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Emergency department nurses need a good understanding of decision making theories to support their increasing autonomy and extended roles, says CATHERINE EVANS
There is increasing interest in understanding how nurses make decisions in clinical practice (Smith Higuchi and Donald 2002) and during triage assessment (Gerdtz and Bucknall 1999).
A clearer understanding of how decisions are made could, according to Buckingham and Adams (2000a), help assist multidisciplinary working and would be of benefit to nursing as a profession.
Nurses can better articulate the nature of their expertise and scope of their practice if they can rationalise and justify the professional decisions they make. This is particularly true in the context of changing nursing roles, where increasing autonomy and broadening of nurses' scope of practice require greater accountability and use of evidence based practice.
Decision making theory is particularly relevant to emergency nursing practice, where nurses are generally the first professionals to see and assess patients.
This is because emergency nurses regularly make clinical judgements based on minimal information in situations requiring rapid assessment and immediate intervention (Edwards 2000) and, because such decisions affect the subsequent management of patients, emergency nurses should be able to explain and justify them.
An ability to demonstrate accountability for practice by rationalising decisions is also important for both emergency nurse practitioners and those emergency nurses who take on expanded roles, including wound assessment and closure. X-ray requesting and giving analgesia at triage.
DECISION MAKING THEORIES
There is a wealth of literature on different decision making models, of which the four major ones are described briefly in Box 1.
The most recent literature suggests that no single theory can be applied universally, and that different theories are appropriate depending on their context and the experience of the decision makers (Elstein and Schwarz 2002, Offredy 1998).
Moreover, theories often overlap in different situations. For example, pattern recognition can be used to generate hypotheses, and hypotheticodeductive reasoning can become subconscious with experience, which leads to 'intuitive' decision making.
New ways of describing decision making that reflect this more flexible approach and recognises similarities between theories have been proposed (Elstein and Schwarz 2002).
For example, Thompson (1999) describes a continuum of decision making activity encompassing different theories, and Buckingham and Adams (2000a, 2000b) propose...