Nurses' critical event risk assessments : a judgement analysis

Aims. To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

Background. Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

Methods. A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

Results. Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (Ra) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

Conclusion. Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

Relevance to clinical practice. Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

Recent research (N=9,305) underscores the importance of using age-stratified actuarial tables in sex offender risk assessments

A useful understanding of the relationship between age, actuarial scores, and sexual recidivism can be obtained by comparing the entries in equivalent cells from “agestratified” actuarial tables. This article reports the compilation of the first multisample age-stratified table of sexual recidivism rates, referred to as the “multisample age-stratified table of sexual recidivism rates (MATS-1),” from recent research on Static-99 and another actuarial known as the Automated Sexual Recidivism Scale. The MATS-1 validates the “age invariance effect” that the risk of sexual recidivism declines with advancing age and shows that age-restricted tables underestimate risk for younger offenders and overestimate risk for older offenders. Based on data from more than 9,000 sex offenders, our conclusion is that evaluators should report recidivism estimates from age-stratified tables when they are assessing sexual recidivism risk, particularly when evaluating the aging sex offender.

Towards a knowledge perspective in information security risk assessments - an illustrative case study

Many methodologies exist to assess the security risks associated with unauthorized leakage, modification and interruption of information for a given organisation. We argue that the traditional orientation of these methodologies, towards the identification and assessment of technical information assets, obscures key risks associated with the cultivation and deployment of organisational knowledge. Our argument is developed through an illustrative case study in which a well-documented methodology is applied to a complex data back-up process. This process is seen to depend, in subtle and often informal ways, on knowledge to sustain operational complexity, handle exceptions and make frequent interventions. Although typical information security methodologies identify people as critical assets, we suggest a new approach might draw on more detailed accounts of individual knowledge, collective knowledge, and their relationship to organisational processes. Drawing on the knowledge management literature, we suggest mechanisms to incorporate these knowledge-based considerations into the scope of information security risk methodologies.

Incorporating a knowledge perspective into security risk assessments

Purpose – Many methodologies exist to assess the security risks associated with unauthorized leakage, modification and interruption of information used by organisations. This paper argues that these methodologies have a traditional orientation towards the identification and assessment of technical information assets. This obscures key risks associated with the cultivation and deployment of organisational knowledge. The purpose of this paper is to explore how security risk assessment methods can more effectively identify and treat the knowledge associated with business processes.

Design/methodology/approach – The argument was developed through an illustrative case study in which a well-documented traditional methodology is applied to a complex data backup process. Follow-up interviews were conducted with the organisation’s security managers to explore the results of the assessment and the nature of knowledge “assets” within a business process.

Findings – It was discovered that the backup process depended, in subtle and often informal ways, on tacit knowledge to sustain operational complexity, handle exceptions and make frequent interventions. Although typical information security methodologies identify people as critical assets, this study suggests a new approach might draw on more detailed accounts of individual knowledge, collective knowledge and their relationship to organisational processes.

Originality/value – Drawing on the knowledge management literature, the paper suggests mechanisms to incorporate these knowledge-based considerations into the scope of information security risk methodologies. A knowledge protection model is presented as a result of this research. This model outlines ways in which organisations can effectively identify and treat risks around process knowledge critical to the business.

Towards consistency, rigour and compatibility of risk assessments for ecosystems and ecological communities

Ecosystem-level conservation is increasingly important at global, national and local levels. Many jurisdictions have developed and apply their own protocols for assessing the threat status of ecosystems, often independently, leading to inconsistencies between and within countries which are problematic for cross-jurisdictional environmental reporting. Australia is a good example of these historic legacies, with different risk assessment methods applied nationally and in most states. The newly developed criteria for the International Union for the Conservation of Nature (IUCN) Red List of Ecosystems (RLE) provide a framework to compare and contrast apparently divergent protocols. We critically reviewed the Australian protocols and compared them with the IUCN RLE, based on the following components of a risk assessment protocol: (i) categories of threat; (ii) assessment units; (iii) underlying concepts and definitions; (iv) assessment criteria; (v) uncertainty methods; and (vi) assessment outcomes. Despite some differences in specific objectives, criteria and their expression, the protocols were structurally similar, included broadly similar types of criteria, and produced assessment outcomes that were generally concordant. Alignment with the IUCN RLE would not require extensive changes to existing protocols, but would improve consistency, rigour and robustness in ecosystem risk assessment across jurisdictions. To achieve this, we recommend: (i) more quantitative assessments of functional change; (ii) separation of management and policy considerations from risk assessment; and (iii) cross-referencing of assessment units in different jurisdictions. We argue that the focus on processes and ecological function, rather than only patterns, is key to robust risk assessment. © 2014 The Authors.

Fire fighters' assessments of fireground risk

Fire fighters are often required to work in dynamic and hazardous environments involving a high level of uncertainty. The present study investigated 110 volunteer fire fighters’ assessments of levels of risk associated with a photographic depiction of a typical grassland fire situation. The fire fighters used a standard fire agency risk-rating matrix procedure requiring them to specify the severity of the hazards depicted and the probability of a mishap in order to rate overall level of risk (1 = Low; 4 = Extreme). The risk ratings made by the fire fighters varied greatly. The overall rate of agreement with the risk level rating of the situation made by a panel of expert fire officers (=1, Low) was only 27%. It seems that use of a standard risk-rating matrix procedure by fire fighters at incidents, as recommended currently by many fire agencies, is likely to result in unreliable risk assessments, at least in the absence of effective training in the risk assessment procedure. The 110 volunteers were also asked to identify the total number of potential hazards apparent in five photographs depicting different kinds of emergency incidents. Identifying more hazards was found to be associated with (a) previous personal experience of a ‘near-miss’; and (b) higher levels of education. The findings imply that when faced with identical fire ground situations, individual fire fighters are likely to differ in their situational awareness of hazards and consequent risk assessments.

Terrify and control: the politics of risk society

The article presents information on the idea of risk management. The origins of the contemporary constructions of risk are found in the seventeenth century, with the development of maritime insurance. In the context of maritime trading, risk came to be seen in terms of the balance between acquisitive opportunities and potential dangers and calculations of future loss of a ship or cargo. Today perceptions of risk affect our actions and strategies in areas of our life as diverse as health, parenting, crime prevention, recreation and travel. Public policy tends to be focused around risk avoidance and risk management, particularly in areas of child protection and aged care. While most of the discussions of risk have focused on risks as bads in society, risk has also been identified as a good. Risk is deemed a good when it challenges people to think differently and creatively. From a neo-liberal perspective risk opens up opportunities for unleashing of entrepreneurial capacity. In the context of the modernist commitment to the idea that people have the potential to control their own destiny, identification of threats and dangers can energize people to be adventurous. The discourse of risk has framed all the reports of the outbreaks of new strains of infection and includes instructions on how to recognize the risk assessments of its spread and instructions on how to avoid its spread.

Integrating insurance services, trust and risk mechanisms into multi-agent systems

In multi-agent systems, there is often the need for an agent to cooperate with others so as to ensure that a given task is achieved timely and cost effectively. Currently multi-agent systems maximize this through mechanisms such as coalition formation, trust and risk assessments, etc. In this paper, we incorporate the concept of insurance with trust and risk mechanisms in multi-agent systems. The novelty of this proposal is that it ensures continuous sharing of resources while encouraging expected utility to be maximized in a dynamic environment. Our experimental results confirm the feasibility of our approach.

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.

Risk assessment with female sex offenders : can women meet the criteria of community protection laws?

Although females represent a small proportion of the sex offender population, they occasionally appear before the courts under the current generation of laws intended to protect the public from high-risk sex offenders. In this context, practitioners are called upon to provide assessment of the risk these women pose for sexual re-offending. The primary issues addressed in this paper are related to the validity of conducting such risk assessments and providing professional opinions as to the risk of further sexual offences that may be committed by female offenders. The approach taken is to summarize briefly the available professional literature regarding female sex offenders, and then to present the findings of the relatively few empirical studies that address sexual recidivism in females. The final section examines the positions taken in the published works of various international experts regarding risk assessment with females, followed by conclusions and recommendations in light of the standards typically prescribed by community protection laws.