Contemporary issues
Think and think again! Clinical decision making by advanced nurse practitioners in the Emergency Department

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Introduction

Clinical decision making is a key component of all clinical practice. Over the years many decision making strategies and theories have been developed in order to assist nurses and other healthcare professionals with implementation of appropriate pathways of care for patients [2]. The decision making capabilities of the novice nurse in comparison to the expert has evoked much opinion and debate over the years [3], [14]. Recent literature highlights common decision making strategies and the decision making capabilities of nurses in the clinical area [7], [15]. Critical thinking ability, clinical experience, an in-depth knowledge base, and the ability to integrate and assimilate evidenced based research into practice, are just a few of the many skills required to assist in any decision making process [12]. In an Emergency Department (ED) it is clear that many of these decision-making attributes acquired by nurses are also challenged by often rapidly fluctuating contextual issues that may arise on any given day in the busy environment of the ED. However, over the past 40 years diagnostic errors have fallen from 17% to 12% which is good news but also disappointing given the advances in diagnostic tools [9]. A focus on clinical decision making may help in understanding the failure to reduce this incidence further.

The advanced nurse practitioner (ANP) in the ED faces decision making challenges daily. The role of the ANP in Ireland requires autonomous independent decision making for a specific identified cohort of patients. The ANP assesses, diagnoses and initiates a pathway of care for the patient within a strict criteria of guidelines and protocols from initial presentation to discharge. However, multiple stressors and the vastly unpredictable nature of the ED can present challenges to the decision making behaviour and thinking processes of ANP’s in assessing, diagnosing and providing appropriate treatment for their patients. Several key components such as cognitive aspects of human judgement and contextual issues that influence these human thought processes have been identified in the literature [9], [10].

In this paper it is proposed, using a case example, to reflect upon the processes of thought during the clinical decision making process used by an ANP during a consultation in the ED.

Section snippets

Psychological and contextual factors in decision making

Many theories on decision making have emerged from analysis of these human thought processes. Significant among these is the dual process decision making theory as identified by Croskerry [5] and Kahneman [10]. This theory identifies two main psychological processes of thought within clinical decision making as intuitive and analytical [6]. Intuitive decisions also known as System 1 Thinking are fast and abbreviated, with initial impressions forming unconscious diagnosis. Intuitive decision

Case discussion: intuition and analytical decision making

This case (Box 1) highlights the numerous contextual and psychological complexities and constraints that can accompany many seemingly straightforward case presentations for the ANP in the Emergency Department. In this case example, both the ANP and patient had limited time due to the ANP’s shift ending and the patient wanting to get home before midnight. It is reasonable to think that the intuitive thinking process by the experienced ANP in this apparently simple case should have been

Conclusion

Within nursing, the development of advanced practice roles for nurses involved in assessment, prescribing, referring and discharging patients, has seen the need for the adaptation of many strategies such as care pathways and algorithms for cardio pulmonary resuscitation and basic life support, in order to avoid bias and complacency in patient assessment and ensure rigor and error avoidance in the nurse/clinician/patient consultation and the decision making process. In supporting and educating

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