Confidence, Learning and Decision-Making in Urgent, Emergency and Crisis Care
Urgent, Emergency and Crisis Care [UEC] is all about making decisions under pressure.
“Should this person go to hospital?”
“Is it safe for them to return home?“
“Is there an alternative pathway that could prevent admission and support recovery just as well—or better?”
These decisions happen everywhere across the system: in a patient’s home, in a primary care service, in an emergency department cubicle, or in a same day emergency care clinic.
We often talk about system pressures—capacity, flow, workforce shortages—but behind every clinical decision is something we talk about much less:
How the human brain makes decisions under pressure.
Understanding this matters. Because many of the challenges we see as caused by risk-averse decisions—inappropriate conveyance, unnecessary admissions and discharge delays—are not just individual clinician decisions, they are system decisions. And these decisions are human factors problems.
At the centre of those human factors are confidence, emotional intelligence and learning.
The Neuroscience of Decision-Making
Complex clinical decisions are not made in a single moment. They are the result of a high-level cognitive process where the brain integrates multiple types of information: sensory data, previous experiences, emotional signals and contextual knowledge. And different parts of the brain perform different roles.
· The prefrontal cortex, the area of the brain responsible for reasoning, judgement and complex planning, is the primary coordinator of decision making.
· The ventromedial prefrontal cortex evaluates the value of different options—essentially asking “which choice leads to the best outcome?”.
· The dorsolateral prefrontal cortex manages working memory and cognitive control, allowing clinicians to hold multiple pieces of information in mind while weighing risk.
· The anterior cingulate cortex monitors conflict, when two options seem equally valid—or equally risky—this region signals the brain that deeper thinking is needed.
Other parts of the brain also contribute.
· The hippocampus draws on past experiences to predict possible outcomes.
· The striatum processes reward and reinforcement learning, helping us remember what worked before.
· Neurotransmitters such as dopamine, serotonin and noradrenaline regulate motivation, emotional stability and alertness during this process.
Together, these systems gradually accumulate evidence until the brain reaches a threshold where a decision is made.
But there is another layer to this process that is often overlooked.
Confidence.
Confidence: The Hidden Driver of Clinical Decisions
Confidence is not simply a feeling—it is a measurable neurological signal that reflects how certain the brain is about a decision. In simple terms, confidence acts as a second-order evaluation of our thinking. It determines whether we act immediately, seek more information, or hesitate.
When confidence is high, evidence accumulates quickly and decisions are made faster. When confidence is low, the brain slows down the process and seeks additional confirmation. In clinical environments, this has important implications.
· Low confidence can lead to delayed decisions, repeated checking, or escalation to more cautious options.
· High confidence often allows clinicians to make timely decisions and communicate clearly with patients and colleagues.
· Excessive confidence can lead to premature closure, where a clinician stops gathering information too early.
In UEC, low confidence therefore can lead to more risk averse decisions—conveyance or admission becomes the safest and easier decision. However whilst confidence can lead to decisions with higher risk, excessive confidence can run the risk of premature or even harmful decision making.
Decision-Making at the Front Door
This dynamic can play out in every part of the UEC system, and the patient may even experience this multiple times in one episode of care. Ultimately, confidence strongly influences the outcome.
When clinicians feel confident in their assessment and the available pathways, they are more likely to accurately identify the patient’s need whilst also supporting alternatives to conveyance or admission.
But when confidence is low—because of uncertainty, lack of support, unclear pathways or time pressure—the decision often shifts toward hospital admission. Not because it is always the best option, but because it feels like the safest one.
And if confidence is too high, the patient maybe discharged from the pathway too soon, only to return with worsening health and care needs.
Both extremes create problems.
Over-confidence can lead to premature conclusions, failure to seek advice, or overlooking complex factors. Experienced clinicians are not immune to this. In fact, experience sometimes increases confidence faster than it improves accuracy.
Under-confidence, on the other hand, leads to hesitation, delayed decisions and unnecessary escalation. Research suggests low decision-making confidence is associated with increased delays in acute care interventions and higher rates of preventable adverse events.
The ideal position sits somewhere between these two extremes. Some learning theorists call this the “humility zone”—where clinicians are confident enough to act, but open enough to continue questioning their judgement. Achieving that balance requires both experience and self-awareness.
This is where emotional intelligence becomes critical.
Emotional Intelligence, Neurodivergence and Clinical Judgement
Emotional intelligence (EI) is the ability to recognise, understand and manage emotions—both our own and those of others.
In clinical settings, this helps clinicians interpret subtle cues from patients, families and colleagues. It also reduces the cognitive load associated with stress and uncertainty.
High emotional intelligence supports:
Better communication with patients
Improved shared decision-making
Greater awareness of bias and assumptions
Calmer responses under pressure
In UEC, where decisions often involve risk and uncertainty, this ability to regulate emotions can prevent what many clinicians recognise as decision paralysis.
Another important dimension of confidence relates to neurodiversity.
Many healthcare professionals are neurodivergent, including those with ADHD, autism or other cognitive differences. These clinicians often bring exceptional strengths—pattern recognition, creativity, hyperfocus and systems thinking—but may experience confidence differently.
Many neurodivergent individuals report fluctuating confidence, shaped by years of social expectations, misunderstanding or masking behaviours to fit into neurotypical workplaces. In high-pressure environments such as emergency departments, this can create additional cognitive load.
Recognising and valuing neurodiversity in healthcare is therefore not just a wellbeing issue—it is also a workforce and decision-making issue. Supporting diverse cognitive styles can strengthen teams, improve problem-solving and reduce risk averse decision making.
The Impact of Pressure and Silo Working on Confidence and Decision Making
UEC environments are inherently stressful. High patient volumes, staff shortages, time pressures and uncertainty place continuous demand on cognitive systems. Research shows that burnout and emotional exhaustion can significantly reduce clinicians’ confidence in their own judgement. Over time, this can erode professional confidence and contribute to workforce attrition as well as impulsive or risk averse decision making.
Another major influence on confidence is how healthcare systems are organised. When professionals work in silos, decision-making becomes isolated. Communication barriers limit understanding of available pathways and reduce trust between teams. This isolation can make clinicians feel unsupported and uncertain about alternatives to admission.
In contrast, integrated working builds confidence by creating shared understanding and collective responsibility. When clinicians know the capabilities of other teams—community services, social care, voluntary sector support—they are more confident in exploring alternatives to hospital admission.
Integrated teams also allow professionals to share expertise, reducing the burden of decision-making on individuals and fosters team and system supported decision making.
The Learning, Development and Confidence Equation
If confidence is such a critical factor in decision-making, the question must shift from how we stop decision making becoming risk averse, to:
How do we increase positive risk taking in a healthy and sustainable way?
Learning and development plays a key role. Confidence grows through repeated exposure to challenging situations combined with structured reflection and support.
Effective approaches include:
· Simulation and role-play allow clinicians to practice complex scenarios in a safe environment.
· Mentorship and coaching help professionals recognise their strengths and develop their personal and professional judgement.
· Reflective practice encourages clinicians to analyse both successful and difficult decisions.
· Interprofessional learning builds understanding of how different disciplines approach risk and problem-solving.
These approaches help align confidence with competence, reducing both self-doubt and overconfidence.
Building Confidence Through Integrated Practice
Integrated working also strengthens confidence in powerful ways. When professionals collaborate across disciplines—AHPs, nurses, doctors, social workers and community teams—they develop a broader understanding of patient needs and available solutions. This shared understanding improves decision-making in both hospital and community settings.
For example, when clinicians know that urgent community response teams, virtual wards or rehabilitation pathways are available, they are more confident supporting people to remain at home. Similarly, when hospital teams trust community colleagues to follow up safely, discharge decisions become easier.
“Confidence, in this sense, becomes a system property, not just an individual one.”
UEC will always involve uncertainty. No clinical decision can ever be completely risk-free. But systems that support confident, well-informed decision-making can manage this uncertainty far more effectively.
By investing in learning, emotional intelligence, integrated working and psychological safety, we create environments where clinicians feel supported to make balanced decisions. Decisions that consider not only immediate medical risk, but also functional ability, independence and long-term outcomes.
In the end, improving flow and reducing pressures in UEC is not just dependent on more beds, staffing or pathways. It also dependent on something far more human:
The individual’s confidence and emotional intelligence, with system support, to make the right decision at the right time and in the right place.
