nur3052 ch7
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Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 7Patient Concerns, Choices, and Clinical Judgment in Evidence-
Based Practice
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Research and Patient Concerns Research evidence needs to be considered in light of the
patient’s concerns and preferences
Good clinical judgment is required, not only research evidence
Critical judgment requires two components
The validity of the evidence itself needs to be examined carefully
How the evidence is applied to clinical decision making must be examined
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Applying Evidence
The fit between evidence and clinical reality is rarely perfect
Every patient is different
Patients never exhibit only one problem
Nurses must judiciously consider relevant patient particularities and concerns in making clinical decisions
Ethics must also be considered
A “narrative understanding” of each patient is necessary
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Elements of Good Clinical Judgment
Knowing the patient
Reasoning through time
Appraising and judging research evidence
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Judgment and Self-Improving Practices The goal is for practice to be self-improving through
science and experiential clinical learning and correction
Dependent on experiential learning
Turning around preconceptions, expectations, sets, and routines or adding new insights to a particular practical situation
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Experiential Learning
Techne
Producing outcomes by a means-ends strategy, whereby the maker or producer governs the outcome by mastering the means of its production
Phronesis
Reasoning across time about changes in the particular patient’s condition and changes in the clinician’s understanding
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Risks of “Leveling”
Above-average performance is harmed when it is brought down to the clinical “standard,” even if the standard is evidence-based
Variation below the standard must be brought up to the standard, but variation above the standard should not be brought down
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Tell whether the following statement is true or false.
An evidence-based standard of practice represents the best possible outcomes that can expected in a particular clinical context.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
Rationale: A standard of practice may represent a baseline or average level of outcomes that is significantly below what is possible in some settings.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Expertise
Not every aspect of nursing practice is “formalizable”
The ethos (i.e., ethics or notions of good) of practice influences what is considered relevant science
Knowledge alone is not sufficient to ensure that nurses will form helpful relationships with patients or that nurses will notice and correctly identify early signs and symptoms
Formal measurements cannot replace perceptual skills
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
How Narratives Inform Clinical Understanding A narrative mode of description best captures clinical
judgment and experiential learning
A narrative can capture chronology, the concerns of the actor, and the ambiguities and puzzles as the story unfolds
Nurses’ clinical narratives can reveal their taken-for-granted clinical understandings
Narratives reveal clinical wisdom that other nurses can identify with, and appropriate for, their own clinical practices
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Grasp
Encompasses
Making qualitative distinctions
Engaging in detective work
Recognizing changing clinical relevance
Developing clinical knowledge about specific patient populations
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A nurse who provides care on the renal unit of a hospital has developed a skilled clinical grasp that allows her to provide highly competent care. The nurse’s clinical grasp has been primarily enhanced by:
a. Making qualitative distinctions
b. Engaging in detective work
c. Recognizing changing clinical relevance
d. Developing clinical knowledge about specific patient populations
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
d. Developing clinical knowledge about specific patient populations
Rationale: Refinement of clinical judgment is possible when nurses have the opportunity to work with specific patient populations. The nurse’s opportunity to provide care exclusively to patients with kidney disease will foster skilled clinical judgment in this area.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Forethought
Refers to at least four habits of thought and action
1. Future think is the practical logic of the practitioner situated in practice
2. Clinical forethought about specific patient populations
3. Anticipation of risks for particular patients
4. Seeing the unexpected
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Tell whether the following statement is true or false.
A consistently high level of clinical performance is necessary in order for a nurse to engage in experiential learning.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
Rationale: Focusing only on performance and on “being correct” and not on learning from breakdown or error dampens the curiosity and courage to learn experientially. Experiential learning requires engagement with complex clinical realities, which nurses will sometimes interpret or respond to incorrectly.
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