Nursing Practice Overview and Clinical Judgment

Nursing Practice Overview

• Nursing intertwines science and theory, establishing it as a complex, multidimensional discipline.
• Historically regarded as a practice discipline, nursing faces underdetermined circumstances where not all variations can be accounted for by scientific evidence.

Clinical Judgment and Evidence-Based Practice

• Nurses bear a societal obligation to apply good clinical judgment backed by evidence-based practices rooted in research.
• Clinical reasoning is essential for nurses to navigate unique patient situations and select applicable scientific knowledge.
• Effective patient care requires ongoing attention to the evolving nature of a patient's clinical condition and responses over time.

Person-Centered Care

• Domain 2 of the AACN Essentials emphasizes the importance of person-centered care.
• Nurses must focus on individual patient circumstances and recognize key changes or trends in health status.
• Implementation of good clinical judgment is crucial when offering tailored nursing care.

Systems-Based Perspective

• Domain 7 of the AACN Essentials highlights the significance of understanding social determinants of health.
• Nurses need to be aware of the complex interplay between the environment, individual health responses, and overall health status.
• Factors such as access to healthcare and health literacy are vital to consider within the broader healthcare system context.

Overview of Nursing Practice and DNP Projects

• Nursing phenomena can drive exploration in nursing practice, enhancing understanding for Doctor of Nursing Practice (DNP) projects.
• Nursing theory and knowledge play significant roles in guiding DNP students toward identifying relevant phenomena.

Influence of Key Reports on Nursing Practice

• The Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) published a pivotal report in 2011, “The Future of Nursing: Leading Change, Advancing Health.”
• This report emphasizes the importance of nurses in leading collaborative efforts with other healthcare professionals to enhance healthcare quality and accessibility.

Expert Nursing Practice

• Understanding expert nursing attributes is crucial for addressing the challenges outlined by IOM.
• Key characteristics of expert nurses include:
  • Ability to assess complex individual circumstances.
  • Recognition of significant changes and trends in patient conditions.
  • Application of clinical judgment to deliver patient-centered care.

Recent Developments in Nursing Reports

• The National Academies of Sciences, Engineering, and Medicine (NAM) and RWJF released “The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.”
• This report highlights nursing as essential in achieving health equity, advocating for enhanced nursing capacity and expertise.

Decision-Making and Deliberative Rationality

• Nurses should engage in deliberative rationality, which involves reflecting on the apparent goals, actions, and appropriate strategies for patient care.
• This approach enables effective problem identification and solution development within nursing practice.

Importance of Nursing in Clinical Inquiry

• Nurses possess a unique skill set enabling them to identify clinical concerns that need further investigation or improvement, addressing community healthcare needs effectively.
• Being intentionally present with patients allows nurses to understand individual instances and choose tailored interventions that enhance patient care.
• The impact of nursing is often understated; the profession has historically emphasized technical skills over the relational aspects of care, which play a crucial role in patient experience and outcomes.

Advanced Practice and Nursing Care Value

• The use of the medical model in advanced nursing practice often overshadows the nuanced, person-centered care provided by nurses.
• Nursing care's effectiveness, especially in achieving health outcomes, is often unmeasured, despite its significance in patient recovery and satisfaction.
• The current focus on person-centered care emphasizes the need to highlight the nursing contributions that stem from a comprehensive understanding of healthcare phenomena.

Holistic Approach to Patient Care

• Nurses consider various health determinants that influence the therapeutic relationship, including social, medical, economic, historical, and structural factors.
• Employing a systems perspective allows nurses to identify barriers to care and enhance health equity through resource optimization and interdisciplinary collaboration.

Identifying Phenomena of Interest

• DNP (Doctor of Nursing Practice) students may struggle to articulate their phenomena of interest due to the complexity or breadth of their ideas.
• It is essential for students to narrow their focus to a topic relevant to their practice setting and meaningful to their professional development.
• Identifying a phenomenon of interest is crucial in developing a DNP project and requires individual reflection and guidance from advisors.

Definition and Nature of Nursing Phenomena

• A "phenomenon" refers to a fact or event of scientific interest that requires description and explanation.
• Nursing phenomena specifically relate to factors influencing health status and are characterized by their relevance to nursing practice.
• These phenomena encapsulate interactions among humans, their environments, and the various complexities inherent in health-related issues, necessitating systems thinking for effective analysis.

Identifying the Phenomenon of Interest

• Clinical expertise plays a crucial role in identifying phenomena among DNP students.
• Phenomenon identification originates from relevant practice situations and experiences between nurses and patients.
• Observations from specific patient populations provide guidance in identifying barriers to care.
• Example: Patients with diabetes often face multifaceted barriers to insulin initiation, such as fear of injections or feelings of failure related to lifestyle changes.
• Family history can influence patient perceptions and attitudes toward insulin administration, complicating the initiation process.
• Expert nurses are equipped to explore and address these barriers, enhancing glucose control and health outcomes.

Clinical Problem Recognition

• Identifying clinical problems within organizations is essential for DNP students.
• Common barriers may prevent certain patient populations from achieving healthcare goals.
• Understanding organizational needs and gaps in care delivery is a vital competency for DNP students.
• Analyzing system processes is a learning objective identified in the AACN Essentials for Advanced-Level Nursing Education.

Systems Thinking in Practice

• Systems thinking enhances the ability to analyze interactions within healthcare organizations.
• It helps in recognizing the interconnectedness of components that influence organizational behavior.
• This mindset supports effective interventions and sustainable change in healthcare systems.

Strategies for Identifying Topics

• Students are encouraged to cast a wide net while exploring areas of interest in nursing.
• Reviewing sources like CINAHL databases and professional journals can help identify relevant topics for exploration.
• The process of identifying interests should consider personal passions that can drive sustained engagement through the doctoral journey.

Evolution of Topics

• Initial topics are likely to evolve as students are exposed to new ideas and concepts during their education.
• Continuous reflection on the phenomenon will be necessary, allowing topics to refine into actionable DNP projects.

Importance of Focus

• Narrowing down broad areas of interest is critical to avoid frustration and ensure manageability.
• A comprehensive understanding of chosen topics is necessary for successful project completion.
• To establish a focused topic, a thorough review of existing literature is needed to identify gaps in knowledge.

Techniques for Topic Narrowing

• DNP students should employ specific questions to hone their focus:
  • Who is the population of interest?
  • What unique elements or issues pertain to this group?
  • Where are these populations located?
  • When are the observations relevant—current or historical, and over what life stages?
• Care must be taken not to narrow the focus excessively to the point of inadequate available literature for the project.

Problem Identification in Nursing

• Exposure to local problems can highlight phenomena affecting organizational outcomes.
• Viewing issues through a phenomenological lens can drive innovation and improvements.
• Importance of assessing the relevance of a topic, especially regarding nursing practice and patient outcomes.
• Consideration of unmet societal needs that could benefit from policy initiatives.
• Frequent issues warranting further exploration should be identified.
• Preliminary literature review aims to gain a general understanding of a topic and assess prior work.
• Clear project articulation and understanding of required resources are crucial for feasibility.
• Consultation with an advisor can help identify potential burdens and establish project viability.

Nursing Theory as a Tool

• Nursing theory provides a structured approach to understanding phenomena.
• Theories emerged to clarify the nursing domain and guide professional practice.
• Concepts and propositions within nursing theory explain relationships and phenomena of interest.
• Constructs describe non-observable elements, such as social support, relevant in nursing contexts.

Classification of Nursing Theories

• Grand Theories: Most abstract, offering broad explanations of nursing concepts. Examples include:
  • Orem's self-care deficit theory
  • Parse's theory of human becoming
  • King's open system theory
• Middle-Range Theories: More specific, generalizable, and testable theories focused on understanding nursing-related phenomena. Examples include:
  • Pender's health promotion model
  • Mishel's uncertainty in illness theory
  • Lenz and Pugh's theory of unpleasant symptoms
• Practice Theories: Narrow in scope, guiding specific practice areas with measurable concepts. Known as "situation-specific theories," they address unique patient group needs. Example:
  • Mercer's theory of maternal role attainment.

Interplay of Theory, Research, and Practice

• Theory informs and is informed by research, impacting practice positively.
• The relationship facilitates opportunities for further studies and enhances nursing knowledge.
• Theory can help identify health-related antecedents affecting populations (e.g., colon and prostate cancer).
• Theory aids in recognizing health patterns and developing person-centered interventions.
• DNP students often come to realize the practical application of nursing theory in their existing practice.
• Ongoing evolution of nursing theories is essential for relevant scholarly work and doctoral education.
• Connecting theory to DNP projects deepens understanding and provides a strong framework for phenomena exploration.

The Phenomenon of Interest and Theoretical Framework

• Using one or several theories to view a phenomenon helps DNP students better describe or explain the phenomenon
• Identifying the concepts and relationships among them can be achieved by reviewing the literature and published articles
• The student can select a theory that best represents the concepts that describe their phenomenon of interest
• Concept analysis can further inform the understanding of the phenomenon

Strategies for Theory Selection

• Review the literature to identify concepts and theories used to describe the phenomenon
• Utilize online and print resources to explore numerous theories available
• Evaluate each theory by considering questions such as:
  • Does the theory reflect the student's personal nursing practice?
  • Does the theory help to describe, explain, and predict the phenomenon of interest?
  • Can the theory be used as a guide in the framework of the DNP project?
  • Does the theory offer a way to develop, assess, implement, and evaluate innovations that the project explores?
  • Will the use of this theory help to support excellent nursing practice?

Nursing Theories and Interdisciplinary Aspects

• Examples of nursing theories include Hildegard Peplau's theory of interpersonal relations in nursing, Jean Watson's caring science, and Rosemarie Parse's human becoming theory
• Theories from other disciplines include the health belief model, the theory of planned behavior, and the social cognitive theory
• Complexities, critical, feminist, or environmental theories may be relevant for phenomena related to societal aspects

Ways of Knowing

• The patterns of knowing in nursing were initially identified by Carper in 1978
• Ways of knowing provide a holistic framework designed to direct practice, education, and research
• Carper's original four fundamental patterns of knowing are:
  • Empirical knowing (science of nursing)
  • Esthetics (art of nursing)
  • Personal knowledge (therapeutic use of self)
  • Ethical knowledge (moral knowledge in nursing)

Empirical Knowledge

• Includes knowledge that is objective and quantifiable
• Tested, replicated, and proved through scientific methods
• Systematically organized into general laws and theories for the purpose of describing, explaining, and predicting phenomena of concern to nursing
• Evidence-based practice is an example of empirical knowledge that informs nursing practice

Esthetic Knowledge

• Used to understand each patient's unique health experience
• Encompasses the lived experience and is expressive in nature
• The nurse assists the patient in coping with the experience through perceived insight that is gleaned from being in the moment with the patient
• Critical questions ask about the meaning and significance of the experience to the patient

Personal Knowledge

• Encompasses the way nurses view themselves and the patient
• Largely expressed in personality; it is subjective and incorporates experience and reflection
• The nurse is able to view the patient from a holistic perspective rather than from a strictly biological or medical perspective, promoting wholeness and integrity
• Critical questions ask about the meaning and significance of the experience to the patient through reflection

Ethical Knowledge

• Based on obligation to service and respect for human life
• Used to address conflicting norms and interests, and to provide insight into untestable areas
• Requires rational examination and evaluation of what is good, valuable, and desirable for health maintenance or restoration

Nursing and Moral Courage

• Nurses must act with moral courage, addressing situations with conviction and confidence
• Must overcome fear of uncertainty and conflicting personal core values or beliefs
• Must do what is right for the patient, asking what is right and responsible
• Uses esthetic knowledge to recognize forces driving patient decisions

Esthetic Knowledge

• Uses empathy, caring, and engagement to understand patient needs
• Identifies long-term history, extraordinary stressors, and desire to quit
• Recognizes lack of perceived coping strategies and incorporates personal knowledge
• Helps inform nurse and patient relationship

Personal Knowledge

• Influenced by personal biases and values
• May help or hinder patient progress
• Must recognize and consider personal biases and values

Empirical Knowledge

• Focuses on data: smoking is detrimental to health, damages lung tissue, and is a concern for COPD patients

Patterns Gone Wild

• Occurs when a nurse only considers one lens or perspective, limiting understanding of the phenomenon
• Prevents development of patient-centered interventions and positive outcomes

Emancipatory Knowing

• Added by Chinn and Kramer in 2008
• Explores social, cultural, and political stances and envisions what can be
• Drives critical examination of the status quo toward corrective action
• Considers equity, justice, and transformation
• Expressed in praxis, reflecting on unfair issues and initiating changes

Concept Analysis

• Concept analysis matches phenomena with concepts, categorizing information into defining characteristics called attributes.
• It helps distinguish between similar concepts, clarify terms, and refine ambiguous ideas.
• An analysis on "overcoming" highlights its importance for homeless families, aiming to develop a precise operational definition and identify its attributes and characteristics.
• The analysis process follows Walker and Avant's method, offering guidelines for conducting effective concept analyses.
• Producing an operational definition aids in clarifying problem definitions and contributes to standardizing nursing language.
• Concept analysis is structured, yielding precision, while the outcome can vary due to differing perspectives and evolving knowledge.

Steps in Concept Analysis

• Identify a critical concept to keep the analysis manageable and enhance understanding.
• Frame the concept within an introduction that avoids umbrella terms for specificity in definitions.
• Utilize diverse sources for concept definitions, including literature and practical experiences, to broaden understanding.
• Identify defining attributes consistently found across literature; for "overcoming," three attributes lead to a comprehensive definition.
• Recognize antecedents (preconditions for the concept) and consequences (results of the concept) for deeper understanding.
• Empirical referents are critical for measuring the concept's occurrence, suggesting constructs like resilience and optimism for indirect measurement.
• Develop models, borderline cases, and contrary cases to clarify what the concept is and is not, enhancing overall comprehension.

Foundational Tenets of Nursing Knowledge

• Reflecting on personal and professional philosophies helps identify underlying frameworks in practice.
• Bunkers (2000) described foundational tenets in nursing, emphasizing lived experiences, openness to uncertainty, and diversity awareness.
• Considering these tenets aids in finding appropriate theories and frameworks to support nursing practice.

Selecting a Phenomenon of Interest

• Choosing a phenomenon for DNP projects is a dynamic process affected by professional experiences and relevant issues.
• Discussions with peers, faculty, and practice partners enrich the exploration of potential topics.
• Time constraints, such as graduation timelines, play a significant role in decision-making for topic selection.
• Selecting a personally meaningful topic fosters passion, motivating effort and dedication in project completion.
• Phenomenon identification can drive innovation and lead to ongoing improvements in patient and healthcare system outcomes.

Nursing Practice and Theory

• Nursing is influenced by both scientific principles and theoretical frameworks.
• Practice demonstrates the implications of science and theory in real-world settings.

Opportunities in Nursing Practice

• The complexity of nursing creates numerous opportunities to explore various phenomena related to patient care.
• Hidden aspects of nursing work significantly shape patient experiences and enhance clinical outcomes.

Importance of Phenomena in DNP Projects

• DNP projects must focus on topics meaningful to the student and valuable within their practice environment.
• "Nursing phenomenon" refers to factors influencing health that are relevant to nursing.

Considerations for Phenomena

• DNP scholars should reflect on practice aspects that impact both nurses and patients during care delivery.
• A clearly articulated phenomenon indicates a societal need, feasibility for implementation, and potential nursing strategies to address the issue.

Theoretical Frameworks and Patterns of Knowing

• Examining phenomena through specific theoretical frameworks clarifies their nature and guides DNP projects.
• DNP students can analyze phenomena using various patterns of knowing, aiding in description and deeper understanding.

Concept Analysis in DNP Studies

• Conducting a concept analysis helps align phenomena with relevant concepts, differentiate similar terms, and refine vague ideas.
• This analysis supports the evolution of a phenomenon into a well-defined DNP project as the student reflects on their area of interest.

This quiz covers the essentials of nursing practice, including the integration of science and theory, the importance of clinical judgment, and the application of evidence-based practices. It emphasizes person-centered care and the ongoing assessment of patient conditions, providing a comprehensive look at modern nursing responsibilities.