Textbook of Medical-Surgical Nursing 3e

18

Unit 1 Contemporary concepts in nursing

CHART 2-1

The inquiring mind: Critical thinking in action

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 • 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?

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, • 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? 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?