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Critical care outreach: The need for effective decision-making in clinical practice (Part 1)
Intensive and Critical Care Nursing (2007) 23, 15—22
ORIGINAL ARTICLE
Critical care outreach: The need for effective decision-making in clinical practice (Part 1) Helen C. Hancock a,∗, Lesley Durham b a
Centre for Integrated Health Care Research, School for Health, Durham University, United Kingdom b City Hospitals Sunderland NHS Foundation Trust, United Kingdom Accepted 12 June 2006
KEYWORDS Critical care outreach; Decision making; Knowledge that informs practice
Summary Since the publication of ‘Comprehensive Critical Care’ (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision ‘without walls’. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services. © 2006 Elsevier Ltd. All rights reserved.
Introduction It has become increasingly evident that there are patients at risk, as well as many deteriorating ∗
Corresponding author. Tel.: +44 191 3340378; fax: +44 191 3340374. E-mail addresses: [email protected] (H.C. Hancock), [email protected] (L. Durham).
on general wards, who need critical care (Audit Commission, 1999; DoH, 2000; Chellel et al., 2002; NCEPOD, 2005). Critical care outreach (CCOR) is part of a new approach to the management of these patients, irrespective of their location in a hospital. While such patients often have poor outcomes, the evidence suggests that many of these are avoidable through CCOR provision (McQuillan et al., 1998; Goldhill and Sumner, 1998; McGloin et al., 1999;
0964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2006.06.003
16 Priestly et al., 2004; Durham et al., 2004; NCEPOD, 2005). While isolated models of CCOR service provision were introduced during the late 1990s, the publication of comprehensive critical care (DoH, 2000) prompted a rapid introduction of these services in England and Wales. Charged with the management of all level one and two patients through collaborative partnerships with ward-based teams, its development has been diverse and, arguably, somewhat disordered. To some extent, local priorities, resources and enthusiasm have determined the introduction and, therefore, the characteristics of CCOR teams and services. Team configurations vary in relation to the number, grades (bands), educational preparation and disciplines of their members. To date, there is no evidence about what constitutes an optimal team, nor any nationally agreed standards for preoperational and ongoing educational programmes to prepare and support the level of decision making required by the professionals within them. As the extension of nursing into previously medical roles and the demand for evidence-based practice continue to increase, the quality of practitioners’ decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and the patient, especially in the provision of CCOR, in order to improve the outcomes of patient care and management. With changes in health care delivery and increased accountability for practitioners’ decisions, it is important that we understand more about how practitioners make clinical decisions and what factors influence them. The authors, a nurse consultant in CCOR and a Research Fellow, aim to address this area and to inform preparation for clinical decision making in CCOR. This, the first of two papers, will address the theoretical background of clinical decision making and the knowledge that underpins practice. In the second paper, through collaborative reflection and analysis of a case study, they bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services.
Decision making The ability of CCOR practitioners to make pertinent and timely clinical decisions is crucial in order to ensure the effective provision of patient care and management. While increasing, the process of clinical decision making receives relatively little atten-
H.C. Hancock, L. Durham tion in the literature. As a result, there is limited understanding about the correlation between information and the decisions reached. The literature that exists uses a number of terms interchangeably to describe clinical decision making, these include: decision making, judgement making, clinical judgement, clinical inference, clinical reasoning, diagnostic reasoning and problem solving. Essentially, these terms are interchangeable as they describe a ‘choice’ made by a practitioner from a number of alternatives. For the purposes of these two papers, whose focus is on ‘how’ practitioners choose a particular course of action, the term decision making will be used and the following definition applied: Clinical decision making refers to ‘‘. . . situations in which a choice is made from among a number of possible alternatives, often involving tradeoffs among . . . different outcomes’’ (Baumann and Deber, 1989, p. 1). Although it is not possible to include a systematic review of the decision making literature here, it is important to include a number of fundamental concepts and models as well as relevant literature in order to inform the discussion. CCOR teams include experienced health care professionals with expertise in the assessment and planning of care for patients at risk of critical illness (Coombs and Dillon, 2002). While many have multi-professional membership, the majority are comprised mainly of nurses with a critical care background. This reflects, to some degree, the increasing role of nurses in clinical decision making (RCN, 2005; DoH, 2003). Thompson et al. (1999) identified six key areas in which nurses made decisions. • Intervention/effectiveness: Choosing between interventions. • Targeting: Choosing which patient will most benefit from a given intervention. • Timing: Choosing the best time to carry out particular interventions. • Communication: Choices about information delivery to patients/families and colleagues. • Service organisation, delivery and management: Decisions about service delivery. • Experiential, understanding or hermeneutic: The interpretation of cues in the process of care. More recently, a joint Royal College of Nursing (RCN) and Department of Health (DH) funded survey (2005) of nurses working in advanced and extended roles, found that they spend 60% of their time in clinical activity, 17% in education, 14% in management activity and 4% in research. Core activities, which included patient assessment/referrals,
The need for effective decision-making in clinical practice (Part 1) autonomous decision making and offering specialist advice, were undertaken by 9 out of 10 respondents, with 97% reporting that a high level of autonomy is required in their role. Despite this and the fact that decision making is an increasingly crucial part of the CCOR practitioner’s role, there are few empirical studies that address actual decision making in these settings. CCOR practitioners operate at high levels of decision making and make decisions that have significant implications for patient outcomes. Much of the earlier literature on decision making is based on rationalist approaches such as information processing (discussed later) and involves the use of highly controlled decision tasks at the expense of the context in which clinical decisions are made (Bucknall, 2003). There is also an apparent lack of a means by which practitioners can share knowledge about their decision making (Aitken, 2003). It is imperative that a way of communicating professional decision making and the knowledge and experience that underpin the process is developed. While the discussion below is relevant to all practitioners, the reader is encouraged to read it with the CCOR practitioner in mind.
The process of decision making Three major approaches to the process of clinical decision making are described in the literature:
Information processing (systematic-positivist) models The move towards evidence based practice in health care has placed an emphasis on this approach to decision making. In this approach, analysis of a situation is carried out by the practitioner, any actions that follow are rational and logical and the practitioner is able to articulate the knowledge base underpinning the decision. The basis of these models is that short-term memory contains stimuli that ‘unlock’ knowledge in the long-term memory. This ‘unlocking’ comprises a four stage, hypothetico-deductive process (Thompson, 1999): Cue acquisition The practitioner gathers preliminary clinical information from a patient encounter (and readily available information), for example the patient appears flushed and vaso-dilated, temperature 38.5, respiratory rate 44, white cell count (WCC) 28.4, (normal range 4.0—11.0). These cues are the building blocks
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from which decisions are made about a patient’s state of health and treatment options. Dowie and Elstein (1988) suggest that these cues fall into one of three categories; technical cues; such as physiological parameters, interactive cues; information from the environment and the presence or absence of equipment and perceptual cues; such as body language and patient responses. Hypotheses generation Following the patient encounter, the practitioner generates a number of hypotheses (or differential diagnoses) that are related to the technical cues or preliminary clinical information, for example, from the cues above: Hypotheses: Is this Sepsis or is this a systemic inflammatory response (SIRS) from some other cause? The practitioner looks for interactive and perceptual cues to inform these: Is it hot in the room? Has the patient just had a bath? Has the patient recently exercised? Is the patient retaining carbon dioxide? Is it an anaphylactic reaction? How did the patient respond? How is the patient positioned?
Interpretation The practitioner interprets the cues and hypotheses drawn from them, classifying them as likely, unlikely or inconsequential, for example: Neither taking a bath nor exercise are likely causes, anaphylaxis is also unlikely as the patient’s blood pressure is maintained and he/she has not received any medication. Decision The practitioner weighs up the pros and cons of each decision alternative and chooses the one most favoured by the evidence for example, given elevated temperature and increased WCC, sepsis is most likely. According to this approach, decision making appears a simple and linear process, involving the rational assessment of alternatives and the selection of a clear course of action. Referred to as ‘rationalist’ (Harbison, 1991) or ‘decision analysis’ (Baumann and Deber, 1989), this view is derived from a research tradition that has tended to involve controlled, laboratory-based investigations of decision making about hypothetical situations. While recognising the value of the approach, the authors support the belief that such a view ignores the complexities of actual decision making. In clinical practice, practitioners are faced with ‘messy’, dynamic, complex situations including relationships, hierarchy, ownership, experience, levels of responsibility, confidence, knowledge and competence, which
18 affect their decision making (Hancock and Easen, 2004).
Intuitive-humanist approaches These approaches emphasise the progress of the individual from that of a novice, where he or she relies on theory and reduces situations into discrete parts, to expert, where decision making is based on experience and considers situations holistically (Dreyfus and Dreyfus, unpublished; Benner, 1984). Novices, for example, may not recognise the relationship(s) between cues and states of health. As a result, the novice tends to believe that if a cue is present there is a 100% chance of a particular state of health, e.g. in intensive care: a normal PaO2 on an arterial blood gas result is seen as a definitive sign of a patient’s readiness for extubation, rather than as one of a number of parameters. Similarly, in the ward environment, anuria in a catheterised patient is attributed to hypovolaemia, rather than a catheter blockage. Experienced practitioners not only have greater knowledge for decision making, they have also developed knowledge structures that enable them to identify more cues and to make better use of these during decision making about patient care. Many practitioners attribute at least some of their decision making to intuition and see it as a valid and valuable part of their practice. Intuition is however, often viewed as inferior to information processing and not regarded as ‘legitimate knowledge’. Benner’s (1984) definition of intuition as ‘understanding without rationale’ has done little to change this view. It is met by criticism from those who believe that ‘‘intuition’’ involves the use of a sound rational, relevant knowledge base in situations that, through experience, are so familiar that the person has learned to recognise and act on appropriate patterns in the presenting problem’’ (Easen and Wilcockson, 1996, p. 672). Motivation for an intuitive decision is not only based on the task or situation faced, but is dependent upon the individual undertaking it. An expert decision maker, for example, does not rely on guiding rules, but has an intuitive grasp of situations, only reverting to an information-processing approach when new or unexpected situations are faced.
Cognitive continuum theory This approach views information-processing and intuitive-humanist approaches as being at opposite ends of a (cognitive) continuum, rather than as separate entities. The basis of the theory is that practitioner cognition is neither purely intuitive nor
H.C. Hancock, L. Durham purely analytical, but that it is commonly located at some point in between (Hamm, 1988). According to this theory, decision making approaches are dictated by the task or decision faced. This has three dimensions: • The structural complexity, for example, the number of cues present. • The ambiguity of the task, for example, how clear a diagnosis or treatment option(s) are. • The way in which the decision task is presented, for example, subjective or objective cues. According to this theory, practitioners need to be competent in information seeking strategies as well as possessing a good foundation of theoretical knowledge. The cognitive continuum theory differs from the information-processing model in its inclusion of the variables of power, social structure and individual knowledge. It recognises that decision making is a complex process affected by a number of factors, which include: knowledge, experience, responsibility, relationships, the individual, context and power.
Evidence to inform practice Clinical decisions should be based on best evidence. It is important, therefore, to consider what constitutes best evidence, how it is derived and what factors affect its application. Evidence may be defined as ‘information indicating whether a belief or proposition is true or valid’ (Concise English Dictionary, 2001). The popular conception of science teaches us that science is a collection of facts that are reproducible and repeatable. An underlying assumption of evidence based practice is that science based (systematic-positivist) evidence will tell us what the most successful and cost-effective approaches to health care are. As a result, the culture of health care has given privileged status to evidence derived from systematic-positivist research, such as the randomised controlled trial (RCT), which is seen as the ‘‘gold standard’’ in evidence of effectiveness (see Table 1). Although its proponents would argue that evidence based practice is not limited to the utilisation of the results of empirical research, there has been considerable emphasis placed on RCTs and meta-analyses. This has drawn criticism from those who regard qualitative research methods as equally valid forms of research. While the RCT is probably the ‘‘best’’ approach to generating evidence of effectiveness, health professionals are concerned with more than cause and effect questions. This is reflected by the
The need for effective decision-making in clinical practice (Part 1) Table 1
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Hierarchy of evidence
Adapted from Agency for Health Care Policy & Research, USA (1992).
wide range of research approaches utilised to generate knowledge for practice in health care. Practitioners and patients are faced with situations of uncertainty, instability and complexity that are unique and unsolvable by the strict application of information processing approaches. Each patient is an individual with physical, social and emotional needs. Situations in the clinical area and particularly in CCOR, are not limited to medical and technical interventions and treatments, but include the culture and context in which they take place as well as the relationships, practices, attitudes, beliefs and values encountered.
Types of knowledge Knowledge is fundamental to the definition, delineation, description and operation of a profession (Higgs and Titchen, 1995). It is essential for reasoning and decision making, both of which are central to clinical practice. There are a number of types of knowledge that are used to inform practitioners’ decision making. These include: Knowledge from evidence The decisions made by practitioners delivering services are informed by evidence from a number of sources. The advent of National Service Frameworks (NSFs), The Commission for Health Improvement (CHI) and the National Institute for
Health and Clinical Excellence (NICE), mean that evidence based approaches to health care have become firmly established in research, professional and policy agendas. Practitioners and increasingly patients, are the vehicles through which research and evidence based approaches to healthcare are applied. Practical knowledge The literature refers to numerous theories regarding the development of practical knowledge and skills. The most widely known in nursing is that of The Model of Skill Acquisition (Benner, 1984). Based on ascending levels of proficiency, the model refers to the process of ongoing development from that of novice, through competent to expert practitioner. Originally developed by Dreyfus and Dreyfus (unpublished), it was generalised to nursing by Benner (1984) and has been accepted by educationalists and practitioners. The model refers to the process of ongoing development as the nurse progresses through five stages of development: (i) novice, (ii) advanced beginner, (iii) competent, (iv) proficient and (v) expert practitioner. He/she moves from a (novice) stage of a reliance on theory and reducing situations into discrete parts, to (expert) decision making about whole situations. Benner et al. (1992) asserts that, in learning, changes in four general aspects of performance take place:
20 (1) Movement from a reliance on abstract principles and rules to the use of past, concrete experience. (2) A shift from a reliance on analytic rule based thinking to intuition. (3) Change in the practitioner’s perception of the situation from one in which it is viewed as a compilation of equally relevant parts, to a complex whole, in which certain parts are relevant. (4) Passage from a detached observer, standing outside the situation to one of a position of full engagement in the situation (Benner et al., 1992). Experiential learning theory (Dewey, 1938; Lewin, 1951; Piaget, 1970; Kolb, 1984) offers an alternative to theories of learning such as that of Benner (1984). Recent work highlights the crucial, but frequently forgotten, difference between learning from experience and experiential learning. Learning from experience, which reflects that described by Benner (1984), takes place in everyday contexts. In contrast, experiential knowledge is key to a discourse that constructs experience as something from which knowledge can be derived, through dynamic and transformative processes such as observation and reflection (Usher and Solomon, 1999). According to experiential learning theory, learning is a process of creating knowledge. Knowledge is the result of the transaction between social knowledge: the objective accumulation of previous experience and personal knowledge: the accumulation of an individual’s subjective life experiences (Dewey, 1938). Knowledge results from the transaction between these objective and subjective experiences. Learning and, therefore, knowing requires the representation and transformation of experience. The perception of experience is not sufficient for learning; something must be done with it (Kolb, 1984). Within clinical practice in health care, the translation of knowledge into action (i.e. the translation of what one knows into what one does) combines five fundamental types of knowledge that are necessary for the practice of professional nursing (Carper, 1978). While Carper (1978) refers specifically to nursing knowledge, the following apply to all practitioners: (1) Empirics: The science of nursing knowledge. This knowledge is typically gained through formal education (e.g. anatomy, physiology, pharmacology), it aims to test, explain, describe and predict theories through systematic investigation.
H.C. Hancock, L. Durham (2) Aesthetics: The art of nursing knowledge. Such knowledge is gained through experience and is concerned with the particular rather then universal phenomena; it is expressed as intuition and made visible by action. (3) Personal knowledge: Self-understanding. This is ‘‘concerned with the knowing, encountering and actualizing the concrete, individual self’’ (Carper, 1978, p. 220) so that the therapeutic use of ones self is possible. Knowing the self and, the ability to trust ones self, is something all independent practitioners have to learn as new services, such as CCOR, develop. (4) Ethics: The moral component of nursing. This concept focuses on issues of duty and responsibility. It extends beyond knowledge of ethical codes and conduct to include the ability to discriminate and make moral judgements in complex situations. This involves acting as an advocate for others. (5) Socio-political: The context of nursing. This addresses the context within which nurses and others work, as well as nursing practice from society’s perspective and that of the nursing profession. Such knowing is operationalised through knowledge of health care systems, which includes organizational and contextual understanding and health policy (White, 1995). All five types of knowing are crucial, interrelated and interdependent elements of practice. There is not however, a simple connection between knowing how to do something and being able to do it; theoretical knowledge has to be transformed into and applied as practical knowledge. The former is simply a method of knowing how to do something, focused solely on the task, the latter, on the other hand, goes beyond knowing how to knowing what to do when, doing the right thing at the right time and knowing the limits of knowledge. Intuition As previously indicated, scientific, rational and linear methods of reasoning are frequently regarded as ‘real thinking’. For many, intuition is not ’legitimate knowledge’, for others however; intuition is recognised as a valuable element of knowledge. Expert practitioners, for example, have included ‘gut feelings’ when they list the various factors that influence their decision making. For some practitioners ‘gut feelings’ refer to a ‘falling out of pattern’ in the signs and symptoms of a patient, while for others it means an ‘intuitive’ feeling. The experience of making an intuitive decision is not only disconcerting for a number of practitioners
The need for effective decision-making in clinical practice (Part 1) but, at least for some, is also considered to be in some way unprofessional, with intuitive judgements being compared unfavourably with rational, linear, scientific decision making. Easen and Wilcockson (1996) believe that the confusion associated with intuition stems from the mistaken belief that intuition is an irrational process. They distinguish between its process and content, so that, while intuition may be seen as an irrational process, the basis of the intuitive decision need not be so. In their view, the nature of the knowledge and pattern recognition used by the intuiter is rooted in past learning and experience. Tacit knowledge Tacit knowledge is another term used to describe the knowledge that professionals use but find difficult to articulate. Polanyi (1958) addressed the limitations of scientific knowledge and concluded that ‘‘... to the extent to which our intelligence falls short of the ideal of precise formalisation, we act and see by the light of unspecifiable knowledge’’ (Polanyi, 1958, p. 53). Tacit knowledge emerges from experience and become almost intuitive as practitioners act without necessarily being consciously aware of the knowledge they have. Eraut (1994) explains how tacit knowledge develops in relation to skilled behaviour. He refers to conscious or semi-conscious pattern recognition that takes place during professional activity. Complex actions can become so routine that they are carried out semi-automatically. Expert practitioners, for example, view situations holistically and much of their knowledge is embedded in their practice. As a practitioner learns to perform a skill, he/she becomes increasingly less conscious of the means by which he/she carries this out. Eventually he/she is unable to describe the components of a skill, with any attempt to break it down resulting in his/her inability to perform. Knowledge from reflection Reflection is both an essential and enlightening skill and the foundation of advanced practice. Reflection about thought and action provides a strategy for promoting deliberation about one’s practice within the context of particular clinical situations (Schon, 1987; Harris, 1993). It occurs when practitioners contemplate past clinical situations, especially those that were puzzling, troublesome or particularly interesting. While there are numerous theoretical accounts and definitions of reflective practice in the literature, one developed by Harbison (1991) in a review of Schon’s (1987) work is applicable here. Harbison (1991, p. 404) defined the
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reflective practitioner as: ‘‘... one who constantly ‘watches’ herself in action: discovers and acknowledges the limits of her expertise, attempts to extend this ... she is professionally mature enough to reveal uncertainty, and accept the risks inherent in all decision making.’’ It is suggested that, if considered from a purely theoretical point of view, reflection can ‘switch off’ the reflector and that it is important to apply reflection to practice situations. Practitioners’ decision making takes place within a context where both decisions made and outcomes reached need to be considered. Unpicking these in order to inform future decision making is vital to ensure clinical competence. The definition above recognises the central role that experiential learning plays in the development of competence and emphasises the individual’s responsibility to maintain and increase the level of that competence. Reflection has been hugely influential in elucidating the tacit knowledge and intuition that underpin clinical practice as well as providing insight into the process of applying knowledge into practice. Since reflection occurs after a particular event, the knowledge gained usually cannot make a difference to the event at hand. It can, however, influence clinical decision making in similar (future) situations. Collaborative reflection: in depth discussion and reflection with a colleague, is important in order to enhance the individual’s ability to effectively evaluate his/her own knowledge and decision making.
Conclusion Changes to the roles of health care practitioners, with particular reference to CCOR practitioners in the context of this discussion, means that their decisions have a significant impact on health care outcomes and patients’ experiences. As both the extension of roles and the demand for evidencebased practice have increased, competent decisions have become imperative. With such changes, accountability for practitioners’ decisions has also increased. This paper has addressed the theoretical background of decision making and the knowledge that underpins practice. In doing so, it informs further discussion of the factors that inform and influence practitioners’ decision making. In their next paper, the authors examine the realities of a CCOR practitioners’ decision making in context. Collaborative reflection is used to analyse the thoughts and actions of a critical care nurse consultant in the management of a patient referred to the critical care outreach team.
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References Agency for Health Care Policy Research. US department of health and human services: public health service. USA: Agency for Health Care Policy & Research Publications Rockville; 1992. Aitken LM. Critical care nurses’ use of decision makingstrategies. J Clin Nurs 2003;12:476—83. Audit Commission, 1999. Critical to success: the place of efficient and effective critical care services within the acute hospital. London, Audit Commission. Baumann A, Deber R. Decision making and problem solving in nursing: an overview and analysis of relevant literature. Faculty of Nursing, University of Toronto; 1989. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park: Addison Wesley; 1984. Benner P, Tanner C, Chelsea C. From beginner to expert gaining a differentiated clinical world in critical care nursing. Adv Nurs Sci 1992;14(3):13—28. Bucknall T. The clinical landscape of critical care: nurses’ decision making. J Adv Nurs 2003;43(3):310—9. Carper BA. Fundamental patterns of knowing in nursing. Adv Nurs Sci 1978;11(1):3—11. Chellel A, Fraser J, Fender V, Higgs D, Buras-Rees S, Cook C, et al. Nursing observations on ward patients at risk of critical illness. Nursing Times 2002;98(46):36—9. Concise English Dictionary, 2001. Oxford University Press, Oxford. Coombs M, Dillon A. Crossing boundaries, re-defining care: the role of the critical care outreach team. J Clin Nurs 2002;11:387—93. Department of Health. Comprehensive critical care: a review of adult critical care services. London: The Stationary Office; 2000. Department of Health. Critical care outreach. Progress in developing services. London: The Stationary Office; 2003. Dewey J. Experience and education. New York: Kappa Delta; 1938. Dowie J, Elstein A. Introduction to professional judgment. In: Dowie J, Elstein A, editors. Professional judgment: a reader in clinical decision-making. Cambridge: Cambridge University Press; 1988. Dreyfus H, Dreyfus S. A five stage model of the mental activities involved in directed skill acquisition. University Of California Berkley, unpublished study. Durham LK, Thompson C, Cunningham L, Carpenter MR. The effect of introduction of a Critical Care Outreach team on cardiac arrest calls in a District General Hospital. Intensive Care Society State of the Art Meeting Dec. 2004. Easen P, Wilcockson J. Intuition and rational decision making in professional thinking: a false dichotomy? J Adv Nurs 1996;24:667—73. Eraut M. Developing professional knowledge and competence. London: Falmer Press; 1994. Goldhill DR, Sumner A. Outcome of intensive care patients in a group of British intensive care units. Crit Care Med 1998;26:1337—45.
H.C. Hancock, L. Durham Hamm RM. Clinical intuition and clinical analysis: expertise and the cognition continuum. In: Dowie J, Elstein A, editors. Professional judgment: a reader in clinical decision-making. Cambridge: Cambridge University Press; 1988. Hancock HC, Easen PR. Evidence based practice: an incomplete model of the relationship between theory and professional work. J Eval Clin Pract 2004;10(2):187—96. Harbison J. Clinical decision making in nursing. J Adv Nurs 1991;16:404—7. Harris JB. New expectations for professional competence. In: Curry L, Wergin J, editors. Educating professionals: responding to the new expectations of competence and accountability. San Francisco: Josey Bass; 1993. p. 17—22. Higgs J, Titchen A. Propositional, professional and personal knowledge in clinical reasoning. In: Higgs J, Jones M, editors. Clinical reasoning in the health professions. London: Butterworth Heinmann; 1995. Kolb DA. Experiential learning: experience as the source of learning and development. USA: Prentice Hall; 1984. Lewin K. Field theory and social sciences. New York: Harper And Row; 1951. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?, vol. 33. London: JR College Physicians; 1999, 255—258. McQuillan P, Pilkington F, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. Br Med J 1998;316:1853—8. NCEPOD. An acute problem? A report of the National Confidential Enquiry into Patient Outcome and Death, 2005. Piaget J. Genetic epistemology. New York: Columbia University Press; 1970. Polanyi M. Personal knowledge: towards a post-critical philosophy. London: Routledge & Kegan Paul; 1958. Priestly G, Watson W, Rashidian A, Mozley C, Russel D, Wilson J, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 2004;30(7):1398—404. RCN. Maxi nurses: nurses working in advanced and extended roles promoting and developing patient-centered health. London: RCN; 2005. Schon DA. Educating the reflective practitioner. San Francisco: Jossey Bass; 1987. Thompson C. A conceptual treadmill: the need for ‘middle ground’ in clinical decision making theory in nursing. J Adv Nurs 1999;30(5):1222—9. Thompson C, MaCaughan D, Cullum N, Sheldon T, Thomspon D, Mulhall A. Nurses’ use of research information in clinical decision making: A descriptive and analytical study. 1999; http: www.york.ac.uk/healthsciences/centres/evidence/decrpt. pdf. Usher R, Solomon N. Experiential learning and the shaping of subjectivity in the workplace. Stud Educ Adults 1999;31(2):155—63. White J. Patterns of knowing: review, critique and update. Adv Nurs Sci 1995;17:73—85.
ORIGINAL ARTICLE
Critical care outreach: The need for effective decision-making in clinical practice (Part 1) Helen C. Hancock a,∗, Lesley Durham b a
Centre for Integrated Health Care Research, School for Health, Durham University, United Kingdom b City Hospitals Sunderland NHS Foundation Trust, United Kingdom Accepted 12 June 2006
KEYWORDS Critical care outreach; Decision making; Knowledge that informs practice
Summary Since the publication of ‘Comprehensive Critical Care’ (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision ‘without walls’. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services. © 2006 Elsevier Ltd. All rights reserved.
Introduction It has become increasingly evident that there are patients at risk, as well as many deteriorating ∗
Corresponding author. Tel.: +44 191 3340378; fax: +44 191 3340374. E-mail addresses: [email protected] (H.C. Hancock), [email protected] (L. Durham).
on general wards, who need critical care (Audit Commission, 1999; DoH, 2000; Chellel et al., 2002; NCEPOD, 2005). Critical care outreach (CCOR) is part of a new approach to the management of these patients, irrespective of their location in a hospital. While such patients often have poor outcomes, the evidence suggests that many of these are avoidable through CCOR provision (McQuillan et al., 1998; Goldhill and Sumner, 1998; McGloin et al., 1999;
0964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2006.06.003
16 Priestly et al., 2004; Durham et al., 2004; NCEPOD, 2005). While isolated models of CCOR service provision were introduced during the late 1990s, the publication of comprehensive critical care (DoH, 2000) prompted a rapid introduction of these services in England and Wales. Charged with the management of all level one and two patients through collaborative partnerships with ward-based teams, its development has been diverse and, arguably, somewhat disordered. To some extent, local priorities, resources and enthusiasm have determined the introduction and, therefore, the characteristics of CCOR teams and services. Team configurations vary in relation to the number, grades (bands), educational preparation and disciplines of their members. To date, there is no evidence about what constitutes an optimal team, nor any nationally agreed standards for preoperational and ongoing educational programmes to prepare and support the level of decision making required by the professionals within them. As the extension of nursing into previously medical roles and the demand for evidence-based practice continue to increase, the quality of practitioners’ decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and the patient, especially in the provision of CCOR, in order to improve the outcomes of patient care and management. With changes in health care delivery and increased accountability for practitioners’ decisions, it is important that we understand more about how practitioners make clinical decisions and what factors influence them. The authors, a nurse consultant in CCOR and a Research Fellow, aim to address this area and to inform preparation for clinical decision making in CCOR. This, the first of two papers, will address the theoretical background of clinical decision making and the knowledge that underpins practice. In the second paper, through collaborative reflection and analysis of a case study, they bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services.
Decision making The ability of CCOR practitioners to make pertinent and timely clinical decisions is crucial in order to ensure the effective provision of patient care and management. While increasing, the process of clinical decision making receives relatively little atten-
H.C. Hancock, L. Durham tion in the literature. As a result, there is limited understanding about the correlation between information and the decisions reached. The literature that exists uses a number of terms interchangeably to describe clinical decision making, these include: decision making, judgement making, clinical judgement, clinical inference, clinical reasoning, diagnostic reasoning and problem solving. Essentially, these terms are interchangeable as they describe a ‘choice’ made by a practitioner from a number of alternatives. For the purposes of these two papers, whose focus is on ‘how’ practitioners choose a particular course of action, the term decision making will be used and the following definition applied: Clinical decision making refers to ‘‘. . . situations in which a choice is made from among a number of possible alternatives, often involving tradeoffs among . . . different outcomes’’ (Baumann and Deber, 1989, p. 1). Although it is not possible to include a systematic review of the decision making literature here, it is important to include a number of fundamental concepts and models as well as relevant literature in order to inform the discussion. CCOR teams include experienced health care professionals with expertise in the assessment and planning of care for patients at risk of critical illness (Coombs and Dillon, 2002). While many have multi-professional membership, the majority are comprised mainly of nurses with a critical care background. This reflects, to some degree, the increasing role of nurses in clinical decision making (RCN, 2005; DoH, 2003). Thompson et al. (1999) identified six key areas in which nurses made decisions. • Intervention/effectiveness: Choosing between interventions. • Targeting: Choosing which patient will most benefit from a given intervention. • Timing: Choosing the best time to carry out particular interventions. • Communication: Choices about information delivery to patients/families and colleagues. • Service organisation, delivery and management: Decisions about service delivery. • Experiential, understanding or hermeneutic: The interpretation of cues in the process of care. More recently, a joint Royal College of Nursing (RCN) and Department of Health (DH) funded survey (2005) of nurses working in advanced and extended roles, found that they spend 60% of their time in clinical activity, 17% in education, 14% in management activity and 4% in research. Core activities, which included patient assessment/referrals,
The need for effective decision-making in clinical practice (Part 1) autonomous decision making and offering specialist advice, were undertaken by 9 out of 10 respondents, with 97% reporting that a high level of autonomy is required in their role. Despite this and the fact that decision making is an increasingly crucial part of the CCOR practitioner’s role, there are few empirical studies that address actual decision making in these settings. CCOR practitioners operate at high levels of decision making and make decisions that have significant implications for patient outcomes. Much of the earlier literature on decision making is based on rationalist approaches such as information processing (discussed later) and involves the use of highly controlled decision tasks at the expense of the context in which clinical decisions are made (Bucknall, 2003). There is also an apparent lack of a means by which practitioners can share knowledge about their decision making (Aitken, 2003). It is imperative that a way of communicating professional decision making and the knowledge and experience that underpin the process is developed. While the discussion below is relevant to all practitioners, the reader is encouraged to read it with the CCOR practitioner in mind.
The process of decision making Three major approaches to the process of clinical decision making are described in the literature:
Information processing (systematic-positivist) models The move towards evidence based practice in health care has placed an emphasis on this approach to decision making. In this approach, analysis of a situation is carried out by the practitioner, any actions that follow are rational and logical and the practitioner is able to articulate the knowledge base underpinning the decision. The basis of these models is that short-term memory contains stimuli that ‘unlock’ knowledge in the long-term memory. This ‘unlocking’ comprises a four stage, hypothetico-deductive process (Thompson, 1999): Cue acquisition The practitioner gathers preliminary clinical information from a patient encounter (and readily available information), for example the patient appears flushed and vaso-dilated, temperature 38.5, respiratory rate 44, white cell count (WCC) 28.4, (normal range 4.0—11.0). These cues are the building blocks
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from which decisions are made about a patient’s state of health and treatment options. Dowie and Elstein (1988) suggest that these cues fall into one of three categories; technical cues; such as physiological parameters, interactive cues; information from the environment and the presence or absence of equipment and perceptual cues; such as body language and patient responses. Hypotheses generation Following the patient encounter, the practitioner generates a number of hypotheses (or differential diagnoses) that are related to the technical cues or preliminary clinical information, for example, from the cues above: Hypotheses: Is this Sepsis or is this a systemic inflammatory response (SIRS) from some other cause? The practitioner looks for interactive and perceptual cues to inform these: Is it hot in the room? Has the patient just had a bath? Has the patient recently exercised? Is the patient retaining carbon dioxide? Is it an anaphylactic reaction? How did the patient respond? How is the patient positioned?
Interpretation The practitioner interprets the cues and hypotheses drawn from them, classifying them as likely, unlikely or inconsequential, for example: Neither taking a bath nor exercise are likely causes, anaphylaxis is also unlikely as the patient’s blood pressure is maintained and he/she has not received any medication. Decision The practitioner weighs up the pros and cons of each decision alternative and chooses the one most favoured by the evidence for example, given elevated temperature and increased WCC, sepsis is most likely. According to this approach, decision making appears a simple and linear process, involving the rational assessment of alternatives and the selection of a clear course of action. Referred to as ‘rationalist’ (Harbison, 1991) or ‘decision analysis’ (Baumann and Deber, 1989), this view is derived from a research tradition that has tended to involve controlled, laboratory-based investigations of decision making about hypothetical situations. While recognising the value of the approach, the authors support the belief that such a view ignores the complexities of actual decision making. In clinical practice, practitioners are faced with ‘messy’, dynamic, complex situations including relationships, hierarchy, ownership, experience, levels of responsibility, confidence, knowledge and competence, which
18 affect their decision making (Hancock and Easen, 2004).
Intuitive-humanist approaches These approaches emphasise the progress of the individual from that of a novice, where he or she relies on theory and reduces situations into discrete parts, to expert, where decision making is based on experience and considers situations holistically (Dreyfus and Dreyfus, unpublished; Benner, 1984). Novices, for example, may not recognise the relationship(s) between cues and states of health. As a result, the novice tends to believe that if a cue is present there is a 100% chance of a particular state of health, e.g. in intensive care: a normal PaO2 on an arterial blood gas result is seen as a definitive sign of a patient’s readiness for extubation, rather than as one of a number of parameters. Similarly, in the ward environment, anuria in a catheterised patient is attributed to hypovolaemia, rather than a catheter blockage. Experienced practitioners not only have greater knowledge for decision making, they have also developed knowledge structures that enable them to identify more cues and to make better use of these during decision making about patient care. Many practitioners attribute at least some of their decision making to intuition and see it as a valid and valuable part of their practice. Intuition is however, often viewed as inferior to information processing and not regarded as ‘legitimate knowledge’. Benner’s (1984) definition of intuition as ‘understanding without rationale’ has done little to change this view. It is met by criticism from those who believe that ‘‘intuition’’ involves the use of a sound rational, relevant knowledge base in situations that, through experience, are so familiar that the person has learned to recognise and act on appropriate patterns in the presenting problem’’ (Easen and Wilcockson, 1996, p. 672). Motivation for an intuitive decision is not only based on the task or situation faced, but is dependent upon the individual undertaking it. An expert decision maker, for example, does not rely on guiding rules, but has an intuitive grasp of situations, only reverting to an information-processing approach when new or unexpected situations are faced.
Cognitive continuum theory This approach views information-processing and intuitive-humanist approaches as being at opposite ends of a (cognitive) continuum, rather than as separate entities. The basis of the theory is that practitioner cognition is neither purely intuitive nor
H.C. Hancock, L. Durham purely analytical, but that it is commonly located at some point in between (Hamm, 1988). According to this theory, decision making approaches are dictated by the task or decision faced. This has three dimensions: • The structural complexity, for example, the number of cues present. • The ambiguity of the task, for example, how clear a diagnosis or treatment option(s) are. • The way in which the decision task is presented, for example, subjective or objective cues. According to this theory, practitioners need to be competent in information seeking strategies as well as possessing a good foundation of theoretical knowledge. The cognitive continuum theory differs from the information-processing model in its inclusion of the variables of power, social structure and individual knowledge. It recognises that decision making is a complex process affected by a number of factors, which include: knowledge, experience, responsibility, relationships, the individual, context and power.
Evidence to inform practice Clinical decisions should be based on best evidence. It is important, therefore, to consider what constitutes best evidence, how it is derived and what factors affect its application. Evidence may be defined as ‘information indicating whether a belief or proposition is true or valid’ (Concise English Dictionary, 2001). The popular conception of science teaches us that science is a collection of facts that are reproducible and repeatable. An underlying assumption of evidence based practice is that science based (systematic-positivist) evidence will tell us what the most successful and cost-effective approaches to health care are. As a result, the culture of health care has given privileged status to evidence derived from systematic-positivist research, such as the randomised controlled trial (RCT), which is seen as the ‘‘gold standard’’ in evidence of effectiveness (see Table 1). Although its proponents would argue that evidence based practice is not limited to the utilisation of the results of empirical research, there has been considerable emphasis placed on RCTs and meta-analyses. This has drawn criticism from those who regard qualitative research methods as equally valid forms of research. While the RCT is probably the ‘‘best’’ approach to generating evidence of effectiveness, health professionals are concerned with more than cause and effect questions. This is reflected by the
The need for effective decision-making in clinical practice (Part 1) Table 1
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Hierarchy of evidence
Adapted from Agency for Health Care Policy & Research, USA (1992).
wide range of research approaches utilised to generate knowledge for practice in health care. Practitioners and patients are faced with situations of uncertainty, instability and complexity that are unique and unsolvable by the strict application of information processing approaches. Each patient is an individual with physical, social and emotional needs. Situations in the clinical area and particularly in CCOR, are not limited to medical and technical interventions and treatments, but include the culture and context in which they take place as well as the relationships, practices, attitudes, beliefs and values encountered.
Types of knowledge Knowledge is fundamental to the definition, delineation, description and operation of a profession (Higgs and Titchen, 1995). It is essential for reasoning and decision making, both of which are central to clinical practice. There are a number of types of knowledge that are used to inform practitioners’ decision making. These include: Knowledge from evidence The decisions made by practitioners delivering services are informed by evidence from a number of sources. The advent of National Service Frameworks (NSFs), The Commission for Health Improvement (CHI) and the National Institute for
Health and Clinical Excellence (NICE), mean that evidence based approaches to health care have become firmly established in research, professional and policy agendas. Practitioners and increasingly patients, are the vehicles through which research and evidence based approaches to healthcare are applied. Practical knowledge The literature refers to numerous theories regarding the development of practical knowledge and skills. The most widely known in nursing is that of The Model of Skill Acquisition (Benner, 1984). Based on ascending levels of proficiency, the model refers to the process of ongoing development from that of novice, through competent to expert practitioner. Originally developed by Dreyfus and Dreyfus (unpublished), it was generalised to nursing by Benner (1984) and has been accepted by educationalists and practitioners. The model refers to the process of ongoing development as the nurse progresses through five stages of development: (i) novice, (ii) advanced beginner, (iii) competent, (iv) proficient and (v) expert practitioner. He/she moves from a (novice) stage of a reliance on theory and reducing situations into discrete parts, to (expert) decision making about whole situations. Benner et al. (1992) asserts that, in learning, changes in four general aspects of performance take place:
20 (1) Movement from a reliance on abstract principles and rules to the use of past, concrete experience. (2) A shift from a reliance on analytic rule based thinking to intuition. (3) Change in the practitioner’s perception of the situation from one in which it is viewed as a compilation of equally relevant parts, to a complex whole, in which certain parts are relevant. (4) Passage from a detached observer, standing outside the situation to one of a position of full engagement in the situation (Benner et al., 1992). Experiential learning theory (Dewey, 1938; Lewin, 1951; Piaget, 1970; Kolb, 1984) offers an alternative to theories of learning such as that of Benner (1984). Recent work highlights the crucial, but frequently forgotten, difference between learning from experience and experiential learning. Learning from experience, which reflects that described by Benner (1984), takes place in everyday contexts. In contrast, experiential knowledge is key to a discourse that constructs experience as something from which knowledge can be derived, through dynamic and transformative processes such as observation and reflection (Usher and Solomon, 1999). According to experiential learning theory, learning is a process of creating knowledge. Knowledge is the result of the transaction between social knowledge: the objective accumulation of previous experience and personal knowledge: the accumulation of an individual’s subjective life experiences (Dewey, 1938). Knowledge results from the transaction between these objective and subjective experiences. Learning and, therefore, knowing requires the representation and transformation of experience. The perception of experience is not sufficient for learning; something must be done with it (Kolb, 1984). Within clinical practice in health care, the translation of knowledge into action (i.e. the translation of what one knows into what one does) combines five fundamental types of knowledge that are necessary for the practice of professional nursing (Carper, 1978). While Carper (1978) refers specifically to nursing knowledge, the following apply to all practitioners: (1) Empirics: The science of nursing knowledge. This knowledge is typically gained through formal education (e.g. anatomy, physiology, pharmacology), it aims to test, explain, describe and predict theories through systematic investigation.
H.C. Hancock, L. Durham (2) Aesthetics: The art of nursing knowledge. Such knowledge is gained through experience and is concerned with the particular rather then universal phenomena; it is expressed as intuition and made visible by action. (3) Personal knowledge: Self-understanding. This is ‘‘concerned with the knowing, encountering and actualizing the concrete, individual self’’ (Carper, 1978, p. 220) so that the therapeutic use of ones self is possible. Knowing the self and, the ability to trust ones self, is something all independent practitioners have to learn as new services, such as CCOR, develop. (4) Ethics: The moral component of nursing. This concept focuses on issues of duty and responsibility. It extends beyond knowledge of ethical codes and conduct to include the ability to discriminate and make moral judgements in complex situations. This involves acting as an advocate for others. (5) Socio-political: The context of nursing. This addresses the context within which nurses and others work, as well as nursing practice from society’s perspective and that of the nursing profession. Such knowing is operationalised through knowledge of health care systems, which includes organizational and contextual understanding and health policy (White, 1995). All five types of knowing are crucial, interrelated and interdependent elements of practice. There is not however, a simple connection between knowing how to do something and being able to do it; theoretical knowledge has to be transformed into and applied as practical knowledge. The former is simply a method of knowing how to do something, focused solely on the task, the latter, on the other hand, goes beyond knowing how to knowing what to do when, doing the right thing at the right time and knowing the limits of knowledge. Intuition As previously indicated, scientific, rational and linear methods of reasoning are frequently regarded as ‘real thinking’. For many, intuition is not ’legitimate knowledge’, for others however; intuition is recognised as a valuable element of knowledge. Expert practitioners, for example, have included ‘gut feelings’ when they list the various factors that influence their decision making. For some practitioners ‘gut feelings’ refer to a ‘falling out of pattern’ in the signs and symptoms of a patient, while for others it means an ‘intuitive’ feeling. The experience of making an intuitive decision is not only disconcerting for a number of practitioners
The need for effective decision-making in clinical practice (Part 1) but, at least for some, is also considered to be in some way unprofessional, with intuitive judgements being compared unfavourably with rational, linear, scientific decision making. Easen and Wilcockson (1996) believe that the confusion associated with intuition stems from the mistaken belief that intuition is an irrational process. They distinguish between its process and content, so that, while intuition may be seen as an irrational process, the basis of the intuitive decision need not be so. In their view, the nature of the knowledge and pattern recognition used by the intuiter is rooted in past learning and experience. Tacit knowledge Tacit knowledge is another term used to describe the knowledge that professionals use but find difficult to articulate. Polanyi (1958) addressed the limitations of scientific knowledge and concluded that ‘‘... to the extent to which our intelligence falls short of the ideal of precise formalisation, we act and see by the light of unspecifiable knowledge’’ (Polanyi, 1958, p. 53). Tacit knowledge emerges from experience and become almost intuitive as practitioners act without necessarily being consciously aware of the knowledge they have. Eraut (1994) explains how tacit knowledge develops in relation to skilled behaviour. He refers to conscious or semi-conscious pattern recognition that takes place during professional activity. Complex actions can become so routine that they are carried out semi-automatically. Expert practitioners, for example, view situations holistically and much of their knowledge is embedded in their practice. As a practitioner learns to perform a skill, he/she becomes increasingly less conscious of the means by which he/she carries this out. Eventually he/she is unable to describe the components of a skill, with any attempt to break it down resulting in his/her inability to perform. Knowledge from reflection Reflection is both an essential and enlightening skill and the foundation of advanced practice. Reflection about thought and action provides a strategy for promoting deliberation about one’s practice within the context of particular clinical situations (Schon, 1987; Harris, 1993). It occurs when practitioners contemplate past clinical situations, especially those that were puzzling, troublesome or particularly interesting. While there are numerous theoretical accounts and definitions of reflective practice in the literature, one developed by Harbison (1991) in a review of Schon’s (1987) work is applicable here. Harbison (1991, p. 404) defined the
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reflective practitioner as: ‘‘... one who constantly ‘watches’ herself in action: discovers and acknowledges the limits of her expertise, attempts to extend this ... she is professionally mature enough to reveal uncertainty, and accept the risks inherent in all decision making.’’ It is suggested that, if considered from a purely theoretical point of view, reflection can ‘switch off’ the reflector and that it is important to apply reflection to practice situations. Practitioners’ decision making takes place within a context where both decisions made and outcomes reached need to be considered. Unpicking these in order to inform future decision making is vital to ensure clinical competence. The definition above recognises the central role that experiential learning plays in the development of competence and emphasises the individual’s responsibility to maintain and increase the level of that competence. Reflection has been hugely influential in elucidating the tacit knowledge and intuition that underpin clinical practice as well as providing insight into the process of applying knowledge into practice. Since reflection occurs after a particular event, the knowledge gained usually cannot make a difference to the event at hand. It can, however, influence clinical decision making in similar (future) situations. Collaborative reflection: in depth discussion and reflection with a colleague, is important in order to enhance the individual’s ability to effectively evaluate his/her own knowledge and decision making.
Conclusion Changes to the roles of health care practitioners, with particular reference to CCOR practitioners in the context of this discussion, means that their decisions have a significant impact on health care outcomes and patients’ experiences. As both the extension of roles and the demand for evidencebased practice have increased, competent decisions have become imperative. With such changes, accountability for practitioners’ decisions has also increased. This paper has addressed the theoretical background of decision making and the knowledge that underpins practice. In doing so, it informs further discussion of the factors that inform and influence practitioners’ decision making. In their next paper, the authors examine the realities of a CCOR practitioners’ decision making in context. Collaborative reflection is used to analyse the thoughts and actions of a critical care nurse consultant in the management of a patient referred to the critical care outreach team.
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