Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

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

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