Biomedical subjects

J Cioffi

Publications and source records attributed to J Cioffi.

14 recordsLinked to original sources

PubMed2001

A study of the use of past experiences in clinical decision making in emergency situations.

Making decisions to call emergency assistance to patients is an important dimension of nursing practice. Most usually these decision making situations are uncertain and it is expected nurses rely on past clinical experiences. This study, approved by the ethics committees of both a university and an area health service, aimed to describe nurses' reliance on past experiences and identify associated judgement strategies (heuristics). Thirty-two registered nurses with five or more years experience were interviewed. Main findings were: nurses did use their past experiences and these experiences were used in the form of the three "classic" heuristics, representativeness, availability and anchoring and adjustment. It can be concluded past experiences are intrinsic to decision making and this has implications for both the clinical components of nursing educational programs and staffing allocations made by administrators. Some nurses, however, did not include referral to past experiences in their decision-making accounts which may be a limitation of the study design.

Adaptation, Psychological↗

PubMed2001

Clinical simulations: development and validation.

Simulations used as an educational strategy can mimic clinical reality bringing real life activity into the learning environment. This paper presents a conceptual approach to simulation development and validation that is applied to develop assessment simulations for both childbirth and triage situations. A process-based method of presenting information to the learner in the assessment phase is incorporated in simulations developed from actual clinical cases. The uncertain conditions of assessment are recognized as mirroring practice reality and validation of this construct and that of expertise are considered. Use of these simulations has the potential to provide learners with the opportunity to experience dimensions of simulated practice reality and educators with an experiential strategy that can be used to prepare students and also clinicians who are unfamiliar with new clinical practice areas.

Adult↗

PubMed2000

Nurses' experiences of making decisions to call emergency assistance to their patients.

Patient survival often depends on decisions by nurses to call emergency assistance. The experiences of nurses calling emergency assistance have not been described. This descriptive study explored the experiences of registered nurses (n=32) using unstructured interviews. The main findings were that nurses questioned whether they were doing the 'right thing' calling the emergency team, sometimes collaborated with others prior to calling and most felt nervous and anxious. They recognized patient deterioration from feelings they had that something was wrong. However, they were not able 'to put their finger on it'. Knowing the patient and past experiences were involved in the recognition of deterioration. This association indicates the importance of experience in the development of clinical decision-making skills. Further, nurses calling emergency assistance need to be provided with the opportunity to debrief after calling. Their heavy reliance on subjective data before searching for objective data as outlined in the emergency calling criteria suggests that it is essential that nurses do not devalue or ignore concerns they may have about patients.

Decision Making↗

PubMed1999

Triage decision making: educational strategies.

Patient triage in Accident and Emergency departments requires emergency nurses to make rapid decisions based on their knowledge and experiences. The development of triage decision-making skills can be addressed through the use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced emergency nurses. Clinical educators and experienced emergency nurse mentors are encouraged to recognize that skill acquisition in triage decision making requires practice before registered nurses can engage fully in the process of triaging patients in the emergency department. It is essential to experience the process of triage decision making in order to develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information leading to a decision on the triage category for each patient. By using triage simulations developed from 'real triage cases' the process of decision making can be experienced by nurses. Further, if these simulations are accompanied by the collection of verbal protocols, nurses have opportunities retrospectively to explore their decision making with reflection. In addition, the presentation and use of decision rules used by experienced triage nurses can enhance the development of skills in novice triage nurses.

Clinical Competence↗

PubMed1998

Education for clinical decision making in midwifery practice.

OBJECTIVE: To present an approach to developing clinical decision-making skills in midwifery students. DESCRIPTION: Use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced midwives are proposed for developing clinical-reasoning skills and acquiring skilled clinical knowledge. IMPLICATIONS: Educators are encouraged to recognise that skill acquisition in clinical decision making requires practise before students engage fully in the clinical setting. The process of decision making is emphasised as essential for students to experience so they develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information to reach clinical judgements. By using clinical simulations developed from 'real cases' the process of decision making is able to be experienced by students. Further, if these simulations are accompanied by the collection of verbal protocols, students have opportunities to retrospectively explore their decision making with reflection. In addition, the presentation and use of decision rules of experienced midwives has the potential to enhance the development of skills in students.

Clinical Competence↗

PubMed1998

Decision making by emergency nurses in triage assessments.

Triage assessment of patients on arrival at emergency departments involves complex decision making, resulting in categories being assigned to prioritize patients' needs for attention. The actual process of triage decision making has received limited attention. The aims of this study were to describe aspects of the triage decision-making process used by both more and less experienced nurses (n = 20) and to test the effect of uncertainty in the triage situation on the use of probability judgements (heuristics). Six triage cases based on actual triage situations were simulated to subjects, and their verbal protocols were collected. Protocols were transcribed and analysed. Main findings were: in conditions of higher uncertainty in triage situations all nurses used more probability in their judgements (t-test -2.37, df = 17, P = 0.03) with the heuristic of representativeness being relied on the most. The triage categories finally assigned for each triage situation showed no agreement on a specific triage category for each triage case and past triage experiences were used in decision making. The more experienced group reported higher estimations of correctness regarding the final category assigned, used more single previously experienced cases from memory, collected less data and made more judgements than the less experienced group. Further examination of the decision-making process of triage assessment should occur with attention to the variable use of triage categories, the role of past triage experiences in making judgements and development of triage decision rules for skilling nurses for triage.

Clinical Competence↗

PubMed1997

Clinical decision-making by midwives: managing case complexity.

In making clinical judgements, it is argued that midwives use 'shortcuts' or heuristics based on estimated probabilities to simplify the decision-making task. Midwives (n = 30) were given simulated patient assessment situations of high and low complexity and were required to think aloud. Analysis of verbal protocols showed that subjective probability judgements (heuristics) were used more frequently in the high than low complexity case and predominated in the last quarter of the assessment period for the high complexity case. 'Representativeness' was identified more frequently in the high than in the low case, but was the dominant heuristic in both. Reports completed after each simulation suggest that heuristics based on memory for particular conditions affect decisions. It is concluded that midwives use heuristics, derived mainly from their clinical experiences, in an attempt to save cognitive effort and to facilitate reasonably accurate decisions in the decision-making process.

Case Management↗

PubMed1997

Heuristics, servants to intuition, in clinical decision-making.

This paper explores intuitive judgements of nurses in clinical decision-making situations. The qualities of intuition are presented from both theoretical and practical perspectives and attitudes towards intuition from both nurses themselves and other health professionals are identified. An heuristic framework from cognitive psychology is applied to intuitive aspects of the clinical judgements that nurses have made. This interpretation is proposed as a partial explanation of intuition, and its use in advancing the understanding of intuition is recommended.

Clinical Competence↗

PubMed1995

B cell differentiation factor-induced B cell maturation: regulation via reduction in cAMP.

We have previously described a novel human B cell differentiation factor (BCDF), 446-BCDF, that is distinct biochemically and functionally from other cytokines. Since signal transduction pathways involved in human B cell differentiation have been incompletely studied and are poorly understood, we assessed the effects of 446-BCDF on various intracellular second messenger systems. After exposure of B cells to 446-BCDF, intracellular cAMP concentration started to decrease at 5 min and was significantly lower at 30 min and reached the lowest level at 4 hr. In most cases, cAMP concentrations returned toward baseline by 24 hr. A cAMP analog (dibutyryl cAMP), a stimulator of adenyl cyclase (forskolin), and phosphodiesterase inhibitors (aminophylline and IBMX) which inhibited the 446-BCDF-induced decrease in intracellular cAMP, inhibited 446-BCDF-induced B cell differentiation, suggesting that the fall in intracellular cAMP was a critical event in this process. To understand the mechanism involved in the reduction of cAMP, B cells were treated with pertussis toxin (PTX), a Gi protein inhibitor. Pertussis toxin blocked 446-BCDF-induced B cell differentiation as well, suggesting that 446-BCDF may function by stimulation of a Gi-linked receptor resulting in the inhibition of adenylate cyclase with a consequent reduction in cAMP. Other cytokines known to promote Ig secretion (IL2 and IL6) also caused a reduction in cAMP, suggesting that this pathway may be generally important in B cell differentiation. Taken together, these data suggest that at least one pathway of terminal maturation in B cells may involve the reduction of intracellular cAMP.

Adenylate Cyclase Toxin↗

PubMed1995

B cell differentiation factor-induced human B cell maturation: stimulation of intracellular calcium release.

We have recently identified a novel human B cell differentiation factor, 446-BCDF, derived from anti-CD3-stimulated peripheral blood (PB) T cells. This novel cytokine, which may act through a pertussis toxin-sensitive Gi-linked receptor, induces a 5- to 100-fold increase in immunoglobulin (Ig) secretion by SAC (0.001%, v/v)-activated PB B cells. Coculture of B cells with 446-BCDF induces a decrease in intracellular cAMP which is necessary but not sufficient to drive terminal B cell differentiation. A second signal appears to be required. We therefore measured Ca2+ flux in indo-1 AM-loaded PB B cells. Stimulation with 446-BCDF resulted in an immediate rise in intracellular Ca2+ comparable to that seen with the anti-IgM mAb HB57. Ca2+ appeared to be mobilized from internal stores as pretreatment with BAPTA but not EGTA inhibited the response. Ca2+ mobilization was critical for the induction of differentiation as BAPTA pretreatment of PB B cells completely inhibited Ig secretion without affecting cell viability. In contrast, neither SAC, rIL6, IL2, IFN-gamma, nor IL4 could mobilize Ca2+. Pertussis toxin, a Gi and G0 protein inhibitor, was able to inhibit 446-BCDF-induced Ca2+ flux as well as Ig secretion. To determine whether the Ca2+ flux was generated in the course of inositol phosphate turnover, we measured IP3 turnover and the translocation of PKC from cytosol to membrane. An increase in IP3 comparable to that seen with a monoclonal anti-human IgM antibody was noted and was specifically inhibited by the 446-BCDF-specific mAb 929. Interestingly, no membrane PKC was demonstrable in either SAC- or BCDF-stimulated B cells, although PMA (50 ng/ml) could directly activate PKC. To confirm these findings functionally, B cells were stimulated with SAC and 446-BCDF in the presence of two known PKC inhibitors, staurosporin and calphostin. No inhibition of Ig secretion was detected at any concentration tested (0.39-100 nM staurosporin and 0.0625-1 microM calphostin C). These data suggest that induction of B cell differentiation is a Ca(2+)-dependent and PTX-sensitive event.

Alkaloids↗

PubMed1994

Dissociation, childhood trauma, and the response to fluoxetine in bulimic patients.

Histories of childhood trauma have been reported previously in bulimic subjects but no study to date has assessed how these experiences may affect response to fluoxetine. Thirty outpatient subjects in a placebo-controlled trial of 60 mg of fluoxetine for the treatment of bulimia nervosa completed the Dissociative Experiences Scale and a self-report instrument assessing trauma. Response to treatment was measured with the Hamilton Depression Scale-17 (HAMD-17), the CGI, the PGI, and the change in number of binges per day. Subjects taking fluoxetine with histories of physical abuse showed a significantly greater drop in HAMD-17 scores than those without such histories. No relationship between a reported history of abuse and the response of binging to fluoxetine was found. A history of abuse does not appear to predict the response of binging to fluoxetine but may predict a greater response of nonspecific symptoms like depression.

Adolescent↗

PubMed1979

Laterality for stereognostic accuracy of children for words, shapes, and bigrams: a sex difference for bigrams.

Children identified nonsense shapes by touch better with their left hand and words better with their right hand. Bigrams were processed by boys as shapes and by girls as words, which suggests a sexual dimorphism of brain functioning for bigrams. A relative specialization of the hemisphere for stereognostic processing is also suggested, since the accuracy of identification by both hands was greater than chance for all three types of stimuli.

Adolescent↗

PubMedDate not supplied

The relationship of depression to dissociation in patients with bulimia nervosa.

Dissociative Experiences Survey scores were compared between bulimics with and without depression, and among depressed patients with and without bulimia. An association is noted between depression and dissociation, confounding the previously noted relationship between bulimia nervosa and dissociation.

Adolescent↗

PubMedDate not supplied

Recognition of patients who require emergency assistance: a descriptive study.

OBJECTIVE: The purpose of this study was to explore and describe the patient characteristics and the process of recognition nurses use to recognize patients about whom they are seriously worried. DESIGN: The study design was qualitative, exploratory, and descriptive, and it used in-depth interviews and a purposive sample. SETTING: The study setting included a teaching hospital and a peripheral hospital in a Sydney area health service. PARTICIPANTS: Participants included registered nurses (N = 32) with 5 or more years of experience and a history of calling the medical emergency team (MET). Mean years of experience as a registered nurse was 14 years, and the mean calls to the MET since employed in current hospital was 16 calls. FINDINGS: Primary findings showed that nurses relied on 4 patient characteristics to apply the MET criterion, "seriously worried about a patient." These 4 characteristics were (1) feeling "not right," (2) color, (3) agitation, and (4) observations marginally changed or not changed at all. The process used to gather and interpret information to recognize these patients who were deteriorating involved touching, observing, listening, feeling or sensing, and "knowing." In this process of recognition, nurses relied heavily on past experiences and knowledge to detect differences in patient condition. CONCLUSIONS: The 4 characteristics need to be included as an explanation for the MET criterion, "seriously worried about a patient." Additional validation and refinement of the 4 characteristics of the nonspecific MET criterion, "seriously worried about a patient," should be carried out. Continuing education programs in health care facilities need to support the use of subjective information in complex situations that result in decisions to call emergency assistance so patients whose conditions are deteriorating can be identified early and responded to rapidly.

Australia↗