Clinical judgement and decision-making in nursing - nine modes of practice in a revised cognitive continuum

Title. Clinical judgement and decision‐making in nursing – nine modes of practice in a revised cognitive continuum Aim. This paper is a report of an evaluation of cognitive continuum theory and identification of revisions required for application to clinical judgement and decision‐making in nursing. Background. The importance of nurses’ developing and applying sound clinical judgement is reflected in an international classification of nursing practice. Cognitive continuum theory synthesizes rival and complementary approaches to decision theory in an accessible format, which has been applied in medicine, and various nursing scholars have advocated its use to enhance the effectiveness of nurses’ clinical judgement and decision‐making. Method. Parse’s structure and process criteria are applied in critiquing the relevance of cognitive continuum theory to nursing. Findings. Cognitive continuum theory illustrates how different judgement tasks are suited to different thought processes and how matching the two can optimize decision‐making. However, existing modes of inquiry applied to medicine emphasize experimental research, ignoring many alternative approaches used in nursing. A revised version of the cognitive continuum is developed, incorporating examples of nursing judgements and decisions, a broader evidence base, an ethical dimension, and evaluative competence criteria. Conclusion. The revised cognitive continuum promotes awareness of the nature and the variety of patient‐centred judgement tasks and decisions in nursing, how to select the most suitable intervention tactic from available options, and the fallibility of all forms of human judgement from intuitive/experiential to analytic/rational. Hence, it is recommended for use as an educational tool and practice guide to facilitate theory development and the practice of judgement and decision‐making in nursing.     

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory

BACKGROUND: Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills. While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development. Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts. AIMS: This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills. METHODS: Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases. The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking. FINDINGS: Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition. This skill acquisition is best accomplished through teaching-learning attention to self-regulation learning theory. A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory. It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development. Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development. While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts. CONCLUSIONS: Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies. The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts.     

Measuring the quality of judgement and decision-making in nursing

AIM: This paper discusses measurement of the quality of judgement and decision-making in nursing research. It examines theoretical and research issues surrounding how to measure judgement accuracy as a component of evaluating decision-making in nursing practice. DISCUSSION: Judgement accuracy is discussed with reference to different methods of measurement, including comparing judgements with independent criteria and inter-judge approaches. Existing research on how judgement accuracy has been measured in nursing practice is examined. Evaluation of decisions is then discussed, including consideration of the process of decision-making and evaluating decision outcomes. Finally, existing research on decision-making in nursing is assessed and the strengths and limitations of different types of measurement discussed. CONCLUSION: We suggests that researchers examining the quality of judgement and decision-making in nursing need to be aware of both the strengths and limitations of existing methods of measurement. We also suggest that researchers need to use a number of different methods, including normative approaches such as Bayes' Theorem and Subjective Expected Utility Theory.     

Promoting Clinical Practice Knowledge in an Age of Taxonomies and Protocols

The proliferation of classification schemes, practice guidelines, and critical pathways expresses our modern faith in theoretical reasoning and scientific evidence. This mode of knowing is almost universally championed for providing the evidence that will guide and advance nursing practice. The nature and complexity of clinical expertise, however, are misconstrued with the quest to standardize nursing practice. After distinguishing between theoretical and clinical reasoning, several narratives from two interpretive studies of public health nursing practice will illustrate how clinical practice resists theoretical understanding and must be more fully articulated if clinical and ethical reasoning is to be preserved and strengthened.     

Evidence and clinical judgement

Widespread acceptance of the neologism 'evidence-based medicine' (EBM) has had the consequences of obscuring what evidence really is, and of eroding the importance of judgement in clinical situations. In this essay I seek to correct this lack of balance in the view of clinical encounters as portrayed by EBM. A better understanding of what evidence is can be obtained by looking beyond medicine to the way in which scientists and detectives view evidence. In both spheres, the importance of judgement is emphasized, even if it is a technical type of judgement. Clinicians also employ a technical kind of judgement, similar to that in science and detective work, when assessing the evidence relating to the truth of a diagnosis for an individual patient; but judgements relating to the ongoing care and treatment of that patient are based on what Aristotle calls phronesis or 'practical wisdom'.     

An agenda for clinical decision making and judgement in nursing research and education

Nurses’ judgements and decisions have the potential to help healthcare systems allocate resources efficiently, promote health gain and patient benefit and prevent harm. Evidence from healthcare systems throughout the world suggests that judgements and decisions made by clinicians could be improved: around half of all adverse events have some kind of error at their core. For nursing to contribute to raising quality though improved judgements and decisions within health systems we need to know more about the decisions and judgements themselves, the interventions likely to improve judgement and decision processes and outcomes, and where best to target finite intellectual and educational resources. There is a rich heritage of research into decision making and judgement, both from within the discipline of nursing and from other perspectives, but which focus on nurses. Much of this evidence plays only a minor role in the development of educational and technological efforts at decision improvement. This paper presents nine unanswered questions that researchers and educators might like to consider as a potential agenda for the future of research into this important area of nursing practice, training and development.     

Diagnostic errors and reflective practice in medicine

BACKGROUND: Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that as far as it explains reasoning processes involved in clinical judgements. The literature has indicated the capability of critically reflecting upon one's own practice as a key requirement for developing and maintaining medical expertise throughout life. OBJECTIVES: This article explores potential relationships between reflective practice and diagnostic errors. METHODS: A survey of the medical expertise literature was conducted. Origins of medical errors frequently reported in the literature were explored. The potential relationship between diagnostic errors and the several dimensions of reflective practice in medicine, brought to light by recent research, were theoretically explored. RESULTS AND DISCUSSION: Uncertainty and fallibility inherent to clinical judgements are discussed. Stages in the diagnostic reasoning process where errors could occur and their potential sources are highlighted, including the role of medical heuristics and biases. The authors discuss the nature of reflective practice in medicine, and explore whether and how the several behaviours and reasoning processes that constitute reflective practice could minimize diagnostic errors. Future directions for further research are discussed. They involve empirical research on the role of reflective practice in improving clinical reasoning and the development of educational strategies to enhancing reflective practice.     

Clinical decision making and critical thinking in the nursing diagnostic process

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".     

A definitional analysis of specialist practice in orthopaedic nursing

Literature pertaining to orthopaedic nursing and specialist practice indicates a limited evidence base when both terms are integrated. Through an active review of literature and practice this article aims to briefly define orthopaedic nursing providing a more in-depth definition and evaluation of specialist practice. Assembled evidence will strive to evaluate specialist practice from a clinical practice and educational perspective examining the inpatient distribution for orthopaedic patients within Northern Ireland. Recommendations are offered for future practice. The conclusion will review all the evidence gathered and indicate where specialist practice in orthopaedic nursing stands within the present day clinical arena in Northern Ireland.     

Problem solving in clinical nursing practice

Problem solving in clinical nursing practice is the essence of good care delivery. This paper gives an overview of a research study which identified the cognitive problem solving process nurses use while delivering care. The study was conducted in the clinical setting and used a qualitative research methodology of observation, followed by in-depth semi-structured interview. The analysis of the study revealed diagnostic reasoning is the process used by clinicians. Information regarding the differences between novices and experts is offered as topics for discussion throughout the paper, and recommendations for changes to educational processes are made.     

Reflexivity and metapositions: strategies for appraisal of clinical evidence

According to Sackett, evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. In this article, clinical reasoning is depicted as multilayered processes of evidence construction by means of social interaction and human interpretation. A basic set of knowledge is the doctors initial capital at the onset of the individual encounter. This is a necessary, but insufficient, presumption for the elaboration of clinical knowledge required to solve the particular problem. A diagnostic conclusion may appear to constitute the most obvious part of knowledge. Yet the formulation of hypotheses and the choice of adequate strategies for the pursuit of evidence are perhaps even more significant dimensions of clinical knowledge. Potential biases affect the ways in which evidence is gathered and used. When clinicians are not committed to appraising the evidence constituting the foundations of their enterprise, quality assessment of clinical practice becomes casual and unreliable. Reflexivity implies having a self-conscious account of the production of knowledge as it is being produced. From metapositions, critical questions can be asked and sometimes answered. Evidence-based practice in the original sense requires that doctors reflect upon their own positions as knowers, in the process of situated knowing, where certain rhetorical spaces rule.     

Clinical judgement in the era of big data and predictive analytics

Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data‐driven, mathematical approaches which we contrast with narrative, virtue‐based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue‐based clinical reasoning will remain indispensable in an era of big data and predictive analytics.     

Teaching clinical judgment in Taiwan

Clinical judgment is a process that nurses use during the course of their daily practice to gather and to evaluate data, define the needs of the clients, and to judge the outcome of patient care. Such judgment is also a critical ability used to assess the progress of nursing students. The purpose of this qualitative research was to describe the clinical judgment teaching in nursing education in Taiwan and provide baseline data for future nursing students to learn in a more effective way. Data was collected by in-depth individual interviews of 10 participants, all of whom were senior nursing faculty members from different nursing subspecialties. Two findings were reached. First, clinical judgment included not only the cognitive and the psychomotor domain of learning, but also the affective domain of reasoning. Second, due to cultural differences, " intuition " had never been mentioned in Taiwan, but a similar concept was substituted by use of the term " experience ". The findings suggested a holistic and integrative perspective was needed when teaching clinical judgement in Taiwan.     

Undergraduate student nurses’ perspectives of an integrated clinical learning model in the mental health environment

Providing nursing students with appropriate clinical practice during their undergraduate programme is critical to ensuring that graduates meet the competency requirements to gain registration as a nurse. In response to the predicted nursing workforce shortage, universities have been significantly increasing the enrolment of undergraduate nurses into Bachelor of Nursing courses. This has placed a demand on the availability of clinical placements and often universities struggle to find appropriate places. In this study, a Bachelor of Nursing course incorporated an Integrated Clinical Learning Model (ICLM) for the first time during a mental health placement. The model offered students the flexibility of attending their clinical placement over a 16‐week period instead of a traditional block of 4 weeks. The aim of this study was to evaluate the student perspective of this model and whether it prepared them for the nursing workforce. Focus groups were conducted with undergraduate nursing students following their mental health clinical placement at an acute and extended care inpatient unit. Data were analysed using thematic analysis. Main themes included preparedness for practice, maintaining a work–life balance, and perceiving they were part of a team. The ICLM deepened students’ knowledge and had a positive impact on their overall clinical learning.     

An epistemological shift: from evidence‐based medicine to epistemological responsibility

In decision making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet we argue that the current paradigm for best medical practice – evidence‐based medicine (EBM) – does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials in the testing of new treatments and prophylactics and rule‐based reasoning in clinical decision making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article, we build on this critique and argue that rule‐based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision making. Instead, we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice and at the same time maintains the quality usually associated with ‘scientific’. The medical epistemology we propose conforms to the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent ‘picture’ of a specific patient. In the proposed epistemology, we consider this ‘picture’ as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.     

Clinical supervision: what do we know and what do we need to know? A review and commentary

AIMS: This study is addressed to nurses but the issues are of equal concern to both midwives and health visitors. Clinical supervision ideally both challenges nurses as well as help their practice. There is need to identify critical elements that help professional practice and understand more clearly the changing nature of supervisory relationships. BACKGROUND: Clinical supervision in nursing is over a decade old in the UK and yet emerging nursing literature suggests that many ideas remain unfamiliar to nursing practice. The resistance shown by nurse towards clinical supervising remains perplexing. Moreover, ideas concerning clinical supervision have been applied without a substantive evidence base. METHODS: The discussion draws on varied ideas concerning supervision, including those outside of nursing, to ask what do we know and still need to know about clinical supervision. This study suggests that, a single approach to clinical supervision could be unhelpful to nursing. FINDINGS AND CONCLUSION: Nursing knowledge concerning many aspects of clinical supervision is increasing because of research. Much of the literature suggests that clinical supervision is scholarly activity requiring much the same attention to relationships as the therapeutic activities it supports. This discussion concludes with the idea that clinical supervision might work at its best as a quiet activity allowing nurses to think about nursing work in ways that suit individual learning styles.     

The ethics of human dignity: a nursing theoretical perspective

The concept of human dignity is a term commonly used in professional codes and standards for biomedical healthcare disciplines and professional nursing practice. What is the definition of this ethical concept? This column offers a unique definition from a nursing disciplinary perspective. Common straight thinking or ethical questions emerging with the application of the concept in practice are offered along with a discussion of misunderstandings regarding the use of the concept in nursing practice and in professional healthcare arenas.