Fundamentals of Nursing and Midwifery 2e

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

integrated and synthesised, the clinician must make a judge- ment and decide what actions are to be taken and in what order. Clinical judgement is interconnected with decision making, which will be explained in the following section. Decision making Person-centredness also applies to reasoning and thinking, as these ‘higher order thinking skills have no value unless they are applied for the good of the patient’ (Tanner, 2006, p. 209). Person-centred processes of care also require clini- cians to be effective decision makers (Martin, 2002). Indeed, the ultimate goal of clinical reasoning is the pro- duction of effective decisions to direct the provision of care. The complex and often confusing problems that arise from the physical and psychosocial status of the person require the nurse or midwife to collect, organise and process a large amount of data. Martin (2002, p. 1) states that ‘the nurse must recognise, interpret, and integrate new information and make decisions about the course of action to follow. For satisfactory client outcomes, complex decision making goes hand in hand with critical thinking’. The process of decision making in nursing, midwifery and medical contexts is often described through a hypothetico- deductive model (Banning, 2008). This type of decision making comes from the science of logic. As described above, once a problem has been identified, the first step involves the collection of data (or cues), the interpretation of which leads to the creation of a preliminary hypothesis to explain the data. The data are then grouped into categories through a process of pattern matching that has been established through previ- ous experiences or learning. More data may then be collected, providing the evidence to support or disprove the hypothesis, which then determines the action to be taken. Duchscher (1999) describes how this way of thinking underpins the traditional concept of the nursing process. This kind of scientific thinking is useful, as thinking needs to be systematic. However, it can become a problem for clinical reasoning if thinking is restricted solely to this

type of logical, scientific thought and does not also acknowledge other ways of thinking—such as creative and intuitive thinking as discussed above—as this restricts the range of possible solutions that may be considered. Clinical actions are discussed in the following section. ACTIONS OF CLINICIANS Like beliefs and values, decision making is often not overtly expressed but is evident in the behaviour or actions of the clinician. An action taken may be defined simply as ‘the behaviour following on from a judgement or decision’ (Thompson & Dowding, 2002, p. 14). This action may be a simple act or a series of acts; it may involve undertaking a practical task or communicating with another clinician. Like clinical reasoning, the actions taken by a clinician are dependent on the confidence and competence of the clini- cian and on an assessment of the risks involved (O’Neill, Dluhy & Chin, 2005). Actions that demonstrate the use of clinical reasoning, judgement and decision-making skills in clinical practice are listed in Box 14-5. Decisions to be made include when the action will be undertaken. This is often referred to as ‘patient prioritisation’, and is a skill that is enhanced by experience. When there are time pressures, the quality of the decision and hence of the action may be affected. This is a very important consideration in contemporary healthcare, as time is seen as being inadequate in most clinical settings (Duffield et al., 2007). From what you have learnt so far, construct a summary of each of the following steps required for thoughtful practice: 1. Collect data (cues). 2. Recognise a problem. 3. Process the information using critical, creative and intuitive thinking. 4. Come to a judgement. 5. Make a decision on what action to take (or not to take).

BOX 14-5 Actions that demonstrate clinical reasoning, judgement and decision-making skills • Applying standards and principles in the processes of care, assessing systematically and comprehensively to identify health-related problems • Evaluating information for bias, identifying assumptions and inconsistencies, checking accuracy and reliability Judgement and decision making • Predicting complications, anticipating consequences and including these in planning care • Determining priorities and including key stakeholders in decisions, including patient and family perspectives • Managing risks, balancing risks and benefits of interventions to the individual • Determining individualised outcomes and monitoring progress • Determining the significance of data, distinguishing relevant from irrelevant data, clustering relevant data together, seeking missing information, drawing reasonable conclusions • Identifying underlying causes and related factors, considering multiple explanations and solutions • Communicating effectively, both orally and in writing • Identifying ethical issues and taking appropriate action • Identifying appropriate resources (human, information and technological)

Source: Adapted from Alfaro-LeFevre, 2012.