NURS 3517: Module 2D - Decision-Making in Nursing - Reviewing & Reflecting

Class Learning Objectives

  • Demonstrate links between outcomes of care, quality improvement initiatives, and personal reflection.
  • Provide examples of when reflection on actions would indicate the need for practice to be adapted or changed.

Overview/Agenda

  • Importance of reviewing actions and what it involves.
  • Skills required for review/reflection.
  • Barriers to reviewing actions.
  • Strategies to use when reviewing actions.
  • Case study.

Terms to Know

  • Research: Systematic study of issues using rigorous data collection, testing, and analysis to develop approaches that improve processes and outcomes (text, p. 127).
  • Evidence-based Practice: Development of new practices after considering the best information from research, clinical experts, and client values and preferences (text, p. 127).
  • Quality Improvement: Application of evidence-based practices to develop standards, policies, guidelines, and procedures to address relevant issues (text, p. 127).
    • A process that initiates positive changes and better outcomes through a continuous cycle of systematic, evidence-informed approaches based on direct evaluations and comparisons of results to a benchmark or standard.
  • Evaluation: A review to determine the effectiveness of nursing care, practiced in various frameworks and models, based on various inputs and feedback.
  • Feedback: Giving and responding to information (both verbal and written) about nursing care and performance to facilitate professional and personal growth, practical improvements, and optimal care. Feedback can come from anyone involved in care, including the client.

Pulling It All Together

Concepts Studied

  • Thinking Ahead (Anticipatory Reflection): Planning and considering future actions.
  • Thinking in Action (Reflecting in Action): Reflection occurring during the action.
  • Thinking on Action/Thinking Back (Reflecting on Action): Deconstructs logic and clinical reasoning to look for flaws with the purpose of gaining understanding/correcting for future experiences.

Closing the Loop: Looking Back on Actions

  • Importance of evaluating client care.
  • Engaging in Continuous Quality Improvement.
  • Reflecting as a learner and professional.

Process for Evaluating Client Care

Five steps to consider (Astle & Duggleby, 2024):

  1. Identifying the review criteria and standards.
  2. Collecting and interpreting information to evaluate if the criteria and standards were met.
  3. Analyzing and summarizing findings.
  4. Recording findings and clinical judgments.
  5. Closing the loop by discontinuing, continuing, or revising care.
    • Note: This process resembles the overall thinking and decision-making process: look at information, analyze it, make a determination, and revise.

Importance of Review/Reflection

Evaluation as a Review and a Reflective Activity

  • Based on process: Use of methodologies or mechanisms available to solve problems.
  • Based on outcomes: Responses observed as a result of an intervention or action; measurements that relate to the effectiveness and efficiency of an action.

Nursing-sensitive Indicators (NSIs)

  • Clinical care client outcomes influenced by changes to nursing interventions, according to empirical evidence (D’Amour et al., 2014).
  • Examples include:
    • Pressure injuries.
    • Falls.
    • Medication administration errors.
    • Pneumonia.
    • Catheter-associated urinary tract infections.
    • Use of restraints.

Quality Improvement (QI) Methods

Description and Questions/Process

  • Time Out: Stepping back from care delivery as a team to consider questions aimed at goals, change, and improvement:
    • Are we doing the same things?
    • Are we doing the right things?
    • Are our actions consistent with policy and procedure?
    • Is there a better way?
  • Huddle: Short meetings for teams to review performance and anticipate potential upcoming issues, which can be utilized at the start of a shift or in response to urgent issues:
    • What are the issues?
    • Are there associated risks?
    • What are possible solutions?
    • What can be done to prevent this issue from recurring?
  • Plan-Do-Study-Act (PDSA) Cycle: A systematic method for testing changes:
    • Plan: State change idea, identify what will be measured and how.
    • Do: Conduct the test and document.
    • Study: Analyze outcomes of change and compare with intended effects.
    • Act: Make revisions, plan for next improvements, and test.
    • Adapted from: Harwood & Wilson (2022); Waddell & Walton (2022).

Connecting Concepts of Client Care and QI

  • Continuous focus on Quality Improvement (QI): Research, QI, and Evidence-Based Practice (EBP) intertwined with nursing care and evaluation.

Recall Reflection Theory and Reflection Cycle

  1. Description: What happened?
  2. Feelings: Thoughts and emotions.
  3. Evaluation: Good and bad aspects.
  4. Analysis: Sense-making.
  5. Conclusion: What else could have been done?
  6. Action Plan: For future situations.

Reflection-on-Action

  • A practice that completes the reflection cycle; reveals what nurses learned from their experiences, contributing to ongoing clinical knowledge development and enhancing clinical judgment.

Novice to Expert: Reflective Activities

  • Importance of reflection to professional growth:
    • Incorporate others' perspectives.
    • Develop intuitive (System 1) thinking as a nurse.
    • Required competency for entry to practice, meeting standards.
    • Necessary for improving practice quality and nursing knowledge.
    • Ensure client and system safety.
    • Aim: Improve actions and practice outcomes.

Thinking Skills for Reviewing and Reflecting

  • Identify quality improvement approaches and evidence gaps.
  • Evaluate effectiveness of actions and outcomes.
  • Debrief with peers/self and other professionals.
  • Incorporate new knowledge and evidence.
  • Review personal learning plans.
  • Predict future client needs.
  • Reflect on actions.

Clinical Reasoning and Other Skills When Reviewing Actions

  • Recognize relationships between concepts and data.
  • Recall science-based, ethics, and nursing knowledge.
  • Assess systematically and comprehensively.
  • Identify pre-existing biases and assumptions.
  • Anticipate care needs in the client context.
  • Form therapeutic relationships, considering client expectations.
  • Use nursing knowledge to inform actions, review, and decision-making.
  • Implement effective communication strategies in care delivery.

Barriers to Reflecting and Reviewing

Internal Barriers

  • Ensuring all necessary information is considered.
  • Not applying the full model of thinking (stopping after action is performed).
  • Inconsistent behaviors, resulting in a lack of insight and poor professional growth.

External Barriers

  • Unit and environmental culture that may not support improvement.
  • Time restrictions and distractions.

Strategies for Improving Reflection and Review

  • Self-Regulation: Ability to adapt and correct behaviors for client care, health systems, and professional growth.
  • Debriefing: A structured form of reflection through group or individual discussions.
  • Framework Application: Engaging in relevant self-regulation activities to improve performance and thinking.

Self-Regulation Considerations

For Client Care

  1. Assess if the client achieved identified outcomes.
  2. Identify outstanding care issues that need resolution or changes.
  3. Ensure the documentation of interventions and outcomes is accurate.
  4. Solicit input from the client or other healthcare providers to enhance care.

For Health Systems

  1. Evaluate access to necessary resources for care provision.
  2. Review policies or procedures to prepare for similar future situations.

For Professional Practice and Growth

  1. Reflect on the completion of care phases accurately and professionally.
  2. Identify areas needing more in-depth self-review and peer input.
  3. Explore formal strategies to deepen and expand knowledge (workshops, reading, etc.).

Review Actions: A Holistic Approach

NRCE - Nursing Knowledge

  • Practice or specialty-based nursing knowledge is essential for comparing outcomes with intended goals.
  • Identify unexplored areas in research or gaps in nursing knowledge to inform quality improvement initiatives.
  • Example Scenario: Discharge teaching after a bowel resection for diverticulitis requires a thorough review of educational strategies and techniques to assess the client’s understanding and support.

NRCE - Professional Role

  • Review the nursing role regarding decisions and interventions with other healthcare professionals. Reflection is crucial for maintaining professional practice standards.

NRCE - Client Context

  • Obtain feedback from clients and evaluate their perceptions of care outcomes, both physical and emotional.

NRCE - Healthcare Environment

  • Evaluate the effects of environmental influences, such as policy gaps or structural limitations on care delivery.

Lasater Clinical Judgement Rubric (LCJR)

  • The LCJR is a tool for reflecting on the Clinical Judgement Model, assessing clinical thinking rather than dictating it.
  • The rubric consists of:
    • Noticing: Focused observation; recognizing deviations from expected patterns.
    • Interpreting: Prioritizing and making sense of data.
    • Responding: Clear communication and intervention planning.
    • Reflecting: Self-analysis and commitment to improvement.
  • Scoring:
    • Exemplary (4), Accomplished (3), Developing (2), Beginning (1).
    • Range: Highest score 44; Lowest score 11.

Clinical Judgement

  • Defined as the outcome of critical thinking and decision-making, focusing on client's healthcare needs; utilizes nursing knowledge for observing and assessing situations, prioritizing concerns, and generating evidence-based solutions.

Case Study: Application of the Clinical Judgement Model

  • A 60-year-old client underwent a bowel resection and has a temporary colostomy post-diverticulitis treatment.
  • Essential nursing responses include assessing postoperative recovery details such as pain management, colostomy care, client preferences, and ensuring clear communication about dietary needs.
  • Reflective analysis should focus on quality improvement approaches, effectiveness of actions, and peer debriefing.

Reflective Practice Moment

  • Reflect on the last clinical experience: identify skills utilized, reflect before and during care, and what was learned afterward.

Class Learning Objectives Met

  • Achieved connections between care outcomes, quality improvement initiatives, and personal reflection.
  • Provided relevant examples indicating reflection's significance in practice adaptation or change.

Activity

  • Online quiz covering this week’s material (Week 8).
  • Test next week covering Weeks 5-8 of Module 2.