Chapter 2
Thoughtful practice
15
by the context in which the relationship takes place. In a
hospital, the person may be referred to as a ‘patient’, whereas
in the community the person may be called a ‘client’. The
terminology becomes irrelevant because when care is delivered
in a manner that reflects the principle of personhood,
person-
centred care
is enacted.
Indeed, the concept of personhood can only be maintained
when processes of care are underpinned by these principles.
In any healthcare setting, each individual interaction or
intervention should be undertaken in the spirit of partnership
and social justice. This partnership approach necessitates
empowerment, a sharing of power, by accepting the rights of
people, acknowledging autonomy, and engaging in informed
decision making with the person and others that are part of the
relationship (National Ageing Research Institute, 2006). This
is achieved by the person being empowered to make decisions
about his or her healthcare and taking
responsibility
for those
decisions.
The person-centred care approach is sometimes criticised
for being too individualistic and care can be time consum-
ing and difficult to achieve within the demands of the acute
care setting. However, when care focuses on tasks or a case it
values the system rather than the person. As a result, it can
lead to ritual behaviour and care where clinicians become
disconnected and disengaged. However skilled and committed
clinicians, whose focus on knowing the person carries over
into the care processes, can assist in overcoming these barriers.
In addition, the physical surrounding can be made to preserve
people’s privacy and dignity so that their sense of self is not
threatened. The culture of the healthcare environment can
be directed to working in this person-centred way and services
made supportive and easy for users to navigate a path through.
Unfortunately, in many healthcare environments, schedules,
routines and timetables take precedence over people. This
does not mean that person-centred care is impossible in large
organisations but it does mean that it can be more difficult to
achieve. It requires commitment to the moral principles of
personhood and an ethical approach to care delivery.
In today’s healthcare arena, nurses are faced with increas-
ingly complex issues and situations resulting from advanced
technology, greater acuity of patients in hospital and com-
munity settings, an ageing population, and complex disease
processes, as well as ethical and cultural factors. Traditionally,
nurses have used a problem-solving approach in
planning
and
providing nursing care. Today the decision-making dimension
of
problem solving
has become increasingly complex and
requires clinical reasoning. The terms of clinical reasoning,
critical thinking
, clinical judgement, problem solving, and
decision making do not have settled definitions. Although
many of the explanations overlap, there are common features
in the definitions such as their grounding in knowledge, a will-
ingness to pursue answers, and an ability to develop new solu-
tions that are often innovative and outside current knowledge.
Clinical reasoning
Clinical reasoning
is the process for analysing a situation,
making a judgement, determining possible alternative actions,
and choosing an action to be taken. It includes the cognitive
processes of critical thinking that occurs in response to a
clinical situation within a specific context. It is the process
by which nurses collect
cues (
the pieces of data collected
through observation, reading records, and talking to patients
and others), process and interpret the information, make
a judgement about a patient’s problem or situation, come
to a decision, plan and implement interventions, evaluate
outcomes, and reflect on and learn from the process. Clinical
reasoning depends upon the nurse’s ability to collect the right
cues and to take the right action for the right patient at the
right time and for the right reason (Levett-Jones et al., 2010).
By applying clinical reasoning skills, the clinician can identify
options for care and choose a course of action that provides
a solution or temporary relief of a health problem. This is
called
clinical judgement
, which involves decision making,
and which can be influenced by the personal attributes and
experiences of the clinician and how they respond within the
specific health setting.
Thoughtful practice describes the global process of clinical
reasoning (Figure 2-2).
Reasoning environment
The complexity of the healthcare environment, the way work
is organised and the number of interruptions experienced can
affect the reasoning undertaken by clinicians. The quality of
the reasoning undertaken may also be affected if greater value
is placed on activities such as completion of tasks (Smith,
Higgs & Ellis, 2008). The social context in which the reason-
ing takes place that involves the culture of the unit, and even
the power differentials between work groups, have also been
found to have an effect on the decisions and actions taken.
Clinical reasoning depends on the expertise and confidence
of the decision maker (Jensen, Resnik & Haddad, 2008). In
order to reason through a clinical situation, nurses draw upon
a body of knowledge that emanates from research. The specific
knowledge base required is determined by the actual clinical
situation. If the situation calls for reasoning related to the
manifestation of a physical problem, reasoning will require
an understanding of the disease or condition; its epidemiol-
ogy; the mechanisms of its pathophysiology; its physical and
psychological manifestations, signs and symptoms; and the
probabilities of its progression or outcome. If the clinical situ-
ation is related to a cultural or ethical problem, the knowledge
base must have regard to the cultural context as well as an
understanding of the ethical principles involved.
Personal attributes
Reasoning has a logical cognitive (thinking) component as
well as an emotional or affective (feeling) component and
is affected by the personal attributes of the thinker. Clinical
reasoning is also affected by the beliefs and values the clinician
brings to the practice (Hoffman, Donoghue & Duffield, 2004).
The willingness of the nurse to put all the data together into a
complete picture is also crucial to the reasoning process. Person-
centredness and clinical reasoning occur in tandem because rea-
soning is also affected by how well the nurse has come to know
the patient as not just a source of data to be reasoned through,
but as a person with their own unique needs, values and individ-
ual responses to a situation (Tanner, 2006). Open-mindedness
and the ability to see several viewpoints is also an important
attribute for clinical reasoning (Banning, 2008).
Clinical experience
The experience of the clinician has a profound effect on his or
her ability to reason and make decisions about what action to
