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Venous leg ulcer management in the UK varies significantly. Judgements made by nurses contribute to this variability and it is often assumed that specialist nurses make better judgements than non-specialist nurses. This paper compares the judgements of community tissue viability specialist nurses and community generalist nurses; specifically, the ways they use clinical information and their levels of accuracy.To compare specialist and non-specialist UK community nurses' clinical information use when managing venous leg ulceration and their levels of accuracy when making diagnoses and judging the need for treatment.Judgement analysis.UK community and primary care nursing services.18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses.Data were collected in 2011 and 2012. 18 community generalist nurses and 18 community tissue viability specialist nurses made diagnostic and treatment judgements on 110 clinical scenarios and indicated their confidence in each of their judgements. Scenarios were generated from real patient cases and presented online using text and photographs. An expert panel made judgements, and reached consensus on the same scenarios. These judgements were used as a standard against which to compare the participants. Logistic regression models and correlational statistics were used to generate various indices of judgement "performance": accuracy, consistency, confidence calibration and information use. Differences between groups of nurses with different levels of characteristics linked to expertise were explored using analysis of variance.Specialist nurses had similar cue usage to the generalist nurses but were more accurate when making diagnostic and treatment judgements.It is not obvious why the tissue viability specialist nurses were more accurate. One possible reason might be the greater opportunities for 'deliberate practice' afforded to specialists. However, restricting aspects of practice only to specialist nurses is likely to hinder the judgement performance of generalists.

Background Apparent overconfidence and underconfidence in clinicians making clinical judgements could be a feature of evaluative research designs that fail to accurately represent clinical environments. Objectives To test the effect of improved realism of clinical judgement tasks on confidence calibration performance of nurses and student nurses. Design A comparative confidence calibration analysis. Settings The study was conducted in a large university of Northern England. Methods Ninety-seven participants rated their confidence – using a scale that ranged from 0 (no confidence) to 100 (totally confident) on dichotomous clinical judgements of critical event risk. The judgements were in response to 25 paper-based and 25 higher fidelity scenarios using a computerised patient simulator and clinical equipment. Scenarios, and judgement criteria of ‘correctness', were generated from real patient cases. Using a series of calibration measures (calibration, resolution and over/underconfidence), participants' confidence was calibrated against the proportion of correct judgements. The calibration measures generated by the paper-based and high fidelity clinical simulation conditions were compared. Results Participants made significantly less accurate clinical judgements of risk in the high fidelity clinical simulations compared to the paper simulations ( P =0.0002). They were significantly less confident in high fidelity clinical simulations than paper simulations ( P =0.03). However, there was no significant difference of over/underconfidence for participants between the two simulated settings ( P =0.06). Participants were no better calibrated in the high fidelity clinical simulations than paper simulations, P =0.85. Likewise, participants had no better ability of discriminating correct judgements from incorrect judgements as measured by the resolution statistic in high fidelity clinical simulations than paper simulations, P =0.76. Conclusions Improving the realism of simulated judgement tasks led to reduced confidence and judgement accuracy in participants but did not alter confidence calibration. These findings suggest that judgemental miscalibration of confidence in nurses may be a systematic cognitive bias and that simply making scenarios more realistic may not be a sufficient condition for correction.

Objectives Despite the growing popularity of decision making in nursing curricula, the effectiveness of educational interventions to improve nursing judgement and decision making is unknown. We sought to synthesise and summarise the comparative evidence for educational interventions to improve nursing judgements and clinical decisions. Design A systematic review. Data sources Electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and PsycINFO, Social Sciences Citation Index, OpenSIGLE conference proceedings and hand searching nursing journals. Review methods Studies published since 1960, reporting any educational intervention that aimed to improve nurses' clinical judgements or decision making were included. Studies were assessed for relevance and quality. Data extracted included study design; educational setting; the nature of participants; whether the study was concerned with the clinical application of skills or the application of theory; the type of decision targeted by the intervention (e.g. diagnostic reasoning) and whether the evaluation of the intervention focused on efficacy or effectiveness. A narrative approach to study synthesis was used due to heterogeneity in interventions, study samples, outcomes and settings and incomplete reporting of effect sizes. Results From 5262 initial citations 24 studies were included in the review. A variety of educational approaches were reported. Study quality and content reporting was generally poor. Pedagogical theories were widely used but use of decision theory (with the exception of subjective expected utility theory implicit in decision analysis) was rare. The effectiveness and efficacy of interventions was mixed. Conclusions Educational interventions to improve nurses' judgements and decisions are complex and the evidence from comparative studies does little to reduce the uncertainty about ‘what works'. Nurse educators need to pay attention to decision, as well as pedagogical, theory in the design of interventions. Study design and reporting requires improvement to maximise the information contained in reports of educational interventions.

Uncertainty is a fact of life for practising clinicians and cannot be avoided. This paper outlines the model of uncertainty presented by Katz (1988, Cambridge University Press, Cambridge, UK. pp. 544-565) and examines the descriptive and normative power of three broad theoretical and strategic approaches to dealing with uncertainty: rationality, bounded rationality and intuition. It concludes that nursing research and development (R&D) must acknowledge uncertainty more fully in its R&D agenda and that good-quality evaluation studies which directly compare intuitive with rational-analytical approaches for given clinical problems should be a dominant feature of future R&D.