Fundamentals of Nursing and Midwifery 2e

259 Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care

Problem solving that takes into account critical thinking, creative, non-traditional and reflective approaches enables additional solutions to be formulated (Chabelli, 2006). The different methods of problem solving are explained below. However, the first step to problem solving is recognising that there is a problem. Recognising a problem As previously discussed, in any clinical situation, the clini- cian is presented with a wide range of information acquired through observation, patient records, knowledge of the person and the context of the environment. When all of this information is indexed against the knowledge base and experience of the clinician, patterns are built. The clinician is able to recognise when there is a discrepancy between the needs of the person and what is actually happening. The cli- nician is therefore able to recognise this as a problem. This recognition may in turn lead to the collection of more cues. In Chapter 1, the context of modern practice and rapid change in knowledge and technology is discussed. One point that is made is that the acuity of patients in hospitals has increased, and their care has correspondingly become more complicated (Duffield et al., 2007). This may create circum- stances in which there is a potential for error through not recognising that a problem is occurring. This might lead to incorrect decisions or actions by the clinician. Such errors are called adverse events , and they may affect the health or well- being of the patient. They may also be unrelated to the reasons for the patient’s admission. These events that occur by com- mission or omission are now measured and studied using such techniques as critical incident analysis to determine if there is an error in the system that can be rectified (Wilson et al., 1995). In Chapter 13, an adverse event by commission—a medication error—is used in an example of a critical incident analysis. The other type of error is one of omission, where poor clinical reasoning leads to a failure to act, often called a ‘ failure to rescue ’, where a deteriorating situation (a problem) is not recognised or is not responded to appropriately by a cli- nician (Duffield et al., 2007; Thompson et al., 2008). Therefore, problem-solving skills are imperative for any clini- cian preparing for practice (Higuchi & Donald, 2002). Once a problem has been identified, problem solving may then take different forms, as explained below. Trial-and-error problem solving involves testing a number of solutions until one is found that works for that particular problem. For example, you might use this approach in trying to solve a clue in a cryptic crossword puzzle, coming up with several possible answers and then working out which one best fits the clue. However, if used in clinical practice, this method can be dangerous for the patient. For example, you would not use a trial-and-error approach when deciding which of the multiple chest drains to remove for a patient fol- lowing surgery, as the wrong option may harm the patient. Forms of problem solving Trial-and-error problem solving

Scientific problem solving Scientific problem solving is closely related to the more general problem-solving processes commonly used by health- care professionals as they work with patients. It involves identifying a problem, collecting data and interpreting the results to form a hypothesis based on scientific knowledge, which in turn drives the action taken. An example is where a clinician responds to a person who says ‘I feel unwell’ (a problem) by taking the person’s temperature (collecting data), reviewing these data against what the clinician knows to be the normal parameters for body temperature (interpreting the results), deciding that the person needs medical review because of a possible infection (forming a hypothesis) and so ringing a doctor (taking an action). Intuitive problem solving Many experienced clinicians can describe situations in which a ‘gut feeling’ or ‘inner prompting’ led to a quick intervention that saved the life of a patient. This type of feeling is often referred to as ‘tacit knowledge’, and is built up over years of experience (Benner, Hughes & Sutphen, 2008). When nurses and midwives directly relate a situation to other situations based on similarities or differences, they are using intuitive problem solving. An emergency nurse who realises that a trauma patient is deteriorating before there are measurable signs to suggest trouble is using intu- itive problem solving, as is a midwife who somehow ‘senses’ the right moment to intervene in a seemingly uncomplicated birth. As intuitive problem-solving ability comes only through years of practice and observation, beginning clinicians must use their knowledge and scientific problem solving skills as the basis of the care they give (Benner, Tanner & Chelsa, 2009). However, intuition is a skill that can be nurtured through such techniques as brainstorming (Alfaro-LeFevre, 2012). You may have used brainstorming in your group work. Thinking logically about each new idea can sometimes stifle the flow of ideas; therefore, in brainstorming we draw on our intuitive thinking to generate ideas, which can then be discussed in a more logical fashion once the brainstorming is complete and all the new ideas have been collected. Recall a time when you used brainstorming. Think about how this process worked. Did you use your intuition or did you rely on logical thinking? However, intuitive problem solving also has disadvan- tages. While the use of intuition can often move problem solving forward quickly, it can also result in a trial-and-error approach and it does not necessarily foster ‘outside-the-box’ ideas or creative ways of solving problems. As well as this, certain aspects of practice require a more logical or evidence- based approach to thinking, such as developing policies and procedures or planning care. If we were to undertake these tasks based purely on intuition without the benefit of evi- dence, we may increase the risk to the patient with little or