Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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R E S E A R C H I N P R A C T I C E

Clinical decision making in the rural context

Clinical judgement In this chapter so far you have been learning about the foun- dations (personal attributes, knowledge and experience) that underpin the processes (problem solving, critical thinking, creative thinking and intuitive thinking) of clinical reason- ing, as illustrated in Figure 14-1. The culmination of clinical reasoning is clinical judgement and decision making, as this is what determines the actions taken and the processes of care. (See Figure U3-1 for how clinical judgement fits within the model of thoughtful practice.) Clinical judgement is a term frequently linked to, and used interchangeably with, problem solving, critical thinking and decision making (Duchscher, 1999). Clinical judgement is the next step in the clinical reasoning trajectory that trans- lates into nursing and midwifery action. 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). Many situa- tions in nursing and midwifery care require the clinician to analyse the situation and come to some decisions related to the actions to be taken. 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 (Oermann, Truesdell & Ziolkowski, 2000). Clinical judge- ment is therefore often referred to as a process of elimination. This study involved a small group of novice registered nurses in rural hospitals. These early-career nurses were often working with limited support, while managing an ever-changing clinical environment and acuity of patients. Decision making usually involves ill-structured problems set in situations where patient safety is a concern. To study decision making, a grounded theory approach was used that evolved from face-to-face inter- views with 12 nurses and observations of nine of them during their work day. The participants were interviewed Much has been written about decision making in acute care contexts, but many of the conditions that exist in this setting do not apply in a rural context. Hence, decision-making processes are different. Here nurses are often the first to assess and interpret the cues from the patient’s clinical presentation. Related research Seright, T.J. (2011). Clinical decision-making of rural novice nurses. Rural and Remote Health , 11, 1726. Available online via www.rrh.org.au.

This situation is demonstrated when you undertake an assessment (Levett-Jones et al., 2010). You must identify cues or signals in the data collected, and organise the data into meaningful clusters. In an assessment, cues can range from simple observational data such as height and weight to more complicated data such as pathology reports. Through a process of pattern-matching, your previous learning gives meaning to the current data. The more experienced you are, the more developed the patterns with which the new data can be matched. You must then decide what actions should be taken, using clinical judgement. For instance, when a nurse decides to alert a doctor to a potential problem that may be developing, the nurse is described as having good clinical judgement. When a nurse does not respond appro- priately to an abnormal observation, the nurse is said to have poor clinical judgement. Clinical judgement does not always lead to the correct clinical decision, as it is depend- ent on the accuracy of the data collected, the experience of the clinician and the confidence of the decision maker (Cioffi, 2002). Failure to rescue is an example of poor clin- ical judgement (Levett-Jones et al., 2010). Clinical judgement can also be based on what is not observed. When a situation does not match the expected pattern, this can alert the clinician to a health problem. For instance, when a labouring woman experiences pain that does not fit the usual patterns of a normal uncomplicated delivery, the midwife is alerted to investigate further. This demon- strates good clinical judgement. When all the data have been The need for mentorship, facilitation and orientation is just as acute in rural settings as in urban settings. Deci- sion making should be guided by more experienced nurses who are willing to encourage novice nurses to reflect upon their clinical decisions. In a rural setting, this is especially important because novice nurses are required early in their career to make significant deci- sions that may have to be done independently with little support. a second time so they could review their transcripts, the emerging themes and categories. From an axial coding process, ‘sociocentric rationalising’ emerged as the central phenomenon and referred to the sense of belong- ing and agency that impacted on the decision making in this group of nurses. Despite access to a number of resources at their disposal (including policy books, decision trees, standing orders, textbooks and, in some cases, Internet resources), the nurses in this study indi- cated collaboration with colleagues was a major means of facilitating their decision making. Relevance to practice