From Novice to Expert: A Qualitative Analysis of Cue Detection & Clinical Decision Making by NICU Nurses.

BACKGROUND: The ability of Neonatal Intensive Care Unit (NICU) nurses to recognize clinical cues indicating neonatal deterioration and make timely clinical decisions is essential for positive patient outcomes. How nurses progress from novice to expert in clinical cue recognition and decision making remains underexplored. PURPOSE: This qualitative descriptive study examines how cue recognition, clinical decision making, assessment techniques, and advocacy confidence evolve across novice, intermediate, and experienced NICU nurses. METHODS: Individual semi-structured interviews were conducted with NICU nurses. Thematic analysis was used to identify patterns of cue detection and clinical decision making within and across experience levels. RESULTS: Findings revealed a gradual shift from monitor dependence to behavioral assessment, protocol-based to individualized care, and reactive responses to predictive interventions. Novices relied on monitors, whereas experts prioritized subtle behavioral and physiological cues. IMPLICATIONS FOR PRACTICE AND RESEARCH: These findings emphasize the need for mentorship programs fostering pattern recognition, early advocacy, and diagnostic differentiation to accelerate NICU clinical expertise. Developing an assessment tool and signal detection trials to evaluate nurses' cue recognition and clinical decision-making skills could support structured staff development.