Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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engagement they have with the person being cared for (Tanner, 2006). Person-centredness refers to the quality of the relationship that occurs at the clinician–patient interface when the clinician ‘knows’ not only themselves but also the patient, in a holistic sense that is not just related to the person’s physiology or illness history (O’Neill, Dluhy & Chin, 2005). Clinical reasoning that is undertaken without full engagement by the nurse or midwife may result in processes that are ritualised or depersonalised. However, not all processes of care require the same degree of engagement; in some cases a high level of engage- ment may be inappropriate to the situation. When the level of engagement does not match the patient’s needs, it can detract from the quality of the reasoning, the interaction and the creation of a therapeutic relationship. Therefore, one of the skills required of the nurse or midwife is to match the level of engagement to the needs of the person (Table 14-1). In these situations, the competence of the clinician is para- mount in making decisions regarding the level of engagement that is appropriate. For this reason, being empathic, listening well and showing an ability to imagine others’ feelings and difficulties are also important attributes in reasoning ability (Alfaro-LeFevre, 2012). Willingness to put all the pieces together Recall the list of personal attributes required for person- centred care in Box 1-5 in Chapter 1. Two important attributes were motivation and moral agency. These attrib- utes are also essential for clinical reasoning. Motivation is the potential within the individual that accounts for consis- tency of effort expended in carrying out the required activities of the clinician (Janssen, de Jonge & Bakker, 1999). Moral agency involves translating ethical principles into action. Nurses and midwives are acknowledged as key personnel in collecting the data that underpin decisions and actions in

healthcare (Levett-Jones & Hoffman, 2013). Clinical reason- ing requires clinicians to put together what is seen, heard and known into a coherent whole in order to come to a judgement (DiVito-Thomas, 2005). A desire to do one’s best work ( motivation ), combined with a desire to do what is right for the person ( moral agency ), enhances the clinician’s ability to ‘put the pieces together’, looking beyond the known to the unknown when seeking solutions and thus improving the reasoning process (Fowler, 1998). To achieve excellence in reasoning that is driven by high levels of motivation and moral agency, clinicians are required to be motivated, genuine, honest and upright. The person doing the reasoning must seek the truth, even if it sheds unwanted light, must be knowledgeable, flexible and open-minded (Paans et al., 2012), must admit flaws in their own thinking, and must be willing to admit to mistakes and learn from them. Clinicians must also be able to reason in a professional way, taking into account policies and procedures, professional standards, law and ethics (Alfaro-LeFevre, 2012). Willingness to make a decision Clinical reasoning has also been shown to be influenced by the confidence of the clinician and the clinician’s levels of anxiety experienced in the situation (O’Neill, Dluhy & Chin, 2005). Anxiety can cause a novice clinician to over- look significant cues and thus can lead to poor reasoning, judgement and decision making. The influence of anxiety on reasoning can be mitigated by the presence of supervi- sion or support from more experienced clinicians who are available for consultation and discussion related to the sig- nificance of the cues. Clarity of roles and responsibilities also helps to make reasoning a less anxiety-provoking activity, thereby improving its effectiveness. The Nursing and Midwifery Board of Australia (NMBA) (2007) has developed a framework to assist clinicians in developing skills in decision making.

TABLE 14-1 Levels of engagement that affect reasoning and the process of care

Level of engagement

Description of engaged practice The clinician participates in shared decision making with the patient in order to be able to recognise a problem, collect the full range of cues needed to enable sound clinical reasoning and negotiate a plan of care that reflects the values and beliefs of the patient. This may occur when the clinician does not know the patient or when the context and priorities of the moment do not allow for the building of a therapeutic relationship (e.g. when the clinician is part of a visiting resus- citation team). Reasoning can be affected by incomplete information. There is no encouragement for the patient to participate in decisions related to their care. Reasoning is dominated by factors other than patient’s needs and values.

Full engagement or total connectedness between the clinician and the patient

Partial engagement, or where a problem or the context affects the relationship between the clinician and the patient

Disengagement, or where there is no relationship between the clinician and the patient, or where the relationship is dominated by ritual or routine actions

Source: McCormack & McCance, 2010.