Coronary care nurses' clinical decision making

Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses’ decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be in-corporated into knowledge-system design. One implication of the variability in subjects’ line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects’ performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.     

Classifying clinical decision making: a unifying approach

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.     

Line of reasoning as a representation of nurses' clinical decision making

Line of reasoning (LOR) is offered as an alternative representation of clinical decision making for studies using protocol analysis. A LOR is defined as an argument or set of arguments leading to a conclusion. Because LOR combines both knowledge and cognitive processes, it provides a more complete representation of how a person uses knowledge to make a decision in a particular situation than do other representations. Operationalization of LOR in the form of templates and narratives enhances systematic data interpretation and coding. The use of LOR as a representation is illustrated in a study of critical care nurses' clinical decision making, specifically the determination of a patient's readiness to wean from mechanical ventilation. © 1997 John Wiley & Sons, Inc. Res Nurs Health 20: 353–364, 1997     

A review of clinical decision making: models and current research

Aims and objectives. The aim of this paper was to review the current literature clinical decision‐making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information‐processing model, the intuitive‐humanist model and the clinical decision‐making model. Background. Clinical decision making is a unique process that involves the interplay between knowledge of pre‐existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information‐processing model and the intuitive‐humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information‐processing model but also examines patient specific elements that are necessary for cue and pattern recognition. Design. Literature review. Methods. Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005. Results. The characteristics of the three models of decision making were identified and the related research discussed. Conclusions. Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision‐making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed. Relevance to clinical practice. It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing‐related problems. It is suggested that O'Neill's clinical decision‐making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.     

Cognitive balanced model: a conceptual scheme of diagnostic decision making

Rationale Diagnostic reasoning is a critical aspect of clinical performance, having a high impact on quality and safety of care. Although diagnosis is fundamental in medicine, we still have a poor understanding of the factors that determine its course. According to traditional understanding, all information used in diagnostic reasoning is objective and logically driven. However, these conditions are not always met. Although we would be less likely to make an inaccurate diagnosis when following rational decision making, as described by normative models, the real diagnostic process works in a different way. Recent work has described the major cognitive biases in medicine as well as a number of strategies for reducing them, collectively called debiasing techniques. However, advances have encountered obstacles in achieving implementation into clinical practice. Aims and objectives While traditional understanding of clinical reasoning has failed to consider contextual factors, most debiasing techniques seem to fail in raising sound and safer medical praxis. Technological solutions, being data driven, are fundamental in increasing care safety, but they need to consider human factors. Thus, balanced models, cognitive driven and technology based, are needed in day‐to‐day applications to actually improve the diagnostic process. The purpose of this article, then, is to provide insight into cognitive influences that have resulted in wrong, delayed or missed diagnosis. Conclusions Using a cognitive approach, we describe the basis of medical error, with particular emphasis on diagnostic error. We then propose a conceptual scheme of the diagnostic process by the use of fuzzy cognitive maps.     

临床决策能力测评研究进展

临床决策能力是护生和护士必须掌握的核心能力之一。现就临床决策能力测评的意义、方法、现状和趋势进行综述,旨在为护理教育和护理管理工作提供参考。     

护理专业本科实习学生临床决策能力的现状调查

目的了解护理专业本科学生临床决策能力。方法对在重庆市5所三级甲等医院实习的护理专业学生253人进行临床决策能力测量。结果护理本科实习学生临床决策能力总分为（81．60±9．85）分,临床环境适应性、临床思维、知识结构、护患沟通能力、综合基础素质得分较低。结论护理专业学生临床决策能力水平偏低,提示应采取针对性干预措施,不断提高其临床决策能力。     

Clinical decision making in nursing: theoretical perspectives and their relevance to practice

AIM OF PAPER: This paper is a response to Thompson's paper 'A conceptual treadmill: the need for a middle ground in clinical decision making theory' published in the Journal of Advanced Nursing in 1999. SUMMARY OF CONTENT: This author agrees with his main recommendations, which are to seek a middle ground in the current polarized debate over clinical decision making in nursing, and to draw upon Hammond's Cognitive Continuum theory to do so. The theoretical background is sketched out, and the implications of these recommendations are analysed against this. It is argued that nurses now need to move the academic debate forward in such a way as to make serious impact on developing and improving practice. Cognitive continuum theory, in the way in which it focuses on practice, holds considerable potential to assist this move. CONCLUSION: Drawing on cognitive continuum theory necessarily leads to consequences which are not addressed in Thompson's paper: namely a need to consider the quality of nursing decisions, and a willingness to consider approaches to decision making which have been neglected or criticised by nurses. These consequences are explored here, and the implications of adopting this approach for nurses are outlined.     

Wound care in the community setting: clinical decision making in context

Sixty-two community nurses in northern England of grades B and D to H were interviewed by a team of four researchers. The interviews were semi-structured, and were tape-recorded, fully transcribed and content analysed. They were conducted as part of a larger study, the aim of which was to examine community nurses' perceptions of quality in nursing care. One of the main themes the work focused on was decision-making as an element of quality. Data relating to wound care were considered from the perspective of the insights they offered into clinical decision-making. Data were interpreted in the light of a literature review in which a distinction had been made between theories which represented clinical decision-making as a linear or staged process and those which represented it as intuitive. Within the former category, three sub-categories were suggested: theorists could be divided into 'pragmatists', 'systematisers' and those who advocated 'diagnostic reasoning'. The interpretation of the data suggested that the clinical decisions made by community nurses in the area of wound care appeared largely intuitive, yet were also closely related to 'diagnostic reasoning'. They were furthermore based on a range of sources of information and justified by a number of different types of rationale.     

Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches.     

护理临床决策能力在护理教育中的培养现状

从护理临床决策的概念、内涵、教学模式和评价方法等方面对护理临床决策能力在护理教育中的培养现状进行了综述。     

Community ambulation: Influences on therapists and clients reasoning and decision making

Background. Community ambulation is an important element of a rehabilitation training programme and its achievement is a goal shared by rehabilitation professionals and clients. The factors that influence a physiotherapist's or health professionals decision making around the preparation of a client for community ambulation and the factors that influence a client's decision to return to walking in their community are unclear.

Objective. To review the available literature about the factors that have influenced the reasoning and decision making of rehabilitation therapists and clients around the topic of ambulation in the community.

Method. Three separate searches of the available literature were undertaken using Ovid, Cinahl, ProQuest, Medline and Ebscohost databases. Databases were searched from 1966 to October 2006.The first search explored the literature for factors that influence the clinical reasoning of rehabilitation therapists. The second search explored the literature for factors that influence client's decision to ambulate in the community. A third search was undertaken to explore the literature for the demands of community ambulation in rural communities.

Results. Very few studies were found that explored community ambulation in the context of clinical reasoning and decision making, the facilitators and barriers to a clients return to ambulation in their community or the demands of ambulation in a rural community.

Conclusion. Consideration of the environment is key to the successful return to walking in the community of clients with mobility problems yet little literature has been found to guide physiotherapist's decision making about preparing a clients to return to walking in the community. An individual's participation in their society is also a result of the interaction between their personal characteristics and his or her environment. The influence of these characteristics may vary from one individual to another yet the factors that influence a person's decision to return to walking in their community after stroke remain unclear.     

护理本科生临床实习环境与职业决策自我效能感的相关研究

目的了解护理本科生临床实习环境、职业决策自我效能的现状,探讨二者之间的相关性。方法选取306名护理本科生进行问卷调查,采用护理本科生一般资料调查表、临床实习环境评价量表、职业决策自我效能问卷进行调查。结果护理本科生临床实习环境评价总分为(119.33±20.80)分,职业决策自我效能总均分为(3.72±0.46)分,临床实习环境评价与职业决策自我效能呈正相关(P0.05);教学方法、工作氛围、组织支持维度可影响护理本科生的职业决策自我效能。结论创建一个良好的、支持性的临床学习环境,可提升护理本科生的职业决策自我效能。     

The influence of objective measurement tools on communication and clinical decision making in neurological rehabilitation

Rationale Routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neuro‐rehabilitation teams, one which routinely used standardized measurement tools and the other which did not. We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice. Method Non‐participant observation of MDT meetings in two neurological rehabilitation units in England. Semi‐structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data. Results Differences in team members' communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient's abilities rather than individual professionals' contributions. This led to differences in the way team members identified the nature and cause of patients' problems, monitored their progress and planned for discharge. They provided a ‘neutral ground’ to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news. Conclusion Using standardized measurement tools can promote a patient‐focused approach to care, thus facilitating treatment planning and clinical decision making.     

The slave of duty: Why clinical educators across the continuum of care provide clinical education in physiotherapy

This study was a qualitative investigation aimed at exploring clinical educator’s perceptions of the clinical education experience and barriers to providing more clinical education. An online questionnaire was sent to physiotherapy clinical educators at hospital and community sites operated by Southern Health in Victoria, Australia. Using the responses, a framework involving key themes “motivators for delivering clinical education,” “consequences of delivering clinical education,” and “beneficiaries of clinical education” was constructed. Motivation for delivering clinical education was consistently reported as duty or responsibility. Consequences of delivering clinical education were comprised of positive effects on department profile, educator professional development, student professional development, and development of the physiotherapy profession, and negative effects on non-clinical tasks. The effect of clinical education on workload was seen as both positive and negative, depending on student ability, attitude, and quantity, as well as on staffing levels. These consequences were distributed across a range of beneficiaries of clinical education, inclusive of students, educators, patients, the department, and the profession. Strategies aimed at enhancing the positive aspects and managing the negative aspects for the clinical educator may be more successful in increasing capacity for student placements.     

Overview and critique of judgement and decision making in health care: social and procedural dimensions

This paper presents an outline of the scope for the application of decision theory to health care. Firstly, the main approaches to and assumptions of decision theory are discussed. Secondly, health care decision making is reviewed. It is noted that decision theory can be applied to either the health care professional or to the lay person. Applications of decision theory to clinical practice, to the management of care and to resourcing are considered. Thirdly, some areas which would repay further research are identified. These include social processes in individual and group decision making, the temporal distribution of outcomes and the development of techniques capable of dealing with the complex and dynamic features of decisions. On the basis of the foregoing, some conclusions are drawn.     

临床推理与决策课程对护理本科生评判性思维能力的影响

目的探讨内地首门“临床推理与决策”课程对护理本科生评判性思维能力的影响。方法采用前后对照设计。在“临床推理与决策”课程开设前后,组织选修该门课程的38名护生填写评判性思维态度倾向量表一中文版（CTDI—CV）,进行前后对照分析。结果教学后护理本科生的评判性思维能力总分为（318．05±24．87）分,高于教学前的（308．49±22．96）分,组间比较差异具无统计学意义（t=-1．839,P=0．074）。7个评判性思维维度中,寻找真相、系统化能力以及批判性思维的自信心得分增加,差异有统计学意义（t分别为-2．727,～2．622,-2．417;P〈0．05）。结论在护理本科生中推行临床推理与决策课程有助于提高学生的评判性思维能力。     

Diagnostic reasoning processes using patient simulation in different learning environments

The purpose of the study was to explore the diagnostic reasoning process among nursing students with different learning environments. A case-study design was adopted. Twenty subjects were randomly drawn from the last year of a pre-registration nursing programme in two institutions, 10 from a university and 10 from a nursing school. They were asked to complete the Bigg's Study Process Questionnaire and identify the differential diagnosis for the three simulated scenarios. The results showed no significant difference in study approaches between the two groups. Two subjects from the university made an incorrect differential diagnosis, as did one from the nursing school. Subjects from the university showed a mix of horizontal (66.6%) and vertical reasoning patterns (33.4%), while those from the nursing school used horizontal (100%) reasoning patterns. The results indicated that all subjects from the nursing school adopted backward chaining strategies (horizontal) for decision-making, i.e. hypothesis-driven. About a third of the subjects from the university adopted forward chaining strategies (vertical), i.e. data-driven. The study did not show any particular advantages from either of the two learning environments in terms of study approach. However, it highlighted the variations in decision strategies among students in the university setting.