Clinical Judgment, Decision Making & Problem Solving

Decision Making

choosing with a given set of options

Problem Solving

a process that helps make the decision-making process work

Clinical Judgement

“ process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning. This process is used to understand and interpret information in the delivery of care. Clinical decision-making based on clinical judgment is directly related to care outcomes problem-solving.” (AACN)

The 6 Functions of Clinical Judgment

1. recognize cues

2. analyze cues

3. prioritize hypotheses

4. generate solutions

5. take action

6. evaluate outcomes

The Nursing Process

1. assessment

2. analysis

3. planning

4. implementation

5. evaluation

Recognizing cues:

¡Identify information, subjective, objective, history.

What is relevant? What is most important? Is there anything urgent?

Analyze cues:

¡Organize the cues, how do they reflect the current condition/s? Is there anything that may represent a different problem? Why are these cures concerning? Is there any other information needed that would help?

Prioritize hypotheses:

¡Determine urgency of the data, what is most likely happening? Is anything serious to warrant immediate needs?

Generate Solutions

¡– Identify what outcomes are expected based on data. What interventions can be done to achieve those outcomes? Does anything need to be avoided? Think of goals and interventions.

Take Action

Implement the solution/s that have the highest priority first. What interventions must be done first? How are these interventions accomplished?

Evaluate Outcomes

¡Compare the observed outcomes, were goals achieved? Were the interventions effective? Does something need to be altered? How does one determine if the goals were met?

Supporting others in decision making

¡Recognize/celebrate differences and diversity

¡Gender differences

¡Values/beliefs

¡Past experiences

¡Personal choice

¡ Learning/thinking styles

Elements of decision quality:

1. appropriate frame

2. creative doable alternatives

3. meaningful reliable information

4. clear values and trade offs

5. logically correct reasoning

6. committment to follow through

Results of Rushing decisions

¡Skydiving without a parachute: i.e. lacking data before calling provider, not having the right equipment before a procedure

¡Assumptions overtake real data: i.e. prejudices of disease (alcoholism, drug abuse, psych conditions, morbid obesity), personal biases

¡Overconfidence can be detrimental,  ASK questions: You are responsible for human lives!

• Not considering other points of view: Seasoned staff know more than you, be open-minded, self-reflect, avoid stubbornness

• Shooting from the hip with no data to support: “Well, I think it is…..,” know EBP

• Doing the first thing that comes to mind because you PANIC: i.e. calling a code before checking the DNR status, asystole but really was a lead placement issue

Decision making through experience

¡Skill development as a novice nurse

¡Refine skills and clinical judgment over time

¡Delegation and prioritization

¡Novice nurse task focused – i.e. assess for pain, give medication, checklist completed = task complete – THIS IS NORMAL for first 1-2 years, you will get there!

¡Expert nurse this more holistically and ask why – i.e. why are they still having pain, is there something else besides medication I can do, do I need to call the provider for an alternate medication, let me assess the problematic area. They continue to seek reasoning beyond the task, prevent situations again, and refine goals based on outcomes.

NOVICE to Expert

BE PATIENT, it takes time to be comfortable in the nurse role!

Novices have these qualities:

¡Linear thinker, black & white, no gray

¡React quickly, lack data for rationale

¡Need clear instructions/guidelines

¡Task orientated

¡Learning to delegate and prioritize

¡Internships & preceptor models well received    

Experts have these qualities:

¡Organize data well

¡Assess early, put all the pieces together, then act, prioritizes

¡Know when and how to get things done

¡Confident, leadership qualities

¡Pays close attention to patient responses

¡Vast knowledge, great preceptor/mentor

Administrative decision making

¡Know who the leaders are in an organization; is there equality 

¡What kind of management structure does the organization have?

¡How can staff implement change; is there shared governance?

¡Does the organization value nurse decision-making?

¡Magnet hospitals

¡Many tools can be used to help guide decision-making