Investigating failure to recognize clinical deterioration cues among less and more experienced nurse participants

Background. A report conducted in 2013 by Queensland Hospitals to investigate incidents of failure to recognize and respond to clinical deterioration identified that among the 172 incidents of failure to respond appropriately to clinical deterioration, 81% of cases resulted from failure to recognise deterioration cues. Paradoxically, unrecognized changes in a patient's physiological parameters are often familiar and obvious to attending nursing staff, are present for some time, and are occasionally documented in the vital signs chart; however, in some cases no further assistance is sought. Failure to recognize important cues leads to a failure to act applicably. Consequently, the time of patient hospitalization may extend, and there is an increased likelihood of unplanned transfers to intensive care cardiac resuscitation and death. In the past two decades, the problem of failure to recognize the deteriorating patient has received particular attention, with only minimal improvements in management.
   Aim. Using a screen based simulated patient, this study aimed to investigate lapses in clinical observation concerning failure to recognize clinical deterioration cues, among less and more experienced nurses, despite those cues being clinically evident. The phenomenon was investigated from a perceptual information processing perspective.  
   Design. A mixed method two phase sequential explanatory design was utilised for the study. In Phase One, 40 participants studying in a Monash University nursing program during the period April to June, 2014 volunteered to take part in a screen based scenario https://proxy.qualtrics.com/proxy/?url=http://first2actweb.com/&token=+DH/WYFK9OQivBIXBZkWdJaZv4Ve4nMusPsCBKjzpWk= , covering initial management of hypovolemic shock. Participants’ interaction with the simulated patient was recorded as video, gaze and mouse clicks movements using a Tobii eye tracking system. In Phase Two, 18 of those participants who volunteered in Phase One agreed to be involved in a gaze path cued retrospective thinking aloud interview. A triangulation of quantitative and qualitative data was established at the time of data collection. The data was analysed in three components: (1) cognitive task analysis; (2)Tobii eye tracking software data analysis; and (3) thematic analysis.  
   Results. Seventy eight percent of participants did not appropriately respond to the screen based patient and were not able to meet the minimum level of task goal achievement with no differences noted between groups. Factors leading to the failure of participants to achieve the task goal were attributed to, inattention blindness (p =0.008) which refers to failure of the participant to notice a cue that is in plain sight, and cognitive bias (p =0.001) which refers to a deviation from rationale clinical judgment. No differences were noted between groups in relation to inattention blindness and cognitive bias. Thirty five percent of participants had fixated for sufficient time upon important cues but no action followed, indicating they had recognition failure. A failing that was more apparent in the more experienced participants (p =0.015). Further, of all participants, 45% had a limited overall view of the scenario and focussed on individual cues ignoring the holism of the clinical situation. A failing that was more likely with the less experienced participants (p =0.046).
   Through employing thematic analysis in Phase Two of the study, cue recognition processes were modelled. During the process of abstraction of the clinical problem, participants moved from a global impression (context perception) to recognition (pattern matching), to hypothesis formation. Decision-making involves using heuristic and analytical approaches, with evidence of interaction between these two systems. Two types of heuristic approach outcomes that require further investigation were identified: recognition and insight.
   Conclusion. Collectively, these findings have expanded our understanding of the role of perceptual and cognitive performance in screen based clinical scenarios. Errors in cue processing were classified as those related to perceptual failure (inattentional blindness), pattern-matching failure (recognition failure) and decisional error (cognitive bias). These errors can cause a failure to recognize patients’ cues. There is a need for further work relating to visual perception and cognition in clinical settings. Such findings may develop ways for the development of cue recognition in learners.