Abstract
BackgroundMisplaced or poorly calibrated confidence in healthcare professionals’ judgments compromises the quality of health care. Using higher fidelity clinical simulations to elicit clinicians’ confidence 'calibration' (i.e. overconfidence or underconfidence) in more realistic settings is a promising but underutilized tactic. In this study we examine nurses’ calibration of confidence with judgment accuracy for critical event risk assessment judgments in a high fidelity simulated clinical environment. The study also explores the effects of clinical experience, task difficulty and time pressure on the relationship between confidence and accuracy.Methods63 student and 34 experienced nurses made dichotomous risk assessments on 25 scenarios simulated in a high fidelity clinical environment. Each nurse also assigned a score (0–100) reflecting the level of confidence in their judgments. Scenarios were derived from real patient cases and classified as easy or difficult judgment tasks. Nurses made half of their judgments under time pressure. Confidence calibration statistics were calculated and calibration curves generated.ResultsNurse students were underconfident (mean over/underconfidence score −1.05) and experienced nurses overconfident (mean over/underconfidence score 6.56), P = 0.01. No significant differences in calibration and resolution were found between the two groups (P = 0.80 and P = 0.51, respectively). There was a significant interaction between time pressure and task difficulty on confidence (P = 0.008); time pressure increased confidence in easy cases but reduced confidence in difficult cases. Time pressure had no effect on confidence or accuracy. Judgment task difficulty impacted significantly on nurses’ judgmental accuracy and confidence. A 'hard-easy' effect was observed: nurses were overconfident in difficult judgments and underconfident in easy judgments.ConclusionNurses were poorly calibrated when making risk assessment judgments in a high fidelity simulated setting. Nurses with more experience tended toward overconfidence. Whilst time pressure had little effect on calibration, nurses’ over/underconfidence varied significantly with the degree of task difficulty. More research is required to identify strategies to minimize such cognitive biases.
Highlights
Misplaced or poorly calibrated confidence in healthcare professionals’ judgments compromises the quality of health care
Judgment task difficulty To investigate whether nurses’ confidence calibration was affected by the ease or difficulty of the clinical judgment task we explored the uncertainty associated with each task
Proportion correct In the high fidelity clinical simulation settings, no significant differences in proportion correct were found between the student and experienced nurse group, t (95) = 0.11, P = 0.91
Summary
Misplaced or poorly calibrated confidence in healthcare professionals’ judgments compromises the quality of health care. In this study we examine nurses’ calibration of confidence with judgment accuracy for critical event risk assessment judgments in a high fidelity simulated clinical environment. The ability of nurses (like all clinicians) to be appropriately confident in their clinical judgments is an important part of safe and effective healthcare. Overconfidence in judgments such as “critical event” (such as cardio pulmonary arrest) risk assessment may result in delayed or inappropriate interventions [1,2]. Confidence calibration studies describe the degree of concordance between perceived confidence in an event occurring and the probability of its occurrence. Overconfidence occurs when perceived confidence exceeds judgment correctness. Underconfidence occurs when judgment performance exceeds perceived confidence
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