Appropriate clinical decision-making is an intrinsic and frequently complex process at the heart of clinical practice (Hardy & Smith 2008) with some situations being more complex than others as they involve more unknowns and uncertainties (Cioffi & Markham 1997, Cioffi 1998). Decisions should be based on best practice and have an evidence base to them, this is essential to optimize outcomes for patients, improve clinical practice, achieve cost-effective nursing care and ensure accountability and transparency in decision-making (Canadian Nurses Association 2002). This process should not, therefore, be underestimated. The assessment, evaluation and subsequent changes made to a patient’s care are intrinsically involved. The assessment process and the effective use of assessment information through appropriate decision-making are essential to improve outcomes of care (Aitken 2003). Within the patient assessment the nurse should, through a systematic approach, support clinical findings with hard scientific fact.

Requesting tests and the analysis of data completes this process. Simply put, if a nurse omits to request a relevant test there will be no scientific evidence to support the initial working diagnosis. Bochund & Calandra (2003) identified that requesting relevant tests during the initial assessment significantly reduced morbidity and mortality rates.

Within the modern protocol-driven emergency department (ED) a working diagnosis is essential to provide an efficient and structured patient experience through the department, concluding in their discharge or referral to a specialist service.

This chapter focuses on the importance of applying the key skills of critical thinking and clinical decision-making to everyday practice and the ways of facilitating nurses into the acquisition of these key skills. The chapter commences with an overview of emergency nursing and the importance of applying critical thinking to the assessment process. The focus will then be divided between the application of the nursing process within emergency nursing, how nurses construct their thought processes in relation to initial and continual patient assessments, and how the application of the key skills of critical thinking and clinical decision-making within their everyday practice will benefit both patient and nurse.

When assessing a patient the ED nurse must decide what data to collect; this is dependent on the nurse’s initial clinical findings. In an age of clinical resource management and target-focused quantitative care it is essential that appropriate tests are ordered, to reduce an unnecessary workload resulting in wasted laboratory test time, to reduce false positives, and to facilitate a proficient cost-effective qualitative service. The importance of these initial data cannot be overemphasized, as analysis of these data will form the pathophysiological basis from which the medical diagnosis is made.

In order to understand the processes involved in clinical decision-making it is essential to consider the context in which decision-making activities are being performed. The ED was the portal for over 12.3 million annual visits in England in 2007–8, of which 20 % required hospital admission (Health and Social Care Information Centre 2009). These millions of patients attend with any number of clinical presentations and complaints requiring the assistance of every medical specialty. The role of the emergency nurse is unique in this respect, as in no other clinical setting is the nurse called upon to assess and identify the needs of such a wide range of potential patient conditions.

Initial assessment

The ED is the interface between patients and emergency care. Within this setting a patient’s first contact with a healthcare professional will usually be with a nurse; the process of initial assessment. Nursing triage is a dynamic decision-making process that will prioritize an individual’s need for treatment on arrival to an ED and is an essential skill in emergency nursing (Smith 2012). An efficient triage system aims to identify and expedite time-critical treatment for patients with life-threatening conditions, and ensure every patient requiring emergency treatment is prioritized according to their clinical need. The ethos of triage systems relates to the ability of a professional to detect critical illness, which has to be balanced with resource implications of ‘over triage’ i.e., a triage category of higher acuity is allocated. A decision that underestimates a person’s level of clinical urgency may delay time-critical interventions; furthermore, prolonged triage processes may contribute to adverse patient outcomes (Travers 1999, Dahlen et al. 2012).

In this context, the triage nurse’s ability to take an accurate patient history, conduct a brief physical assessment, and rapidly determine clinical urgency are crucial to the provision of safe and efficient emergency care (Travers 1999). These responsibilities require triage nurses to justify their clinical decisions with evidence from clinical research, and to be accountable for decisions they make within the clinical environment. The legal significance of undertaking an assessment relates to whether the nurse has sufficient knowledge to perform the assessment competently: if the patient care is compromised a tort of negligence could be issued (Dimond 2004).

It has been identified that many factors impact on the nurse’s ability to make accurate decisions; for example, an unpredictable workload, poor professional continuity in relation to communication, and inexperience of the initial nursing assessor, or subsequent nursing staff (Tippins 2005). This has been exacerbated by demographic changes, such as an ageing population and the subsequent associated chronic pathologies, which have placed an enormous strain on primary care services (Dolan & Holt 2007), and secondly on the subjective clinical decision-making of the triage nurse (Cooke & Jinks 1999). If there is a failure to recognize deterioration in a patient’s condition and intervention is delayed, the condition of these patients can potentially become critical. The care provided during the ED stay for critically ill patients has been shown to significantly impact on the progression of organ failure and mortality (Rivers et al. 2002, Church 2003). It is, therefore, essential that the care provided in the ED reflects the severity of the condition of the patient, the focal point being that accurate and dynamic patient assessment is imperative.

Continued assessment

The continued assessment and monitoring of patients is imperative in order that subtle changes in their condition can be recognized and intervention instigated and evaluated. Physiological monitoring and the identification of deterioration in patients’ conditions are an essential part of the role of the ED nurse; however, it remains uncertain whether this translates into the clinical setting. Patients who are critically ill are more likely to be recognized as such at initial assessment than if they deteriorate following that assessment (Cooke & Jinks 1999, Tippins 2005). For example, a patient who presents to the ED with a blood pressure of 89/38, pulse of 127 and respiratory rate of 31 is likely to be allocated a high clinical priority. In contrast, if the same patient presented an hour earlier with a blood pressure of 109/72, pulse of 98 and a respiratory rate of 24, they may not be allocated as high a priority on initial assessment, and their subsequent deterioration an hour later (after their first set of observations) will not necessarily result in a reallocation of priority (Cooke & Jinks 1999, Tippins 2005).

This phenomenon can be explained by a failure in the reassessment process and priority reallocation necessary to reflect the patient’s changing physical condition. The introduction of education programmes, such as the Acute Life-threatening Events, Recognition and Treatment (ALERT) course, and tools such as the Modified Early Warning Score (MEWS), may be of benefit to assist staff in identifying patients who are deteriorating or are at risk of doing so. At the very least they ensure a structured approach to patient assessment and the regular and accurate recording of basic physiological observations, a crucial first step in recognizing patients at risk. Other possible explanations for the delay in recognizing patient deterioration could be external factors such as workload pressures, breakdown of communication, and lack of senior input (National Confidential Enquiry into Patient Outcome and Death 2009). The inexperience of staff in dealing with critically ill patients, the impact of teamwork and complacency when faced with certain conditions have also been shown to have an impact on clinical decision-making and, therefore, the care of critically ill patients (Bakalis & Watson 2005, Tippins 2005).

Clinical decision-making

In emergency care, nurses make multiple decisions rapidly in highly complex environments in order to deliver expert individualized care. Emergency care is different from other areas of nursing, as many patients are critically ill and frequently highly unstable. As a result their rapidly changing condition demands intelligent and decisive decision-making from nurses in short timeframes (Ryan & Tatumm 2012). Despite this there remains minimal research on the clinical decision-making skills of emergency nurses.

Decision-making can be divided into three categories: normative, descriptive and prescriptive approaches. Each of these categories has its own unique features, ideas and terminology. Normative decisions can be described as assuming the decision-maker is logical, rational and concentrates on how decisions are made in the ideal world. In comparison, descriptive theories attempt to describe how decisions are made and so are more concerned with the process of decision-making and how individuals reach that decision. Prescriptive theories try to improve the individual’s decisions by looking at how decisions are made by understanding how a decision is formulated (Thompson & Downing 2009). Of these different approaches to decision-making, prescriptive and descriptive approaches are the most common approaches used by practitioners (Cioffi & Markham 1997, Lurie 2012).

Clinical decision-making can be defined as the process nurses use to gather patient information, evaluate that information and make a judgement which results in the provision of patient care (White et al. 1992). This process involves collecting information with the use of both scientific and intuitive assessment skills. This information is then interpreted through the use of knowledge and past experiences (Cioffi 2000a, Evans 2005, Evans & Tippins 2007).

There are many theories on how to teach these essential and dynamic skills; however, learning or the acquisition of new knowledge does not necessarily guarantee the clinical application of expert practice (Tippett 2004) or critical thinking. Many theories of teaching and learning the art of critical thinking and expert clinical decision-making exist; behaviourist, cognitive, and humanistic being the commonly used three (Sheehy & McCarthy 1998). The behaviourist theory relates to reactionary learning whereby the learning occurs when an unmet need causes the learner to embrace the learning process; unfortunately the inclination to learn is often stimulated due to the learner feeling inadequate due to uncertainty and a lack of confidence. The cognitive theory relates to the interaction between the learner and their immediate environment, i.e., learning through experience and professional stimulation. The humanistic theory relates to adult-based learning where the focus is clearly on the learner to ascertain new knowledge through the process of self-discovery. A teacher who has understanding will present organized subject matter that is relevant to the learner’s need and will, therefore, propagate learning. The expert practitioner perceives the situation as a whole, uses past concrete situations as paradigms and moves to the accurate region of the problem without wasteful consideration of a large number of irrelevant options.