice development. In International
Practice Development in Nursing and Healthcare (Manley K.,
McCormack B. & Wilson V., eds), Blackwell Publishing,
Chichester, pp. 84–104. doi: 10.1002/9781444319491.
fmatter.
Carroll J.S. & Johnson E.J. (1990) Decision Research: A Field
Guide Sage Publications, Thousand Oaks, CA.
© 2016 John Wiley & Sons Ltd
Cato M. (2012) Using simulation in nursing education. In
Simulation in Nursing Education: From Conceptualization to
Evaluation (Jeffries P.R., ed.), Lippincott Williams & Wilkins,
New York, pp. 3.
Cooper S., Cant R., Porter J., Sellick K., Somers G., Kinsman L. &
Nestel D. (2010) Rating medical emergency teamwork
performance: development of the Team Emergency Assessment
Measure (TEAM). Resuscitation 81(4), 446–452. doi:10.1016/
j.resuscitation.2009.11.027.
Cooper S., Beauchamp A., Bogossian F., Bucknall T., Cant R.,
DeVries B., Endacott R., Forbes H., Hill R., Kinsman L., Kain
V., McKenna L., Porter J., Phillips N. & Young S. (2012)
Managing patient deterioration: a protocol for enhancing
undergraduate nursing students’ competence through web-based
simulation and feedback techniques. BMC Nursing 11(1), 18.
doi:10.1186/1472-6955-11-18.
Cranley L., Doran D., Tourangeau A.E., Kusniruk A. & Nagle L.
(2012) Recognizing and responding to uncertainty: a grounded
theory of nurses’ uncertainty. Worldviews on Evidence-based
Nursing 9(3), 149–158. doi:10.1111/j.1741-6787.2011.00237.x.
Davis P., Lay-Yee R., Briant R., Ali W., Scott A. & Schug S.
(2002) Adverse events in New Zealand public hospitals I:
occurrence and impact. The New Zealand Medical Journal 115
(1167), U271.
Dowie J. & Elstein A.S., eds (1988) Professional Judgment: A
Reader in Clinical Decision Making. Cambridge University Press,
Cambridge, UK.
Endacott R., Bogossian F.E., Cooper S.J., Forbes H., Kain V.J.,
Young S.C., Porter J.E. & the First2Act, T (2015) Leadership
and teamwork in medical emergencies: performance of nursing
students and registered nurses in simulated patient scenarios.
Journal of Clinical Nursing 24(1–2), 90–100. doi:10.1111/
jocn.12611.
Ericsson K.A. & Simon H.A. (1993) Protocol Analysis: Verbal
Reports as Data MIT Press, Cambridge, Massachusetts.
Gerdtz M.F. & Bucknall T.K. (2007) Influence of task properties
and subjectivity on consistency of triage: a simulation study.
Journal of Advanced Nursing 58(2), 180–190. doi:10.1111/
j.1365-2648.2007.04192.x.
Guan Z., Lee S., Cuddihy E. & Ramey J. (2006) The validity
of the stimulated retrospective think-aloud method as
measured by eye tracking. In Proceedings of the SIGCHI
Conference on Human Factors in Computing Systems.
Montreal, Quebec, Canada, pp. 1253–1262. doi: 10.1145/
1124772.1124961.
Guinane J., Bucknall T.K., Currey J. & Jones D. (2013) Missed
Medical Emergency Team (MET) actions: tracking decisions and
outcomes in practice. Critical Care and Resuscitation 15(4),
266–272.
Hammond K.R. (1996) Human Judgment and Social Policy.
Oxford University Press, New York.
Hardy S., Garbett R., Titchen A. & Manley K. (2002) Exploring
nursing expertise: nurses talk nursing. Nursing Inquiry 9(3),
196–202. doi:10.1046/j.1440-1800.2002.00144.x.
Hicks F.D., Merritt S.L. & Elstein A.S. (2003) Critical thinking
and clinical decision making in critical care nursing: a pilot
study. Heart and Lung: Journal of Acute and Critical Care 32(3),
169–180. doi:10.1016/S0147-9563(03)00038-4.
11
T.K. Bucknall et al.
Hoffman K., Aitken L. & Duffield C. (2009) A comparison of
novice and expert nurses’ cue collection during clinical decision-
making: verbal protocol analysis. International Journal of
Nursing Studies 46, 1335–1344. doi:10.1016/j.ijnurstu.2009.
04.001.
Jeffries P. & Rogers K. (2012) Theoretical framework for
simulation design. In Simulation in Nursing Education: From
Conceptualization to Evaluation (Jeffries P.R., ed), Lippincott
Williams & Wilkins, New York, pp. 25–41.
Lamond D. & Farnell S. (1998) The treatment of pressure sores: a
comparison of novice and expert nurses’ knowledge, information
use and decision accuracy. Journal of Advanced Nursing 27(2),
280–286. doi:10.1046/j.1365-2648.1998.00532.x.
Leape L.L., Brennan T.A., Laird N., Lawthers A.G., Localio A.R.,
Barnes B.A., Hebert L., Newhouse J.P., Weiler P.C. & Hiatt H.
(1991) The nature of adverse events in hospitalized patients.
Results of the Harvard Medical Practice Study II. New England
Journal of Medicine 324(6), 377–384. doi:10.1056/
nejm199102073240605.
Liaw S.Y., Scherpbier A., Klainin-Yobas P. & Rethans J.-J. (2011)
A review of educational strategies to improve nurses’ roles in
recognizing and responding to deteriorating patients.
International Nursing Review 58(3), 296–303. doi:10.1111/
j.1466-7657.2011.00915.
Lyons E.M. (2008) Examining the effects of problem-based
learning and NCLEX-RN scores on the critical thinking skills of
associate degree nursing students in a southeastern community
college. International Journal of Nursing Education Scholarship
5(1), 1–17. doi:10.2202/1548-923X.1524.
McCaughan D., Thompson C., Cullum N., Sheldon T. & Raynor
P. (2005) Nurse practitioner and practice nurses’ use of research
information in clinical decision making: findings from an
exploratory study. Family Practice 22(5), 490–497. doi:10.1093/
fampra/cmi042.
McKenna L., Missen K., Cooper S., Bogossian F., Bucknall T. &
Cant R. (2014) Situation awareness in undergraduate nursing
students managing simulated patient deterioration. Nurse
Education Today 34(6), e27–e31. doi:10.1016/j.nedt.2013.
12.013.
Nursing and Midwifery Board of Australia (2013) National
Competency Standards for the Registered Nurse. Retrieved from
www.nursingmidwiferyboard.gov.au.
Ritchie J. & Spencer L. (1994) Qualitative data analysis for applied
policy research. In Analysing Qualitative Data (Bryman A. &
Burges R., eds), Routledge, London, pp. 173–194.
Tanner C.A. (2006) Thinking like a nurse: a research-based model
of clinical judgment in nursing. Journal of Nursing Education 45
(6), 204–211.
12
Tanner C.A., Padrick K.P., Westfall U.E. & Putzier D.J. (1987)
Diagnostic reasoning strategies of nurses and nursing students.
Nursing Research 36(6), 358–365.
Taylor C. (1997) Problem solving in clinical nursing practice.
Journal of Advanced Nursing 26(2), 329–336. doi:10.1046/
j.1365-2648.1997.1997026329.x.
Thomas S.A., Wearing A.J. & Bennett M.J. (1991) Clinical
Decision Making for Nurses and Health Professionals. W.B.
Saunders/Bailliere Tindall, Sydney.
Thompson C. & Dowding D. (2001) Clinical Decision-Making and
Judgement in Nursing. Churchill Livingstone, London.
Thompson C. & Stapely S. (2011) Do educational interventions
improve nurses’ clinical decision making and judgement? A
systematic review. International Journal of Nursing Studies 48
(7), 881–893. doi:10.1016/j.ijnurstu.2010.12.005.
Thompson C., Dalgleish L., Bucknall T., Estabrooks C.,
Hutchinson A.M., Fraser K., de Vos R., Binnekade J., Barrett G.
& Saunders J. (2008) The effects of time pressure and experience
on nurses’ risk assessment decisions: a signal detection analysis.
Nursing Research 57(5), 302–311. doi:10.1097/01.NNR.0000
313504.37970.f9.
Thompson C., Yang H. & Crouch S. (2012) Clinical simulation
fidelity and nurses identification of critical event risk: a signal
detecion analysis. Journal of Advanced Nursing 68(11), 2477–
2485. doi:10.1111/j.1365-2648.2012.05945.x.
Todd M., Manz J.A., Hawkins K.S., Parsons M.E. & Hercinger M.
(2008) The development of a quantitative evaluation tool for
simulations in nursing education. International Journal of
Nursing Education Scholarship 5(1), 1–17. doi:10.2202/1548-
923X.1705.
Vincent C., Neale G. & Woloshynowych M. (2001) Adverse events
in British hospitals: preliminary retrospective record review. BMJ
322(7285), 517–519. doi:10.1136/bmj.322.7285.517.
White J.E., Nativio D.G., Kobert S.N. & Engberg S.J. (1992)
Content and process in clinical decision-making by nurse
practitioners. Image: the Journal of Nursing Scholarship 24(2),
153–158. doi:10.1111/j.1547-5069.1992.tb00241.x.
Wilson R.M., Runciman W.B., Gibberd R.W., Harrison B.T.,
Newby L. & Hamilton J.D. (1995) The quality in Australian
health care study. Medical Journal of Australia 163(9), 458–
471.
Wilson R.M., Harrison B.T., Gibberd R.W. & Hamilton J.D.
(1999) An analysis of the causes of adverse events from the
Quality in Australian Health Care Study. The Medical Journal of
Australia 170(9), 411–415.
© 2016 John Wiley & Sons Ltd
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