Decision_Making

Decision making and The Emergency Nurse Practitioner Word Count: 2700 Susan Fairbairn BSc Autonomous Healthcare Practice Applied Practice: Decision making 2003/04 Government policy, in recent years, has led to changing roles for nurses in the National Health Service. Many nurses now work autonomously within the Scope of Professional Practice (NMC 2002). These new roles come with a greater responsibility to be able to account for both actions and decisions. To this end, increasing importance is given to continuing education and evidence-based practice. Thompson and Dowding (2002 p5) suggest that the link between knowledge and decision making has been an important factor as nurses endeavour to establish their professional status. The subject of decision making has been studied for over fifty years by many different people, and many different theories have been developed. Carroll and Johnson (1990) cited in Bicknell (2003 p312) define decision making as “a process by which a person, group or organisation identifies a choice or judgement to be made, gathers and evaluates information about alternatives and selects from among alternatives”. This assignment intends to explore the topic of clinical judgement and decision making with particular reference to decision making in the expanding role of nurse practitioners. Decision making is often referred to as clinical judgement. A distinction was made between the two by Dowie (1993 p8), cited in Thompson and Dowding ( 2002 p7). He described judgements as the evaluation of alternatives and decisions as selecting from among these alternatives. In nursing the two go hand in hand and are therefore often referred to as the same thing. Crumbie (2002 p3-11) states that using a problem solving approach as the basis for clinical decision making leads to more accurate diagnosis and more appropriate treatment. She identifies two theories of problem solving: The information processing system theory (Newell and Simon 1972) and the Stages Model theory (Hurst 1993). The Information Processing System Theory is based on solving a problem by analysing the information provided and using knowledge and experience to sort out what is relevant. She suggests that this system is useful with well defined problems, but not always appropriate for more complex nursing problems. Information processing theory is also known as the hypothetico-deductive approach and, in contrast to Newell and Simon (1972), Elstein, Shulman and Sprafka (1978) cited in Offredy (1998 p991) point out that this method of decision making is often used in more complex situations. Thompson and Dowding (2002 p9) share this view, and discuss the phases that nurses go through when making a decision, as suggested by Elstein et al. (1978), who puts forward four stages: cue acquisition, hypothesis generation, cue interpretation and hypothesis evaluation. The Stages Model theory has been discussed by many different authors. Hurst (1993) puts forward five stages: identification of the problem, assessment, planning and hypothesis formation, implementation and Evaluation. Other authors have varying numbers of stages, for example Bond and Kendall (1990) have eight. These models are more able to take into account the more complicated problems that nurses may have to deal with. Crumbie (2002 p4) suggests that a model developed by Barrows and Pickell (1991) for medical students would also work well for nurse practitioners. This is because it includes physical examination, patient education, compliance and patient- centred care. The model is based on two components: the knowledge base of the practitioner and the method of manipulation used to apply this knowledge. There is also room for reflection, which helps to identify areas for learning or improvement of skills. Schon (1987) cited in Palmer et al (1994 p67) encourages reflection in action where problems are identified and solved immediately. A skilled practitioner can use previous experience and knowledge to aid this process. Problem solving usually culminates in decisions being made and action taken. In the uncertain world of nursing, the decision analysis approach may be of use when making decisions. It is based on Bayes theorem of subjective expected utility and involves estimating probabilities and utilities. Harbison (2001 p129) describes this theory as follows: “The probability of a condition existing is dependant on the significance of the evidence which indicates its existence, combined mathematically with the prevalence of the condition in the population”. Decision analysis theory is a system used under conditions of uncertainty (Offredy 1998 p992). The clinical problem is broken down into a number of parts which can be analysed one by one, and then assembled into choices. Values are given to each outcome and the probabilities are assigned to possible chance occurrences. Values and probabilities are then mathematically combined to reach expected utilities. Decision trees can be used to show possible options with their outcomes and values. The route leading to the highest expected utility would normally be the route of choice. This type of decision making could be useful when producing treatment protocols, but not so useful during a consultation when decisions need to be made quickly, based on the sometimes limited information available at the time. Cioffi (2002 p50) notes that studies carried out on the thought processes of nurses have found that the hypothetico-deductive approach is often utilised, and that the strategies used most are cue-based. Making a judgement based on a set of cues is known as pattern recognition. Many patients attend units with the same or similar symptoms to patients previously seen and are, therefore, given the same diagnosis. Pattern recognition is just one type of heuristic used by nurses in problem solving. Hedberg and Larsson (2003 p220) suggest that pattern recognition, or similarity recognition, often develops in experts. Dreyfus (1979) in Benner (1984 p3) confirms this idea stating that the expert nurse uses past experiences as evidence and progresses to the root of the problem without wasting time considering many irrelevant choices. Thompson (2003 p231) notes that nurses rely heavily on experience to provide information when faced with day to day choices, but that this type of evidence is not always based on good quality research. Intuition is often linked with pattern recognition. The nurse can arrive at a particular decision without being aware of how she got there, but having subconsciously followed a set of cues (Buckingham and Adams 2000 p984). Cioffi (1997 p206) agrees, saying that heuristic reasoning is an important element of intuition. Hammond, Hamm, Grassia and Pearson, in Goldstein and Hogarth (1997 p147), consider that judgement is called intuitive if it is arrived at by an unrecognised and unprepared method of reckoning without using analytical processes or planned calculations. McCutcheon and Pincombe (2001 p345) go further, concluding that intuition is a result of the interaction between experience, expertise and knowledge, combined with personality and environment. They consider that it plays a valid and important role in decision making. Heuristics are commonly described as ‘rules of thumb’. They are defined by Thompson and Dowding (2002 p15) as “particular strategies that individuals have developed to process a large amount of information efficiently”. Two types of heuristics are described by Tversky and Kahneman (1974) in Buckingham and Adams (2000 p984). Both representativeness and availability heuristics are, it is suggested, used by nurses. The former allows nurses to estimate the likelihood of a particular condition based on how representative of that condition the patient is. The latter leads to a conclusion based on the nurses’ experience of patients presenting with the same set of cues, how recently the event took place or how memorable the case was. Tversky and Kahneman (1974), in Cioffi (1997 p207), also describe the anchoring and adjustment heuristic. This involves establishing an initial value and making adjustments to this value based on additional information and knowledge. Experience is therefore related to heuristics as more experienced nurses will have more of these memories than those with less experience. When using heuristics it is possible for errors of judgement or biases to creep in. Reason (1987) cited by O’Kell (1998 p2) identified some errors that may affect the decision making process. He concentrates on the physical and psychological limits of the human body stating that strategies and heuristics are often inadequate and over used and that information processing tends to err on the side of the most memorable data. Tversky and Kahneman (1974) also cited by O’Kell (1998 p2) add long term memory problems and lapses, misconceptions, and errors in judgement or deductive reasoning. Thompson (2003 p231) suggests that evidence-based nursing is a systematic way of avoiding the biases that arise from a decision made without research to back it up. Flemming and Fenton (2002 p114) put forward four influences on evidence-based decision making: clinical experience, research evidence, patient preference and resource availability. Greater importance may be given to any one of these depending on a particular set of circumstances. The Patients Charter (DoH 1991) advocates patients being involved in, and taking responsibility for their own decisions. The NMC (2002) Code of professional conduct document also urges nurses to provide care which is patient centred and where these patients are the primary decision makers. Nurse practitioners must take into consideration the individuals personal set of circumstances when making decisions about particular treatments. For example a self-employed labourer will not get paid if he does not work, and may refuse a certain treatment if it would be detrimental to his business. Similarly, an elderly person living on their own may not be able to cope if the prescribed treatment is carried out. Experience and evidence-based knowledge of conditions and alternative treatments, alongside risk assessment, can allow the practitioner to suggest and discuss the problems associated with making a compromise. Patients have a right to make their own decisions about health care issues, and as long as they are in possession of all the facts nurses must respect these decisions even if they differ from the norm (Henderson 2002 p525). Gray (1997) cited in Thompson and Dowding (2002 p115) agrees with this approach to decision making where the practitioner consults with a patient, discusses the best evidence and chooses the option best suited to the patient. Reaching an evidence-based decision relies heavily on the health care professional having the know how to search for best evidence and to interpret it appropriately. Research into particular areas, for example to produce guidelines or protocols, is often carried out by a group of practitioners who all have a common interest in the subject. Brown (2000 p41) discusses the works of R. F. Bales who studied group activities in the 1950’s. He used the assumption that all group members were working towards the same goal and that their interactions would, therefore, revolve around this goal. Tension in the group could be generated when members disagree with each other, or by outside influences, for example time constraints. Bales (1953) suggests that undertaking a task has three components. The group must first establish the exact nature of the problem to be solved and familiarise themselves with all the relevant information. This involves good communication and exchange of ideas and opinions. The ideas and information then have to be evaluated in order to move towards an outcome. During this phase group members will start to exert their control over each other in order to get support and agreement for their own particular preferences. Brown (2000 p 198) conclude that when groups make decisions, the combined judgement of the group is usually more extreme than the average of the individual opinion. This is known as polarization. Three possible reasons for this are suggested. Firstly, the social comparison theory, which states that polarization occurs due to group members competing with one another to give support to the socially most pleasing stance. Secondly, persuasive arguments theory leads to polarization because new evidence comes to light during the discussion. Thirdly, the social identity approach suggests that polarization occurs as a result of group members agreeing with the majority. In any one group, two or more of these theories is usually causing polarization. Poole and Baldwin (1996 p215) observe that interaction is at the heart of group decision making. They highlight elements such as communication, listening skills and challenges between individuals, alongside relationship building and a commitment to work together towards a common goal. Nurse practitioners working alongside each other utilise all these elements in the course of their work. Although many clinical decisions are made independently during a consultation, advice is often sought from colleagues or other specialists, and group discussions often take place to solve more complex or continuing problems. Many departments have protocols and guidelines to follow which have been agreed on by both the practitioners and other members of the multidisciplinary team. During regular meetings, these protocols can be updated or revised as new evidence comes to light or as working policy dictates. In the present climate of change in the Primary care sector, nurses’ roles are expanding. Services are being reorganised to accommodate not only new General Practitioner contracts, but also the higher expectations of the public. Nurses are taking on new practitioner roles and many Minor Injury Units are changing to Walk-in-Centres. Keyzer and Wright (1998 p9) recommend that in view of these changes, nurses need to develop their expertise in change management. They suggest that formulating a plan for change requires the nurse to have good skills in problem solving, decision-making and communication. The leadership role is usually taken by those already in leadership positions, such as nurse managers or consultants, but success relies on the cooperation of the group. Bennis, Benne, Chin and Corey (1976), cited in Wright (1998 p11), identify three change strategies: The rational-empirical strategy states that individuals are reasonable beings and use rational thought in determining the need for change. The power-coercive strategy relies on the use of political, economic or ethical power to reach the desired goal. Both these strategies are implemented by the people in charge. In contrast, normative-re-educative approach is seen as a bottom-up strategy where a group see a need for change and are involved in developing new models for practice. Within nursing, both bottom-up and top-down change strategies are used. According to Wright (1998 p40), many nurses lack the evidence-based knowledge to recognise that a change in practice is required, and react negatively if a change is imposed upon them. Resistance is usually rooted in fear of the unknown, or lack of understanding. Providing knowledge and support can help overcome these fears. The role of a clinical leader within an organization should be able to provide this support. Acting as a change agent rather than forcing change can reduce anxiety and motivate staff by instilling a sense of ownership of the proposed change. Using a democratic and approachable style of leadership with an open-door problem solving approach, encourages participation and a shared vision of improved patient care (Christian and Norman 1998 p108-116) Ethical considerations are a part of any decision that requires action to be taken. Environment and policies need to be developed that respect moral values (Palmer 2003 p158). Kingston (REF) suggests asking the three questions put forward by Blanchard and Peale (1998), before making a difficult decision. Is it legal; Are the wishes of others respected; and, would you be happy if the decision was made public. Ethical decision making requires practitioners to identify and evaluate alternative actions and their consequences in order to decide what path to take. The amount of risk involved should be considered, and if the risk is great help should be sought from other members of the multidisciplinary team or the individuals who will be affected by the decision (Erlen and Sereika 1997 p954). Changes in the way Health care is provided have led to nurses taking on new roles with more responsibility and autonomy. This naturally leads to independent decision-making, requiring more extensive knowledge and experience. All the types of decision- making discussed in this assignment are utilised by nurse practitioners during the course of their work. Group decisions including the use of decision analysis and decision trees are used in management and protocol development, and the hypothetico-deductive approach combined with different types of heuristics are used during the everyday consultations with patients. Nurses are accountable for both their actions and omissions. The NMC (2002) Code of Professional Conduct states that it is the responsibility of the individual nurse to keep their skills and knowledge updated, and to share their knowledge with colleagues when it is beneficial to patients or clients. Education is highlighted by many authors as being essential for effective decision-making. Evidence-based knowledge, experience and an ethical perspective will lead to nurses making sound clinical decisions with confidence and integrity. References Bales, R. F. (1953). The equilibrium problem in small groups. In T. Parsons, R. F. Bales &E. A. Shils (Eds.), Working papers in the theory of action. New York: Free Press. Cited in Brown, R. (2000). Group processes. Oxford: Blackwell publishers. Barrow, H. S. & Pickell, G. C. (1991). Developing clinical problem solving skills: A guide to more effective diagnosis and treatment. New York: Norton medical Books. Cited in Crumbie, A. (2002). Problem solving. In M. Walsh, A. Crumbie & S. Reveley (Eds.), Nurse Practitioners, clinical skills and professional issues (pp. 3-11). Edinburgh: Butterworth Heinemann. Benner, P. (1984). From novice to expert. California: Addison Wesley Publishing Co. Bennis, W. G., Benne, K. D., Chin, R. & Corey, K. E. (1976). The planning of change. London: Holt, Rinehart & Winston. Cited in Wright S. G. (Ed.), Changing nursing practice. London: Arnold. Blanchard, K. & Peale, N. (1988). The power of ethical management. New York: Ballantine Books. Cited in Kingston, M. (n.d.). Effective decision making for the clinical nurse. Retieved March 15, 2004, from http://www.nurseweek.com Bond, M. & Kendall, S. (1990). Improving your decision making. London: South Bank Distance learning Centre. Cited in O’Kell, S. Structured models of decision making- Lecture notes (2000). Brown, R. (2000). Group processes. Oxford: Blackwell publishers. Buckingham, C. D. & Adams, A. (2000). Classifying clinical decision making: a unifying approach. Journal of Advanced Nursing, 32(4), 981-989. Carroll, J. S. & Johnson, E. J. (1990). Decision Research. Newbury Park: Sage Publications. Cited in Bucknall, T. (2003). The clinical landscape of critical care: Nurses’ decision making. Journal of Advanced Nursing, 43(3), 310-319. Christian, S. L. & Norman, I. J. (1998) Clinical leadership in nursing development units. Journal of Advanced Nursing, 27(1), 108-116. Cioffi, J. (1997). Heuristics, servants to intuition in clinical decision making. Journal of Advanced Nursing, 26, 203-208. Cioffi, J. (2002) What are clinical judgements. In C. Thompson & D. Dowding (Eds.), Clinical decision making and judgement in nursing (pp. 47-65). London: Churchill Livingstone. Crumbie, A. (2002). Problem solving. In M. Walsh, A. Crumbie & S. Reveley (Eds.), Nurse Practitioners, clinical skills and professional issues (pp. 3-11). Edinburgh: Butterworth Heinemann. Dowie, J. (1993). Clinical decision analysis: Background and introduction. In H. Llewelyn & A. Hopkins (Eds.), Analysing how we reach clinical decisions. London: Royal College of Physicians. Cited in C. Thompson & D. Dowding (Eds.) (2002) Clinical decision making and judgement in nursing. London: Churchill Livingstone. Dreyfus, H. (1979). What computers can’t do: the limits of artificial intelligence. New York: Harper and Row. Cited in Benner, P. (1984). From novice to expert. California: Addison Wesley Publishing Co. Elstein, A., Shulman, L. S. & Sprafka, S. A. (1978) Medical problem solving, an analysis of clinical reasoning. Massachussetts: Harrod University Press. Cited in Offredy, M. (1998). The application of decision making concepts by nurse practitioners in general practice. [Electronic version]. Journal of Advanced Nursing, 28(5) 988-1000. Erlen, J. A. & Sereika, S. M. (1997). Critical care nurses, ethical decision making and stress. Journal of Advanced Nursing, 26(5), 953-961. Flemming, K. & Fenton, M. (2002). Making sense of research evidence to inform decision making. In C. Thompson & D. Dowding (Eds.) (2002) Clinical decision making and judgement in nursing. London: Churchill Livingstone. Gray, J. A. M. (1997). Evidence based health care: How to make health policy and management decisions. Edinburgh: Churchill Livingstone. Cited in Flemming, K. & Fenton, M. (2002). Making sense of research evidence to inform decision making. In C. Thompson & D. Dowding (Eds.) (2002) Clinical decision making and judgement in nursing. London: Churchill Livingstone. Great Britain. Department of Health. (1991). The Patients Charter. London: HMSO Hammond, K. R., Hamm, R. M., Grassia, J. & Pearson, T. (1997). Direct comparison of the efficacy of intuitive and analytical cognition in expert judgement. In W. M. Goldstein & R. M. Hogarth (Eds.), Research on judgement and decision making (pp. 144-180). Cambridge: Cambridge University Press. Harbison, J. (2001). Clinical decision making in nursing: theoretical perspectives and their relevance to practice. Journal of Advanced Nursing, 35(1), 126-133. Hedburg, B. & Larsson, U. S. (2003). Observations, confirmations and strategies – useful tools in decision-making process for nurses in practice' Journal of Clinical Nursing, 12, 215-222. Henderson, S. (2002). Influences on patient participation and decision-making in care. Professional Nurse, 17(9), 521-525. Hurst, K. (1993). Problem solving in nursing practice. London: Scutari Press. Cited in Crumbie, A. (2002). Problem solving. In M. Walsh, A. Crumbie & S. Reveley (Eds.), Nurse Practitioners, clinical skills and professional issues (pp. 3-11). Edinburgh: Butterworth Heinemann. Keyzer, D. & Wright, S. G. (1998). Change strategies: The classic models. In S. G. Wright (Ed.), Changing nursing practice (pp. 7-24). London: Arnold. Kingston, M. (n.d.). Effective decision making for the clinical nurse. Retieved March 15, 2004, from http://www.nurseweek.com McCutcheon, H. H. I. & Pincombe, J. (2001). Intuition: an important tool in the practice of nursing. Journal of Advanced Nursing, 35(3), 342-348. Newell, A & Simon, H. A. (1972). Human problem solving. New Jersey: Prentice- Hall. Cited in Crumbie, A. (2002). Problem solving. In M. Walsh, A. Crumbie & S. Reveley (Eds), Nurse Practitioners, clinical skills and professional issues (pp. 3-11). Edinburgh: Butterworth Heinemann. Nursing and Midwifery Council. (2002). Code of Professional Conduct. London: NMC Offredy, M. (1998). The application of decision making concepts by nurse practitioners in general practice [Electronic version]. Journal of Advanced Nursing, 28(5), 988-1000. Palmer, D. (2003) Professional judgement and clinical decision making. In D. Palmer & K. Surrinder (Eds.), Core skills for nurse practitioners (pp145-159). London: Whurr Publishers. Poole, M. S. & Baldwin, C. L. (1996) Developmental processes in group decision making. In R. Y. Hirokawa & M. S. Poole (Eds.), Communication and group decision making. California: Sage Publications ltd. Reason, J. (1987). A framework for classifying errors. In J. Rasmusen, K. Duncan and J. Leplat (Eds.), New technology and human error. London: John Wiley. Cited in O’Kell, S. Heuristics, biases and errors in decision making – lecture notes (1998) Schon, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass publishers. Cited in Palmer, A., Burns, S. & Bulman, C. (Eds.) (1994) Reflective practice in nursing. Oxford: Blackwell Science Ltd. Thompson, C. (2003). Clinical experience as evidence in evidence-based practice. Journal of Advanced Nursing, 43(3), 230-237. Thompson, C. & Dowding, D. (Eds.)(2002) Clinical decision making and judgement in nursing. London: Churchill Livingstone. Tversky, A. & Kahneman, D. (1974). Judgement under uncertainty: heuristics and biases. Science, 185, 1124-1131. Cited in Buckingham, C. D. & Adams, A. (2000). Classifying clinical decision making: a unifying approach. Journal of Advanced Nursing, 32(4), 981-989. Tversky, A. & Kahneman, D. (1974). Judgement under uncertainty: heuristics and biases. Science, 185, 1124-1131. Cited in Cioffi, J. (1997). Heuristics, servants to intuition in clinical decision making. Journal of Advanced Nursing, 26, 203-208 Tversky, A. & Kahneman, D. (1974). Judgement under uncertainty: heuristics and biases. Science, 185, 1124-1131. In O’Kell, S. Heuristics, biases and errors in decision making – lecture notes (1998). Wright, S. G. (Ed.) (1998). Changing nursing practice. London: Arnold.