Clinical decision making by nurses when faced with third-space fluid shift. How well do they fare?

Nurses' use of knowledge, the connection of this knowledge to treatment decisions and information actually used to reach such decisions, delineates nurses' level of expertise. Previous research has shown that nurses in their clinical decision-making use the hypothetico-deductive method and intuitive judgment or pattern recognition. This interpretive study explored experienced critical care nurses' (n = 5) and gastrointestinal surgical nurses' (n = 5) clinical decision-making processes through ascertaining their knowledge and understanding of third-space fluid shift in elderly patients undergoing major gastrointestinal surgery. Both groups of nurses, because of their experience with elderly patients undergoing gastrointestinal surgery, were assumed to be experts. Data collection techniques included semi-structured interviews and the use of think aloud protocol for clinical scenario analysis. The findings demonstrated that the gastrointestinal surgical nurses used the hypothetico-deductive method to recognize critical cues and the existence of a problem but could not name the problem. The critical care nurses, on the other hand, used a combination of the hypothetico-deductive method and pattern recognition as a basis for identification of critical cues. The critical care nurses also possessed in depth knowledge of third-space fluid shift and were able to use pivotal cues to identify the actual phenomenon. Ultimately, it would appear that the structure of critical care nurses' work, their increased educational qualifications and the culture of the critical care unit promote a more proactive approach to reasoning in the physiological domain. The findings have implications for the development of practice guidelines and curriculum development in both tertiary and continuing nurse education.