Miniratu Deen-Savage

Head Nurse, Labour & Delivery

Historical Background

The Nursing discipline’s pursuit of professional recognition relies heavily upon the ability of practicing Nurses to correctly define and solve problems which are uniquely Nursing in origin (Jones 1988).

One way of doing this is to identify the factors which can act as barriers to effective problem solving.

Factors that affect midwives/ nurses decision making in practice

Some of the barriers that may enhance or impede effective clinical decision making in midwifery/nursing are discussed:Clinical Reasoning/Decision making- Why you should care

Intuitive knowledge

Education/Training

Staffing

Communication/Attitude

Resources

CLINICAL REASONING / DECISION

MAKINGClinical decision making can also be referred to as clinical

reasoning, clinical judgement, clinical inference & diagnostic reasoning ( Hardy et al 2008). For the purpose of this lecture, clinical reasoning/decision is used.

Clinical reasoning is a multidimensional concept that involves a wide range of cognitive activities that underline judgement, decision, and action by health professionals (Munroe H, 1996).

Clinical reasoning can be thought of as an internal dialogue that occurs before, during and after patient care (Jenson et al 1999).

Numerous factors influence the clinical reasoning/decision making process. These include: Individual Variables and Contextual Variables

Factors affecting clinical Reasoning/Decision Making

1. Individual variables: Experience and knowledge (Benner 1984,

Benner& Tanner 1987). Example- novice to expert, Benner 1984

Creative thinking (Pardue 1987) Self concept(Joseph 1985, Seymour 2003)These factors may enhance or impede clinical

reasoning & decision making in practice

Experience and KnowledgeAre two major factors affecting decision making. Decision making in discipline such as nursing involves more

than the application of theoretical knowledge

A deep understanding of the situation is required if treatment approaches are to address the experience of illness as it relates to a particular patient.

Care-giving requires the nurse to have a detailed understanding of the patient's condition, response, needs, and wishes (Grinspun 2003).

For example recognising a deviation from the normal to the abnormal during labour comes with both having the theoretical knowledge of normal & abnormal labour & also the experience of recognising any deviation & to take appropriate action to prevent adverse effects on the patient.

Critical and creative thinking are prerequisites to narrowing the disjuncture between research and practice (Seymour et al 2003)

It is suggested that educators and practitioners explore structured ways of meeting together to appraise literature as a possible means of making use of their thinking and knowledge in clinical practice.

That is bridging the gap between theory & practice

CREATIVE THINKING

Self ConceptAn individual's self-concept is conceived as that individual's summary formulation of his or her status. (Ossorio, 1978; 1998).

Self-concept can also refer to the general idea we have of ourselves (Huitt, W (2009).

Clinical Reasoning /Decision Making

WHY SHOULD YOU CARE?One of the most important decisions

facing physicians & nurses /midwives is what is the diagnosis, or at least what life threatening event do I need to rule out.

In order to do this properly, the health professional must use clinical reasoning which involves both medical inquiry and clinical decision making.

Clinical Reasoning /Decision Making-

WHY SHOULD YOU CARE?

Medical enquiry refers to the skills or techniques used to gather data such as the medical/obstetric history & physical and labs.

Clinical reasoning/decision making uses this information to make decisions concerning the diagnosis or treatment.

Clinical Reasoning /Decision Making-WHY SHOULD YOU CARE? because:

Clinical reasoning is the thought process that guides our practice.

Clinical reasoning is the backbone of our profession, without it we have random activities that are chosen for no set purpose (Mendez and Jodene 1999).

Neistadt (1996) found that making clinicians more aware of the complexities of their work and thinking not only validated their profession, but also increased their job satisfaction

clinical reasoning gives words to what goes on in our minds.

Clinical Reasoning /Decision Making WHY SHOULD YOU CARE?

We need to be able to explain the reasons behind our treatment choices to each other, other professional & most importantly our patients.

Clinical reasoning is a great way to start framing our thought processes in words and explaining the rationale behind our decisions (Neistadt, 1996)

Without clinical reasoning nurses/midwives and other members of the multidisciplinary team will see Nursing in a fragmented way (Mendez and Jodene 2003)

Clinical Reasoning /Decision Making-

WHY SHOULD YOU CARE?Therefore, clinical reasoning links our theory to our

practice: it uses past experience to guide our decisions: it incorporates the limitations of the environment in which we are practicing and it connects our personal values and style to our therapeutic intervention choices.

It is the thread that weaves together the choices, treatment & daily work of our practice.

Extended role-Nurses/midwives are now carrying out some procedures that junior physicians usually do. e.g. consultant midwifery performing instrumental delivery/specialist positions such as practice/lecturer in practice midwifery

Intuition Intuition is the apparent ability to acquire

knowledge without reason (Chopra et al 2005). It provides us with beliefs that we cannot

necessarily justify. It is an important tool in nursing and part of

nurses' synergistic response to patients and events (Chopra et al 2005)

(Synergistic- working together for a common end)

Intuition Intuition is a rapid, unconscious process, it is

context-sensitive, it comes with practice It involves selective attention to small details It cannot be reduced to cause-and-effect logic (B

happened because of A) It addresses, integrates, and makes sense of,

multiple and complex pieces of data of the care given.

Benner (1994,1998) used the term 'intuition' for the fifth stage of practice (novice/adv.learner/comp/expert)

How reliable is our intuition?How much should we depend on gut-level instinct

rather than rational analysis in clinical reasoning/decision making?

Nurses with greater expertise and experience are more likely to use intuition to make decisions or evaluate patients (Benner 1984)

However, Paley (1998) has criticized Benner's model for its lack of clarity about the nature of an expert practitioner.

This criticism is further justified by Benner's inadequate explanation of “expert”.

How does intuition affect clinical reasoning/decision making

Some evidence, validates the use of intuitive decision-making as a construct in explaining expert clinical decision-making practices.

The validity of intuitive practice should be recognized. It is essential to recognize the conditions that support practice development, and in the pre-novice stage (during their university course) factors such as reflection, research (in its broadest sense) and clinical curiosity should be fostered.

How does intuition affect clinical reasoning/decision making

Advocates of a humanistic, intuitive approach to clinical care - impossible to integrate the 'science' of evidence-based medicine with the intuitive 'art' of clinical judgement, and that whilst the rules of evidence-based medicine can be taught, clinical intuition is an unfathomable phenomenon that simply "happens“.

Communication/Attitude In using a proactive approach to communication,

healthcare professionals must become increasingly sensitized to the stresses associated with illness and hospitalization and must learn the importance of good listening and effective communication to ensure high quality patient care.

A study by Lester and Smith (1993) demonstrated that time-limited, negative communications by doctors/nurses is associated with increased litigious intentions among patients, even when outcomes were neither adverse nor negligent.

Communication/Attitude An integral part of the nurses’ role is patient

assessment on initial contact, following a physician referral or admission to an inpatient ward

At this stage of contact, nurses should attempt to reassure patients, convey a sense of warmth and put them at ease by using communication skills such as questioning, reflecting, listening, summarising, paraphrasing and so on.

This interaction also has the potential - if managed skilfully - to instil confidence and a sense of safety in the service offered

Communication/AttitudeCommunication is the most powerful tool in

clinical practice. Repeatedly, research has shown that good

communication skills result in better clinical outcomes, a greater need to follow clinical recommendations and reduced risk of clinical negligence and complaints(Wilson 1998,Cemach, 2005)

Communication/AttitudeBARRIERS TO EFFECTIVE

COMMUNICATIONNo matter how good the communication

system in an organisation is, unfortunately barriers can and do often occur.

Physical barriers  are often due to the nature of the environment.

Thus, for example, the natural barrier which exists if staff are located in different buildings or on different sites.

Communication/Attitude Attitudinal barriers come about as a result of problems with staff in an

organisation. These may be brought about, for example, by such

factors as Poor management, Lack of consultation with employees, Personality conflicts which can result in people

delaying or refusing to communicate, Personal attitudes of individual employees which may

be due to lack of motivation or dissatisfaction at work, brought about by insufficient training to enable them to carry out particular tasks, or

Resistance to change due to entrenched attitudes and ideas.

Communication/AttitudePoor or outdated equipment, particularly the failure of

management to introduce new technology, may also cause problems.

Staff shortages are another factor which frequently causes communication difficulties for an organisation.

Whilst distractions like background noise, poor lighting or an environment which is too hot or cold can all affect people's morale and concentration, which in turn can interfere with effective communication.

STAFFING/RESOURCESPatient safety has always been a primary

concern of nurses, particularly in hospitals and other institutions (RCN 2003)

Clinical risk management is now an important dimension of the clinical governance agenda

This means that decisions about staffing levels and skill mix must be integrated with a systematic approach to safety and continuous quality improve ment (RCN 2003)

SKILL MIXSkill mix has been defined as:The balance between trained and untrained staff,Qualified , unqualified and supervisory An optimum skill mix is achieved when the

desired standard of service is provided, at the minimum cost, which is consistent with efficient deployment of trained, qualified and supervisory personnel, and the maximisation of contributions from all staff members.

American Nurses Association, 1999

STAFFING/RESOURCES-SAFE STAFFING

Safe Staffing means that an appropriate number of staff, with a suitable mix of skill levels, is available at all

times to;

Ensure that patient care needs are met and that hazard-free working conditions are maintained

Skill /scope of practice Poor skill mix can lead to clinical errors, adverse patient & organisational

outcomes Safe staffing ratio may improve care & outcomes of patients

(American Federation of Teachers (1996)

STAFFING- PATIENT SAFETYWhy is patient safety important It focuses on a variety of care indicators such as: Adverse /sentinel events as a result of the

care/management provided e.g.; falls, medication errors, inappropriate treatment/surgery

(American Nurses Association 1999)

failure to recognise & failure to act appropriately & timely (CEMACH 2003) leading to adverse patient outcome

Education/Training/ResourcesClinical competencies provide the cognitive-

affective structure that guides clinical decision-making in nursing.

Clinical competencies help nurses to explain "what they know" and the justification for particular decisions that facilitate the promotion of the health of the individual, or groups .

However, clinical competencies alone will not facilitate quality clinical decisions.

Human and material resources are necessary to promote and facilitate quality clinical decision-making in nursing

Together, clinical competencies and resources are frameworks the nurse uses and relies on during clinical decision-making.

We need to invest in education and training for all staff . Staff are responsibility for their own professional development

We need to ensure staff have support in the clinical areas to foster their ability to formulate clinical reasoning/decisions about patients care/ management

We need to involve our patients in the education process of their disease and care management.

Clinical competencies and appropriate resources, such as human and material resources, enable the nurse to assess a particular situation on the one hand, recall and apply appropriate procedures and methods to make and implement clinical decisions on the other (Marshall, 1995).

TO SUMMARIZEClinical reasoningIntuitionCommunicationStaffingEducation/trainingResources