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decision making in nursing practice. Nurse triage in the accident unit
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DECISION MAKING IN NURSING PRACTICE NURSE TRIAGE IN THE ACCIDENT UNIT MODULE NUMBER: (UZA 016S2) SEPTEMBER 1998 98000663 WORD COUNT: 4302 For the purpose of this assignment, I have selected to discuss triage nursing in the Accident and emergency department. The assignment will consider how the implementation of the Manchester triage system in the accident unit affects clinical decision making and consider different theoretical decision making frameworks to analyse these effects. I chose the subject of triage for this assignment after a clinical placement in the accident unit. Triage nurses have to make rapid decisions based on their knowledge and experience and the use of the Manchester triage system appears to be a useful and universal tool in the implementation of these decisions although it does have limitations. I will discuss the limitations and effectiveness of this tool in this assignment. Clinical decision making is a complex process in which nurses choose the type of information that they want to collect, recognise problems from the clues picked up whilst collecting this information and decide upon the appropriate interventions to tackle these problems. (Tanner et al.1987 and Thomas et al. 1991). The complexity of this process is due to the huge variation in clues presented, the enormity of the information that needs to be processed and the difficulty in predicting outcomes (Hammond, 1960, cited by Pardue, 1987). Various factors influence the clinical decision making process (Pardue 1987) These include such things as the individual making the decisions, their experience and knowledge (Benner 1984), creative thinking ability, education (Pardue 1987) and self concept (Joseph 1985) as well as environmental and situational circumstances. (Evans 1990). Experience and knowledge are two of the major factors that affect decision making in clinical practice involving much more than just theoretical knowledge. Experience increases the cognitive resources available for interpretation of information which results in more accurate decision making, Intuition, defined by Benner and Tanner (1987) as “Understanding without rationale” represents the hallmark of expert judgement. The ability to quickly identify the relevant and important facts limits the number of alternatives to be evaluated, which in turn reduces the number of decisions to be made. Hamm (1988) developed a system, which he described as The Cognitive Continuum, in order to determine how professionals make judgements. Hamm believes that human judgement lies somewhere between the two forms of thought of intuition and analysis. The Cognitive Continuum suggests that we do not use just one or the other, but that most of our cognitive activity involves both intuition and analysis. The theory suggests that if the nature of the task is poorly structured, intuitive decision making is evoked, whilst a well structured task would initiate a more analytical approach. Generally speaking, the more clues that are presented, the more likely the professional is to use an intuitive approach. If the problem is complex and the clues ambiguous, then an analytical approach may be used. If applying this framework to system of triage in the accident unit and the use of the Manchester Triage System, it would appear that this theory has a founding. For example; A 10 year old boy presented to the unit with a history of a simple fall, where he landed on his arm, the presenting arm was very swollen and grossly deformed. The triage nurse had no need to utilise the discriminators and flow charts of the Manchester Triage System. Her own intuition gained from experience and knowledge told her that the possibility of the young mans arm being fractured were extremely high and clinical priority was given accordingly. However, an elderly patient who presented with the same swelling and deformity of her arm, could not explain how or why she fell. She experienced some dizziness but could not say whether she lost consciousness or not before or after the fall. A different priority was allocated to this patient after consulting the flow charts in order to determine the correct category due to the unknown risk factors of the individual case. The decision made in this case was more objective, the discriminators were not so clear cut so the use of the decision making tool was incorporated alongside the nurses own intuition and experience. Hamm (1988) also describes other factors, which may influence choice, such as the amount of time available for making the decision. If only a short time is available, perhaps due to the critical nature of the situation, an intuitive approach is likely to be used. This again can be seen in the decisions of the triage nurse, simple observation can sometimes be all that is needed to know that someone is “not quite right”. Hamm (1988) believes that intuitive thought involves very quick unconscious “data processing” that combines the information available by “averaging” it, it is low in consistency and fairly accurate. He describes analytical thoughts as slow, conscious and consistent, usually accurate, which combines information by organisational principles. Analysis, by definition, breaks things down so that we can gain better understanding whilst intuition retains wholeness, which may make it more attractive to the nurse for an holistic approach. Benner (1984) applied the work of Dreyfuss and Dreyfuss (1986) on skills acquisition and described five categories of skill level; Novice, advanced beginner, competent, proficient and expert. Benner suggested that with increased experience, situations are seen less as a minefield of separate tasks and more as a whole problem to be solved. The practitioner will move from being a detached observer to an involved performer. Novices are described by Benner (1984) as beginners with no experience of the situations in which they are expected to perform. They know the theory but have no practical experience and are not able to make clinical decisions. This can lead to limited and inflexible performance as the novice has to follow the rules and is unable to deviate from them. The novice cannot use intuition to make decisions because of the academic nature of their knowledge. Once the novice nurse reaches the advanced beginner stage they can give what Benner (1984) describes as “marginally acceptable performance” and begin to make basic decisions about small aspects of care. Although the advanced beginner has started to recognise patterns of care, she still needs help in priority setting. At the competent stage, the nurse begins to see actions in terms of long term goals and is able to prioritise. She can make multiple decisions about immediate and appropriate care and has the ability to cope with clinical demands on her time and has become more efficient and organised. Proficient performers perceive a situation as a whole because they understand its meaning in terms of long term goals. They have the experience to recognise whole situations. Proficient nurses use guidelines but know that they can have significance at one time but may mean something entirely different in another situation.
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