The effects of time pressure and experience on nurses' risk assessment decisions : a signal detection analysis

Background: Time pressure and, occasionally, suboptimal assessment decisions are features of nursing in acute care.

Objectives: To explore the effect of generic and specialist clinical experience on the ability to detect the need to take action in acute care and the impact of time pressure on nurses' decision-making performance.

Methods: Experienced acute care registered nurses (n = 241) were presented with 50 vignettes of real clinical risk assessments. Each vignette contained seven information cues. In response to these vignettes, nurses had to decide whether to intervene or not. The 26 vignettes were time limited and mixed randomly into the 50 cases. Signal detection analysis was used to establish nurses' performance, personal decision thresholds ([beta]), and their abilities (d') to distinguish a signal of clinical risk from the clinical noise of noncontributory information.

Results: Nurses had significantly lower d' and were significantly less likely to indicate intervening under time pressure. For ability-but not threshold-there was a significant interaction of time pressure and years of experience in acute care. With no time pressure, d' increased in line with years of experience. Under time pressure, there was no effect.

Discussion: Time pressure reduced nurses' ability to detect the need and the tendency to report intervening. Thus, there were more failures to report appropriate intervention under time pressure, and the positive effects of clinical experience were negated under time pressure. More and larger scale research on the effect on clinical outcomes of time pressured nursing choices is required.

Assessing risk post intervention for an acute coronary syndrome: a review of the risk assessment tools and their development

Considerable variability in survival rate after an acute myocardial infarction exists and accurate risk stratification is of significant importance. The American College of Cardiology and the American Heart Association has recommended early risk stratification using several clinical risk scoring instruments to identify high risk patients. The aim of this paper is to identify secondary cardiovascular risk scoring instruments that could be utilized at the time of intervention for acute coronary syndromes and compare their psychometric properties as they were developed. A search using Medline, Cumulative Index to Nursing and Allied Health Literature and the Psychology and Behavioral Sciences Collection data-bases identified studies published between January 1990 and January 2010 used to measure risk after intervention for acute coronary syndrome. Four validated secondary risk prediction scoring instruments were identified for comparison.Secondary risk prediction scoring instruments for the acute coronary syndrome patient population are evidence based, valid and reliable. Use of the instruments by cardiac focused clinicians will aid in the determination of treatment strategies, and estimation of short and long term events and mortality.

Combining clinical judgement and formalised risk assessment techniques in anaesthesiology : lessons from bushfire emergency management

The underlying thinking in bushfire management has much to offer anaesthetists. Although it is imperative to develop improved methods of predicting the risk of perioperative patient morbidity and mortality, we must avoid them being used in a way that can undermine both individual clinical judgment on a case-by-case basis and the effectivenessof the methods themselves. This requires all concerned to be aware of the reliability and validity of the algorithms used to provide such predictions as well as the quality of the data upon which they are based. Like fire behaviour analysts, anaesthetists should still be free to trust their knowledge, expertise and experience. When experienced fire fighters sense a conflict between what the evidence on the ground is telling them and what a predictive fire map is saying, they use their understanding of limitations of the fire analysts’ predictions to inform their own professional judgment.

Quantitative microbial risk assessment modelling for the use of reclaimed water in irrigated horticulture

Reuse of treated sewage effluent for the irrigation of horticultural crops is being propounded and practiced as a means of alleviating pressure on freshwater resources. Concerns have been raised. however, as to the risk to human health, primarily disease, associated with this practice. Quantitative Microbial Risk Assessment (QMRA) is a useful tool for estimating this risk. We describe how QMRA works and the current state of knowledge of the components of QMRA models for the horticultural reuse scenario.

Risk assessment in child protection: problem rather than solution?

Risk assessment in child protection services has been promoted as the most reliable way to ensure that maltreatment to children is prevented and has become central to practice with children and families. However, recent research in Australia has suggested that children are being left in unsafe situations, leading to further maltreatment, by the very agencies responsible for their protection. The present article explores the reasons why child protection has become central to child protection practice and presents a wide ranging critical appraisal of risk assessment and its application. It is argued that risk assessment is a flawed process and, as a central tenet of practice, is implicated in any problems that children's protective services face. Consequently, any future reconfiguration of services for children in need of protection needs to include a re-evaluation of the efficacy of risk  assessment.

Quantitative microbial risk assessment models for consumption of raw vegetables irrigated with reclaimed water

Quantitative microbial risk assessment models for estimating the annual risk of enteric virus infection associated with consuming raw vegetables that have been overhead irrigated with nondisinfected secondary treated reclaimed water were constructed. We ran models for several different scenarios of crop type, viral concentration in effluent, and time since last irrigation event. The mean annual risk of infection was always less for cucumber than for broccoli, cabbage, or lettuce. Across the various crops, effluent qualities, and viral decay rates considered, the annual risk of infection ranged from 10–3 to 10–1 when reclaimed-water irrigation ceased 1 day before harvest and from 10–9 to 10–3 when it ceased 2 weeks before harvest. Two previously published decay coefficients were used to describe the die-off of viruses in the environment. For all combinations of crop type and effluent quality, application of the more aggressive decay coefficient led to annual risks of infection that satisfied the commonly propounded benchmark of ≤10–4, i.e., one infection or less per 10,000 people per year, providing that 14 days had elapsed since irrigation with reclaimed water. Conversely, this benchmark was not attained for any combination of crop and water quality when this withholding period was 1 day. The lower decay rate conferred markedly less protection, with broccoli and cucumber being the only crops satisfying the 10–4 standard for all water qualities after a 14-day withholding period. Sensitivity analyses on the models revealed that in nearly all cases, variation in the amount of produce consumed had the most significant effect on the total uncertainty surrounding the estimate of annual infection risk. The models presented cover what would generally be considered to be worst-case scenarios: overhead irrigation and consumption of vegetables raw. Practices such as subsurface, furrow, or drip irrigation and postharvest washing/disinfection and food preparation could substantially lower risks and need to be considered in future models, particularly for developed nations where these extra risk reduction measures are more common.

A retail supply chain risk assessment conceptual model

Supply chains are increasingly relying on information and communications technologies and in particular electronic commerce to facilitate transactions between supply chain partners. The adoption of these enabling technologies brings several enhancements to the conduct of business including gains in efficiency. However there are also drawbacks inherent in these technologies that include threats that are imposed on businesses that use them. This paper presents a study on retail supply chains and the risks and vulnerabilities that cooperating supply chain partners are exposed to when adopting these technologies. In particular, the paper discusses the various threats and vulnerabilities of retail supply and presents a conceptual model of such risks.

The mental health Risk Assessment and Management Process (RAMP) for schools: II. Process evaluation

The Risk Assessment and Management Process (RAMP) is a whole-school process for the assessment and management of student’s mental health and wellbeing in primary and secondary schools. A process evaluation revealed that RAMP was implemented as intended across six primary and three secondary schools in Melbourne, Australia. Using the RAMP risk and protective factors monitoring form and screening processes, each school identified ‘at-risk’ students who had not previously been identified or received assistance from welfare staff at the school. School staff and mental health workers from local agencies reported improvements in their knowledge of risk and protective factors, and their ability to identify at-risk students following RAMP. They also reported satisfaction in outcomes for at-risk students managed within the school using RAMP. All the primary schools and one of the
secondary schools continued to use some RAMP processes in their school up to 6 months after the initial implementation of the program.