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.

Nursing process

The nursing process is a tool used by nurses to assist with decision-making and to predict and evaluate the results of nursing actions (Reeves & Paul 2002). The deliberate intellectual activity of the nursing process guides the professional practice of nursing in providing care in a systematic manner. The nursing process has evolved over recent years to incorporate five or six phases or stages (Box 37.1 and Fig. 37.1) (Reeves & Paul 2002, Ryan & Tatum 2012).

Box 37.1 The nursing process

Assessment – collection of subjective and objective clinical data to provide a rationale for care

Nursing/working diagnosis – analysis of physical presentation confirmed by scientific fact (data collection results)

Planning/outcome identification – plan of care and realistic goals discussed with patient

Implementation – performing interventions, reassess plan following each intervention to determine initial response

Evaluation – have expected outcomes been achieved? Determine patient’s level of clinical need and regularity of subsequent assessment

Figure 37.1 The nursing process illustrating a one-dimensional and a dynamic nursing process.

Movement between these phases is unusually linear; there is free movement among the phases during clinical practice. Once an assessment begins the nurse should begin to formulate diagnoses and eliminate others. As more information is gathered, through physical and technological findings, the practitioner should begin to narrow the possibilities. The worst possible diagnosis should be paramount in the practitioner’s hypotheses, as this must be addressed and eliminated before moving on. By using a systematic approach patient problems can be identified and acted upon in the most effective way to ensure the best possible outcome for the patient. Examples of a systematic approach are those adopted by the Resuscitation Council (2011) on the Advanced Life Support (ALS) course with the ABC mnemonic (airway, breathing and circulation) and ABCDE (airway, breathing, circulation, disability and environment), taught by the Royal College of Surgeons (2005) and American College of Surgeons (2008) in the Advanced Trauma Life Support (ATLS) course.

An obvious nursing diagnosis, such as difficulty in breathing in the patient with acute exacerbation of asthma, may be developed while data collection is still ongoing. In this situation implementation of life-saving actions, such as administration of oxygen therapy and bronchodilators, in which the desired outcome is obvious, may have begun before the assessment, diagnosis, outcome identification, and planning phases can occur. Throughout the phases, reassessment can lead to immediate changes in any of the previous phases. Reassessment and the further collection and analysis of data is a continuous, ongoing dynamic process and should not be confused with evaluation, which measures outcomes. Reassessment may lead to a change in the working diagnosis, which in turn could lead to a change in outcome identification, planning, implementation and evaluation as the process continues.

In order to demonstrate the nursing process a clinical scenario will be presented and discussed to demonstrate the practice from both a unilateral and a critical thinking perspective (Box 37.2 and Fig. 37.2).

Box 37.2 Scenario 1

A 28-year-old female attends the ED at 08.30 via the ambulance service as a result of a collapse while on a bus. She is alert and oriented and able to recall the events prior to the collapse, and has not sustained any obvious injuries. The patient states that she has not eaten breakfast as she has been feeling nauseous and has been vomiting for the past 48 hours. The patient also adds that she is 13 weeks pregnant.

Figure 37.2 The nursing process applied to scenario 1.

The nurse assessing the patient in a one-dimensional way will focus only on the patient’s presenting complaint, and in this case attempt to establish a cause for the collapse. The nurse demonstrating critical thinking, however, will take into account all available information gained from the assessment and utilize it in order to establish a working diagnosis. In this example the one-dimensional process disregards the fact that the patient is pregnant. The dynamic model will take this information into account and process it along with all other available information, considering the bigger picture. With the use of critical thinking a working diagnosis/hypothesis will be formulated: hyperemesis; and appropriate scientific fact sought to either confirm or refute it. When the evaluation phase is reached, the nurse in the one-dimensional example may not have established a cause for the patient’s collapse and, as a result, may have to go back to previous phases. In contrast, the critical thinker may have confirmed a working diagnosis, established a subsequent care plan and moved on.

The current demands placed on clinicians require the ED practitioner to be proactive and dynamic in their utilization of the nursing process. They need to know which stages can be safely omitted, combined or delayed, and also which situations warrant a rigorous, comprehensive approach (Alfaro-LeFevre 2004). There is, therefore, a clear need to implement a tool or structure to the diagnostic process directly aimed at ED nurses to facilitate the application of critical thinking. Novice practitioners frequently require a clear-cut approach to patient assessment; this can be achieved by applying the DEAD mnemonic as an aide-memoire or self-questioning analytical tool. This approach is outlined in Box 37.3 (Evan & Tippins 2007).

Box 37.3 The DEAD mnemonic

D: Data (scientific facts) – this should be based on what facts the nurse has and what other data the nurse can collect to validate or negate them.

E: Emotions – intuition or gut feelings/reactions, what are your instincts telling you, how can you consolidate or negate these.

A: Advantages – what advantage to others would result from actions the nurse takes, i.e., would an action instigated at the initial assessment improve the patient’s prognosis, an example being the dispensing of an anti-platelet drug to a patient experiencing an acute coronary syndrome. The practitioner should also consider that a test requested when the patient presents may hasten their visit and result in an increasingly proficient service.

D: Disadvantages (differential diagnoses) – what could go wrong, in the worst case scenario what could this be, how I can rule this out?

By utilizing this structured framework, those less experienced in critical thinking will have a clear systematic outline to assist them in the organization of their thought process. This, in turn, could facilitate development of critical thinking and decision-making skills.

Critical thinking

The clinical scenarios outlined in Box 37.4 will be discussed to demonstrate the critical thinking and clinical decision-making involved in the initial and continuing assessment process.

Box 37.4 Scenario 2

A 76-year-old woman is admitted to the emergency department via the ambulance service complaining of a sudden onset of left-sided chest pain that commenced two hours previously. The pain radiates through to the centre of her chest; she also complains of a vague discomfort in her left arm. On examination, she has severe pain in her chest and back, she is pale and drowsy.

Vital signs reported: BP 110/60 mmHg, and a weak radial pulse.

Data The data the initial assessor will require are based on the patient’s presenting complaint and medical history. The initial nursing or working diagnosis in this case would be an acute coronary syndrome (ACS). The nurse should be quick to ascertain the nature of the patient’s pulse. A radial pulse can reflect the onset of physiological shock or the presence of life-threatening arrhythmias, including complete heart block, atrial fibrillation and tachycardias. The nursing diagnosis and need for immediate intervention can be either validated or negated by the recording of an ECG which would reflect the pathological changes associated with acute ST segment elevated myocardial infarction (STEMI). The data recording at this point should include the requesting of blood tests, particularly as other co-existing pathologies may be exacerbating this presentation, such as anaemia.

Emotions The assessor’s gut reaction in this case should be to consider the working diagnosis of STEMI. Comparing the current presentation with previously experienced situations should alert the nurse to the potential severity of the condition, the process of pattern recognition and experiential learning (Cioffi 2001, Muir 2004, Tippins 2005).

Advantages The advantages involved in this situation would be an early door to treatment time, which has been shown to dramatically improve morbidity and mortality rates. The rapid diagnosis and treatment of life-threatening pathologies such as ACS is essential (Department of Health 2000a).

Disadvantages (differential diagnosis). The priority in this case is to confirm or dispel STEMI. The assessor also needs to consider other possible diagnoses, for example a dissecting aneurysm, which would be a contraindication to therapy. This possibility would result in the assessor returning to the data collection phase of the process in order to negate a potential aneurysm via further data collection.

Based on the clinical presentation the nurse will apply the DEAD mnemonic to aid critical thinking and decision-making.

Data What facts does the nurse have? This patient is presenting with the classical clinical signs of a respiratory infection. The fact that he smokes initially reinforces the nurse’s first impression. The patient discussed having chest pain; the nurse should ascertain the nature of this pain, and ask whether it increases on inspiration, for example. The data needed to justify the nursing diagnosis will include the patient’s respiratory rate, rhythm and depth. Oxygen saturation and a sample of the sputum should be requested. The nurse should look for clinical manifestations of chronic related pathophysiological changes associated with smoking; these include peripheral and potential central cyanosis and nail bed changes. Radial pulse and capillary refill time should be ascertained; the patient’s blood pressure should be noted. An ECG should be recorded, as much respiratory-related pathology coincides with cardiac pathology. The patient’s temperature should also be recorded. By recording and requesting data the nurse is validating the working diagnosis and negating other or coexisting pathologies.

Emotions Intuition and previous experience (experiential learning) have instigated this plan of care; the nurse is now applying critical thinking to the intuitive process to provide hard facts to justify gut reactions.

Advantages The nursing goal is to provide the patient with a quick efficient service. From the initial clinical signs and vital sign data collection the nurse has established this is not a life-threatening presentation. Within many departments the nurse will be able to request a chest X-ray, which will save time if requested early on.

Disadvantages The clinical decision-making process must include a quick analysis of the patient’s presentation; this should include ‘what is the worst case scenario?’ Has the assessor negated immediate life-threatening pathologies? The ongoing process of excluding differential diagnoses now begins and the nurse may still think of other possible rule-out tests that could be requested.

Past experiences

In decision-making involving complexity, studies have shown that decision-making strategies are dependent on the individual’s experiences (Cioffi 1998, Tippins 2005). Nurses use past experiences to assist in decision-making by comparing the current situation to previously experienced situations held in their memory (pattern recognition). This can manifest itself in a variety of forms, including recognizing a similarity between the present patient’s condition/situation and a group of patients previously cared for with this presenting condition/situation, to describing quite specifically identified characteristics (Grossman & Wheeler 1997, Cioffi 1998, 2001). For example, a nurse who has previously cared for a patient with meningococcal meningitis may identify a future patient with the condition by recognizing a specific sign or symptom witnessed in the first instance, such as the petechial rash. Benner (1984) discusses the differences between a novice and an expert and proposes that they can be attributed to the know-how that is acquired through experience.

Furthermore, past experiences with patients’ symptoms and their probable outcomes is a factor that will determine the action a nurse will take in response to a patient’s presentation (Radwin 1998). A recommendation for practice, therefore, must be to provide teaching to staff on conditions and situations common, but infrequently experienced, within the ED. This could facilitate the development of pattern-recognition skills, and improve response to critical care events. This could also address the retention of knowledge and skills gained in continuing professional development courses (Department of Health 2000b).

The use of reflection to assist in personal debriefing has an impact on the management of future practices when patients present with similar conditions (Evans 2005, Tippins 2005). By reflecting both on and in practice, with the use of critical thinking, best outcomes can be hypothetically discussed. This will result in modifications in an individual’s clinical practice, and ultimately a positive impact on the care of future patients. Reflective practice has become an integral part of daily nursing life (Johns & Freshwater 1998). The need to reflect, critically analyse, develop and, where possible, improve is the constant aim of the nursing profession in the twenty-first century.

Intuition

Generally it is accepted that hard facts or science are the base from which nursing practice is delivered, and that intuition or logic do not directly influence clinical practice. In contrast the reality is very different, the rationalist paradigm of knowledge is logic, and the empiricist paradigm is science. Interestingly, empirical knowledge is less certain than logic; it is tentative, responsive to new evidence and better research, and always open to re-testing. The primary aim of applying theory in practice is to improve the patient’s quality of care. Experts are able to generate better hypotheses due to a larger database of knowledge from which to pull ideas. This expert knowledge may also be assembled from intuition. Robinson (2000) identifies that clinical decision-making is the foundation of how an expert clinician can utilize their experientially based knowledge base to draw conclusions when assessing each new encounter.

Nurses’ experience plays a major role in the development of critical observations, skills and subsequent intuition (Benner & Tanner 1987). When confronted with situations in which clinical judgements are characteristically uncertain, the nurse will rely upon the use of intuition to assist with their clinical decision-making (Benner & Tanner 1987). It has been argued that intuition actually accelerates the analytical process that leads to a nursing intervention (King & Appleton 1997). The use of intuition and systematic processes of decision-making has predominantly been believed to have occurred only in the more experienced and expert nurses (Benner & Tanner 1987, Watkins 1998, Rew 2000). Intuitive aspects of decision-making may, however, commence in nurses at an early point in their career and strengthen or lessen with time depending on their experiences and developing expertise (Sirkka et al. 1998, King & MacLeod Clark 2002).

Emergency nurses often have to deal with patients with life-threatening conditions, and sometimes reach a critical stage of perceiving a change in a patient’s condition signifying that the patient may soon deteriorate. This use of intuitive judgement has been shown to be useful in the recognition of patient deterioration (Cioffi & Markham 1997, Cioffi 2000b, Tippins 2005, Harties et al. 2011). When used to identify deterioration this feeling is associated with knowing the patient (Cioffi 2000b), for which continuity of care is necessary (Grossman & Wheeler 1997).