The Concept of Clinical Decision Making exemplar 36

Responding - Tanner's

Analyzing a situation and choosing the best course of action Intuitive "knowing" from past similar experiences Includes using past similar experiences to "make sense" of a present clinical situation Responsive actions by the nurse

Problem solving

Because some patients have complex health issues, their care is equally complex and involve problems that are not always easy to "fix." To "fix" the nurse obtains information that clarifies the nature of the problem and identifies possible solutions. The nurse then carefully evaluates the possible solutions and chooses the best one to implement. Then see if everything worked out

Benner's Skill Acquisition Model

It was a study of 5 levels of proficiency a nurse progresses through

What role regarding sound clinical decision making in patient care is expected of the licensed registered nurse?

Nurses are expected to use all available information, sound reasoning, and clinical judgment when making decisions regarding patient care.

clinical decision making

Problem-solving approach that nurses use to define patient problems and select appropriate treatment.

Tanner's Clinical Judgment Model

Tanner's "thinking like a nurse" approach in her clinical judgment model emphasizes the importance of elements the nurse uses in cognitive processing: different types of knowledge (e.g., textbook, transferred, on-the-job, abstract), length of nursing experience, values, morals, intuition, and knowing the patient (i.e., being familiar with expected patterns of responses to a medical condition or knowing the individual patient)

Can consideration always be given to every alternative?

The list of alternatives could be quite lengthy, so limit the list to the top five options for serious consideration.

What questions might the nurse ask of Tyesha (a small child afraid of her incentive spirometer) to isolate the reasons the incentive spirometry device frightens her?

The nurse might ask if Tyesha has ever seen the device before or if she has seen something that looks like the device. She might also ask what it is about the device that frightens her.

critical thinking

All or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity

What legal actions may occur if the nurse fails to make prudent clinical decisions? Explain your answer.

Answers may vary but should address the following: Nurses are responsible and accountable for clinical decisions made, guided by their scope of practice, standards of care, and criminal and civil law. They can be held for negligence or malpractice. They can be charged with intentional torts of assault, battery, false imprisonment, and invasion of privacy.

Problem solving example: Austin (4 yo with asthma) history of frequent colds allergy to grass. Dad smokes 3 packs of cigarettes a day and Austin has been playing with the neighbor's cats

Assessment: check breathing, Vitals, O2 stat, CBC, Chest x-ray, past medical history Diagnosis: Focus on difficulty breathing Planning: What is the goal? example lung sounds will be clear Implementation: how is that gonna happen-O2? Nebulizer? Assess lungs q whatever? Up fluids? Evaluation: is it working?

Opinions

Beliefs formed over time; may include judgments that may fit facts or be in error (for example Nursing intervention can assist in maintaining the patient's blood pressure within normal limits.)

Facts

Can be verified through investigation. For example Blood pressure is affected by blood volume.

Inferences

Conclusions drawn from facts; going beyond facts to make a statement about something not currently known (If blood volume is decreased (e.g., in hemorrhagic shock), the blood pressure will drop.)

Judgments

Evaluation of facts or information that reflect values or other criteria; a type of opinion (for example It is harmful to the patient's health if the blood pressure drops too low.)

Noticing - Tanner's

Having a sense of what is happening in the patient situation May include recognition of or absence of expected significant cues from the patient's response to illness or a medical condition Includes influences of the nurse's own health beliefs about patient situations and expectations of the work culture for patient care

The nurse with strong critical thinking maintains an evidenced-based practice by __________.

Keeping current in nursing knowledge, skills, and attitudes through continuing educational activities; maintaining level of competency; integrating best practice from professional research; and continuously looking for opportunities to improve the professional self.

What ethical obligation does the nurse hold toward the hiring facility related to clinical decision making?

Making clinical decisions is a process that nurses follow. There is an ethical responsibility to make these decisions using all resources available and keeping the care patient-centered.

What ethical obligation does the nurse hold toward the patient related to clinical decision making?

Patients should have input into decisions made concerning their care as much as they are able to do so. They need to be informed about procedures and therapies. They need to be a partner in their care and not just a receiver of care.

What role regarding sound clinical decision making in the workplace does the employer expect of the nurse?

The care of patients is entrusted to nurses. Employers have policies and guidelines for nurses to follow when making decision about this care. The expected performance and decisions made would follow acceptable standards of nursing care set up by professional organizations such as the ANA.

If Tyesha (a small child who is afraid of her incentive spirometer) didn't want to blow bubbles, what might an effective alternative be that could fulfill the same purpose?

The nurse could use a penlight as a "candle" that Tyesha could blow out. The blowing motion is similar except for the controlled exhalation.

How might the nurse explain the purpose of the incentive spirometry device to Tyesha (a small child afraid of her incentive spirometer) in a way that would make her less frightened of it?

The nurse should first assure Tyesha that the incentive spirometry device cannot hurt her in any way. The nurse could explain the purpose of the device in simple terms and might use a doll-like model or diagram to explain how the device affects the lungs.

A nurse reads a peer-reviewed article that recommends changing currently accepted practice. What critical thinking will the nurse perform before accepting the article's recommendations?

The nurse will use the PICOT method to find the best practice with similar recommendations and analysis results to identify the course of action. The nurse will also critically think about the use of this change with specific patients.

Reflecting - Tanner's

Using cognitive processes to review a clinical situation Considering appropriateness of assessment data obtained in the situation, actions taken, and positive and negative outcomes for patient Making mental response adjustments for similar future situations Learning from actions (done or not done)

Interpreting - Tanner's

Using logical reasoning to gain understanding about a situation and determine appropriate actions

Lasater's Clinical Judgment Rubric

Very similar structure to Tanner's model; however, has a greater emphasis on data collection and interpretation. Also measures progress in all 4 catagories.

Inquiry

examines objective information to gain clarification and find solutions to problems. Questions like: Why do we apply the dressing this way? What can I do to help patient swallow medication better?

Creativity

finding unique solutions to unique problems when traditional interventions are not effective; for example, finding just the right way to connect with a patient who does not want to talk about her diabetes or finding interventions that best help a patient meet a goal so he can be discharged from the hospital.

Inductive reasoning

involves working from the "bottom up." The nurse observes specific behaviors or symptoms and develops a general conclusion by putting significant, specific cues together

Noticing cues

putting them together into a complete idea

Clinical reasoning

requires critical thinking and the ability to reflect on previous situations and decisions and evaluate their effectiveness. With effort and time, new nurses learn critical thinking and integrate it into daily routines.

salient cues

significant data that informs and influences conclusions about the patient's health status. For example: Labs, vital signs, a variation from normal (eating only one bite of meals) statements ("I have been experiencing shortness of breath when climbing stairs.")

Intellect

the ability to think, understand, and reason.

Reflection

the action of retrospectively making sense of occurrences, experiences, situations, or decisions and consequently learning from them. It is the process of figuring out what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, what necessary resources were available

deductive reasoning

the nurse works from the "top down" by starting with general ideas, observations, or principles and analyzing them to develop specific predictions. from general to specific

intuition

the use of nursing knowledge, experience, and expertise for understanding without the conscious use of reasoning. What they call a "gut reaction" or a "feeling that something is wrong" when working with patients