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The Effects of Time Pressure and Experience on Nurses' Risk Assessment Decisions: A Signal Detection Analysis

Thompson, Carl; Dalgleish, Len; Bucknall, Tracey; Estabrooks, Carole; Hutchinson, Alison M.; Fraser, Kim; de Vos, Rien; Binnekade, Jan; Barrett, Gez; Saunders, Jane

doi: 10.1097/01.NNR.0000313504.37970.f9

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 (β), 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.

Carl Thompson, PhD, RN, BA, is Senior Lecturer, Department of Health Sciences, University of York, United Kingdom.

Len Dalgleish, PhD, BSc, is Professor, Department of Nursing and Midwifery, University of Stirling, United Kingdom.

Tracey Bucknall, PhD, BN, RN, ICU Cert, is Professor, Cabrini-Deakin Centre for Nursing Research, Cabrini Institute and Deakin University, Melbourne, Australia.

Carole Estabrooks, PhD, RN, is Professor and Canada Research Chair in Knowledge Translation; Alison M. Hutchinson, PhD, RN, Cert of Midwifery, BAppSci, MBioethics, is Postdoctoral Research Fellow; and Kim Fraser, RN, is Doctoral Candidate, Faculty of Nursing, University of Alberta, Edmonton, Canada.

Rien de Vos, PhD, RN, is Head of School; and Jan Binnekade, PhD, RN, is Lecturer, Department of Nursing, Academic Medical Centre, University of Amsterdam, Netherlands.

Gez Barrett, BSc, RGN, is Development Sister; and Jane Saunders, BSc, RN, is Outreach Sister, Bradford Hospitals NHS Trust, West Yorkshire, United Kingdom.

Editor's Note: Additional information provided by the authors expanding this article is on the editor's Web site at

Accepted for publication June 2, 2008.

Financial support for Dr. Thompson was provided by the UK Department of Health's Nursing and Allied Health Professionals Post-Doctoral Award Scheme. Financial support for Professor Dalgleish was provided by the Scottish Executive initiative for Nursing Midwifery and Allied Health Professions research through HealthQWest (a research consortium for the West of Scotland). Financial support to Professor Estabrooks is provided by the Canadian Institutes of Health Research (CIHR) Canada Research Chair program and to Ms. Fraser in the form of doctoral fellowships from CIHR and the Alberta Heritage Foundation for Medical Research.

Professor Bucknall was employed as director of Nursing Research and Development at Western Health and as associate professor at the School of Nursing, University of Melbourne, Australia, when the research was conducted. Dr. Hutchinson was working formerly as a research fellow at Nursing Research and Development, Western Health, School of Nursing, University of Melbourne, Melbourne, Australia.

Corresponding author: Carl Thompson, PhD, RN, BA, Area 2, Department of Health Sciences, University of York, York, YO10 5DD, United Kingdom (e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.