Nursing: Good Clinical Decision-Making

Class Learning Objectives

• Describe the relationships between analysis, interpretation, synthesis, and prioritization.
• Explain how nursing standards and regulations aid in clinical decision-making.
• Identify strategies to address a 'failure to rescue' situation.

Good Decisions

• Decision-making is selecting the best option from available alternatives, requiring critical thinking and clinical reasoning in nursing.
• Good decisions effectively address the identified issue or problem, considering available information at the time.
• Decisions systematically consider relevant information and various options.
• The quality of a decision depends on the context; changes after the decision can make it seem poor or ineffective.

What is a Good Decision?

• Determining if a decision was good, is often outcome-focused, asking if the end result was satisfactory.
• Thinking about whether a decision is good can also be process-focused, considering if the way the decision was made was satisfactory.
• Errors in decision-making increase the likelihood of undesired outcomes if there's deviation from a systematic process (Gambrill, 2011).

Foundations for Deciding What to Do: Theory and Concepts

• Analysis involves uncovering patterns and trends in information to establish relationships between data.
• Interpretation is determining and assigning meaning to the information to identify what is occurring related to the identified issue.
• Synthesis combines information to form a whole idea or new perspective, integrating analysis and interpretation and mental skills and competencies (Blondy, et al., 2016, p. 668).
• Prioritization ranks client or nursing-related issues by urgency or importance to plan appropriate actions and addresses the questions "What should I do first?" or "Where should I start?"
• Goals and anticipated outcomes for clients should be determined collaboratively and reflect decisions about care (Astle & Duggleby, 2024).
• Goals are prioritized to meet urgent or short-term needs first.
• Risk is the probability of an event occurring degree of severity of consequences.

Analyzing and Interpreting Information - Example

• The client states, "I feel hot"
• Body temperature reads 38.3°C and pulse is 110 beats per minute which may related and higher than the day before
• The client is shivering under many blankets, trends of surgery evident since surgery occurred
• The room temperature is warm but the environment may contribute to elevated temperature
• The client experienced Emergency bowel resection for obstruction, post operative day 3 Other clinical manifestations may be associated with elevated temperature
• Post-operative infection can be associated with further deterioration, increased length of stay in hospital
• Nurses acknowledge responsibility to address elevated temperatures
• Condition may represent a significant change

Synthesizing and Prioritizing

• Client may have a possible post-operative infection, representing a new condition
• Addressing the potential infection now, may deter complications and delay patient returning to the desired state of health
• Prioritization comes in the form of communicating with other healthcare professionals and performing the interventions. managing environment

Maslow's Hierarchy of Needs

• Physiological Needs are the base of Maslow's Hierarchy of Needs
• Safety and Security is the next level
• Love and Belonging is the third level
• Self-esteem is the fourth level
• Personal Goals/Self-actualization is the top level

CURE Model

• Critical needs require immediate action by using ABCD (Airway, Breathing, Circulation, Disability) and Maslow's hierarchy to identify the client's physiological needs and aspects of care
• Example: Airway compromise, respiratory distress, chest pain, signs of stroke
• Urgent needs require prompt attention after any critical needs due to client discomfort or safety risk
• Example: In postoperative pain, a Fall alarm, or clarification of a prescription prior to administration
• Routine needs: scheduled everyday tasks which are the majority of care
• Example: Prescribed medication administration, performing physical assessments, Care of a client with a chronic stable condition
• Extras: Non-essential tasks that promote client's comfort, provided that the other critical needs are taken care of before
• Example: Hair care and Massage

Deciding What to Do

• Requires specific skills for problem-solving, planning, and applying strategies.
• "Decision making" is used to select from several options
• "Problem-solving" generates alternatives to overcome barriers and achieve a goal.

Professional Standards and CNO Guidelines

• They help to define the scope of practice and competence.
• They are evidence based with decision-trees, based on evidence for safety focused practice activities

Thinking Skills

• Skills that need to be applied: making inferences (drawing valid conclusions), Clustering related cues (signs and symptoms), Distinguishing relevant from irrelevant, Recognizing inconsistencies, Identifying patterns, Identifying Missing Information'

Clinical Reasoning Skills

• Clinical reasoning skills include setting priorities and making inferences
• Important to see patterns over time and group related cues together
• Comparing data with normal ranges helps identify any inconsistent or missing data
• Determining the ability to identify possible bias in data interpretation by matching the situation to past experiences
• Need to verify/validate the data/information and determine the quantity of data available
• Distinguish between what is relevant or not to determine what actions and goals are appropriate
• Consult with client/professionals

Applying Ethical Decision-Making Skills

• Review to check the nursing knowledge, the role of the nurse, the patient and the environment around the patient
• Reflect on, and review the outcome, the process, and learning that occurred
• Assess the information that is available
• Select an action according to a plan

Questions to Ask During Analysis, Interpretation, and Synthesis

• Important to determine if the information is reliable, valid, representing a change in status, the trend, the reoccurrence or the science that back that data
• Avoid overthinking or analysis paralysis and instead take small steps in order to limit those factors
• Schedule to take breaks during analyzing, thinking, and synthesizing

Barriers to Thinking When Deciding: Personal and Relational

• Personal barriers can be influences on logic or thinking, stress, pressure, lack of knowledge, and high cognitive load
• Avoid analysis paralysis by managing these personal factors

Fallacies to Logic

• Ad hominem is when argument attacks the others personal status instead addressing the argument itself
• Ad populum is when argument is correct simply because many people believe it
• Appeal to authority arguments are right because someone powerful supports it
• False dichotomy is assuming there are only two possible solutions when in reality there may be more

More Logistical Fallacies

• Hasty generalization assumes generalization simply because of too small amount sample size
• Post hoc/False cause assumes that because correlation equals causation, an event will predict another
• Missing the Point: Conclusion from the autor doesn't line-up with the premise of the argument

Barriers to Thinking

• Relational challenges can come in the form of inarticulable communication or lack understanding of opinions
• Differences in personal value between the nurse and client, family, or professional can hinder progress
• A main barrier in racial injustices

Barriers to Thinking When Deciding: Organizational and Staffing

• Organizational Barriers can be attributed to environmental factors like the institution's mission, vision, or culture
• Too much distractions in the physical environment and staff that doesn't support collaboration can be a barriers

Unaddressed Barriers and Failure to Rescue

• Lack of nursing care can cause hospital acquired complications or even morality
• "Failure to rescue" can result in falls, wounds, or pain

Ambiguity

• Ambiguity comes from a lack of understanding or information and cause lead to borderline vital signs, conflicting data, and difficulty seeing the who picture
• The Client's Context helps nurses address ambiguity issues as well

Making Decisions About Inaction

• Not responding or intervening has the same reliance on evidence as making decisions
• Even though decisions about inaction are valid, these determinations should be monitoried and tracked, and there should be a rational to support

Strategies: Personal, Relational, and Organizational

• Mindfulness, reflection, metacognition, seeking out decision-making opportunities, improving thinking and collaboration can help improve Personal factors that help with decisions
• A good therapeutic relationship and support from the client and team are Relationship factors that improve decisions
• Policies and procedures and strategies which reduce distractions are Organizational factors that improve the validity when making dicisions

Prioritization Spotlight

• Prioritizing is the ranking of client factors based on emergency, relevance, or importances
• Prioritization can be an action after assessing the Client
• Prioritizing is important because it can limit or prevent harm, death and it promotes efficient healthcare

Prioritizing Strategies

• ABCD or Airway, Breathing, Circulation, Disability can help address immediate clinical needs
• Also helpful is applying Maslow hierarchy
• The CURE model focuses on the need for critical action, being urgent, routine and being an extra consideration

NRCE - Nursing Knowledge

• NRCE includes understanding of a patient's health and the critical thinking skills that relate to that data
• For instance, understand patho to better under identified cues -A patient that indicates to a nurse they would like to be an MAID but the nurse has CO should be reported

NRCE - Healthcare Environment

• The overall environment and the resources that come with it help analysis and interpretation of information
  • Standard operation and staffing also contribute to that

Ethical Decision Example

• In terms of a medical setting, the process that factors into what needs to be accounted for,
  • Assess, reflect with the patient, select an action with the intent of understanding/maximing quality of life, consult the right groups to ensure that the best solution is determined with the least amount of harm