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A study to determine the difference in clinical judgment abilities between BSN and non-BSN graduates.

The purpose of this retrospective study is to determine the difference in clinical judgment abilities of recent baccalaureate nurses (BSN) seeking employment in a large metropolitan hospital and of nurses without a baccalaureate degree. Using an ex post facto design, the orientation records of 116 newly hired nurses were analyzed to determine the clinical judgment abilities using video vignettes produced by Medcom, Inc. Findings indicated that there was no difference in clinical judgment in newly hired BSN and non-BSN graduates. These findings indicate a need for more research studies to determine how clinical judgment is developed and to evaluate teaching strategies that facilitate clinical judgment.

Clinical Competence

Criteria for same and different judgments and visual comparison strategies of four-year-olds.

4-year-olds made same and different judgments about pairs of stimuli requiring detailed comparison in 2 conditions: a judgment-only condition and a justification condition in which children explained the reasons for their judgments. The systematic comparison strategies revealed in the justifications indicated that all children had definite criteria for "same" and "different" although about two-thirds of the children used a criterion that differed from the adult criterion. Judgments were more accurate in the justification than in the judgment-only condition, suggesting that overt verbalizations and gestures may provide a beneficial external support for completion of a child's own visual comparison strategy.

Child Development

A methodological study of factors affecting the judgment of misarticulated /s/.

Two studies involving judgments of /s/ misarticulation are described. The first involved simultaneous audio and video recordings of three clinically different /s/ misarticulating children. Their recorded /s/ productions, embedded in 54 sentences with varying phonetic contexts, were judged on an acceptable/unacceptable/questionable basis. There was a large proportion of judgments in the questionable category, relatively low interjudge reliability, and few clear enhancing contexts. To better define the problems inherent in using recorded /s/ misarticulations, a second study was undertaken in which six specially chosen /s/ defective and eight normally speaking subjects spoke a set of 12 sentences containing a total of 24 /s/ target words. These productions were judged dichotomously as correct/incorrect under live conditions and from tape recorded conditions. Both normal and /s/ defectives were easily and reliably detected under live speaking conditions; judgments from tape recordings showed a reduction in reliability of judgment and reduced ability to detect the /s/ defective speakers' errors. Examination of the recorded /s/ defective productions revealed that certain phonetic contexts, especially adjacent apical stops, appeared to encourage judgments of correct /s/ productions. Thd discussion includes suggestion concerning techniques for sampling and judging /s/ misarticulations.

Child

Does memory affect judgment? Self-generated versus recall memory measures.

Most evidence regarding the independence of memory and judgment comes from studies that used memory measures consisting of Ss' recall of raw input data (recall measures). Such evidence provides the primary support for on-line judgment formation. The results of 2 experiments suggest that self-generated memory measures capture the contents of memory at the time of judgement more effectively than recall measures and, accordingly, are more likely to provide evidence that memory and judgment are related. When directly compared, a self-generated measure provided evidence of a memory-judgment relationship and a recall measure did not. Thus, memory-based judgment formation may be more prevalent than the on-line processing literature suggests.

Adult

Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality.

The relationship between nasalance scores and perceptual judgments of hypernasality and hyponasality was examined for 74 subjects (51 with cleft palate and 23 noncleft controls). Twenty-nine of the 51 subjects with cleft palate had received pharyngeal flap surgery. Predictive analyses were performed to assess the sensitivity, specificity, and efficiency of the Nasometer as a screening instrument. The overall relationship between perceptual judgments of hypernasality and nasalance scores was good for the nonflap subjects when a nasalance cutoff score of 26 was used. A sensitivity coefficient of 0.87 and a specificity coefficient of 0.93 were obtained. Ninety-one percent of the nasometry-based classifications accurately reflected listener judgments of hypernasality. The correspondence between nasalance scores and clinical judgments of hyponasality was also good for the nonflap subjects when a nasalance cutoff score of 50 was used. Ninety-one percent of these classifications were consistent with the listener judgments. Efficiency of nasometry was poorer for the flap subjects.

Adolescent

Influence of six types of visual structure on complexity judgments in children and adults.

Individuals at five grade levels (kindergarten, Grade 2, Grade 4, Grade 6, and college) made pair-comparison judgments of visual complexity. The influence of the presence or absence of six types of visual structure (double symmetry, vertical symmetry, horizontal symmetry, diagonal symmetry, checkerboard organization, and rotational organization) and of amount of contour were examined. Two general developmental trends were revealed: First, the age at which visual structure initially affected complexity judgments varied with the type of structure, independent of amount of contour, within the range of contour values used. Second, there was a uniform increase in the effect of structure on complexity judgments between the fourth and sixth grades. These results are discussed in relation to possible mechanisms of visual pattern encoding and complexity judgment.

Adult

Judgment of contingency in depressed and nondepressed students: sadder but wiser?

How are humans' subjective judgments of contingencies related to objective contingencies? Work in social psychology and human contingency learning predicts that the greater the frequency of desired outcomes, the greater people's judgments of contingency will be. Second, the learned helplessness theory of depression provides both a strong and a weak prediction concerning the linkage between subjective and objective contingencies. According to the strong prediction, depressed individuals should underestimate the degree of contingency between their responses and outcomes relative to the objective degree of contingency. According to the weak prediction, depressed individuals merely should judge that there is a smaller degree of contingency between their responses and outcomes than nondepressed individuals should. In addition, the present investigation deduced a new strong prediction from the helplessness theory: Nondepressed individuals should overestimate the degree of contingency between their responses and outcomes relative to the objective degree of contingency. In the experiments, depressed and nondepressed students were present with one of a series of problems varying in the actual degree of contingency. In each problem, subjects estimated the degree of contingency between their responses (pressing or not pressing a button) and an environmental outcome (onset of a green light). Performance on a behavioral task and estimates of the conditional probability of green light onset associated with the two response alternatives provided additional measures for assessing beliefs about contingencies. Depressed students' judgments of contingency were surprisingly accurate in all four experiments. Nondepressed students, on the other hand, overestimated the degree of contingency between their responses and outcomes when noncontingent outcomes were frequent and/or desired and underestimated the degree of contingency when contingent outcomes were undesired. Thus, predictions derived from social psychology concerning the linkage between subjective and objective contingencies were confirmed for nondepressed students but not for depressed students. Further, the predictions of helplessness theory received, at best, minimal support. The learned helplessness and self-serving motivational bias hypotheses are evaluated as explanations of the results. In addition, parallels are drawn between the present results and phenomena in cognitive psychology, social psychology, and animal learning. Finally, implications for cognitive illusions in normal people, appetitive helplessness, judgment of contingency between stimuli, and learning theory are discussed.

Association Learning

A descriptive study of nursing judgment in the assessment and management of cardiac pain.

Unrelieved cardiac pain in patients admitted to a coronary care unit (CCU) with a diagnosis of coronary artery disease was examined from the perspective of nursing judgment. The purpose of this study was to reveal expert clinical knowledge and judgment in this specific area of critical care practice. Using a naturalistic approach, nurses were observed and interviewed as they made judgments about cardiac pain. Qualitative data analysis identified patterns of nursing actions and thought processes. Findings indicated that clinical knowledge of the titration of drugs was used in the treatment of cardiac pain, and qualitative distinctions and sense of saliency were also important in pain assessment. Intuitive thought processes were identified in the clinical judgment of expert nurses.

Angina Pectoris

Expert judgment in risk analysis and management: process, context, and pitfalls.

The regulation and management of hazardous industrial activities increasingly rely on formal expert judgment processes to provide wisdom in areas of science and technology where traditional "good science" is, in practice, unable to supply unambiguous "facts." Expert judgment has always played a significant, if often unrecognized, role in analysis; however, recent trends are to make it formal, explicit, and documented so it can be identified and reviewed by others. We propose four categories of expert judgment and present three case studies which illustrate some of the pitfalls commonly encountered in its use. We conclude that there will be an expanding policy role for formal expert judgment and that the openness, transparency, and documentation that it requires have implications for enhanced public involvement in scientific and technical affairs.

Expert Testimony

Integration of information in a clinical judgment task, an empirical comparison of six models.

Six models were compared for their effectiveness in reproducing six clinical psychologists' judgments of 38 patients on intelligence, ability to establish contact, and control of affect and impulses. In two of the models, subjective weights were used in the prediction of a judge's ratings. The judges based their judgments solely on verbal protocols from the Rorschach, a sentence completion test, and the Thematic Apperception test. The stability of the linear aspect of the judgment process was very high but decreased as the depth of interpretation of the rating variable increased. The nonlinear aspect of the judgment process had considerably low stability. In general, a model based on subjective weights was most effective in reproducing the judges' ratings.

Adolescent

[Preschool children's prosocial judgments and their reasoning in the empathic situations].

The purpose of this study was to examine preschool children's prosocial judgments and their reasoning for prosocial episodes. One hundred children were individually asked to do prosocial judgments and their reasoning for three prosocial episodes: helping, sharing, and comforting. In the episode there was a crying or a normal facial expression of a person in distress under the condition of high and low empathic situations. The results indicated that the crying face and high empathic situation increased the rate of prosocial judgment more than the normal face and low empathic situation, respectively, and older children (5-year-olds) did prosocial judgment than younger ones (4-year-olds). Furthermore, the crying face induced the empathic reasoning, especially in the high empathic situation. These results supported that preschool children were able to use the empathic reasoning reflected in the negative facial expression and the cause of distress of the victim.

Child Behavior

Order of information presentation and children's moral judgments.

It was hypothesized that age differences in use of intent information in children's moral judgments might be due to a recency effect in the judgments of younger children. A study was conducted to examine the effect of order of stimulus presentation on children's moral judgments. The information was presented to children, ages 4-5 and 8-9 years old, through stories with either normal information order, intent-consequence, or reversed order, consequence-intent. It was found that order has a significant impact on children's moral judgments. In addition, memory data were gathered which indicated that the pattern of forgetting was parallel to the pattern of information preference for the younger subjects. The findings suggested that younger subjects' relative neglect of intent in the normal order of information was based, in part, on their failure to remember the material correctly rather than on differential weighting of the 2 cues.

Age Factors

Utilization of base-rate information during feeling-of-knowing judgments.

We examined whether subjects use base-rate information about item difficulty when making feeling-of-knowing judgments for items they failed to recall. First, the subjects attempted to recall the answers to general-information questions. Then, for those items they recalled incorrectly, half of the subjects received information about the normative probability of recall of each item while judging their feeling of knowing. The other subjects made their feeling-of-knowing judgments without receiving any base-rate information. Finally, all subjects had a forced-choice recognition test on those items to validate the accuracy of their feeling-of-knowing judgments. Relative to the no-base-rate information group, the base-rate group had lower feelings of knowing for normatively difficult items and higher feelings of knowing for normatively easier items. Subjects who had received base-rate information during the judgment state had greater feeling-of-knowing accuracy than subjects who did not receive base-rate information. However, even the predictions from subjects who received base-rate information were not significantly more accurate for predicting subsequent recognition than were the predictions derived from normative information alone.

Adult

When does a response error become a judgmental bias? Commentary on "Judged Frequency of Lethal Events".

The study of Lichtenstein, Slovic, Fischhoff, Layman, and Combs reports several types of errors in subjects' frequency judgments of lethal events. These errors are interpreted as reflecting the operation of two types of judgment biases. In this research, the objective or actual frequency of lethal events served as a standard of comparison; any deviation from this standard was defined as a bias. Thus, the research strategy used is apparently modeled after that of a psychophysicist using illusions to study basic perceptual processes. There is one key difference, however. In the case of illusions, the subject is directly exposed to the physical stimulus object. In the present study, however, subjects were never exposed to actual stimuli. Since subjects were asked to make judgments about things they had not directly experienced, it is not surprising that they would be inaccurate. But unlike the study of illusions, such inaccuracies have not been shown to have any necessary connection to psychological mechanisms. Therefore, it seems somewhat tenuous to offer psychological interpretations of judgmental biases when the origins of those biases have not yet been identified.

Female

Surgical decision making. The reliability of clinical judgment.

Elective surgery second opinion programs are predicted on strict acceptance of the accuracy of the consultant's surgical judgment. The reliability and reproducibility of clinical judgment, therefore, become basic to the effectiveness of such programs. This aspect, however, has received little attention. We report a randomized and controlled survey of surgical specialists which defines agreement/disagreement patterns in surgical decision-making for seven elective surgical procedures. For each disease process, four case histories, including at least one control, were developed by specialty panels of physicians. The case summaries described fictional patients who were seeking professional consultation. The histories were mailed to a random sample of Board-certified specialists from the State of Maryland and the District of Columbia. The response rate was approximately 80% for all five specialties. The respondents were asked to indicate whether they would (Yes) or would not (No) perform the surgical procedure in question. Factual knowledge was not sought, but instead the application of that knowledge and experience to decide on the need for surgical intervention. By comparing the responses for each case history, the agreement/disagreement patterns of inter-observer surgical judgment were determined. Analysis of the data revealed a marked divergence of opinion concerning the need for surgery. The significant point of this study is that surgical judgment differs to a major degree from one surgeon to the next. In a second-opinion program the number of consultants needed to provide a reliable clinical decision probably exceeds the number who are logistically available and that the patient would be willing to visit. Surgical decision-making is a semi-exact scientific process, and it is unreasonable to expect exact answers to clinical problems.

Certification

Priority setting in quality assurance: reliability of staff judgments in medical institutions.

A structured procedure using the judgments of a representative group of local providers for establishing priorities for quality assurance activity in diverse medical institutions was tested for reliability. Two independent matched teams of phy sicians, nurses, administrators, and other staff in eight separate medical facilities generated 320 topics which encompassed areas where quality assurance efforts would have either considerable or little impact in terms of improving health outcomes within reasonable costs. Concordance of judgment between teams in each facility was determined by analyzing the similarity of topics content, the agreement in scaling the health impact of similar topics generated by both teams independently, and the agreement by one team in scaling the health impact of topics generated by the other team. The findings revealed 44 per cent content agreement on topics independently generated, 93 per cent agreement on dichotomous scaling of similar topics, and 87 per cent agreement on five-point scaling of similar topics. Concordance of judgment by one team in scaling the other team's topics was highly significant (p less than .001). Preliminary analysis of topic content and scaling agreement among different facilities indicated low agreement both on the content areas and on the health impact of similar topics. It is concluded that the judgments of local providers in identifying cost-effective quality assurance priorities is highly relaible in the medical institutions studied.

Cost-Benefit Analysis

Judgment error in category vs magnitude scales.

The effects of a variety of experimental conditions on the judgments (length of lines) of 16 normal and 16 mentally retarded observers were examined using category and magnitude scaling techniques. Using error and variability of judgment as criteria for measuring response bias, for normal subjects knowledge about the stimulus range, whether learned or provided, had as much to do with resulting judgments as the type of scale used. Judgment error of the retarded group was significantly greater than the normal group and appeared to be related to their limited ability to assign categories or proportions to the simuli used.

Adult

Relationship of field-dependence--independence to posture and judgment of time duration.

Relationships between 84 field-dependent subjects and 84 field-independent subjects, posture, and judgment of duration of time were examined. An analysis of variance yielded no significant difference between the two groups of subjects in the judgment of a 40-sec. interval while in the standing, sitting or horizontal postures or in the comparison of the three postures. Mean judgments of durations became larger from standing to sitting to horizontal postures and over trials for the three postures. It was suggested that the lengthening of the judgment of the 40-sec. interval could be related to a decrease in kinesthetic stimulation with a resultant increase in muscular relaxation which led to a decrease in vigilance.

Adolescent