Concept of Clinical Decision Making

Concept of Clinical Decision Making

Outline and Learning Outcomes

  • Critical Thinking

  • Clinical Decision Making

  • Clinical Judgment

  • Lifespan Consideration

  • Concepts - Clinical Decision Making

How Nurses Problem Solve

  • The process involves:

    • Questioning

    • Analysis

    • Synthesis

    • Interpretation

    • Inference

    • Inductive and deductive reasoning

    • Intuition

    • Application

    • Creativity

  • Critical Thinking

    • Defined as the ability to reason in dynamic clinical situations considered along with the client and family's needs and concerns.

  • Clinical Reasoning

    • Conclusion regarding a patient's needs, concerns, health problems, and/or the decision to take action (or not).

  • Clinical Judgement

    • The process leading up to these conclusions.

Clinical Decision Making

  • Defined as the process used by nurses in clinical settings to evaluate and select the best actions to meet desired outcomes.

  • Critical components include evaluating:

    • Each patient’s needs

    • Patient preferences

    • Time-constraining activities to make appropriate decisions.

Common Attitudes of Critical Thinkers

  • Independence

    • Engaging in one's own thinking objectively.

    • Open-mindedness toward different methods to achieve a goal.

    • Seeking facts and not being easily influenced by opinions.

  • Fair-mindedness

    • Holds neutral judgments without bias.

    • Considers opposing views.

  • Awareness of Self-Limits

    • Knowing one's intellectual and experiential limits.

    • Seeking new knowledge or skills based on current evidence.

    • Expressing a willingness to self-reflect on personal beliefs and ideas.

  • Integrity

    • Challenges own ideas and methods.

    • Evaluates inconsistencies in nursing practice.

    • Chooses ethical practices over popular choices.

  • Perseverance

    • Motivation to find the best solutions for quality patient outcomes.

    • Exhibits patience throughout processes.

  • Confidence

    • Knowledge of one's knowledge.

    • Trust in one's skills and abilities regarding intellect, creativity, inquiry, reasoning, reflection, and intuition.

Aspects of Critical Thinking

  • Intellect

    • The capacity to think, understand, and reason.

    • Expands knowledge base for reasoning.

    • Aids in differentiating facts from opinions.

    • Involves intentional actions to recognize salient cues.

  • Cues in Noticing

    • Significant or critical cues may include:

    • Random:

      • Productive cough

      • Sad affect

      • Right-handed weakness.

      • Green-colored sputum

      • Disturbed sleeping

      • Foul-smelling sputum

      • Temperature: 101.2°F

      • Respiratory rate: 22/min

      • Shortness of breath

      • Patient states "I don't feel good."

    • Clustered cues must be related to patterns of infection in the respiratory system.

  • Creativity in Critical Thinking

    • Changes tactics and asks novel questions for patient success.

    • Finds solutions outside traditional interventions.

    • Considers innovative strategies to meet patient goals.

  • Inquiry

    • Involves searching for knowledge or facts.

    • Aids in gaining clarification and problem-solving.

    • Encourages critical examination of one’s own nursing practice.

  • Reasoning

    • Deductive Reasoning:

    • Works from general principles to specific predictions (top-down approach).

    • Inductive Reasoning:

    • Works from specific observations to general conclusions (bottom-up approach).

  • Clinical Reasoning

    • Requires critical thinking and reflection on previous situations to evaluate their effectiveness.

  • Reflection

    • The retrospective process of making sense of occurrences, experiences, or decisions.

    • Involves learning from what worked and what did not work.

  • Intuition

    • May involve a gut reaction or feeling that something is wrong.

    • Utilizes nursing knowledge, experience, and expertise in clinical decision-making.

Clinical Decision Making Scenarios

  • Common questions in clinical decision making include:

    • "Which patient should I see first?"

    • "When can I teach my patient (congestive heart failure) about a no-salt diet?"

    • "How long should I wait before doing a bladder scan on my patient who hasn’t voided since the indwelling catheter was removed?"

    • "When’s the best time for me to watch the video on that new dressing?"

    • "Where can I find more linen for the UAPs to finish patient morning care?"

Clinical Judgement

  • It is the final product of clinical decision making which involves:

    • Reaching a conclusion.

    • The competency to make clinical judgments is an expectation for graduate-level nurses.

Tanner’s Clinical Judgment Model

  • Noticing (Step #1):

    • Describe client demographics.

    • Perform a physical assessment and review the electronic health record.

    • Document findings and highlight abnormal data, including the impact of medications and treatments.

  • Interpreting (Step #2):

    • Identify three problem areas utilizing abnormal data to support concerns and list under each problem.

    • For beginners, start with one problem; advanced students should prioritize by numbering.

  • Responding (Step #3):

    • Formulate specific goals (SMART goals).

    • Determine interventions with rationales for each listed problem.

    • Document client responses to interventions.

  • Reflecting (Step #4):

    • Evaluate progress towards the goal outcomes.

    • Assess whether the goal was met, and analyze any necessary changes or updates.

Implementation and Evaluation in Clinical Decision Making

  • Implementation and Evaluation:

    • Evaluate responses/outcomes of interventions after implementation.

    • Recognize cues during assessment and analysis.

    • Implement priority actions and develop solutions based on analysis.

    • Prioritize hypotheses and confirm the diagnosis.

Lifespan Considerations

  • Decision-making capabilities change with age:

    • Children gain understanding of the consequences of their decisions.

    • Pregnant Women:

    • Paternalism assumes providers know best.

    • Consumerism is a hands-off approach in decision-making.

    • Mutualism involves shared decision-making.

    • Older Adults:

    • May have impaired cognition due to disease, requiring support in decision making.

Interrelated Concepts

  • Accountability

    • Nurses must hold responsibility for the clinical decisions supporting desired patient outcomes.

  • Collaboration

    • Effective healthcare requires teamwork.

    • Nurses may refer patients to case management or social services for post-discharge needs.

  • Communication

    • Essential for continuity of care and must be based on correct information sharing.

    • Nurses use plans of care to document and communicate the priority goals.

  • Safety

    • All nursing decisions must prioritize patient safety to avoid harm and uphold nonmaleficence as an ethical foundation for care.

Conclusion

  • Questions?