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Factors influencing decision making among ambulance nurses in emergency care situations
International Emergency Nursing (2009) 17, 83– 89
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/aaen
Factors influencing decision making among ambulance nurses in emergency care situations B.-M. Gunnarsson MSc (RN) a b
a,*
´n Stomberg PhD (Senoir Lecturer) , M. Warre
a,b
¨vde, School of Life Sciences, Sko ¨vde, Sweden University of Sko ¨teborg, Institute of Health and Care Sciences, Sweden University of Go
Received 25 June 2008; received in revised form 16 October 2008; accepted 25 October 2008
KEYWORDS Prehospital; Ambulance nurse; Clinical decision making
Abstract The aim of this study was to investigate which factors that influences decision making among Swedish ambulance nurses in emergency care situations. Nurses in ambulance are sometimes forced to make decisions without adequate information. Data collected from interviews with 14 ambulance nurses was analyzed. The informants described 30 incidents during which they had to make fast decisions. A qualitative content analysis of the text was made, from which different categories were identified. It was found that when nurses are called to an emergency, the extent and degree of difficulty of the incident is decisive for how decisions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision-making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex. Further studies are needed to understand the complexity of decision making in emergency situations.
ª 2008 Elsevier Ltd. All rights reserved.
Background In their professional role, ambulance nurses make a number of decisions on a daily basis. These decisions often have an impact on the patients’ continued lives and possibility of survival. Clinical decision making is a complex process. It * Corresponding author. E-mail address: [email protected] (B.-M. Gunnarsson).
can be seen as a series of decisions which include the observations required, as well as deciding which measures will be carried out in order to provide the patient optimal care. The nurse tries to identify the current problem and, on this basis, makes relevant decisions (Ruland, 1996). The theory about data processing is portrayed in four phases (Elstein et al., 1978). Phase one comprises the search for information and the collection of data, which can to be accomplished through asking the patient or various examinations. In the second phase, a hypothesis is
1755-599X/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.10.004
84 created about the problem based on alternative ways of perceiving the problem. This is followed by a third phase in which the information is interpreted on the basis of the created hypothesis. In conclusion, the information is used to make a decision or establish a diagnosis. The way that the information is interpreted and discussed differs between novices and experts. According to Dreyfus and Dreyfus (1986), the difference in decision making is that novices and advanced beginners do not consider various alternatives, competents make an aware assessment, while expert nurses base decisions on their experience in a way that does not require any aware analysis. Experience is necessary for expert knowledge, because it enables various interpretations of situations when complex decisions must be made (Hicks et al., 2003). However, it must not be assumed that long experience automatically means that the expert level has been achieved (Dreyfus and Dreyfus, 1986; Benner, 1984). In order to be employed as an ambulance nurse in Sweden you have to be a registered nurse. For a permanent appointment, many employers demand specialist training and educational degrees. The most common specialist education is in anaesthesia, intensive care or prehospital care. There is continual internal (on-the-job) training and courses in medical techniques. Furthermore, for work at the incident scene, different courses in prehospital management, such as Major Incident Medical Management and Support (MIMMS), are available. Within the ambulance service, there are established requirements regulating actions in less favourable conditions (SOSFS, 1997), which can be in a patient’s home or at a cold, windy accident scene. In addition, more principles according to Prehospital Trauma Life Support (PHTLS), which is a development of the trauma concept, Advanced Trauma Life Support (ATLS), are applied in ambulance care. Some of the cornerstones of PHTLS are to quickly identify life threatening conditions, minimize the time on the scene, and transport critically assessed patients to treating hospitals as quickly and safely as possible (PHTLS, 2007). Suserud and Haljama ¨e (1997) have described the nurse’s role in prehospital care and claims that significant changes are taking place. These changes concern the need for increased competence. The study shows the necessity of education and the importance of combining prehospital service with hospital care. The nurses called for training and education in disaster medicine. When treatment in the ambulance becomes more sophisticated, it entails increased requirements on the nurse’s knowledge. There is an emphasis here that experience is of utmost importance, since staff members with high competence but little experience can instead delay the transport (Sjo ¨stro ¨m and Johansson, 2000). Svensson and Fridlund (2008) found that increasing working experience was followed by an increasing responsibility to cope with all kinds of situations. However, this increasing responsibility was experienced as worrying. Other studies conclude that reflecting about previous experiences is a tool which mentally prepares the ambulance crew for future situations (Jonsson and Segesten, 2004; McBrien, 2007). In order to evaluate the current Swedish conditions, the aim of this study was to investigate which factors influence decision making among ambulance nurses in emergency care situations.
B.-M. Gunnarsson, M. Warre ´n Stomberg
Methods A qualitative descriptive method, which is appropriate for detecting, describing or understanding a phenomenon in its context, was used (Speziale and Carpenter, 2007).
Sample Fourteen nurses, working at five middle-sized ambulance centres in the central region of Sweden, were identified by consecutive sampling and invited to participate in the study during their on-duty hours for two specified weeks. Approval for the study was obtained from the department manager. The criteria for participating in the study included at least 3 years professional experience as an ambulance nurse and informed consent. All 14 ambulance nurses, invited to participate, gave their informed consent and were included in the study.
Procedure Data was collected from interviews conducted in secluded rooms at the work places of the participants during their working-hours. Each participant was informed, verbally and in writing, about the aim of the study and the way in which it was to be carried out. All of the interviews were conducted by the same researcher (B-MG) and took about 20–40 min. In addition to questions about demographic data, each interview began with; please, tell me about work situations where you had to make a rapid decision. Attendant questions were then put to the informant in order to more fully understand the situation. A pilot study with one participant was carried out before the main data collection, to test the appropriateness of the procedure. The main study was conducted on the basis of this pilot test. Furthermore, all the interviews were taperecorded and transcribed.
Analyses A total of 30 scenarios were generated from the interviews. The contents of the interviews were analyzed in an objective way using a process similar to content analysis. The characteristic of this method is the systematic distillation, through analysis of verbal or written data, in order to describe and quantify specific phenomena into fewer content-related categories sharing the same meaning (Mosby Polit and Beck, 2004). The analysis procedure consists of a sorting of statements in which the criteria for sorting are not decided as a priority, but emerge as the analysis proceeds (Krippendorff, 2004; Graneheim and Lundman, 2004). The steps formed a foundation for the analysis of qualitative data in this study as follows: (1) Familiarization, that is, a primary examination of the whole material. (2) Compilations, that is, identification of relevant individual answers.
Factors influencing decision making among ambulance nurses in emergency care situations (3) Condensation, that is, formulation of the central meaning of longer answers or dialogues. (4) Grouping, that is, answers of similar meaning are classified together. The final outcome of this process was the identification of categories which describe working scenarios and the nurses’ decisions.
Results In the study, eleven men and three women, ranging in age from 29 to 49 years, participated. They had worked as ambulance nurses between 4 and 10 years. Five central categories with associated subcategories were found; the main categories comprise the incident, the external factors, communication and cooperation, knowledge, and ethical dilemmas.
85
What one sees/observes? The ambulance nurses formed a first impression on the basis of what they saw. It was a matter of quickly getting an overall picture of the situation. The informants used kinematics to predict possible further injuries. During the initial examination of the patient, the decision making was based on the vital signs, awareness, respiration and circulation. Subsequently, on the basis of these values, one decided if the patient’s condition would be assessed as critical or noncritical. ‘‘You don’t examine such patients very much, it’s only the vital signs, consciousness and respiration. You are not concerned about the blood pressure, because it’s secondary anyway.’’
External factors Time and distances
The incident The extent of the incidents to which the nurses were called was of crucial importance for how the decisions were made. The incidents contained complex meetings with patients, relatives and other operators. They concerned traffic accidents with many injured, trauma cases with much loss of blood, urgent states of ill-health, such as heart diseases, epilepsy and pulmonary embolism. Nurses described fires, and taking care of patients in relation to serious crimes such as murder. They also gave accounts of caring for intoxicated persons and addicts, partly from the perspective of any threats to their own safety, but also the difficulty of interpreting the symptoms. Problems connected with resuscitation of trauma and disease cases were portrayed both from positive and negative aspects, with the informants emphasising the complexity of the situations and that they must always be seen in a context.
Patient related factors The patient’s physical and psychic status was a part of the decision making basis. The age was of significance when special consideration was taken with children and older patients. In triage and dealing with children, it was difficult to disregard the emotional aspects. Taking care of sick or injured children was, for many, the worst aspect of their work, which was particularly clearly shown by the nurses who had children of their own. ‘‘I have children of approximately the same age and there are such a lot of incredible feelings, as dread and disaster feelings.’’ The oldest patients also aroused special feelings which could lead to that one decided to take it more calmly and refrain from life-supporting treatment. ‘‘She was about 90 years old, a thin lady, and I understood very soon that she would die in a few minutes. Then I said to X; I think we do nothing. And X agreed.’’
The time of day, the season and weather conditions were of significance, because, according to the nurses, it was easier to work in daylight and good weather. In addition, the distance to the alarm address, as well as the state of the roads affected the driving times. The amount of time before further resources, such as additional ambulances, helicopter, and/or anaesthesiologist, could arrive was taken into consideration during the decision making. Long distances and lack of resources meant that the first crews would have to act unaided for an extended period of time. ‘‘A burns patient in the forest. It was a difficult place to find so GPS guidance helped us. There was fairly dense vegetation, and the helicopter had problems landing. It had to land quite a distance away and we had to walk and carry the patient on a stretcher.’’ Decision making was affected by stress, and the informants claimed that despite their knowledge stress could lead to wrong decisions.
Security/threat A significant factor was when there was a threat aspect in the situation. The staff members must primarily attend to their own security. ‘‘When you don’t know what’s happened then it is not appropriate to enter at all.’’ If a nurse was in a personally threatening situation, there were guidelines about when not to proceed. For example, when the situation escalated with verbal threats, one chose to withdraw in order not to risk one’s own and the colleagues’ security.
The environment Persons surrounding the injured or sick patient affected decisions. Relatives could be an aid, but also constituted an obstacle in the work. The relatives’ impact on decisions
86
B.-M. Gunnarsson, M. Warre ´n Stomberg
was clearly illustrated when it concerned the presence of the parents of injured children. In accident scenes there were often many curious onlookers, but also those who offered their help. Those in the environment expected and required that the ambulance nurses would act quickly and effectively. The atmosphere was sometimes heated which could be experienced as stressful. ‘‘We often work in front of others and how it affects us is difficult to say but I’m sure it does affect us. In this case there were hundreds of people watching us.’’
Communication/cooperation With other operators The call out was often the first and only information the ambulance nurses had before arriving at the scene. The information was interpreted and on that basis the informants mentally prepared themselves and created a picture of the incident. ‘‘We knew that we had to hurry so we tried to get more information. Who is there at the scene? Is there any violence involved? We tried to collect information and we got nothing sensible.’’ Also the lack of information was interpreted. ‘‘When there is complete silence on the radio, then nobody gives a report, nobody has time to talk and nobody has time to inform. We understood that the emergency services were there before us and there was silence, then we understood, we felt that this was serious, this was probably something bigger.’’ The cooperation with the emergency rescue service was described as being positive most of the time. It was of significance if one had previous knowledge of each other and was used to collaborating. The presence of the police could be regarded as a provocation which could contribute to inflaming the atmosphere. ‘‘The atmosphere is heated and she is angry at the policemen.’’
‘‘My colleague and I looked at each other. She knew that I knew, we both knew, probably a pulmonary embolism.’’
Function of leadership At the scene, the function of leadership was a central part in accidents involving several casualties. In a number of cases, the ambulance crew knew they would have to act as management, and carried out preparations and distributed the work on the way to the scene. The management function is difficult and requires training and education. When the leadership did not function, the other staff members did not receive any information nor were they assigned relevant duties. ‘‘I felt that I could not come to grips with the situation and my colleague who was first on the scene was very stressed, and I felt we could not establish any contact.’’ In those cases, the decision to take over the management was an alternative, which meant that one relinquished current procedures and ran a risk that the first crew would feel a loss of prestige. ‘‘Then we took over. We restarted.’’
Knowledge The decisions were influenced by the level of the nurses’ knowledge. Education was seen as a prerequisite to making correct decisions. Those nurses who had previously worked in the hospital had the possibility of following patients’ progress, observing symptoms and changes in the patients’ conditions over time. In the hospital environment they had worked with different physicians and nurses, as well as seen various models of caring, which was regarded as a major advantage in the prehospital assessment of patients. The value of previous experience of similar situations was emphasised, and that one must manage alone in order to make the knowledge your own. Through making your own mistakes and reflecting over alternative actions new knowledge was created. The experience comes from recognising situations and over time developing action strategies for different typical cases. ‘‘. . .it is through experience one understands.’’
With colleagues The communication and cooperation with colleagues influenced the decision making. In a team in which the members knew each other well, the subtle non-verbal communication was used. ‘‘We look at each other and if someone wrinkles their forehead then you think a little bit more.’’ Emphasis was put on the importance of being safe with your colleagues and trusting their experience and judgment. With a change of crew or when working with inexperienced colleagues, some of those safe, habitual routines were lost and that certain ‘‘touch’’, or feeling where words are redundant, was missing.
The ambulance nurses trusted their instincts and acted accordingly. The event was reflected upon and analyzed afterwards. ‘‘I think you develop these strategies. They require that you have experienced and sensed the vibrations in a lot of different situations that you know what happens, approximately, when you do this or that, then you can allow yourself to be controlled, quite a lot, by what I call instinct.’’
Ethical dilemmas A formally correct decision could feel wrong ethically. There are guidelines for certain diseases and resuscitation. In certain contexts these guidelines were regarded an obsta-
Factors influencing decision making among ambulance nurses in emergency care situations cle in the work. To be forced to start resuscitation despite knowing that it was meaningless became an ethical dilemma. The nurses would rather have taken care of the relatives and comforted them. In many cases, nothing was absolutely correct or wrong, since the situations were complex. The nurses acted according to how they would want to be treated themselves in the same situation. ‘‘This work involves a great deal of responsibility. But at the same time it’s a responsibility you yourself own. I think you ask yourself, how I would like to be treated when I get older.’’ The problem of integrity became apparent when one worked in the patients’ homes or with other people present. It was difficult to make decisions when there was a risk of giving offence, even if it could be medically correct and it was necessary in order to give the patient the chance to survive. The more seriously injured the patient was, the less the patient’s own views were taken into consideration in the decision making. ‘‘We meet a patient and make a rapid assessment. How fast do we have to work? The more critical the patient’s situation, the fewer considerations we take. And one thing we do not do optimally in such situations is show respect to the patient. That can be a problem.’’
Discussion In this study it was found that the characteristics of the incident and its context were significant for understanding factors influencing decision making in emergency care situations. The incidents that the study refers to are emergency care situations often involving many individuals. Inadequate information and other uncertain factors contribute to making the decision more complex. Hicks et al. (2003) found that the degree of unanimity in the decisions decreases the more complex the situation is. Unanimity is defined when the same decision is made in the fast intuitive and in the analytical decision making process. This study shows that patient related factors influence decision making at an emotional level. Taking care of seriously ill or injured children is, for many, the worst aspect of their work. The ambulance nurses want to do absolutely everything, and have described the work at accident scenes involving children as ‘‘tumultuous’’ since there are a lot of emotions associated with the work. This is similar to Jonsson and Segesten (2003) who found that events where children were injured or had died were among the most trying that can happen to an ambulance crew. When caregivers become aware and identify themselves as parent or victim it becomes difficult to set boundaries. In addition, this attitude becomes problematic when the caregiver is not prepared or able to relocate her/himself between closeness and distance. Ambulance nurses obtain the first, on-the-spot information from what they see, often already before they stop the car. The information is processed while they approach the accident scene and the importance of remaining calm is emphasised. Kinematic rules are used to ‘‘read the place’’. This can be regarded as a result of the increasingly
87
widespread PHTLS-concept. The first assessment of the patient is made on the basis of observations which are in accordance to Hedberg and Sa ¨tterlund Larsson (2003), who show that the nurse applies for clues in the information that can be seen and in observing the patient. Working in darkness and the cold make it considerably more difficult to carry out the observations that are needed for a relevant decision. The pressures of time and the environment can force ambulance nurses to make decisions without having access to necessary information. This study shows that in complex situations where the nurse’s actions were subjected to time pressure, the decisions were not always justified. Bogner (1997) found similar problems with time pressure for decision makers in emergency care. When the environment comprises relatives or curious on-lookers, they can be a distraction that takes energy and makes it difficult to focus on the patient. Hedberg and Sa ¨tterlund Larsson (2004) found that nurses are constantly being disrupted, which contributes to their fragmentary decision making. This study shows that when complete information is missing an expected picture of the event is created. In Jonsson and Segesten’s (2003) materials, preparation for the unknown is the most explicitly expressed. The picture builds on earlier experience. The least experienced need details in order to plan, while the most experienced increase their readiness to act by not creating everything in detailed pictures, since they know that the picture will nevertheless agree. The importance of knowledge and above all the experience of different events are the most dominant factors which impact on the decision making. Education is seen as necessary while experience is gained from participating in different situations. Some of the nurses had exchanged service at the hospital, which they regarded as important in order to maintain current knowledge and to exercise practical aspects, such as tracheal intubation. This is in accordance to Suserud and Haljama ¨e’s finding (1997). Sjo ¨stro ¨m and Johansson (2000) maintain that the difference between novices and experienced ambulance nurses shows in the way they observe the patient and understand the situation. In this study, recognising a situation without directly having seen a similar case has been mentioned. ‘‘I have not been in that situation, but I recognised it as urgent, I known it as a feeling only’’. Dale (2002) speaks about intuition as a ‘‘gut feeling’’ that is built on experience. Currey and Botti (2003) found that experienced nurses developed the ability to recognise and distinguish features and standards on the basis of the patient’s status. Dreyfus and Dreyfus (1986) talk about the actions of experts in urgent situations as unreflective and intuitive. The experts comprehend a pattern in what they see and know what to observe. The information is sorted and given a sense which leads to them solving the problems faster. Sjo ¨stro ¨m and Johansson (2000) identify this as a ‘‘clinical eye’’ which ambulance nurses have so that their actions become more effective. Knowing and trusting your colleagues is an important part of the decision making process. In non-verbal communication, expressions and gestures can cause the decision maker to stop and reflect. Hedberg and Sa ¨tterlund Larsson (2003) show that acknowledgment is an important part of the basis of decision making.
88 The findings in this study indicate a positive unity in the team work among ambulance nurses which may have resonance with other areas of acute nursing practice. The role of leadership is considered to be difficult and means making many decisions that affect patients, colleagues and other operators. The ambulance nurse’s duties include being able to ‘‘function in medical management within the area of injury’’ and ‘‘within that special organisation which concerns major accidents and disasters’’ (SOSFS, 1997, pp. 6, 18). In order for the leadership to function, education and training are required. It is important that everyone knows and understands current procedures, as well as who has the command and makes decisions at the scene. Furthermore, Dale (2002) shows that, in decision making, knowing the context is important. The risks of offending or acting against the patient’s will is greatest in an urgent situation where there is no time or possibility to explain and argue. Integrity is a concern when working in someone else’s home. The majority felt uncomfortable with themselves when they could not explain the situation to the relatives due to the pressure of time. Sjo ¨stro ¨m and Johansson (2000) found similar thoughts among ambulance nurses. Jonsson and Segesten (2004) found that one stress factor for the ambulance crew is the feeling of guilt and shame over leaving someone they had caused ‘‘suffering’’, for example, through informing about the death of a relative.
Methodological considerations In this study information was gathered with the aid of a semi-structured interview which began with an introductory opening question. The interview provided the possibility of explaining and asking follow-up questions, in order to obtain a more detailed and clearer picture of the situation (Mosby Polit and Beck, 2004). However, a more narrative kind of method, such as Benner (1984), to describe nurses’ work and knowledge development may have provided context related statements in another way. In our study, more men than women were represented, which also reflects the current gender division within the ambulance service. It would have been interesting to include more participants with an equal gender division to outline possible gender differences in the result, as well as the significance of professional experience for decision making.
Clinical implications and further research The result highlights the complexity of leadership skills required and focuses the necessity to reflect, discuss and optimize such skills. The simulation of scenarios in the classroom would help to develop decision making skills and prepare for complex management problems. Further studies could include educational simulations for the development of leadership skills, as well as the evaluation of a post-traumatic-stress debriefing.
Conclusion When a nurse is called to an emergency, the extent of the incident and degree of difficulty are decisive in how deci-
B.-M. Gunnarsson, M. Warre ´n Stomberg sions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, insufficient information, leadership problems and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex.
Acknowledgement We are grateful to Vera Lindros for professional language review.
References Benner, P., 1984. From Novice to Expert. Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park. Bogner, M., 1997. Naturalistic decision making in health care. In: Zambok, C., Klein, G. (Eds.), . In: Naturalistic Decision Making, vol. 61–71. Lawrence Erlbaum Associates, Inc. Publishers, New Jersey. Currey, J., Botti, M., 2003. Naturalistic decision making: a model to overcome patient’s hemodynamic statuses. American Journal of Critical Care 12 (3), 206–211. Dale, P., 2002. A phenomenological study of flight nurses clinical decision-making in emergency situations. Air Medicine Journal 21 (2), 28–36. Dreyfus, L., Dreyfus, E., 1986. Mind Over Machine. The Power of Human Expertise in the Era of the Computer. The Free Press, New York. Elstein, A., Schulman, L., Sprafka, S., 1978. Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press, Cambridge. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures, and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Hedberg, B., Sa ¨tterlund Larsson, U., 2003. Observations, confirmations and strategies-useful tools in decision making process for nurses in practice. Journal of Clinical Nursing 12, 215–222. Hedberg, B., Sa ¨tterlund Larsson, U., 2004. Environmental elements affecting the decision making process in nursing practice. Journal of Clinical Nursing 13 (3), 316–324. Hicks, F., Merrit, S., Elstein, A., 2003. Critical thinking and clinical decision making in critical care nursing: a pilot study. Hart and Lung 32 (3), 169. Jonsson, A., Segesten, K., 2003. The meaning of traumatic events as described by nurses in ambulance service. Accident and Emergency Nursing 11, 141–152. Jonsson, A., Segesten, K., 2004. Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel. Accident and Emergency Nursing 12, 215–223. Krippendorff, K., 2004. Content Analysis: An Introduction to its Methodology, second ed.. The Sage COMMText Series SAGE Publications, London. McBrien, B., 2007. Learning from practice – reflections on a critical incident. Accident and Emergency Nursing 15 (3), 128–133. Mosby Polit, D., Beck, C., 2004. Nursing Research Principles and Methods, seventh ed. Lippincott, Phiadelphia. PHTLS, 2007. Basic and Advanced Prehospital Trauma Life Support, sixth ed. Mosby, USA.
Factors influencing decision making among ambulance nurses in emergency care situations Ruland, C., 1996. Clinical decision making in nursing. Va ˚rd i Norden 17 (4), 4–12. Sjo ¨stro ¨m, B., Johansson, B., 2000. Ambulanssjukva ˚rd ur ambulanssjukva ˚rdares och la ¨kares perspektiv. Acta Universitatis Gothoburgesis. Swedish National Board of Health and Welfare, 1997. SOSFS 1997:18 ¨ ndring i allma (M) Socialstyrelsens allma ¨nna ra ˚d. A ¨nna ra ˚d om kompetensbeskrivningar fo ¨r sjuksko ¨terskor och barnmorskor 1995, p. 5.
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Speziale, H., Carpenter, D., 2007. Qualitative Research in Nursing, fifth ed. Lippincott, Philadelphia. Suserud, B.-O., Haljama ¨e, H., 1997. Rule of the nurses in prehospital emergency care. Accident and Emergency Nursing 5, 145–151. Svensson, A., Fridlund, B., 2008. Experiences of and actions towards worries among ambulance nurses in their professional life: a critical incident study. International Emergency Nursing 16 (1), 35–42.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/aaen
Factors influencing decision making among ambulance nurses in emergency care situations B.-M. Gunnarsson MSc (RN) a b
a,*
´n Stomberg PhD (Senoir Lecturer) , M. Warre
a,b
¨vde, School of Life Sciences, Sko ¨vde, Sweden University of Sko ¨teborg, Institute of Health and Care Sciences, Sweden University of Go
Received 25 June 2008; received in revised form 16 October 2008; accepted 25 October 2008
KEYWORDS Prehospital; Ambulance nurse; Clinical decision making
Abstract The aim of this study was to investigate which factors that influences decision making among Swedish ambulance nurses in emergency care situations. Nurses in ambulance are sometimes forced to make decisions without adequate information. Data collected from interviews with 14 ambulance nurses was analyzed. The informants described 30 incidents during which they had to make fast decisions. A qualitative content analysis of the text was made, from which different categories were identified. It was found that when nurses are called to an emergency, the extent and degree of difficulty of the incident is decisive for how decisions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision-making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex. Further studies are needed to understand the complexity of decision making in emergency situations.
ª 2008 Elsevier Ltd. All rights reserved.
Background In their professional role, ambulance nurses make a number of decisions on a daily basis. These decisions often have an impact on the patients’ continued lives and possibility of survival. Clinical decision making is a complex process. It * Corresponding author. E-mail address: [email protected] (B.-M. Gunnarsson).
can be seen as a series of decisions which include the observations required, as well as deciding which measures will be carried out in order to provide the patient optimal care. The nurse tries to identify the current problem and, on this basis, makes relevant decisions (Ruland, 1996). The theory about data processing is portrayed in four phases (Elstein et al., 1978). Phase one comprises the search for information and the collection of data, which can to be accomplished through asking the patient or various examinations. In the second phase, a hypothesis is
1755-599X/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.10.004
84 created about the problem based on alternative ways of perceiving the problem. This is followed by a third phase in which the information is interpreted on the basis of the created hypothesis. In conclusion, the information is used to make a decision or establish a diagnosis. The way that the information is interpreted and discussed differs between novices and experts. According to Dreyfus and Dreyfus (1986), the difference in decision making is that novices and advanced beginners do not consider various alternatives, competents make an aware assessment, while expert nurses base decisions on their experience in a way that does not require any aware analysis. Experience is necessary for expert knowledge, because it enables various interpretations of situations when complex decisions must be made (Hicks et al., 2003). However, it must not be assumed that long experience automatically means that the expert level has been achieved (Dreyfus and Dreyfus, 1986; Benner, 1984). In order to be employed as an ambulance nurse in Sweden you have to be a registered nurse. For a permanent appointment, many employers demand specialist training and educational degrees. The most common specialist education is in anaesthesia, intensive care or prehospital care. There is continual internal (on-the-job) training and courses in medical techniques. Furthermore, for work at the incident scene, different courses in prehospital management, such as Major Incident Medical Management and Support (MIMMS), are available. Within the ambulance service, there are established requirements regulating actions in less favourable conditions (SOSFS, 1997), which can be in a patient’s home or at a cold, windy accident scene. In addition, more principles according to Prehospital Trauma Life Support (PHTLS), which is a development of the trauma concept, Advanced Trauma Life Support (ATLS), are applied in ambulance care. Some of the cornerstones of PHTLS are to quickly identify life threatening conditions, minimize the time on the scene, and transport critically assessed patients to treating hospitals as quickly and safely as possible (PHTLS, 2007). Suserud and Haljama ¨e (1997) have described the nurse’s role in prehospital care and claims that significant changes are taking place. These changes concern the need for increased competence. The study shows the necessity of education and the importance of combining prehospital service with hospital care. The nurses called for training and education in disaster medicine. When treatment in the ambulance becomes more sophisticated, it entails increased requirements on the nurse’s knowledge. There is an emphasis here that experience is of utmost importance, since staff members with high competence but little experience can instead delay the transport (Sjo ¨stro ¨m and Johansson, 2000). Svensson and Fridlund (2008) found that increasing working experience was followed by an increasing responsibility to cope with all kinds of situations. However, this increasing responsibility was experienced as worrying. Other studies conclude that reflecting about previous experiences is a tool which mentally prepares the ambulance crew for future situations (Jonsson and Segesten, 2004; McBrien, 2007). In order to evaluate the current Swedish conditions, the aim of this study was to investigate which factors influence decision making among ambulance nurses in emergency care situations.
B.-M. Gunnarsson, M. Warre ´n Stomberg
Methods A qualitative descriptive method, which is appropriate for detecting, describing or understanding a phenomenon in its context, was used (Speziale and Carpenter, 2007).
Sample Fourteen nurses, working at five middle-sized ambulance centres in the central region of Sweden, were identified by consecutive sampling and invited to participate in the study during their on-duty hours for two specified weeks. Approval for the study was obtained from the department manager. The criteria for participating in the study included at least 3 years professional experience as an ambulance nurse and informed consent. All 14 ambulance nurses, invited to participate, gave their informed consent and were included in the study.
Procedure Data was collected from interviews conducted in secluded rooms at the work places of the participants during their working-hours. Each participant was informed, verbally and in writing, about the aim of the study and the way in which it was to be carried out. All of the interviews were conducted by the same researcher (B-MG) and took about 20–40 min. In addition to questions about demographic data, each interview began with; please, tell me about work situations where you had to make a rapid decision. Attendant questions were then put to the informant in order to more fully understand the situation. A pilot study with one participant was carried out before the main data collection, to test the appropriateness of the procedure. The main study was conducted on the basis of this pilot test. Furthermore, all the interviews were taperecorded and transcribed.
Analyses A total of 30 scenarios were generated from the interviews. The contents of the interviews were analyzed in an objective way using a process similar to content analysis. The characteristic of this method is the systematic distillation, through analysis of verbal or written data, in order to describe and quantify specific phenomena into fewer content-related categories sharing the same meaning (Mosby Polit and Beck, 2004). The analysis procedure consists of a sorting of statements in which the criteria for sorting are not decided as a priority, but emerge as the analysis proceeds (Krippendorff, 2004; Graneheim and Lundman, 2004). The steps formed a foundation for the analysis of qualitative data in this study as follows: (1) Familiarization, that is, a primary examination of the whole material. (2) Compilations, that is, identification of relevant individual answers.
Factors influencing decision making among ambulance nurses in emergency care situations (3) Condensation, that is, formulation of the central meaning of longer answers or dialogues. (4) Grouping, that is, answers of similar meaning are classified together. The final outcome of this process was the identification of categories which describe working scenarios and the nurses’ decisions.
Results In the study, eleven men and three women, ranging in age from 29 to 49 years, participated. They had worked as ambulance nurses between 4 and 10 years. Five central categories with associated subcategories were found; the main categories comprise the incident, the external factors, communication and cooperation, knowledge, and ethical dilemmas.
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What one sees/observes? The ambulance nurses formed a first impression on the basis of what they saw. It was a matter of quickly getting an overall picture of the situation. The informants used kinematics to predict possible further injuries. During the initial examination of the patient, the decision making was based on the vital signs, awareness, respiration and circulation. Subsequently, on the basis of these values, one decided if the patient’s condition would be assessed as critical or noncritical. ‘‘You don’t examine such patients very much, it’s only the vital signs, consciousness and respiration. You are not concerned about the blood pressure, because it’s secondary anyway.’’
External factors Time and distances
The incident The extent of the incidents to which the nurses were called was of crucial importance for how the decisions were made. The incidents contained complex meetings with patients, relatives and other operators. They concerned traffic accidents with many injured, trauma cases with much loss of blood, urgent states of ill-health, such as heart diseases, epilepsy and pulmonary embolism. Nurses described fires, and taking care of patients in relation to serious crimes such as murder. They also gave accounts of caring for intoxicated persons and addicts, partly from the perspective of any threats to their own safety, but also the difficulty of interpreting the symptoms. Problems connected with resuscitation of trauma and disease cases were portrayed both from positive and negative aspects, with the informants emphasising the complexity of the situations and that they must always be seen in a context.
Patient related factors The patient’s physical and psychic status was a part of the decision making basis. The age was of significance when special consideration was taken with children and older patients. In triage and dealing with children, it was difficult to disregard the emotional aspects. Taking care of sick or injured children was, for many, the worst aspect of their work, which was particularly clearly shown by the nurses who had children of their own. ‘‘I have children of approximately the same age and there are such a lot of incredible feelings, as dread and disaster feelings.’’ The oldest patients also aroused special feelings which could lead to that one decided to take it more calmly and refrain from life-supporting treatment. ‘‘She was about 90 years old, a thin lady, and I understood very soon that she would die in a few minutes. Then I said to X; I think we do nothing. And X agreed.’’
The time of day, the season and weather conditions were of significance, because, according to the nurses, it was easier to work in daylight and good weather. In addition, the distance to the alarm address, as well as the state of the roads affected the driving times. The amount of time before further resources, such as additional ambulances, helicopter, and/or anaesthesiologist, could arrive was taken into consideration during the decision making. Long distances and lack of resources meant that the first crews would have to act unaided for an extended period of time. ‘‘A burns patient in the forest. It was a difficult place to find so GPS guidance helped us. There was fairly dense vegetation, and the helicopter had problems landing. It had to land quite a distance away and we had to walk and carry the patient on a stretcher.’’ Decision making was affected by stress, and the informants claimed that despite their knowledge stress could lead to wrong decisions.
Security/threat A significant factor was when there was a threat aspect in the situation. The staff members must primarily attend to their own security. ‘‘When you don’t know what’s happened then it is not appropriate to enter at all.’’ If a nurse was in a personally threatening situation, there were guidelines about when not to proceed. For example, when the situation escalated with verbal threats, one chose to withdraw in order not to risk one’s own and the colleagues’ security.
The environment Persons surrounding the injured or sick patient affected decisions. Relatives could be an aid, but also constituted an obstacle in the work. The relatives’ impact on decisions
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was clearly illustrated when it concerned the presence of the parents of injured children. In accident scenes there were often many curious onlookers, but also those who offered their help. Those in the environment expected and required that the ambulance nurses would act quickly and effectively. The atmosphere was sometimes heated which could be experienced as stressful. ‘‘We often work in front of others and how it affects us is difficult to say but I’m sure it does affect us. In this case there were hundreds of people watching us.’’
Communication/cooperation With other operators The call out was often the first and only information the ambulance nurses had before arriving at the scene. The information was interpreted and on that basis the informants mentally prepared themselves and created a picture of the incident. ‘‘We knew that we had to hurry so we tried to get more information. Who is there at the scene? Is there any violence involved? We tried to collect information and we got nothing sensible.’’ Also the lack of information was interpreted. ‘‘When there is complete silence on the radio, then nobody gives a report, nobody has time to talk and nobody has time to inform. We understood that the emergency services were there before us and there was silence, then we understood, we felt that this was serious, this was probably something bigger.’’ The cooperation with the emergency rescue service was described as being positive most of the time. It was of significance if one had previous knowledge of each other and was used to collaborating. The presence of the police could be regarded as a provocation which could contribute to inflaming the atmosphere. ‘‘The atmosphere is heated and she is angry at the policemen.’’
‘‘My colleague and I looked at each other. She knew that I knew, we both knew, probably a pulmonary embolism.’’
Function of leadership At the scene, the function of leadership was a central part in accidents involving several casualties. In a number of cases, the ambulance crew knew they would have to act as management, and carried out preparations and distributed the work on the way to the scene. The management function is difficult and requires training and education. When the leadership did not function, the other staff members did not receive any information nor were they assigned relevant duties. ‘‘I felt that I could not come to grips with the situation and my colleague who was first on the scene was very stressed, and I felt we could not establish any contact.’’ In those cases, the decision to take over the management was an alternative, which meant that one relinquished current procedures and ran a risk that the first crew would feel a loss of prestige. ‘‘Then we took over. We restarted.’’
Knowledge The decisions were influenced by the level of the nurses’ knowledge. Education was seen as a prerequisite to making correct decisions. Those nurses who had previously worked in the hospital had the possibility of following patients’ progress, observing symptoms and changes in the patients’ conditions over time. In the hospital environment they had worked with different physicians and nurses, as well as seen various models of caring, which was regarded as a major advantage in the prehospital assessment of patients. The value of previous experience of similar situations was emphasised, and that one must manage alone in order to make the knowledge your own. Through making your own mistakes and reflecting over alternative actions new knowledge was created. The experience comes from recognising situations and over time developing action strategies for different typical cases. ‘‘. . .it is through experience one understands.’’
With colleagues The communication and cooperation with colleagues influenced the decision making. In a team in which the members knew each other well, the subtle non-verbal communication was used. ‘‘We look at each other and if someone wrinkles their forehead then you think a little bit more.’’ Emphasis was put on the importance of being safe with your colleagues and trusting their experience and judgment. With a change of crew or when working with inexperienced colleagues, some of those safe, habitual routines were lost and that certain ‘‘touch’’, or feeling where words are redundant, was missing.
The ambulance nurses trusted their instincts and acted accordingly. The event was reflected upon and analyzed afterwards. ‘‘I think you develop these strategies. They require that you have experienced and sensed the vibrations in a lot of different situations that you know what happens, approximately, when you do this or that, then you can allow yourself to be controlled, quite a lot, by what I call instinct.’’
Ethical dilemmas A formally correct decision could feel wrong ethically. There are guidelines for certain diseases and resuscitation. In certain contexts these guidelines were regarded an obsta-
Factors influencing decision making among ambulance nurses in emergency care situations cle in the work. To be forced to start resuscitation despite knowing that it was meaningless became an ethical dilemma. The nurses would rather have taken care of the relatives and comforted them. In many cases, nothing was absolutely correct or wrong, since the situations were complex. The nurses acted according to how they would want to be treated themselves in the same situation. ‘‘This work involves a great deal of responsibility. But at the same time it’s a responsibility you yourself own. I think you ask yourself, how I would like to be treated when I get older.’’ The problem of integrity became apparent when one worked in the patients’ homes or with other people present. It was difficult to make decisions when there was a risk of giving offence, even if it could be medically correct and it was necessary in order to give the patient the chance to survive. The more seriously injured the patient was, the less the patient’s own views were taken into consideration in the decision making. ‘‘We meet a patient and make a rapid assessment. How fast do we have to work? The more critical the patient’s situation, the fewer considerations we take. And one thing we do not do optimally in such situations is show respect to the patient. That can be a problem.’’
Discussion In this study it was found that the characteristics of the incident and its context were significant for understanding factors influencing decision making in emergency care situations. The incidents that the study refers to are emergency care situations often involving many individuals. Inadequate information and other uncertain factors contribute to making the decision more complex. Hicks et al. (2003) found that the degree of unanimity in the decisions decreases the more complex the situation is. Unanimity is defined when the same decision is made in the fast intuitive and in the analytical decision making process. This study shows that patient related factors influence decision making at an emotional level. Taking care of seriously ill or injured children is, for many, the worst aspect of their work. The ambulance nurses want to do absolutely everything, and have described the work at accident scenes involving children as ‘‘tumultuous’’ since there are a lot of emotions associated with the work. This is similar to Jonsson and Segesten (2003) who found that events where children were injured or had died were among the most trying that can happen to an ambulance crew. When caregivers become aware and identify themselves as parent or victim it becomes difficult to set boundaries. In addition, this attitude becomes problematic when the caregiver is not prepared or able to relocate her/himself between closeness and distance. Ambulance nurses obtain the first, on-the-spot information from what they see, often already before they stop the car. The information is processed while they approach the accident scene and the importance of remaining calm is emphasised. Kinematic rules are used to ‘‘read the place’’. This can be regarded as a result of the increasingly
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widespread PHTLS-concept. The first assessment of the patient is made on the basis of observations which are in accordance to Hedberg and Sa ¨tterlund Larsson (2003), who show that the nurse applies for clues in the information that can be seen and in observing the patient. Working in darkness and the cold make it considerably more difficult to carry out the observations that are needed for a relevant decision. The pressures of time and the environment can force ambulance nurses to make decisions without having access to necessary information. This study shows that in complex situations where the nurse’s actions were subjected to time pressure, the decisions were not always justified. Bogner (1997) found similar problems with time pressure for decision makers in emergency care. When the environment comprises relatives or curious on-lookers, they can be a distraction that takes energy and makes it difficult to focus on the patient. Hedberg and Sa ¨tterlund Larsson (2004) found that nurses are constantly being disrupted, which contributes to their fragmentary decision making. This study shows that when complete information is missing an expected picture of the event is created. In Jonsson and Segesten’s (2003) materials, preparation for the unknown is the most explicitly expressed. The picture builds on earlier experience. The least experienced need details in order to plan, while the most experienced increase their readiness to act by not creating everything in detailed pictures, since they know that the picture will nevertheless agree. The importance of knowledge and above all the experience of different events are the most dominant factors which impact on the decision making. Education is seen as necessary while experience is gained from participating in different situations. Some of the nurses had exchanged service at the hospital, which they regarded as important in order to maintain current knowledge and to exercise practical aspects, such as tracheal intubation. This is in accordance to Suserud and Haljama ¨e’s finding (1997). Sjo ¨stro ¨m and Johansson (2000) maintain that the difference between novices and experienced ambulance nurses shows in the way they observe the patient and understand the situation. In this study, recognising a situation without directly having seen a similar case has been mentioned. ‘‘I have not been in that situation, but I recognised it as urgent, I known it as a feeling only’’. Dale (2002) speaks about intuition as a ‘‘gut feeling’’ that is built on experience. Currey and Botti (2003) found that experienced nurses developed the ability to recognise and distinguish features and standards on the basis of the patient’s status. Dreyfus and Dreyfus (1986) talk about the actions of experts in urgent situations as unreflective and intuitive. The experts comprehend a pattern in what they see and know what to observe. The information is sorted and given a sense which leads to them solving the problems faster. Sjo ¨stro ¨m and Johansson (2000) identify this as a ‘‘clinical eye’’ which ambulance nurses have so that their actions become more effective. Knowing and trusting your colleagues is an important part of the decision making process. In non-verbal communication, expressions and gestures can cause the decision maker to stop and reflect. Hedberg and Sa ¨tterlund Larsson (2003) show that acknowledgment is an important part of the basis of decision making.
88 The findings in this study indicate a positive unity in the team work among ambulance nurses which may have resonance with other areas of acute nursing practice. The role of leadership is considered to be difficult and means making many decisions that affect patients, colleagues and other operators. The ambulance nurse’s duties include being able to ‘‘function in medical management within the area of injury’’ and ‘‘within that special organisation which concerns major accidents and disasters’’ (SOSFS, 1997, pp. 6, 18). In order for the leadership to function, education and training are required. It is important that everyone knows and understands current procedures, as well as who has the command and makes decisions at the scene. Furthermore, Dale (2002) shows that, in decision making, knowing the context is important. The risks of offending or acting against the patient’s will is greatest in an urgent situation where there is no time or possibility to explain and argue. Integrity is a concern when working in someone else’s home. The majority felt uncomfortable with themselves when they could not explain the situation to the relatives due to the pressure of time. Sjo ¨stro ¨m and Johansson (2000) found similar thoughts among ambulance nurses. Jonsson and Segesten (2004) found that one stress factor for the ambulance crew is the feeling of guilt and shame over leaving someone they had caused ‘‘suffering’’, for example, through informing about the death of a relative.
Methodological considerations In this study information was gathered with the aid of a semi-structured interview which began with an introductory opening question. The interview provided the possibility of explaining and asking follow-up questions, in order to obtain a more detailed and clearer picture of the situation (Mosby Polit and Beck, 2004). However, a more narrative kind of method, such as Benner (1984), to describe nurses’ work and knowledge development may have provided context related statements in another way. In our study, more men than women were represented, which also reflects the current gender division within the ambulance service. It would have been interesting to include more participants with an equal gender division to outline possible gender differences in the result, as well as the significance of professional experience for decision making.
Clinical implications and further research The result highlights the complexity of leadership skills required and focuses the necessity to reflect, discuss and optimize such skills. The simulation of scenarios in the classroom would help to develop decision making skills and prepare for complex management problems. Further studies could include educational simulations for the development of leadership skills, as well as the evaluation of a post-traumatic-stress debriefing.
Conclusion When a nurse is called to an emergency, the extent of the incident and degree of difficulty are decisive in how deci-
B.-M. Gunnarsson, M. Warre ´n Stomberg sions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, insufficient information, leadership problems and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex.
Acknowledgement We are grateful to Vera Lindros for professional language review.
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