18
Unit 1
Contemporary concepts in nursing
Nurses draw on personal knowledge and a variety of situations
and consider the contextual background of the clinical culture.
As nursing students develop their clinical reasoning skills and
become professional nurses, their ability to reason clinically
and to make sound clinical nursing judgements becomes more
refined.
Critical thinking exercises are offered throughout this
book as a means of practising one’s ability to think critically
because developing the skill of critical thinking takes time and
practice. Additional exercises can be found in the study guide
that accompanies the text. The questions listed in Chart 2-1
can serve as a guide in working through the exercises, although
it is important to remember that each situation is unique and
calls for an approach that fits the particular circumstances
being described.
Clinical judgement and decision making
The culmination of clinical reasoning is clinical judgement
and
decision making
, a term frequently linked to, and used
interchangeably with, critical thinking, decision making, and
problem solving. Clinical judgement has been described as ‘an
interpretation or conclusion about a patient’s needs, concerns
or health problems, and/or the decision to take action (or not),
use or modify standard approaches, or improvise new ones as
deemed appropriate by the patient’s response’ (Tanner, 2006,
p. 204). However, not all clinical situations are clear cut, and
in many circumstances a range of possible solutions to an
identified problem is available to the clinician. Clinical judge-
ment is sometimes a process of elimination and the product of
clinical judgement is a decision. There are degrees of clinical
judgement as the correct clinical decision can be dependent
on the accuracy of the data collected, the experience of the
clinician, and the confidence of the decision maker. For
instance, when a clinician decides to alert a doctor to a poten-
tial problem that may be developing, he or she is described as
having good clinical judgement. Similarly, when a clinician
does not respond appropriately to an abnormal observation,
he or she is said to have poor clinical judgement. The decision
must also be person-centred as these ‘higher order thinking
skills have no value unless they are applied for the good of the
patient’ (Tanner, 2006, p. 209).
Leadership and management
In the clinical situation, nurses are constantly required to
assume a leadership and management role and this may
affect how a problem is reasoned through. This has become
particularly important as different classifications of nurses
are introduced into the healthcare setting. Although often
considered together, management and leadership are different
things. Management concerns the organisation of resources
to meet a specific objective. It is about structures, systems,
policies, methods, results, finance and logistics. As contem-
porary healthcare is characterised by financial constraints,
effective management of resources is considered an essen-
tial competency for all registered nurses (NMBA, 2006a).
Leadership however is about influencing others to achieve a
goal. It is enacted through articulating a vision, demonstrating
sound values and purpose (Davidson, 2009). By these means,
others are inspired and motivated to work with the leader to
achieve a defined purpose. There are different styles of leader-
ship (Frankel, 2008). Transactional leaders use conventional
reward and punishment to achieve the goal. It can be the style
of leadership used when the power to lead comes from the
authority invested in the position itself. This is the traditional
model for leadership in hierarchical traditional health systems.
However, transformational leadership is a style of leader-
ship where the leader gains followers by focusing on people,
encouraging innovation and providing inspiration through
empowering people to take ownership of the problem and the
goal. The leadership style of the clinician can affect decisions
when delegation is necessary.
Clinical practice has become extremely complex. Clinicians
may be caring for a number of significantly ill people at any
given time as well as providing supervision for a number of
The inquiring mind: Critical thinking in action
Throughout the critical thinking process, a continuous flow
of questions evolves in the thinker’s mind. Although the
questions will vary according to the particular clinical situation,
certain general inquiries can serve as a basis for reaching
conclusions and determining a course of action.
When faced with a patient situation, it is often helpful to
seek answers to some or all of the following questions in an
attempt to determine those actions that are most appropriate:
• What relevant assessment information do I need, and how
do I interpret this information? What does this information
tell me? What contextual factors must be considered when
gathering this information?
• To what problems does this information point? Have I
identified the most important ones? Does the information
point to any other problems that I should consider?
• Have I gathered all the information I need (signs/symptoms,
laboratory results, medication history, emotional factors,
mental status)? Is anything missing?
• Is there anything that needs to be reported immediately?
Do I need to seek additional assistance?
• Does this patient have any special risk factors? Which ones
are most significant? What must I do to minimise these risks?
• What possible complications must I anticipate?
• What are the most important problems in this situation?
Do the patient and the patient’s family recognise the same
problems?
• What are the desired outcomes for this patient? Which have
the highest priority? Do the patient and I agree with these
points?
• What is going to be my first action in this situation?
• How can I construct a plan of care to achieve the goals?
• Are there any age-related factors involved, and will they
require some special approach? Will I need to make some
change in the plan of care to take these factors into account?
• How do the family dynamics affect this situation, and will this
have an effect on my actions or the plan of care?
• Are there cultural factors that I must address and consider?
• Am I dealing with an ethical problem here? If so, how am I
going to resolve it?
• Has any nursing research been conducted on this subject?
What are the nursing implications of this research for care of
this patient?
CHART
2-1
