Clinical decision-making (CDM) research has focused on diagnostic reasoning, CDM models, factors influencing CDM and the development of expertise. The research approaches used, including phenomenology, have not addressed the question of how CDM is perceived and approached by nurses. This study describes perceptions of CDM in relation to patients in pain using a phenomenographic methodology. At semi-structured interviews, participants were asked to recall their responses to a situation involving a patient in pain. The responses fell into four categories: (1) the effect of the clinical environment; (2) the role of other health professionals; (3) the place of the patient; and (4) the role of experience. Examples of differences in perceptions that were likely to impact on the nurses� approach to CDM include: the ongoing effects of time and workload demands on CDM; nurses are initially dependent but were eventually able to make decisions autonomously; the patient who may be peripheral or central to CDM; and the nurses� move from the use of theoretical principles to experiential knowledge as reflection-on-practice is employed. Perceptions in all categories are strongly implicated in the nurses� sense of confidence and independence. Implications for nursing practice and nursing education suggested by the findings relate to the number of areas in which graduates work in the first year of practice, the size of new graduate workloads, graduate transition programs, the place of reflection-on-practice and undergraduate (UG) program clinical experience patterns. Among issues for further research arising from the study are: replication of the study; detailed examination of the development of CDM in the first year of nursing practice and during UG nursing education programs; the role of other health professionals in the development of CDM behaviour; the links between CDM and clinical knowledge development; and the type of clinical environments that foster confidence and independence. A conclusion of the study is that the way CDM is approached is influenced by the amount, quality, relevancy and recency of clinical experience. In this study, phenomenography was shown to be an appropriate approach to the description of nurses� perceptions of CDM in relation to patients in pain. In addition, nurses� changing perceptions over two years and the subsequent effect on CDM behaviour were described.

Background and Purpose: Dental hygienists are targeted for practice expansion to improve public access to oral health care and, therefore, must demonstrate decision making capacity. This study aimed to identify and test the impact of factors influential in dental hygiene decision making. Organizational and gender factors were hypothesized to be most influential. Methods: A phased mixed methods approach was used. Phase I: A series of focus groups were conducted to inform a dental hygiene decision making model, which included key predictor variables and the outcome variable: decision making capacity. Phase II: Aspects of the model were tested via an electronic questionnaire and key informant interviews. Statistical and qualitative thematic analyses were conducted and then findings were merged for interpretation. Results and Interpretation: Focus groups yielded over 75 codes and 6 themes (+ 1 theme from the literature) comprising the model and guiding the survey. The survey had a 38% response rate, and moderate to weak correlations between predictors and the outcome measure were shown. The final statistical model demonstrated Individual Characteristics and graduating from a 3-year program together significantly predicted decision making capacity. When merged with the key informant qualitative data, Individual Characteristics were shown to be a product of broad environmental factors and educational preparation had a particularly strong influence. Conclusions: Individual characteristics and education are predictive of decision making capacity but are outcomes of broad structural influences. Thus, it is recommended that modifications are made to these structures to support dental hygiene decision making in expanded practice.

Background and Purpose: Dental hygienists are targeted for practice expansion to improve public access to oral health care and, therefore, must demonstrate decision making capacity. This study aimed to identify and test the impact of factors influential in dental hygiene decision making. Organizational and gender factors were hypothesized to be most influential. Methods: A phased mixed methods approach was used. Phase I: A series of focus groups were conducted to inform a dental hygiene decision making model, which included key predictor variables and the outcome variable: decision making capacity. Phase II: Aspects of the model were tested via an electronic questionnaire and key informant interviews. Statistical and qualitative thematic analyses were conducted and then findings were merged for interpretation. Results and Interpretation: Focus groups yielded over 75 codes and 6 themes (+ 1 theme from the literature) comprising the model and guiding the survey. The survey had a 38% response rate, and moderate to weak correlations between predictors and the outcome measure were shown. The final statistical model demonstrated Individual Characteristics and graduating from a 3-year program together significantly predicted decision making capacity. When merged with the key informant qualitative data, Individual Characteristics were shown to be a product of broad environmental factors and educational preparation had a particularly strong influence. Conclusions: Individual characteristics and education are predictive of decision making capacity but are outcomes of broad structural influences. Thus, it is recommended that modifications are made to these structures to support dental hygiene decision making in expanded practice.

Clinical decision-making (CDM) research has focused on diagnostic reasoning, CDM models, factors influencing CDM and the development of expertise. The research approaches used, including phenomenology, have not addressed the question of how CDM is perceived and approached by nurses. This study describes perceptions of CDM in relation to patients in pain using a phenomenographic methodology. At semi-structured interviews, participants were asked to recall their responses to a situation involving a patient in pain. The responses fell into four categories: (1) the effect of the clinical environment; (2) the role of other health professionals; (3) the place of the patient; and (4) the role of experience. Examples of differences in perceptions that were likely to impact on the nurses� approach to CDM include: the ongoing effects of time and workload demands on CDM; nurses are initially dependent but were eventually able to make decisions autonomously; the patient who may be peripheral or central to CDM; and the nurses� move from the use of theoretical principles to experiential knowledge as reflection-on-practice is employed. Perceptions in all categories are strongly implicated in the nurses� sense of confidence and independence. Implications for nursing practice and nursing education suggested by the findings relate to the number of areas in which graduates work in the first year of practice, the size of new graduate workloads, graduate transition programs, the place of reflection-on-practice and undergraduate (UG) program clinical experience patterns. Among issues for further research arising from the study are: replication of the study; detailed examination of the development of CDM in the first year of nursing practice and during UG nursing education programs; the role of other health professionals in the development of CDM behaviour; the links between CDM and clinical knowledge development; and the type of clinical environments that foster confidence and independence. A conclusion of the study is that the way CDM is approached is influenced by the amount, quality, relevancy and recency of clinical experience. In this study, phenomenography was shown to be an appropriate approach to the description of nurses� perceptions of CDM in relation to patients in pain. In addition, nurses� changing perceptions over two years and the subsequent effect on CDM behaviour were described.

Paramedics are responsible for the care of patients requiring emergency assistance in the out of hospital setting. These health care providers need to make many decisions during the course of an emergency call. This thesis on paramedic clinical decision-making includes two studies, intended to determine which decisions paramedics make that are most important for patient safety and clinical outcome, and what thinking strategies paramedics rely on to make decisions. Forty-two decisions were found to be most important for outcome and safety. The highest decision density of an emergency call is during the on-scene treatment phase. Paramedics use a mix of thinking strategies, including rule out worst scenario, algorithmic, and exhaustive thinking. The results of these studies have implications for future research, paramedic practice and training.

Thesis advisor: Judith A. Vessey / Purpose: The purpose of this study is to investigate staff nurses’ clinical decision making (CDM) regarding pediatric oncology patients’ nutritional status. Background: Malnutrition, both under- and over-nutrition, in children can lead to significant morbidity and even mortality. Pediatric cancer patients are at high risk for malnutrition secondary to the disease process and treatment side effects; malnutrition in pediatric oncology patients is associated with poorer outcomes. Pediatric oncology nurses, with frequent and consistent contact with patients, are in an ideal position to assess nutritional status. Early identification and intervention for nutritional concerns in patients has been shown to improve outcomes. However, research on the quality of pediatric oncology nurses’ CDM regarding nutritional status does not exist. Methods: A web-based survey was distributed to members of the Association of Pediatric Hematology Oncology Nurses; it was comprised of three sections: a demographic data collection form, pediatric oncology nutrition related vignettes, and the New General Self-Efficacy Scale. The vignettes were rated on a one to five scale with one being under-nourished and 5 being over-nourished. Participants were asked to report their confidence in their rating and select cues in the vignette supporting the rating. A multi-level regression analysis was utilized to assess the quality of nurses’ CDM, the confidence of the nurses’ CDM, and the factors associated with CDM. Results: No nurse or organizational factors could be identified as useful in predicting the accuracy of the participants’ nutritional rating; however, nurses were significantly likely to under-rate the vignette when comparted with the expert panel’s rating. Nurses were significantly likely to select fewer cues supportive of nutritional rating than the expert panel. Conclusions: Further research regarding nutritional assessment and nurses’ clinical decision making is warranted. Evidence-based guidelines for nutritional assessment of pediatric oncology patients should be developed and implemented to ensure this patient population receives the highest quality of care. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Background: In hospital critical-care and emergency settings, non-Invasive ventilation (NIV) is increasingly used in neonatal and paediatric patients as an alternative to invasive positive pressure ventilation (IPPV). Critically ill children and babies may need transfer to higher levels of care, but the emergency transport setting is lagging behind the hospital sector in terms of availability of NIV. Aim and objectives: The goal of this study was to assess the evidence on the safety and effectiveness of NIV in children during transportation. Safety outcome measures were intubation or escalation of ventilation mode (during and soon after transport) and adverse event (AE) occurrence during transport. Effectiveness outcome measures related to improvement in clinical parameters during transfer. Methods: A systematised review of the literature was conducted, based on searches of MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials (CENTRAL), African Index Medicus, Web of Science Citation Index and the World Health Organisation Trials Registry (ICTRP). Two reviewers independently reviewed all identified studies for eligibility, with an initial screening round followed by a full-text review of potentially relevant articles. The quality of studies meeting inclusion criteria was evaluated using an adapted quality assessment tool developed for this study. Results: A total of 1287 records were identified; of these, 12 studies met inclusion criteria. Following quality assessment, eight studies were included and four studies were excluded. There were no randomised controlled trials, quasi-randomised controlled trials or non-randomised studies of intervention, to answer the research question. The included studies were all observational in design: seven studies (n= 708) evaluated in-transport use of continuous positive airway pressure (CPAP) and one study (n=150) reported on use of high-flow nasal cannula (HFNC) in children during transport. During transport on NIV, 3/858 (0.4%) patients required either intubation (1/708; 0.1%; CPAP studies) or escalation of mode of ventilation (2/150; 1%; HFNC study). In the 24 hours following transfer, 63/650 (13%) of children transferred on NIV, were intubated. The odds of intubation within 24 hours were significantly higher for CPAP transfer 60/500 (12%) compared with HFNC 3/150(2%): OR (95% CI) 6.68 (2.40 - 18.63), p=0.00003. Adverse events, where reported, were found to occur in 2-4% of NIV transports, with use of BVM in 8/334 (2%), desaturation episodes in 9/290 (3%), apnoea in 11/290(4%) and administration of CPR in 0/290 (0%) cases being described. There was insufficient reporting of change in vital signs or clinical condition during transport for meaningful analysis. Conclusion: This study is the first systematised review indicating that NIV use in children during transport is likely to be safe. From the low-reliability evidence available, it was calculated that NIV use in children during transport would result in a 0.4% rate of intubation or escalation during transport and an in-transport adverse event rate of 2-4%. There was insufficient evidence to comment on clinical effectiveness of NIV during transfer. Following NIV transfer, 13% of patients were intubated within 24 hours, with significantly higher odds of intubation in children transported on CPAP compared with HFNC. Recommendations: Further research is needed in order to make firm recommendations regarding the safety and effectiveness of NIV during transport of children. A recommended minimum data set, for the standardised reporting of observational studies of paediatric NIV use during transport, is suggested. It is recommended that transport databases and registries are expanded to include NIV details as well as information regarding the presence or absence of pre-specified adverse events during transport.

This study questions whether expertise plays a role in how mental health clinicians remember case details about their clients. Specifically, are expert clinicians better at teasing apart complex case details than novices? Clinicians’ diagnostic schemas may afford a mechanism for easily retaining and retrieving information about particular cases. American Board of Professional Psychologists certified clinicians acted as our expert participants. Undergraduate students enrolled in general psychology acted as novices. Results indicated experts recalled more information than non-experts for each of three hypothetical case vignettes—simple, complex-coherent, and complex-incoherent. As complexity of the vignettes increased the overall amount of recall increased for the complex-coherent vignette and then decreased for the complex-incoherent vignette for both groups. Experts also exhibited more false recalls of symptom specific details for the complex-incoherent case. This finding is evidence of schema-based knowledge and experts’ tendency to use schemas in an effort to make sense of illogical cases.

Schizoaffective disorder has routinely exhibited poor outcomes related to diagnostic accuracy and reliability. These pitfalls have been linked to the conceptual nature of Schizoaffective Disorder’s combined psychotic and affective symptoms. Clinicians likely perceive the psychotic components of Schizoaffective Disorder as more severe than the affective symptoms, and have demonstrated a bias toward misdiagnosing Schizoaffective Disorder as Schizophrenia. Thus, the present study sought to examine the clinical conceptualizations of Schizoaffective Disorder compared to Schizophrenia, Bipolar Disorder with psychotic features, and Major Depressive Disorder with psychotic features. The participants were clinicians recruited via email and randomly assigned to either select symptoms from a predetermined criteria list (Recognition group) or to freely list features of the disorders based on their own mental representations (Unprompted group). Participants’ conceptualizations of Schizoaffective Disorder were not entirely congruent with DSM-5 criteria; they conceptualized it as less psychotic than Schizophrenia and less affective than the two mood disorder tasks. Schizoaffective Disorder exhibited the lowest proportion of accurate endorsements, and Schizophrenia had the highest proportion. We hypothesized that Schizoaffective Disorder would have the most overextension endorsements because of its fuzzy boundaries, but Schizophrenia had the highest instead. The Recognition Group outperformed the Unprompted Group overall, which can be explained by the availability heuristic. This study’s findings support the notion that Schizoaffective Disorder’s poor diagnostic outcomes are possibly related to clinicians’ conceptualization of the construct, or that its current diagnostic formulation is not congruent with what clinicians observe in clinical settings.

Due to the increasing demand from teaching institutions and the General Dental Council to provide dental students with accurate assessment and feedback, the focus of this thesis is to evaluate and improve assessment and feedback at Dundee Dental School. The aim is to determine and appraise assessment tools used in evaluating the clinical skills of dental students in laboratory setting. In addition, the purpose of this thesis is to further develop the assessment tools to provide valid and reliable assessment and feedback on students’ performance. Dental students practise clinical procedures in clinical skills laboratories which are evaluated by qualified staff. Effective evaluation should be valid (accurate and reliable) and produce consistently useful feedback. In this thesis, assessment of experienced (senior) examiners demonstrated, unrepeatable (intra-examiner) and reproducible (inter-examiner) evaluation of class II amalgam cavity and full veneer gold shell crown preparations in a clinical skills laboratory (Chapters 3 and 4).Further assessment of a wider group of additional teaching staff also demonstrated poor levels of intra-examiner reliability (repeatability) and inter-examiner reliability (reproducibility) (Chapter 4). Concentrating on the senior examiners, consistent methods, including the use of novel tools, were then devised and tested to improve intra-examiner repeatability and inter-examiner reproducibility. These methods also included feedback sheets which served to provide feedback for students (Chapter 5). Grades awarded from the best senior examiner who had the highest level of intra- and inter-examiner repeatability and reproducibility, respectively, were then tested against known developed standard criteria as well as actual preparations to establish the validity of these grades (Chapter 6). The checklist is the most common assessment method which is used within the Clinical Skills Laboratory in Universities. From five consistent methods, new checklists and reliable tools were established and tested again to demonstrate improved validity and reliability of awarded grades as well as feedback consistency (Chapter 7). This process now requires further testing with another cohort of preparations to affirm its usefulness. The new cohort should include tooth preparations by both novice and expert operators to reflect a greater range of abilities and thus test the assessment process more rigorously.