The ability to exercise clinical judgment and make decisions is essential to professional nursing practice. The Clinical decision making processes of experienced nurses are renowned for being efficient and intuitive. In contrast, the decision-making processes of rookie nurses are known for requiring more work and being more deliberate. Even if it takes beginners longer to make judgments, they still struggle to make decisions that are in their best interests. As a result, the information below is intended to guide you on what clinical decision-making entails, the theories or models that govern it, its process, and lastly, a focus on clinical decision-making in nursing.
Clinical decision making
According to research by the Institute of Medicine, poor medical decision-making is responsible for the deaths of up to 98,000 people annually in the United States. Making decisions is an essential part of the nursing profession. The process of making decisions in the field of acute care nursing is a difficult one. When making judgments to address the needs of patients and their families, nurses must consider various possibly conflicting circumstances. This procedure is made much more difficult because nurses working in acute care settings may be responsible for caring for five or more patients. According to research, additional elements are connected with critical care nurses’ difficulties while making decisions. For instance, nurses working in intensive care might make judgments every 30 seconds. The decision-making process for nurses working in acute care is quite challenging. A better knowledge of the studies on decision-making in this setting may guide future attempts to enhance nursing practice.
What is clinical decision making
Many students new to the medical world wonder what clinical decision-making is. It is vital to understand that making decisions in clinical practice is complex. It involves processing information, evaluating evidence, and applying pertinent knowledge to select the appropriate interventions to provide high-quality care and reduce the risk of patient harm. The process of reaching a decision may vary from brisk, intuitive, or heuristic to deliberate, analytical, or evidence-based.
Therefore, to answer the question of clinical decision-making, you can say that, Clinical decision-making involves striking a compromise between accepted best practices, evidence, research, awareness of the immediate environment and circumstance, and patient understanding. Making an educated choice requires “connecting the dots.”
Clinical decision-making process
The diagnostic, severity evaluation and management stages of clinical decision-making are interwoven. There are several factors to consider when making an appropriate clinical choice, including the requirement for accurate diagnosis and the expenses involved with indiscriminate diagnostic testing. The risk of an unfavourable result due to incorrect care and costs and probable detrimental consequences of therapeutic measures are also evaluated.
A thorough history and physical examination provide the foundation for all three stages of clinical decision-making. Because of the overlap between many different illnesses, making clinical decisions may be challenging. Signs and symptoms associated with a single condition might span a broad range, as can those related to many disorders. The child’s medical history should include a discussion of the current disease. List the child’s present difficulties and the reasons for the visit. Assess the issues in incidence, length, progression, precipitating or aggravating causes, relieving factors, and connections with other issues. Determine the level of functional impairment related to eating, play, sleep, other activities, and absence from school. Inquire about why the child’s parents brought them to visit you. What kind of drug or food allergies does the patient have? There are several medicines that the patient may be taking. Is the child’s vaccination record current? When was the last time the patient was in the hospital or had a significant accident? The medical history examines the status of health of the overall population. Take a look back at your child’s birth and growth. Focus on symptoms, family history, and socioeconomic status to get a clear picture of the patient’s situation.
When doing the physical examination, be patient and approach the youngster with care. To begin, keep a safe distance from the youngster. Before removing the child’s clothes, count their breaths and check for signs of respiratory distress if they have a cold or a cough. Look at the overall design. How well-mannered and calm is the child? Look at the degree of movement and fun in the room. Observe the skin and notice any pallor, erythema, jaundice, cyanosis, or lesions. The lymph nodes should be examined for size, inflammation, and responsiveness. Observe the face and body from head to toe. Assess the mobility and inflammation of the tympanic membrane using a pneumatic otoscope.
Inspect the neck for abnormalities, such as unusual positioning of the thyroid glands, lumps, and oedema. Listen for stridor, rhonchi, wheezing, crepitations, and lung retractions or tachypnea. Take note of tympany, changing dullness, tenderness, rebound tenderness, and any visible organs or masses, as well as any fluid waves and bowel sounds, when doing the abdominal exam. The existence and size of testes and any swellings or lumps should be checked in the male genitalia. Vaginal discharge, adhesions, clitoris enlargement, and pubertal alterations in the female genitalia should be examined. Observe the rectum and the anus to detect any fractures, inflammation, prolapse, tightness of the muscles, or anus imperforation. Take note of limits in the complete range of motion, point discomfort, deformities or asymmetry, and gait problems throughout the musculoskeletal system examination. Observe the joints of the hands, feet, and arms. Note posture, curvatures, stiffness of the spine and back, neck webbing, dimples, and cysts on the spine. Examine the brain, cranial nerves, cerebellar function, the motor system, and reflexes using a neurologic examination.
Nonspecific screening tests such as the complete blood cell count with differential and urine analysis are often used in the first stages of a diagnosis: the results, history, and physical examination guide further laboratory testing and additional procedures. The results of these tests and investigations should reveal the degree and pattern of malfunction. The pattern of indications, symptoms, and results from the ancillary testing is essential in determining the disorder’s aetiology.
Classifying patients into four groups is based on the clinical information gathered from their medical history, physical examination, and other diagnostic procedures. Patients in the most critical condition need prompt stabilization and care to avoid further harm, death, or severe morbidity. Hospitalization is necessary for two reasons: (1) to obtain treatment that isn’t often offered on an outpatient basis, or (2) to be closely monitored because of a high risk of a complication or fast advancement of the illness. Whether a kid should be hospitalized may be influenced by factors such as the parent’s capacity to care for him at home, the child’s geographic isolation, and the weather. Moderately unwell patients require ambulatory care. Self-limiting conditions in mildly unwell people are expected to resolve on their own. If home health care services are substituted for hospitalization, this technique may need to be modified. Patients might be discharged from the hospital early with the help of home health care providers.
The evaluation of the severity and the degree of sickness connects diagnostic decision-making with treatment. E. Four questions are addressed in the management phase of clinical decision-making: The first question to ask is whether or not the patient needs emergency medical attention. (2) Is there a particular treatment that should be used? A critical care unit, a hospital ward, or at the patient’s home? Furthermore, how should the patient be monitored, and what is the recommended follow-up for the patient? Each algorithm’s decision-making process includes stabilization, hospitalization, specialized therapy, and follow-up. Hospitalization in an intensive care unit is necessary for a very unwell patient. Respiratory, circulatory, and neurologic support are all essential components of stabilization.
The purpose of stabilization is to sustain tissue oxygenation, particularly in the brain and other critical organs. O2 supply to tissues is critical to maintaining healthy tissue. To operate appropriately, the respiratory system, including the airways and lungs, must be in good working order, as must the heart’s pump and the body’s ability to transport enough oxygen (haemoglobin). To keep the ABCs is vital (airway, breathing, and cardiac functions). Open the patient’s airway, give them oxygen, and monitor their air exchange while you stabilize them (breathing). Consider intubation and ventilation if exchanging isn’t working. Hypotension or symptoms of inadequate perfusion need the use of circulatory assistance. Pale or mottled skin, cold extremities, and a capillary refill time of more than two seconds are warning indicators. Intravenous fluids are used in the first phase of circulatory support. Pharmacologic therapy may be required in the future. Severe anaemia or bleeding needs transfusions of whole blood or packed red blood cells to restore haemoglobin levels and volume. Some children with seizures or other indicators of neurologic impairment need specialized neuropsychological assistance.
An anticonvulsant with a fast onset of action may be administered, as well as medications to treat low blood sugar or electrolyte imbalances. Include a strategy for keeping tabs on the patient’s progress and evaluating how well the treatment works. Follow-up is often the most critical aspect of a management strategy. A vital part of any treatment strategy is including the patient and their loved ones in the decision-making process and educating them about available options. Follow-up care must include thorough education of the patient and their family. That’s why we need to give it the attention it greatly deserves.
Clinical decision-making in nursing
Regardless of the location or nation in which a nurse practices, her choices while providing nursing care will affect her efficacy in clinical practice and will have a direct bearing on the lives of her patients and their interactions with the healthcare system.
Clinical judgment and decision-making for nursing students
Clinical judgment or decision-making comprises findings of a patient’s state and requirements, a selection of a strategy to adopt to best address those needs, and an evaluation of the patient’s reaction. In the nursing literature, analytical and intuitive processes have been characterized. As a result, you need to note that there are three clinical decision-making models discussed below that nurses utilize in making their decisions while on duty.
Clinical decision-making models
1) The Concept of Reasoned Action
Among the known clinical decision-making theories lies the concept of reasoned action. According to this idea, behaviour is the outcome of an individual’s deliberate decision to engage in a particular action. Before most voluntary actions, individuals set their intentions, and intentions are the most accurate predictions of what people will do. Two elements influence a person’s behavioural intention:
Both perceptions about the consequence of behaviour and assessments of what may be anticipated; as a result, it has a significant impact. The idea that “exercise may help avoid heart disease and make me feel good” and the assessment that “I don’t want to acquire heart disease” and “I want to feel good” may have led to a person’s attitude that “exercise is a good thing to do.”
What a person thinks about their social context is “subjective norms.” These are essentially the belief in and adherence to accepted social norms concerning the appropriateness or acceptability of one’s behaviour. What do others believe I should do? and Do I want to do what they desire? are two of the normative ideas that form the basis of subjective norms, i.e., “what do others think I should?” and “do I want to do what they think?”). “Exercise is proper behaviour,” for example, one may believe. The idea that “my family and friends believe I should exercise” and that “I appreciate their opinion and wish to follow their advice” may have contributed to the development of this subjective norm.
According to this view, the desire to execute the behaviour is created when the two previously mentioned variables (attitude toward the behaviour and subjective norms) come together. Individuals discussed above likely have a strong desire to exercise because of their beliefs, which will motivate them to do so. Depending on the scenario, these two criteria may be weighted differently. Depending on the context, behavioural intents may be more heavily weighted by objective norms than personal views. Still, it is also possible that behavioural standards will be given more weight than individual attitudes.
2) The Transtheoretical Model
In the clinical decision-making theories lies the transtheoretical model. Studies comparing the experiences of smokers who quit on their own with those who needed additional treatment helped Prochaska and DiClemente developed the Transtheoretical Model (also known as the Stages of Change Model) in the late 1970s. This model was developed to understand better why some people could quit smoking alone. According to the findings, people should only stop smoking if they are ready to do so. Thus, the Transtheoretical Model (TTM) is a model of deliberate change that focuses on the individual’s decision-making. The TTM is based on the premise that individuals don’t make drastic changes to their behaviour overnight. Instead, a cyclical process is at work regarding changing behaviour, particularly habitual behaviour. Different behavioural theories and concepts may be applied at different levels of the TTM where they are most successful. The TTM is not a theory but rather a model.
There are six phases of transformation according to the TTM: pre-contemplation, contemplation, prep-action-action-action-maintenance termination. For health-related behaviours, phases of change do not include termination, which is why it is less often employed in practice. It is essential to use the most effective intervention tactics at each step of behaviour change to help people progress through the model to the last stage of behaviour change, which is maintenance.
• Precontemplation is a mental state in which no action is imminently contemplated (defined as within the next six months). People aren’t even conscious that their actions are troublesome or hurt their lives. People at this stage overestimate the negative aspects of altering behaviour and underestimate the positive ones.
• Contemplation – At this point, individuals are mulling over whether or not they should begin practising good habits (defined as within the next six months). There’s a shift in perspective when people realize that their conduct may be a problem and begin to weigh the benefits and drawbacks of altering their ways. Even if individuals are aware of this, they may still be reluctant to change their practices.
• People are ready to take action during the following 30 days at this preparation stage (determination). We see people begin to adjust their behaviour in little ways, believing it might lead to a healthy life.
• Persons who have recently altered their behaviour (within the previous six months) and want to keep on with that behaviour change are in the action stage. Individuals may show this by altering their unhealthy habits or adopting new healthy ones.
• At this stage, individuals can maintain their behaviour modification for an extended period (defined as more than six months). Preventing relapse is the primary goal of those in this stage.
• Termination – People at this stage are confident they will not relapse and have no desire to return to their destructive activities. Achieving and maintaining a healthy weight is difficult for most individuals; therefore, health promotion organizations tend to overlook it.
3) The Fuzzy-trace Theory
Lastly, among the theories of clinical decision-making lies the Fuzzy-trace theory. In the study of critical choices, fuzzy-trace theory (FTT) has been employed as a complete, dual-process model for memory, reasoning, judgment, and decision making. Cognitive systems that transform thoughts into actions are explored in detail in this study, which explains and predicts differences in how individuals recognize and remember prior experiences, make risky judgments and choices, and engage in particular activities under certain circumstances.
Examples of clinical decision-making in nursing
One patient could be required to pick the facility to which they would be released, while another might be needed to choose something as simple as a prescription or activity. Nurses are aware of the significance of patient autonomy and that the patient must make all the choices.
Conclusion
When making decisions in the clinical setting, it is essential to balance utilizing your experience, awareness, knowledge, and information collecting skills, along with consulting with your colleagues and employing evidence-based practice. Effective treatment requires sound decision-making. For clinical decision-making to be successful and efficient, a mix of experience and expertise is required, which primarily encompasses the models or theories of nursing decision-making discussed above.
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