Nursing judgement and decision-making using the Sedation Withdrawal Score (SWS) in children.
OBJECTIVE
The aim of the study was to evaluate registered children's nurses' approaches to the assessment and management of withdrawal syndrome in children.


BACKGROUND
Assessment of withdrawal syndrome is undertaken following critical illness when the child's condition may be unstable with competing differential diagnoses. Assessment tools aim to standardize and improve recognition of withdrawal syndrome. Making the right decisions in complex clinical situations requires a degree of mental effort and it is not known how nurses make decisions when undertaking withdrawal assessments.


METHODS
Cognitive interviews with clinical vignettes.


METHODS
Interviews were undertaken with 12 nurses to explore the cognitive processes they used when assessing children using the Sedation Withdrawal Score (SWS) tool. Interviews took place in Autumn 2013.


RESULTS
Each stage of decision-making-noticing, interpreting and responding-presented cognitive challenges for nurses. When defining withdrawal behaviours nurses tended to blur the boundaries between Sedation Withdrawal Score signs. Challenges in interpreting behaviours arose from not knowing if the patient's behaviour was a result of withdrawal or other co-morbidities. Nurses gave a range of diagnoses when interpreting the vignettes, despite being provided with identical information. Treatment responses corresponded to definite withdrawal diagnoses, but varied when nurses were unsure of the diagnosis.


CONCLUSIONS
Cognitive interviews with vignettes provided insight into nurses' judgement and decision-making. The SWS does not standardize the assessment of withdrawal due to the complexity of the context where assessments take place and the difficulties of determining the cause of equivocal behaviours in children recovering from critical illness.
Department of Anaesthetics, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.|School of Nursing and Allied Health, Liverpool John Moore's University, Liverpool, UK.
Jennie
http://orcid.org/0000-0003-0506-1569
J
Craske
Faculty of Health and Social care, Edge Hill University, Ormskirk, UK.|Children's Nursing Research Unit, Alder Hey Children's NHSFT, Liverpool, UK.|Faculty of Health, University of Tasmania, Hobart, Australia.
Bernie
B
Carter
Department of Applied Mathematics, Liverpool John Moore's University, Liverpool, UK.
Ian H
IH
Jarman
PICU, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.|School of Nursing, University of Central Lancashire, Preston, UK.
Lyvonne N
LN
Tume
D002648:Child; D003657:Decision Making; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007600:Judgment; D009723:Nurse-Patient Relations; D009740:Nursing Staff / Q000523:psychology*
D006993:Hypnotics and Sedatives
cognitive errors; cognitive interviewing; critical care; nursing assessment; paediatric