Abstract：
BACKGROUND: Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications.
OBJECTIVE: To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery.
METHODS: This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory.
RESULTS: Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability.
CONCLUSIONS: Nurses\' decision-making was shaped by their personal attributes, the patient\'s condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation.
CONCLUSIONS: This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.
OBJECTIVE: To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery.
METHODS: This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory.
RESULTS: Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability.
CONCLUSIONS: Nurses\' decision-making was shaped by their personal attributes, the patient\'s condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation.
CONCLUSIONS: This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.
摘要：
背景：心脏手术后出血是常见且严重的，然而,在了解有经验的重症监护护士如何识别和应对此类并发症方面仍然存在差距.
目的：描述有经验的重症监护病房护士处理心脏手术后出血的临床决策。
方法：这项定性研究采用了识别启动决策模型作为其理论框架。来自四个成人重症监护病房的39名经验丰富的护士参加了基于关键决策方法的半结构化访谈。访谈探讨了他们在出血情况下的临床判断和决定，并通过量纲分析对数据进行分析，扎根理论的替代方案。
结果：参与者对心脏手术后出血保持一致的警惕，通过与失血和胸腔引流相关的出血维度和关注血容量减少的影响的低血容量维度来认识它。这些维度组织了他们对出血类型的理解(即，正常,medical,外科,填塞)和必要的行动。他们的决策包括监测出血，找出原因,止血,稳定血液动力学并支持患者和家人。参加者还根据具体情况调整行动，包括当地的做法，专业自主权,跨专业动态和资源可用性。
结论：护士的决策是由他们的个人属性决定的，患者的状况和背景情况，强调他们的专业知识和在预测行动和适应不同条件方面的关键作用。可操作性的概念成为解释他们决策的中心维度，定义为在情况的可能性和约束下实施针对特定目标的行动的能力。
结论：本研究强调需要不断更新护理方案以与当前证据保持一致，并需要采取质量改进措施以缩小现有的实践差距。进一步探索可操作性的概念，制定以适应性为重点的教育计划，了解决策的复杂性对于告知护理教育和决策支持系统至关重要。
目的：描述有经验的重症监护病房护士处理心脏手术后出血的临床决策。
方法：这项定性研究采用了识别启动决策模型作为其理论框架。来自四个成人重症监护病房的39名经验丰富的护士参加了基于关键决策方法的半结构化访谈。访谈探讨了他们在出血情况下的临床判断和决定，并通过量纲分析对数据进行分析，扎根理论的替代方案。
结果：参与者对心脏手术后出血保持一致的警惕，通过与失血和胸腔引流相关的出血维度和关注血容量减少的影响的低血容量维度来认识它。这些维度组织了他们对出血类型的理解(即，正常,medical,外科,填塞)和必要的行动。他们的决策包括监测出血，找出原因,止血,稳定血液动力学并支持患者和家人。参加者还根据具体情况调整行动，包括当地的做法，专业自主权,跨专业动态和资源可用性。
结论：护士的决策是由他们的个人属性决定的，患者的状况和背景情况，强调他们的专业知识和在预测行动和适应不同条件方面的关键作用。可操作性的概念成为解释他们决策的中心维度，定义为在情况的可能性和约束下实施针对特定目标的行动的能力。
结论：本研究强调需要不断更新护理方案以与当前证据保持一致，并需要采取质量改进措施以缩小现有的实践差距。进一步探索可操作性的概念，制定以适应性为重点的教育计划，了解决策的复杂性对于告知护理教育和决策支持系统至关重要。
