NUSC 1P03 - Clinical Judgement & Skills Midterm 2 PDF

NUSC 1P03 – Clinical Judgement & Skills Week 8 – Acting Safely – Part 2 Week 8 Objectives 1. Describe principles of safe communication 2. Discuss standardized communication tools as a strategy for safe communication 3. Describe principles of communication at discharge and transfer of care 4....

NUSC 1P03 – Clinical Judgement & Skills Week 8 – Acting Safely – Part 2 Week 8 Objectives 1. Describe principles of safe communication 2. Discuss standardized communication tools as a strategy for safe communication 3. Describe principles of communication at discharge and transfer of care 4. Describe barriers & facilitators in communication NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Communication for Safety NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS  Why Communication is Important When health care workers The majority of errors in Communication is the key communicate effectively, health care are linked to a to safe health care fewer errors occur, and lack of proper people are more satisfied communication NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What Makes Communication Safe? Sharing enough information to reach a shared Sufficiency understanding Giving and understanding information correctly to Accuracy ensure it's accurate Expressing messages clearly to avoid Clarity misunderstandings Considering factors like hierarchy and time pressure Contextualization that affect understanding Adjusting to each other’s needs (verbal and Interpersonal Adaptation nonverbal) to improve communication (Hannawa, 2018) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What Makes Communication Safe? Create a team Create a Create a culture of blame-free, culture of collaboration nonpunitive safety & cooperation culture NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Barriers to Safe Communication Fragmentation Underreporting Fatigue NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS How Safe Communication is Achieved Communication clarity Principles of Collaboration safe transfers & Cooperation & hand-offs NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Communication Clarity Standardized communication Avoids incomplete or misleading messages Requires consistent adoption & implementation (system → clinician) Leads to clear communication → prevents harm to patients NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Standardized Communication Check lists Structured list of evidence-based actions to be performed in a clinical setting or situation If every step is completed the possibility of miscommunication is reduced Verbal communication tools Structured format for communication SBAR IPASS NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is SBAR? Standardized structured tool to help simplify and quickly communicate pt information to other members of the health care team Useful when brief, clear communication is needed in acute situations, i.e. ↓ pt status, hand-offs (Mallette & Arnold, 2021; Tuttle, 2022) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is it? What might it sound like? Brief statement of the Hello, it’s Jenna from unit 5. problem I’m calling about Jill Smith in Introduce yourself & pt room 406. The reason I’m State what’s going on calling is because the pt is having trouble breathing and is c/o chest pain. (Mallette & Arnold, 2021; Tuttle, 2022) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is it? What might it sound like? Pertinent & brief info r/t the She had a total knee situation replacement 2 days ago. Review the chart before About 2h ago, she began c/o making contact chest pain. Pulse 120, BP Can incl. Dx, code status, 128/54. She is restless and fluids, allergies, VS, meds, test results, etc. SOB. (Mallette & Arnold, 2021; Tuttle, 2022) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is it? What might it sound like? Analysis of what you My assessment of the situation is found/assessed that she may be having a cardiac State your conclusion or event or a pulmonary embolism. what you think is wrong OR State your opinion about I’m not sure what the problem is the pt’s current status but the pt is deteriorating, May incl. pain level, LOC, unstable, has changed, etc. complications, I/O, blood loss, etc. (Mallette & Arnold, 2021; Tuttle, 2022) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is it? What might it sound like? What do you want? I recommend that you see Medication orders? her immediately and that we Clarification? start her on oxygen stat. Transfers? etc (Mallette & Arnold, 2021; Tuttle, 2022) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS I-PASS (Healthcare Excellence Canada, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Care Transitions AKA Transfer of Transfers Hand-offs Handovers Accountability (TOA) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS College of Nurses Care transitions involve the process of communicating pt-specific information from one clinician to another to ensure continuity of care and pt safety. Transfer of accountability – or providing “report” or “handover” – is a crucial component of the care transition process. (CNO, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Principles of Safe Transfers/Hand-offs A TOA or hand-off consists of: transfer of responsibility & accountability clarity of information verbal communication of information acknowledged by receiver opportunity to review (Healthcare Excellence Canada 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS TOA at the Bedside Looks Like… Incoming Nurse Outgoing Nurse Greets their pt Ensures info given was Accepts accountability for their understood by incoming nurse pts at a point in time Provides opps for pt/family Obtains full knowledge of the involvement actual status of their pts Has full knowledge of the Asks questions & clarifies info condition of the pt at point of TOA Says goodbye to their pts (Colluccio & Ead, 2011) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Collaboration & Cooperation Interprofessional collaboration is the process of developing & maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families & communities to enable optimal health outcomes. Elements of collaboration include respect, trust, shared decision making, and partnerships. (CIHC, 2010) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Collaboration & Cooperation Most reported errors have been found to stem from poor teamwork and poor communication An effective team has clear, accurate communication understood by all All team members work together to promote a climate of patient safety When conflict occurs, differences need to be addressed (CIHC, 2010) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Interprofessional Competency Framework Role Clarification Understand your role and the roles of others to optimize collaboration. Team Functioning Foster trust, respect, and open communication for effective teamwork. Patient/Client/Family-Centered Care Engage with patients, families, and caregivers as partners in care. Collaborative Leadership Share leadership roles to support effective decision-making. Interprofessional Communication Use clear communication to promote understanding across disciplines. Conflict Resolution Address and manage conflicts constructively to support team unity. (CIHC, 2010) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Principles of Interprofessional Communication Clarity Use clear, concise language to avoid misunderstandings. Active Listening Listen attentively to understand others' perspectives and ensure mutual understanding. Respectful Tone Communicate with respect and professionalism, acknowledging each team member's contributions. Transparency Be open and honest to build trust and enhance collaboration. Timeliness Share information promptly to support effective decision-making. Adaptability Adjust communication style to meet the needs of diverse team members and contexts. Feedback Provide constructive feedback and be receptive to input from others. (CIHC, 2010) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Restraint Use & Patient Safety NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Types of Restraints Environmental Physical restraints Chemical restraints restraints Restrict or control Are medications Change or modify movement or used specifically to a person's behaviour. They modify or restrict surroundings to may be attached behaviour, for restrict or control to a person's body example, movement, for or create physical tranquilizers and example, a locked barriers. sedatives. door. (Alzheimers Society, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Use of Restraints – Legislation In Ontario, the Patient Restraints Minimization Act asks healthcare settings to consider alternative approaches and only use restraints as a last resort when a person is at risk of harm to themselves and/or others. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS College of Nurses Nurses are accountable for providing, facilitating, advocating & promoting the best possible pt care to take action when patient safety and well-being are compromised, including when deciding to apply restraints. (CNO, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Approach to Least Restraint (RNAO, 2012) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS  Principles of Least Restraint Consent Last Resort Assess Prioritize Minimize Limit Time & Involve the pt & Use restraints Individually Alternatives Restriction Monitor family and only when other Tailor care to Start with non- Choose the least Use for shortest respect their options fail and each patient’s restrictive restrictive option time, with input in care safety is at risk. needs & risks. methods. if restraint is ongoing decisions. necessary. monitoring. (RNAO, 2012) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS "Restraint should never be a treatment, but rather a last resort." ~ Unknown NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS References Alzheimers Society. (2024). Using restraints. https://alzheimer.ca/en/help-support/im-caring-person-living-dementia/ensuring-safety- security/using-restraints Canadian Interprofessional Health Collaborative (CIHC). (2010). A national interprofessional competency framework. CIHC. https://www.cihc.ca Coluccio, A. & Ead, H. (2011, March 22). Transfer of accountability – Ensuring safe patient handoff.[PowerPoint slides]. Nursing Leadership Network of Ontario. https://www.nln.on.ca/wp-content/uploads/2013/11/2012-D4-Ead.pdf College of Nurses of Ontario (CNO). (2024). Understanding restraints. https://cno.org/standards-learning/educational- tools/understanding-restraints#scenarios-case-scenario-three-working-with-patients-and-their-families College of Nurses of Ontario (CNO). (2024). Care transitions: Transfer of accountability. https://www.cno.org/standards- learning/ask-practice/care-transitions-transfer-of- accountability#:~:text=During%20the%20transfer%20of%20care,client%2Dfocused%2C%20and%20comprehensive Hannawa, A. (2018). “SACCIA safe communication”: Five core competencies for safe and high-quality care. Journal of Patient Safety and Risk Management, 23(3), 99-107. https://www.hi.is/sites/default/files/margstefans/hannawa_2018.pdf NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS References Healthcare Excellence Canada. (2024). TeamSTEPPS Canada essentials course. https://www.healthcareexcellence.ca/en/what-we-do/all-programs/teamstepps-canada-essentials- course/?gad_source=1&gclid=Cj0KCQjwpvK4BhDUARIsADHt9sSrGwQx8a_tso8uH1q6DpZyyawRuYTEP c_bdmP1YKjYxFQEA5iKZF8aAmC-EALw_wcB Mallette, C. & Arnold, E. (2021). Arnold and Boggs’s interpersonal relationships: Professional communication skills for Canadian nurses. Elsevier. Patient Restraints Minimization Act, SO 2001, c. 16. https://www.ontario.ca/laws/statute/01p16/v2 Registered Nurses Association of Ontario (RNAO). (2012, February). Promoting safety: Alternative approaches to the use of restraints. https://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints Tuttle, K. [@nurseinthemakingkristine]. (2022, February 27). SBAR explained. #nursingstudent #nursingschool #nurseinthemakin #sbar #nursesoftiktok. [Video]. TikTok. https://www.tiktok.com/@nurseinthemakingkristine/video/7069521781564001579 NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS NUSC 1P03 – Clinical Judgement & Skills Week 7 – Introduction to Quality & Safety Part 1 Week 7 Objectives 1. Describe the most common safety risks in health care. 2. Recognize patient safety incidents and know how to respond effectively to minimize harm to the patient. 3. Understand the importance of reporting safety incidents. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What is patient safety & quality care? I’m glad you asked because next week is Canadian Patient Safety Week! NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Patient Safety – Definition “The absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.“ (WHO, 2023) HOWEVER... “The absence of harm does not mean that care is safe”. (Gilbert et al, 2023) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Quality Care – Definition The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS The reality is that… Unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds Every 13 minutes and 14 seconds, someone dies Patient safety incidents are the third leading cause of death in Canada NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Canadian Quality & Patient Safety Framework Goals & Objectives Goal 2 – Safe Care Goal 3 – Accessible Care Health services are safe and People have timely and free from preventable harm. equitable access to quality Goal 1 – People-centred care health services. People using health services are equal partners in planning, developing, and monitoring care to make sure it meets their needs and to achieve the best outcomes. Goal 4 – Appropriate Care Goal 5 – Integrated Care Care is evidence-informed Health services are and person-centred. continuous and well coordinated, promoting smooth transitions NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Canadian Quality & Patient Safety Framework Goals & Objectives Goal 2 – Safe Care Goal 3 – Accessible Care Safety culture is evident Care, diagnostics & services Safe & effective care is Human resources are Goal 1 – People-centred care provided & monitored matched to pop’n needs Health services are holistic, Safe care is addressed as a dignified & respectful public health concern All care is co-designed with pts & providers Pt & providers have positive experiences Goal 4 – Appropriate Care Goal 5 – Integrated Care Based on needs of pop’n Based on needs of pop’n Actively promoted & Pt information is available monitored across health services Evidence-informed tx & technologies are implemented NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Canadian Patient’s Safety Institute The Safety Competencies Pt safety is a critical aspect of high quality health care Important to foster a culture where staff have a constant & active awareness of the potential for things to go wrong, and the safety to speak up about it. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Fostering a Pt-Centred Safety Culture Continually focusing Acting on risk- on performance- Providing current management findings improvement reliable technology and safety reports programs Providing continuing Integrating evidence- Designing a safe work education and access informed practice environment and to appropriate into procedures atmosphere resources for staff NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Nurses Advocating for Pt Safety (Hamilton Spectator, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Factors Influencing Safety NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Factors Influencing Safety Patient & Health Care Task Factors Technology Factors Provider Factors Characteristics of Characteristics of the Technologies available individuals, such as: tasks that health care within an organization, health, age, weight providers must perform such as: needs, mood, This includes the tasks the number of personality themselves as well as technologies knowledge, experience, their characteristics: the types of intelligence workflow technologies language & cultural time pressure their availability background workload their location. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Factors Influencing Safety Environmental Factors Organizational Factors Features of the work environment Structural, cultural, & policy- lighting related characteristics of the noise institution, e.g.: physical space leadership characteristics layout culture policies hierarchy span of control NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Swiss Cheese Model When the holes line up in certain combinations, hazards are able to sneak through the safeguards and find their way to the pt The holes at the end of the system, which come into contact with the pt, are termed active failures NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Common Safety Risks NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Common Safety Risks Nurses must be aware of regulatory and organizational safety initiatives and individual patient risk factors. A nurse must also be A nurse must be aware of familiar with a patient’s common safety precautions developmental level, and of the special risks to mobility, sensory and safety that are found in cognitive statuses, and health care settings. lifestyle choices. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Risks in Health Care Settings Staff Safety Environmental risk – various forms of chemicals used in health care are a source of risk for both the pt and the health care worker (i.e. WHMIS) IPAC – controlling the spread of infection helps maintain the safety of patients, staff, and visitors Violence – violence may be directed toward nurses from pts or pts’ family members Patient Safety Falls – falls account for up to 90% of all reported incidents in hospitals. Hip fractures are among the most serious fall-related injuries. Procedure-related accidents – include medication errors and improper performance of procedures (e.g., incorrect urinary catheter insertion). Equipment-related accidents – malfunction, disrepair, or misuse of equipment (i.e. IV/PCA pumps) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Risks by Developmental Stage Infants & Children Unintentional injuries b/w ages 1-14 years Adolescents Impulsive & risk-taking → smoking, substance use Adults Frequently r/t lifestyle habits Older Adults Change associated with aging ↑ risk of accidents NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Individual Risk Factors Sensory or Impaired Lack of Safety Communication Mobility Awareness Impairment Visual, hearing, tactile, Such as keeping Muscle weakness, or communication medicine or poisons paralysis, or poor impairment, such as away from children or coordination or balance aphasia or a language observing the expiration barrier date on food products NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Reporting Safety Incidents & Disclosure NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Reporting Safety Incidents When an actual or potential patient safety incident occurs, the nurse or health care provider who was involved MUST complete an incident report. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Patient Safety Incident/Adverse Event An event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. Harmful Incident Resulted in pt harm Near Miss Incident did not reach the pt → no harm No-Harm Incident Incident reached the pt → no discernable harm NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Incident/Occurrence Report Confidential Quality Root Cause Document Improvement Completely Focus is on Analysis of trends describes any pt identifying what, & patterns incident occurring not who, throughout the on the premises contributed to an facility incident Promotes a culture of safety NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS College of Nurses (CNO) – What to Report? CNO’s mandate is to Patient safety is a protect the public collective responsibility This is achieved by partnering You need to send the CNO a with employers, facility report when you believe a operators, nurses and those nurse poses a serious risk of who work with nurses. harm to patients. CNO – What to Report NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Patient Safety & Clinical Decision-Making NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Safety & the Clinical Judgment Framework (CJM) Nurses are responsible for incorporating critical thinking skills when using the nursing process: assessing each patient and their environment for hazards that threaten safety planning and intervening appropriately to maintain a safe environment NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Safety & the CJM A thorough pt assess’t considers possible threats to a pt’s safety: Health Hx Getting the Pt’s home environment Information Health care environment Risk for falls Risk for medical errors Pt expectations NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Safety & the CJM Making After assessing pt safety, review any clusters of Meaning of the data for patterns suggesting that safety is threatened Information During planning, critically synthesize Determining information from multiple sources Goals & outcomes Actions to Take Setting priorities Continuity of care NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Safety & the CJM Interventions are directed toward ensuring pt safety in all settings, and include: Taking Health promotion Developmental interventions Action Environmental interventions Other environmental interventions NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Safety & the CJM Evaluating The actual care delivered by the health care team is evaluated based on expected Outcomes outcomes. Measure patient outcomes against set goals and Your Report and address adverse events Continuously improve care based on pt Thinking safety outcomes NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS “If it’s not safe, it’s not care”. ~ Dr. Tedros Adhanom Ghebreyesus (WHO, 2020) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS References Astle, B. & Duggleby, W. (Eds.). (2024). Potter and Perry’s Canadian fundamentals of nursing (7th ed.). Elsevier. Canadian Patient Safety Institute. (2020, March). The safety competencies: Enhancing patient safety across the health professions (2nd ed.). https://www.healthcareexcellence.ca/media/115mbc4z/cpsi-safetycompetencies_en_digital-final-ua.pdf Caputi, L. & MacMaster, L. (2022). Think like a nurse: The Caputi method for learning clinical judgement. Windy City. College of Nurses of Ontario. (2024). What to report. https://www.cno.org/protect-the-public/file-a-report/reporting-guide/what-to- report#:~:text=If%20you%20have%20concerns%20about,report%20as%20quickly%20as%20possible Frketich, J. (2024, October 17). ‘They’ve put people’s lives at risk’: Hamilton nurses describe dire situation amid Ontario-wide medical supply shortage. Hamilton Spectator. https://www.thespec.com/news/hamilton-region/theyve-put-peoples-lives-at- risk-hamilton-nurses-describe-dire-situation-amid-ontario-wide-medical/article_30294c80-e0c3-55e4-a13f-d752b1d2aaed.html NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS References Gilbert, R., Asselbergs, M., Davis, D., MacLaurin, A., Popescu, I., & Fancott, C. (2023, October). Rethinking patient safety: A discussion guide for patients, healthcare providers and leaders. Healthcare Excellence Canada. https://www.healthcareexcellence.ca/media/gx4l3idd/rethinking-patient-safety.pdf Healthcare Excellence Canada. (2020). The Canadian quality & patient safety framework for health services. https://www.healthcareexcellence.ca/media/e3dkkwos/cpsi-10001-cqps-framework-english_fa_online-final-ua.pdf World Health Organization. (2023, September 11). Patient safety. https://www.who.int/news-room/fact-sheets/detail/patient-safety World Health Organization. (2020, September 17). WHO Director-General’s opening remarks at the press briefing for world patient safety day. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-press- briefing-for-world-patient-safety-day NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS NUSC 1P03 – Clinical Judgement & Skills Week 6 – Determining Actions to Take & Taking Action Week 6 Objectives 1. Explain the connection between nursing diagnoses, the planning process, and the selection of nursing interventions to achieve patient outcomes. 2. Describe Step 3 of the clinical judgement framework and clinical judgment competencies supporting this step 3. Establish patient-centered goals and expected outcomes using the SMART criteria within the context of Step 3 of the CJF. 4. Discuss strategies for prioritizing nursing actions 5. Describe Step 4 of the clinical judgment framework and discuss how to implement care NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Review – Information as a Foundation for Nursing Decisions NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Information & Evidence Information collected from patients along with foundational nursing knowledge, past experiences, and application of standards is the basis for sound clinical decision making (Step 1 of CJF) Nurses use multiple ways of knowing to gather and interpret information → understanding (Step 2 of CJF + Patterns of Knowing) Accurate analysis of information (& evidence) → good decisions → competent, safe, ethical & compassionate care (Step 2 of CJF + EIDM) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 3 – Determining Actions to Take NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 3 – Determining Actions to Take Getting the 1 information Evaluating outcomes 5 and thinking Caputi’s Clinical 2 Making meaning Judgement Framework Determining 4 Taking action 3 actions to take Determining Actions to Take What is the result of Getting the Information and Making Meaning of the Information? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Determining Actions to Take Getting Information + Making Meaning → clear and accurate health concern statement (a.k.a., problem statement, nursing focus, nursing diagnosis…) Nursing Diagnosis Example: Pain [diagnostic label] related to inflammation of the joints [related factor/etiology] as evidenced by patient report of 7/10 on pain scale and facial grimace [support for statement] when performing ROM exercises. Now that the issues, problems, concerns are identified you now need to determine what to do about them. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS CJF & Nursing Process NCSBN (NCLEX) Nursing Process Caputi CJF Recognize Cues Assessing Getting the Information Analyze Cues Diagnosing Making Meaning of the Information Prioritize Hypotheses Planning Determining Actions to Take Generate Solutions Take Actions Implementing Taking Action Evaluate Outcomes Evaluating Evaluating Outcomes and Thinking NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Goals & Expected Outcomes Goal: A patient goal represents predicted resolution of a nursing diagnosis or health problem, proof of progress toward resolution, enhanced improved health status, or continued maintenance of optimal health; provides focus or direction to planning Outcome: Specific, measurable change in a patient’s status that is expected in response to nursing care; determines when a goal has been met Short-term goal objective patient behaviour/response expected within hours to a week Long-term goal objective patient behaviour/response expected within days, weeks, or months [FOR MORE → CH. 14 Astle & Duggleby] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Goals & Expected Outcomes Goal Guidelines & Criteria Patient-centred Singular Specific Observable Measurable Measurable Attainable Time-limited Realistic Mutual goal Time-limited Realistic goal [FOR MORE → CH. 14 Astle & Duggleby; NUSC 1P01 SMART GOALS] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Determining Actions Nursing Diagnosis = starting point Goals/Outcomes = where you want to go Care Planning = how you are going to get there NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Care Planning Considerations 1. Legal, ethical, professional guidelines 2. Institutional policies and procedures 3. Interprofessional team composition/roles 4. Resource availability 5. Individual patient factors (i.e., patient-centred care principles) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 3 Clinical Judgement Competencies Major Step in Caputi CJM Clinical Judgement Competencies (CJCs) Selecting interventions Determining Managing potential complications Actions to Take Setting priorities Selecting Interventions Nursing Intervention – any treatment, based on clinical judgement and knowledge, that enhances patient outcomes Types: Nurse-initiated Physician-initiated Collaborative Direct and indirect NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Selecting Interventions Interventions should alter the etiological (“related to”) factor or signs and symptoms associated with the diagnostic label of a nursing diagnosis Interventions should be evidence-informed Interventions should be feasible in the context of the total plan of care Interventions should be acceptable to the patient [FOR MORE → Box 15.2 Astle & Duggleby] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Concept Mapping Nursing Interventions [FOR MORE → Figure 15.2 Astle & Duggleby] Clinical Practice Guidelines & Protocols Managing Potential Complications Predicting Preventing Addressing Complications Complications Complications List potential Determine what Identify actions that complications based actions can be taken to will be taken if the on information prevent these complication does gathered (STEP 2) complications from occur happening NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Managing Potential Complications – life example Predicting Preventing Addressing Complications Complications Complications Pencil could break Inspect pencil prior to Raise hand, ask during quiz quiz to ensure it is in instructor for spare good working pencil condition NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Managing Potential Complications – clinical example Predicting Preventing Addressing Complications Complications Complications Decreased respiratory Frequent observation Attempt to rouse rate (RR) associated of RR by RN patient with opioid analgesic Electronic monitoring Call for help (i.e., type of pain of RR when obs. not Administer naloxone medication) possible (opioid antagonist) as prescribed NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Setting Priorities AIM: determine which patient issues are most important and the order in which planned interventions will be implemented NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Setting Priorities Tools for prioritization Maslow’s hierarchy Patient acuity ABCs – airway, breathing, circulation CURE – critical needs, urgent needs, routine needs, extras ABCD [Caputi p. 167] SAFER care [week 6 lab] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 4 – Taking Action NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 4 – Taking Action Getting the 1 information Evaluating outcomes 5 and thinking Caputi’s Clinical 2 Making meaning Judgement Framework Determining 4 Taking action 3 actions to take CJF & Nursing Process NCSBN (NCLEX) Nursing Process Caputi CJF Recognize Cues Assessing Getting the Information Analyze Cues Diagnosing Making Meaning of the Information Prioritize Hypotheses Planning Determining Actions to Take Generate Solutions Take Actions Implementing Taking Action Evaluate Outcomes Evaluating Evaluating Outcomes and Thinking NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Step 4 Clinical Judgement Competencies Major Step in Caputi CJM Clinical Judgement Competencies (CJCs) Determining how to implement the planned interventions Assigning Taking Action Communicating Teaching Determining how to implement the planned interventions COGNITIVE INTERPERSONAL PSYCHOMOTOR SKILLS SKILLS SKILLS Assigning A flowchart of a company Description automatically generated Involves giving or transferring the responsibility for the care of a specific patient or specific patient care task to another healthcare provider Considerations: Knowledge, skill, and experience of the person accepting the assignment Complexity, challenges, and/or risks associated with the assignment Environment where the assignment is to be completed [DIG DEEPER → CNO – Assigning, Teaching & Supervising] Communicating What is therapeutic communication? Can you think of a nursing diagnosis where communication would be a possible intervention? [Think NUSC 1P01!] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Communicating AIM: clear and focused communication with the goal of providing quality patient care and contributing to improved patient outcomes. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Teaching How is teaching related to patient care? Can you think of a nursing diagnosis where communication would be a possible intervention? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Teaching AIMS: Using communication skills to create change in a patient through intellectual growth or acquisition of skills. Helping patients learn about their health status, ways of promoting health, and ways of caring for themselves. Key Takeaways 1. Nursing diagnoses are the starting point, goals/outcomes are where you want to end, and nursing interventions are how you plan to get there 2. Nurses must consider potential complications and priorities when selecting interventions 3. There are different types of nursing interventions as well as different ways nursing interventions can be implemented 4. Nurses need to consider the cognitive, interpersonal, and psychomotor skills associated with an intervention when selecting NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What’s Next!? READING BREAK! NOV 17 – Clinical Judgement Application Assignment due - get started now! NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS NUSC 1P03 – Clinical Judgement & Skills Week 5 – Evidence-Informed Decision Making 2 Week 5 Objectives 1. Review nursing’s fundamental patterns of knowing 2. Review EIDM 5 step process 3. Describe appraising evidence to inform nursing practice 4. Describe applying evidence to practice situations NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Review – Patterns of Knowing and Intro. to EIDM NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Remember – Nursing’s Fundamental Patterns of Knowing Empirics: science of nursing Aesthetics: art of nursing Personal knowledge: self-awareness and self-reflection Ethics: moral knowledge in nursing Emancipatory Knowing: being aware of social problems and taking action to create social change Praxis: when the 5 patterns come together to support social justice NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Remember – Evidence-Informed Decision Making (EIDM) EIDM is “an ongoing process that incorporates evidence from research findings, clinical expertise, client preferences and other available resources to inform decisions that nurses make about clients” (CNA, 2018, p. 1). NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Steps of EIDM Appraise Ask a clinical Search and collect (evaluate, critique) question best evidence the evidence Integrate the Evaluate & evidence to Disseminate context [Process is described in detail in NCCMT Introduction to EIDM] Remember – Asking Questions & Searching for Evidence Clear clinical questions are formulated using PICO (or PICO(t), PEO, SPIDER…) A clear question forms the basis for an evidence search Keywords, Boolean Operators (AND, OR, NOT), and filters support searching for evidence in a systematic way NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising & Applying Evidence NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence Why do we need to appraise (critique, evaluate…) the evidence we have gathered from our search? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence Evidence is an important element of quality care in all domains of nursing practice (administration, clinical, education, policy and research) and is integral to improving the health-care system (CNA, 2018) Individual Nurses’ relationship with evidence: Read and critique evidence-informed literature (i.e., research articles, reports) in nursing, health sciences and related disciplines Generate researchable questions and communicate them to their managers, clinical nurse leaders or associated researchers Participate in or conduct research Evaluate and promote evidence-informed nursing practice NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence Where to start → Evidence pyramid Hierarchy for rating scientific evidence Top = strongest evidence Bottom = weakest evidence Search → systematic review = celebrate! [FOR MORE – Evidence Pyramid + Hierarchy explained in WEEK 5 Additional Resources] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence – more pyramids! https://libraryguides.mcgill.ca/ld.php?content_id=34941344 Appraising the Evidence Beyond the pyramids, what factors should nurses consider when evaluating the quality of research studies? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence Critical Appraisal Skills Programme (CASP) Asks: Is the study valid? What are the results? Are the results useful? Checklists across different study types/designs NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Appraising the Evidence Reading Scientific Papers Step 1: Preview the source to get a sense of what it will offer Step 2: Read for understanding and analysis Step 3: Reflect and takes notes on the reading [We will practice appraising research in lab this week] NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Applying the Evidence You are preparing James for discharge after a hospitalization for pneumonia. James also has Type 2 diabetes that is only moderately controlled – which puts him at risk for foot ulcers. You found Diabetes Canada’s Clinical Practice Guideline with the following key messages for patients: Examine feet and legs daily Care for nails regularly Apply moisturizing lotion if feet are dry (but not between the toes) Wear properly fitting footwear Test bath water before stepping in, to make sure the water is not too hot What do you do next? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Integrating Evidence in Context Knowledge-to-Action (KTA) framework developed by Dr. Ian Graham and colleagues (2006) Based on 30 change theories Framework for moving knowledge (research, evidence, …) into practice Context is important [FOR MORE: Additional Resources - RNAO Leading Change Toolkit] EIDM & Patterns of Knowing Empirical knowing ensures that care is based on the best available research. ensures that evidence-based care is aligned with moral Ethical knowing principles. Personal knowing ensures that care is individualized and empathetic. allows nurses to apply evidence in creative and situation- Aesthetic knowing specific ways. encourages advocacy and structural change to ensure Emancipatory knowing evidence-informed practice benefits all patients equitably. Epistemicide & Knowledge Justice Sociologist Bonaventura de Sousa Santos first coined the term “epistemicide,” designating it as “death of the knowledge of [a] subordinated culture” caused by colonization, oppression, and genocide (2007, p.149). How could the discourse of “best- evidence” and/or ”strong” versus “weak” evidence contribute epistemicide? NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Toward Knowledge Justice Stop and Reflect How do I feel about a topic? What are my honest opinions about it? How did I develop those opinions? Have I addressed my biases? Whose Evidence is Best? Who is affected by the topic? Who has lived experience? Who else will be speaking about the topic? Writing about it? (And whose interests do they have in mind?) Whose voices must be included when you're making informed decisions? (McKeown & Campbell, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Toward Knowledge Justice Use Inclusive Language What does the community call themselves? What words do they use for a topic? What terminology or phrasing is considered harmful, out-of-date? Search Outside Your Echo Chamber Where can we hear the voices and perspectives we identified above? Where are they allowed to speak? Where might we search? What types of sources might we look for? (McKeown & Campbell, 2024) NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS Key Takeaways 1. Nurses approach situations they encounter and the people they care for with knowledge (information, data, evidence) from different sources. 2. There are 5 steps for using empirical evidence in nursing decision making 3. Evidence needs to be critiqued/appraised/evaluated before informing practice decisions 4. Nurses need to consider context when applying research evidence to practice 5. Nurses should reflect on the ”best practice” discourse and reconcile this with social justice and emancipatory knowing. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS What’s Next!? Week 5 Lab – practice appraising evidence Week 6 Lab – reminder to complete self-evaluation of preparation and engagement and bring to lab. NUSC 1P03 - CLINICAL JUDGEMENT & SKILLS