EXPERT TITRATION OF MULTIPLE VASOACTIVE DRUGS IN POST-CARDIAC SURGICAL PATIENTS: AN INTERPRETIVE STUDY OF CLINICAL JUDGEMENT AND PERCEPTUAL ACUITY.
Contributors: University of California, San Francisco.
Published: 1995
Number of pages: 487
Subjects: Health Sciences, Nursing.; Health Sciences, Medicine and Surgery.; Psychology, Industrial.
Description: Annually, over 518,000 adults undergo cardiac surgery (AHA, 1994) which renders them life dependent on technology, multiple vasoactive drug (MVD) therapy, skilled critical care nurses (CCN), and other clinicians. Patients commonly require the simultaneous infusion and titration of 2-6 MVDs to hemodynamically stabilize them; yet, research to explicate the skilled clinical knowledge or craft requisite for safe and effective titration of MVD combinations in life-threatening situations has not been conducted. Thus, critical care nurses must learn titration practices primarily by trial and error with little other guidance. The purpose of this study was to articulate the extensive clinical judgment, knowledge, and gaps in knowledge, evident in the practice of expert CCNs as they titrate MVDs in post-cardiac bypass (CAB) patients.

Although standards and guidelines for titration exist, nurses report that these offer limited assistance and value. This interpretive phenomenological study articulates the limits of procedural accounts that eclipse practical knowledge, critical thinking, and engaged reasoning.

This study combined qualitative and quantitative methods. Primary data sources included hemodynamic data on 425 titration events and audiotaped and videotaped clinical observations of five expert CCNs and 15 CAB patients, which provided 84 hours of in-depth narratives.

Findings included nine interconnected domains of situated judgment and practice, the four major ones being clinical grasp, skilled know-how (tact, skill, and craft), clinical forethought, and background practices. These were subjected to consensual validation. Common aspects of expertise and embodied intelligence within each domain pointed to the covered-over and often ineffable practical knowledge that is essential for expertise, yet defies standardization and computerization.

Craft and skill have been marginalized in science; yet, expert clinical judgment and practice, expert science, and excellent patient outcomes depend on both formal and practical ways of knowing and reasoning. To sustain and preserve expertise, clinicians, scientists, policy makers, and educators must recognize that expert "knowledge" alone is not the same as expertise. This work calls into question and offers correction to many assumptions in re-engineering and re-design.
Notes: Source: Dissertation Abstracts International, Volume: 57-01, Section: B, page: 0238.

Thesis (PH.D.)--UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, 1995.

School code: 0034.