Fundamentals of Nursing and Midwifery 2e

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

TABLE 14-2 Steps used by a clinician in a critical thinking activity

Step

Activity involved

Collection

Collecting objective (signs) and subjective (symptoms) data from common information sources related to the care of the patient

‘My patient was a 63-year-old man who was recovering from a traumatic injury involving several frac- tured limbs. He was receiving TPN so I did his observations and asked him how he was feeling. His BP was 140/80, his pulse was 90 and temperature was 38°C. He said he felt quite low and not really well.’ Interpretation Relating the data to the specifics of the situation, making deductions and identifying the meaningful data ‘From the data, I realised that his temperature was raised and so I checked his central line site. It appeared reddened and there were exudates from the entry site. His other observations were fine.’ Accurately interpreting the meaning of the data collected, examining ideas and arguments related to the situation, synthesising data and identifying possible courses of action ‘As he had a raised temperature and his central line site appeared infected, I thought I had better contact the doctor and get him reviewed.’ Querying assumptions and assessing arguments, recognising faulty reasoning, reaching conclusions and validating inferences through acceptance or rejection ‘Then I thought, maybe I am on the wrong track here. His temperature may be from something else and I need to collect some more information.’ Analysis Inference Explanation Clearly explaining and defending the reasoning in the specific patient care situation ‘I rang the doctor and explained the changes in his condition and why I was concerned. I then told her what I had done so far and what I would do next.’ Validating information to ascertain its trustworthiness, resolving incorrect assumptions, evaluating relevance to the situation of the patient ‘I went back and checked his respirations and tested his urine so when the doctor arrived I had all the information ready. These were normal so my original thoughts were probably right.’ Self-regulation Constantly monitoring the quality of one’s own thinking for clarity, consistency and appropriateness ‘In the future I will remember this incident and make sure that I do not jump to conclusions and include all possibilities when I reason through the problem.’ Evaluation

Source: Adapted from Simpson & Courtney, 2003 and Alfaro-LeFevre, 2012.

patient also needed to ambulate, but became very tired holding the arm up by himself. A creatively thinking nurse invented a simple solution to this problem using a mobile drip stand, an inverted pillowcase and some safety pins to elevate the arm while enabling the patient to be active. This simple solution is often used in practice today. Creative thinking is also brought in to play when you ask ‘why?’ or ‘what if?’—questions that often form the basis of research. Intuitive thinking Decision making differs between the various levels of clini- cians according to their experience (Benner, Tanner & Chesla, 2009). Recent research has begun to explain how intuition— subconsciously drawing on knowledge gained through experience—works as a distinguishable cognitive process. When you were on clinical placement, did you ever encounter a situation where the registered nurse made a decision but was unable to explain to you how they came to that decision? The explanation may have been ‘I just knew’. This is often referred to as ‘tacit’ or ‘intuitive’ knowledge. In this situation the clini- cian draws on the health of knowledge that is stored in our

memories without conscious recollection (Paul, 1995). It is also sometimes described as a ‘hunch’ or a ‘gut feeling’, but actually this kind of knowledge is based on our memories of the patterns we have observed in the people we have previ- ously cared for (Buckingham & Adams, 2000a). Buckingham and Adams (2000b) explain how intuitive thinking is based on patterns that are built up in the learning process through experience. A student with no experience must rely on estab- lished rules to give meaning to patterns, in the form of written protocols or directives from experienced others (Gross Forneris & Peden-McAlpine, 2007). Patterns are created as the student gains experience. When pattern X is observed and response Y is generated, neural connections are made and this becomes memory. As the learner becomes more experienced, a bank of patterns is established that enables these connections for meaning to be achieved without reference to rules. This takes time, and explains why expertise is slow to develop. The rise of evidence-based practice, as discussed in Chapter 10, has influenced the use of intuitive thinking and enabled the growth of pattern-matching from experience that is based on evidence. Patterns developed with a sound basis in evidence enable intuitive decision making that is correct.