Fundamentals of Nursing and Midwifery 2e

257 Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care

• Use of healthy strategies to manage stress and enable clear thinking, by being proactive, anticipating consequences, planning ahead and taking advantage of opportunities • Confidence in own ability to reason and learn effectively, being courageous, standing up for own beliefs, advocating on behalf of others and rising to challenges • Acceptance of autonomy and responsibility for thoughts and actions, ability to regulate own activities, beginning and completing tasks without being reminded, expressing ownership of accountability, being self-disciplined and focused on priorities • Resilience by overcoming disappointments, being patient and persistent and persevering for the best outcome • Being analytical and insightful, identifying relationships, expressing deep understanding, being improvement- Responsiveness to the environment The complexity and organisation of the healthcare envi- ronment can also affect the reasoning of clinicians (Raterink, 2008). The way work is organised, the number of interruptions experienced by the clinician and the culture of the healthcare environment can all affect the rea- soning undertaken by clinicians, especially if greater value is placed on activities such as the completion of tasks than on the reasoning process (Ebright et al., 2003). In health- care environments where sound reasoning is valued and time is taken to reason well, better reasoning processes are exhibited by clinicians and fewer errors occur in the processes of care. Conversely, as discussed in Chapter 13, in environments where the work itself, rather than the people, has precedence, practice may be ritualised and reasoning compromised. The personal attributes that affect clinical reasoning, however, are often not expressed but rather are revealed in people’s behaviour. A summary of some of the optimal behaviours that demonstrate the effect of important personal attributes on reasoning processes are presented in Box 14-2. Revisit the personal attributes required for person- centred care discussed in Chapter 1, and examine the parallels with the attributes outlined in Box 14-1. Then reflect on the personal attributes or characteristics that you bring to practice. • Do you think there is a particular personal attribute that might influence the way you approach a situation and thus potentially affect your reasoning? • Think about something you believe in strongly, and reflect on whether this could affect the way you reason through a problem.

• Keep a record of these thoughts, as it may be helpful to revisit them as you progress through your learning about using clinical reasoning in thoughtful practice. All of these factors influence the quality of the clinical reasoning engaged in by the clinician. The following section explains in greater detail the individual components of clini- cal reasoning. Discipline-specific knowledge base In order to reason through a clinical situation, you must be able to draw upon a body of nursing or midwifery knowl- edge that emanates from the sources of knowledge discussed in Chapter 9. Added to this must be evidence that emanates from research. Chapter 1 summarises the know- ledge that is required for care to have a holistic focus. These discussions demonstrate that the discipline-specific know- ledge required is extensive. Contextual knowledge is also required, as can be seen in Box 14-3, which outlines the additional knowledge required for competent clinical rea- soning in nursing or midwifery practice. The specific knowledge required for clinical reasoning will determined by the actual clinical situation. For example, 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 epidemiology, the mechanisms of its pathophysiology, its physical and psychological manifes- tations, signs and symptoms, and the probabilities of its progression or outcome (Szaflarski, 1997). If the clinical sit- uation relates to the problematic discharge from hospital of a patient with disabilities, the knowledge base must include local knowledge of support services available in the specific oriented for self (identifying learning needs, finding ways to overcome limitations, seeking out new knowledge), patients (promoting health, maximising function, comfort and convenience) and systems (identifying risks and problems with healthcare systems, promoting safety, quality, satisfaction and cost containment) • Being alert to context, looking for changes in circumstances that warrant modification of thinking or approaches, drawing reasonable conclusions (if this is so, then it follows that … because), using intuition as a guide to search for evidence, acting on intuition only with knowledge of the risks involved, seeking help when needed, suspending or revising judgement when indicated by new or incomplete data • Being realistic, practical and creative, admitting when things are not feasible and looking for user-friendly

BOX 14-2 Summary of behaviours that demonstrate the effect of personal attributes on reasoning

solutions, offering alternative solutions and approaches, coming up with useful ideas.

Source: Adapted from Alfaro-LeFevre, 2012.