Decision making by emergency nurses in triage assessments

Triage assessment of patients on arrival at emergency departments involves complex decision making, resulting in categories being assigned to prioritize patients' needs for attention. The actual process of triage decision making has received limited attention. The aims of this study were to describe aspects of the triage decision-making process used by both more and less experienced nurses (n = 20) and to test the effect of uncertainty in the triage situation on the use of probability judgements (heuristics). Six triage cases based on actual triage situations were simulated to subjects, and their verbal protocols were collected. Protocols were transcribed and analysed. Main findings were: in conditions of higher uncertainty in triage situations all nurses used more probability in their judgements (t-test -2.37, df = 17, P = 0.03) with the heuristic of representativeness being relied on the most. The triage categories finally assigned for each triage situation showed no agreement on a specific triage category for each triage case and past triage experiences were used in decision making. The more experienced group reported higher estimations of correctness regarding the final category assigned, used more single previously experienced cases from memory, collected less data and made more judgements than the less experienced group. Further examination of the decision-making process of triage assessment should occur with attention to the variable use of triage categories, the role of past triage experiences in making judgements and development of triage decision rules for skilling nurses for triage.     

Clinical decision making and critical thinking in the nursing diagnostic process

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".     

Environmental elements affecting the decision-making process in nursing practice

Background. In their practice nurses constantly make decisions in a dynamic context including complex situations. Besides affecting elements related to the decision‐maker and the task itself, the setting where the decision‐making process takes place are of decisive importance to the quality of the decision‐making outcome. Aim. The aim of this study was to explore environmental elements related to the decision‐making process in nursing practice. Methods. Six expert nurses, from three Swedish nursing settings, participated voluntarily in the study, which were designed of participated observations in everyday nursing practice. Permission to carry out the study was given by the clinics and an ethical committee. A content analysis was used to analyse the field notes where themes emerged which were found to be environmental elements affecting decision‐making process of nurses. Conclusions. The most striking theme, environmental elements, included the sub‐themes interruptions and the work procedures are presented in this report. The implications of environmental elements, are discussed from a perspective of nurses' competence, where the elements could be seen as a facilitator or as a hindrance to developing nursing competence. It were concluded that environmental elements have to be well considered before knowledge can be reached about decision‐making in practice. Relevance to clinical practice. Interpersonal and technological interruptions were features highlighted in the study, features which could jeopardize the decision‐making outcome. Therefore, it is of greatest importance that nurses learn to use decision‐making strategies to guarantee patient care security and patient care quality.     

Nurses, children, and play.

A child's play is recognized as a useful tool for nurses in the diagnostic process of making judgments about a hospitalized child's compliance with medical procedures, adjustment to the hospital environment, degree of pain, and level of psychosocial functioning. However, the knowledge base that is required to effectively help a pediatric patient "play" in a therapeutic mode appears to be extremely limited for most nurses and is rarely addressed in a substantive manner in nursing education. Educational programs must be willing to incorporate a "developmentally appropriate, culturally sensitive, and family-centered approach" using clinical experiences and professional role models in their nursing curricula. The end product should be nurses who are competent in a much wider range of medical technological and psychosocial issues than has been necessary in the past. In short, nurses must learn to play.     

Voices of graduates from second-degree baccalaureate nursing programs.

In response to the nursing shortage, second-degree accelerated nursing programs have proliferated in the past few years. Despite the popularity of these programs, little research has been conducted regarding the effectiveness of these programs in educating professional nurses in 12-18 months. This study explored the student experiences of accelerated second-degree nursing graduates to understand how these experiences best prepared them for practice after graduation. Using a hermeneutic phenomenological approach, 19 second-degree graduates from the mid-Atlantic region of the United States were interviewed face-to-face. Unstructured audiotaped interviews, in which participants were asked to relate an incident that they experienced as a second-degree accelerated nursing student that best prepared them for their current clinical position, were conducted. Data were analyzed utilizing van Manen's approach to human science research. The pattern, "Clearing a Path Toward Possibilities," was identified. Students described the faculty as integral to their success in overcoming barriers to move along a pathway toward their goals. Data suggested that pedagogies that incorporate the rich life and prior educational experiences of second-degree students are needed in accelerated nursing programs.     

A review of clinical decision making: models and current research

Aims and objectives. The aim of this paper was to review the current literature clinical decision‐making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information‐processing model, the intuitive‐humanist model and the clinical decision‐making model. Background. Clinical decision making is a unique process that involves the interplay between knowledge of pre‐existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information‐processing model and the intuitive‐humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information‐processing model but also examines patient specific elements that are necessary for cue and pattern recognition. Design. Literature review. Methods. Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005. Results. The characteristics of the three models of decision making were identified and the related research discussed. Conclusions. Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision‐making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed. Relevance to clinical practice. It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing‐related problems. It is suggested that O'Neill's clinical decision‐making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.     

Tasks and routines in 21st century nursing: student nurses' perceptions

The aim of this study was to explore final year nursing students' views about their clinical experiences. This was the second of three studies using a grounded theory approach overall with theoretical sampling of final year student nurses being chosen as a result of the initial study's findings. The sample was of a volunteer nature. The data collection tool was an open-ended questionnaire, with themes arising from the first study helping to form the questions. It was anticipated that more clinically experienced students would confirm, refute and perhaps provide "new" information about the reality of clinical nursing when compared with the sample of neophyte nurses from the first study. Data were analysed through initial coding of responses and then compared and contrasted to the data of study one. Findings included categories of views about the nurses' roles and tasks, clinical priorities of qualified nurses, holistic care, and care plans. The conclusion suggest that despite nursing theory proclaiming the advent of "new" nursing with hallmarks of holistic care and movement away from tasks and routines, the student nurses did not find this to be the case. Indeed, tasks and routines are what seemed to structure the work of nurses, with little evidence of holistic, patient-centred care occurring clinically.     

Decision making in nursing: an analytical approach.

Decision making is a basic function of all nurse leaders. Because of the complex nature of many decision situations faced by nurses, problem solving and decision making in nursing are as much an art as a science. The Vroom and Yetton model of decision making is an appropriate tool through which nurses involved in patient care management can examine their decision making and improve their decision behavior. Use of this model is suggested as an approach to teaching decision making at the undergraduate and graduate level of nursing education. Case material has been presented to help readers identify their favored methods of decision making and to point out possible deficiencies in these methods.     

Nursing decision making in critical care areas

This exploratory study sought to identify factors that critical care nurses consider relevant in making rapid patient care decisions; to explore the decision making of these nurses in crisis situations; and to identify critical patient care situations where rapid nursing decisions are made. The convenience sample consisted of 50 nurses in critical care settings. A semi-structured interview with a critical care case study was utilized to examine the nurses' decision making. Open ended responses were transformed into fixed categories for tabulation. The findings suggested that:

• 1

   knowledge and experience were the most important factors influencing rapid decision making;
• 2

   although the nurses identified the appropriate decisions in a given crisis situation they had difficulty providing a theoretical rationale for their decisions;
• 3

   the given case study and the 50 crisis situations identified by the subjects indicated that many nursing decisions for critically ill patients were carried out prior to physician assistance. A demographic data questionnaire that examined age, nursing experience, formal education and continuing education of the subjects determined that the majority of the nurses were under 30 years old, had either less than 1 year of experience or 7-9 years in critical care, were graduates of a 2-year diploma programme, and took continuing education courses at the community college level.

     

How do children's nurses make clinical decisions? Two preliminary studies

Aims and objectives. To gain an understanding of how children's nurses make clinical decisions. Background. Several studies have explored how nurses make clinical decisions and the factors that may affect the decision‐making strategies used. However, the results of these studies are contradictory. Further, little is known about children's nurses’ decision‐making strategies. Design. The think aloud technique. Methods. Nurses (n = 12) from three surgical wards and nurses (n = 15) from three medical wards in a Scottish children's hospital were presented with clinical scenarios and asked to think aloud. The verbal protocols were analysed to provide an indication of how children's nurses made decisions. Whether there were any differences in decision‐making between experienced and less experienced nurses and between graduates and non‐graduates was also explored. Results. Analysis of verbal protocols obtained using the think aloud technique suggested that all the nurses in the sample used a hypothetico‐deductive (analytical) model of decision‐making. Further, all participants appeared to use backward reasoning strategies regardless of their level of expertise. This is a characteristic of non‐expert decision‐making. Experienced and less experienced nurses collected similar additional information before planning nursing interventions, supporting the conjecture that they were functioning at a non‐expert level in relation to decision‐making. No differences were seen in the information collected by graduate and non‐graduate nurses. Conclusions. The decision‐making strategies of children's nurses need exploring further and further research is needed to identify factors that may affect decision‐making strategies. Several strategies to support nurses’ clinical decision‐making have been proposed but need testing to ascertain their effectiveness. Relevance to clinical practice. In clinical practice nurses make numerous decisions throughout the course of a shift. Sub‐optimal decision‐making strategies may adversely affect the quality of nursing care provided. It is imperative, therefore, to ascertain how nurses make clinical decisions and the factors that may influence the decision‐making strategies used.     

Critical care nurse practitioners and clinical nurse specialists interface patterns with computer-based decision support systems

PURPOSE: The purposes of this review are to examine the types of clinical decision support systems in use and to identify patterns of how critical care advanced practice nurses (APNs) have integrated these systems into their nursing care patient management practices. The decision-making process itself is analyzed with a focus on how automated systems attempt to capture and reflect human decisional processes in critical care nursing, including how systems actually organize and process information to create outcome estimations based on patient clinical indicators and prognosis logarithms. Characteristics of APN clinicians and implications of these characteristics on decision system use, based on the body of decision system user research, are introduced. DATA SOURCES: A review of the Medline, Ovid, CINAHL, and PubMed literature databases was conducted using "clinical decision support systems,"computerized clinical decision making," and "APNs"; an examination of components of several major clinical decision systems was also undertaken. CONCLUSIONS: Use patterns among APNs and other clinicians appear to vary; there is a need for original research to examine how APNs actually use these systems in their practices in critical care settings. Because APNs are increasingly responsible for admission to, and transfer from, critical care settings, more understanding is needed on how they interact with this technology and how they see automated decision systems impacting their practices. IMPLICATIONS FOR PRACTICE: APNs who practice in critical care settings vary significantly in how they use the clinical decision systems that are in operation in their practice settings. These APNs must have an understanding of their use patterns with these systems and should critically assess whether their patient care decision making is affected by the technology.     

Ethical decision making by nurses in HIV/AIDS situations.

The purpose of this study was to assess the ethical decision making levels of nurses in HIV/AIDS situations. Using an adapted form of Crisham's Nursing Dilemma Test, RNs in various settings in Ohio ranked their reasons for action in responding to vignettes. Findings suggest that nurses are basing their clinical decisions in HIV/AIDS situations on practical considerations rather than on nursing principles. Education programs based on the findings from this study will enhance the use of nursing principles.     

Triage decision making: educational strategies

Patient triage in Accident and Emergency departments requires emergency nurses to make rapid decisions based on their knowledge and experiences. The development of triage decision-making skills can be addressed through the use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced emergency nurses. Clinical educators and experienced emergency nurse mentors are encouraged to recognize that skill acquisition in triage decision making requires practice before registered nurses can engage fully in the process of triaging patients in the emergency department. It is essential to experience the process of triage decision making in order to develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information leading to a decision on the triage category for each patient. By using triage simulations developed from 'real triage cases' the process of decision making can be experienced by nurses. Further, if these simulations are accompanied by the collection of verbal protocols, nurses have opportunities retrospectively to explore their decision making with reflection. In addition, the presentation and use of decision rules used by experienced triage nurses can enhance the development of skills in novice triage nurses.     

Survival strategies of male nurses in rural areas of Japan

Aim: This study seeks to describe the survival strategies of male nurses in Japanese rural areas. Methods: Interviews were conducted with 12 male nurses who described their occupational experiences. The modified grounded theory approach was used for the data collection and analysis. Results: The survival strategies of these male nurses can be categorized into four types: (i) giving priority to the achievement of financial security; (ii) agreeing to a dependent relationship with doctors; (iii) maintaining one's male identity through supporting the female nurses; and (iv) making an appeal to the significance of men in the female‐dominated nursing profession. Conclusion: The survival strategies that were used by the male nurses were subtle, allowing them to influence indirectly both the female nurses and the doctors. These findings contribute to our understanding of the experiences of male nurses, a gendered minority in a female‐dominated workplace, and encourage gender equality in the nursing profession.     

Nursing students' perceptions of anxiety-producing situations in the clinical setting

Aspects of nursing students' clinical experiences are anxiety provoking. High anxiety may contribute to decreased learning. The purpose of this study was to identify potentially anxiety-producing clinical experiences for student nurses. Thirty-nine junior and 53 senior nursing students from a BS degree program completed the "Clinical Experience Assessment Form," a 16-item Likert scale. The items included communication and procedural aspects of patient care, interpersonal relationships with healthcare providers, and interactions with faculty. An open-ended question asked students to identify the most anxiety-producing aspects of their clinical practice. The students expressed the highest anxiety for the initial clinical experience on a unit and the fear of making mistakes. Faculty evaluation and observation were also anxiety-producing. The results of the student t-test indicated that juniors were significantly higher in their expression of anxiety was that students's anxiety was increased in the clinical setting by their perceptions of nonsupportive faculty.