Nursing pain management is closely related to decision making-process, which includes continuous estimate, intervention, monitoring the effect of treatment, identifying the need for changes and alternative treatment. It is generally assumed that education and practical experience increases accuracy in decision-making. Benner presented an extensive theory that suggests five levels of proficiency that nurses pass in acquisition and development of skills from novice to expert. However, this theory does not examine strategies of decision making during these stages. The purpose of the study: (1) to identify the cognitive processes used by nurses when making pain management decisions and the factors which have an influence on these processes. (2) to examine the difference between novice, intermediate and expert nurses, in their decision making about pain management.
Methods:
The subjects constitute a non-random sample of 65 registered nurses working in surgical wards in two academic teaching medical centers located in Israel. The study received approval from both hospitals' institutional review boards. The study is based on three tools: the self-assessment questionnaire of participants' pain management knowledge and skills; vignettes describing common situations which require nurse's decision making followed by questions examining basis of the decision; script concordance test evaluating decision making in common clinical situations. The tools were designed by the researches and validated by expert judgment.
Results:
The decision regarding pain management of expert nurses were mostly based on their experience and intuition, while novices and intermediates relied on guidelines or colleagues' advises. In comparison to novice, expert nurses reported that the decision making process was easier for them (α=0.013). Significantly better decision making was found among the nurses with Master degree (F=7.15, α=005) and among nurses who have participated in pain management educational programs (α=0.02). No association was found between seniority in a surgical ward and accuracy in decision making. The findings were consistent with vignettes and script concordance test.
Conclusions:
There is a substantial difference in the decision making regarding pain management between novices, intermediates and experts, both in quality of the decision and the cognitive process of the decision making. Well-developed guidelines may assist no novice to improve their decision making skills. The script concordance test seems to be an effective tool in evaluating nurses' clinical decisions. This study emphasized the benefit of nurses' higher education and participation in clinical educational programs
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