Clinical Decision-Making
Nursing 487
Wendy Lafreniere, RN,MSN,CCRN
Objectives
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Define and compare the concepts of critical thinking and clinical
judgment in complex patient care scenarios;
Identify and apply two major nursing theories regarding clinical
decision making in high acuity patient scenarios;
Differentiate between patient-focused decisions and populationfocused decisions and list examples of each;
Discuss special considerations regarding high acuity patients
including ethical dilemmas, personal values and nursing
stressors.
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In high acuity settings, the RN must be
able to analyze clinical situations, make
clinical decisions based on this analysis,
& act on the decisions made rapidly &
precisely
Sound clinical decision making is the
basis for good nursing in complex patient
care situations
Critical Thinking
NURSING SKILLS
Decision-Making
Critical Thinking vs
Clinical Judgment
Critical thinking –
purposeful, outcome-directed thinking
based on scientific knowledge or research with the ultimate goal
of identifying nursing interventions and selecting the most appropriate
intervention for the patient.
Clinical judgment – informed opinions and decisions based on
empirical knowledge and experience. Critical thinking and understanding
nursing process are both important aspects of sound clinical judgment.
Essential Cognitive Skills of
Critical Thinker:
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Interpretation
Analysis
Evaluation
Inference
Explanation
Self-regulation
Expert Critical Thinker
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Outcome-directed
Open to new ideas
Flexible
Innovative
Creative
Analytical
Assertive
Caring
Energetic
Knowledgeable
Resourceful
Intuitive
Critical Thinking/Clinical
Judgment Theorists
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Brookfield
CT is a reflective
process
Critical Incidents
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Phenomenography
of Critical thinking in
Nursing
Themes of Critical
Thinking
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Benner
CT is thinking in action
Narratives
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Habits of thought
Domains of practice
Benner: Clinical Judgment
Competent
Adv.
Beginner
Patient
Care
Novice
Proficient
Expert
M Wafer
Brookfield: Critical Thinking
Components
Skepticism
Assumptions
Context
Consequences
M Wafer
Consequences of CT
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Impostership: awareness that you don’t
deserve to be regarded as competent
Cultural Suicide: an affront to the status
quo
Lost Innocence: realizing that there is no
“end” in knowing
Community: sustaining peer groups
Roadrunning: moment of realization that
“old” way of thinking is not working
Nursing Process
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Assessment (of patient's needs)
Diagnosis (of human response needs
that nurses can deal with)
Planning (of patient's care)
Implementation (of care)
Evaluation (of the success of
the implemented care)
Critical thinking + Clinical
judgment + the nursing process
=
Good clinical decision making!
•Patient-focused decisions
•Population-focused decisions
Patient Focused Decisions
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ABC’s
Priorities
Proactive Nursing
Judgment
Prioritize
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Triage
Acuity
Multi-task
Customer Satisfaction
P. Thomas
Rapid Response Teams
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RRT bring critical care to the patient in a
non ICU environment
The goal of RRT is to prevent full patient
cardiac or respiratory arrest – to
PREVENT code BLUE!!
Recommended by the Institute of
Healthcare Improvement
When to call RRT:
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Significant change in heart rate, B/P or
respiratory rate or pattern including O2 sat
Change in LOC or mental status
Acute hemorrhage
Acute seizure
Patient unresponsive
Unrelieved pain
Staff concerned
Population Focused Decisions
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Evidenced Based Practice
Outcome Based
Practice/CQI
Health Initiatives
Joint Commission
Standards of Care and
safety goals
Fiscal/Ethical Factors
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Risk-Benefit ratios
Insurer Issues
Judgmental Issues
Ethical considerations
Consider “what is right; what is wrong &
what ought to be.”
Sometimes this is not so “clear cut”
Must consider legal issues
Individual values and belief systems
Process for Ethical dilemmas
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1. Collect, Analyze & Interpret the Data
2. State the Dilemma
3. Consider the Choices of Action
4. Analyze the Advantages &
Disadvantages of Each Course of Action
5. Make the Decision
Some key concepts to consider in solving ethical dilemmas:
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Autonomy
Justice
Fidelity
Beneficence
Nonmaleficence
Veracity
The standard of best interest
Considerations in High Acuity
Nursing
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Visitation policies
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Staffing
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Technology
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Stressors
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Resources
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Personal Values
References
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Benner, P., Hooper-Kyriakidis, P. & Stannard, D. (1999). Clinical
wisdom and interventions in critical care: A thinking in action
approach. Philadelphia: W.B. Saunders.
Benner, P. (1984). From Novice to Expert: Excellence and Power
in Clinical Nursing Practice. Upper Saddle River, N.J.: Prentice
Hall.
Brookfield, S. (1993). On impostership, cultural suicide, and other
dangers: How nurses learn critical thinking. Journal of Continuing
Education in Nursing, 5(24), 197-205.
Mulligan, A. (2005). Should dying patients be monitored? A
reflective analysis of a critical incident. Nursing in Critical Care, 10
(3), 122-128.