Having strong clinical decision-making skills is crucial for a successful nursing career. When nurses are empowered to make evidence-based healthcare decisions, it benefits patients and society in numerous ways. Improved patient outcomes, increased nurse satisfaction, and reduced overall risk are among the positive impacts of clinical decision making in nursing.
The purpose of this article is to assist healthcare practitioners in making clinical judgments and decisions when providing care to patients and their families, particularly in challenging situations. We will explore the concept of clinical decision making and discuss various theories associated with it.
Understanding Clinical Decision Making
Becoming a nurse requires extensive training and years of experience in delivering healthcare services. Nurses are often the first to notice when patients are in distress or their health is deteriorating rapidly. Therefore, it is crucial for nurses to possess critical thinking skills and make informed decisions regarding patient care.
Clinical decision making involves analyzing a patient’s condition and making treatment decisions based on available evidence. It involves collaboration with multiple healthcare professionals to determine the most appropriate course of action. Patients and their loved ones are actively involved in the decision-making process as they possess valuable insights into their medical conditions and can advocate for themselves.
Effective clinical decision making requires critical thinking, teamwork, communication, collaboration, and familiarity with quality standards. Open lines of communication are maintained between nurses, colleagues, and patients, and all decisions are guided by evidence-based practices.
The Four Main Steps of Clinical Decision Making Process
The process of making clinical decisions in a hospital setting is complex, combining both art and science. While there is no universally perfect approach, reflecting on your decision-making strategy can help you make adjustments as needed to provide the best possible care for your patients. Follow these steps to ensure effective clinical judgments and decision making:
1. Assess the situation:
Evaluate the likelihood of a specific diagnosis based on the patient’s symptoms, medical history, and other relevant factors. For example, if a patient presents with a fever, productive cough, and loss of appetite, potential diagnoses could include pneumonia, bronchitis, or an upper respiratory infection.
2. Gather additional information through patient examination:
Conduct a detailed patient history, assess vital signs, and perform a physical examination to confirm or rule out potential diagnoses.
3. Adjust probabilities based on acquired information:
This step involves refining the pre-test probability of any diagnostic tests that may be necessary. Collect and interpret additional data from diagnostic tests to further refine the differential diagnosis list.
4. Consider intervention based on treatment threshold:
Evaluate whether the benefits of a particular intervention outweigh the associated risks. Adjusting the treatment threshold involves considering additional data, obtaining more information, or exercising patience if there is insufficient evidence to make a definitive decision.
Clinical Decision Making Models
Clinical decision making models can be tailored to suit specific populations, personnel, and evolving circumstances within healthcare teams. As best practices and materials become available, these concepts, tools, and templates can be adapted and implemented. Two notable models are the Warwick model and the Moral Balance model.
1. Warwick model:
Developed by researchers at the University of Warwick, this model focuses on analyzing current procedures for determining the need to escalate a patient’s treatment or admission to the intensive care unit. The model incorporates the principle of reasonable accountability and emphasizes information gathering to guide analysis and treatment planning. It also emphasizes patient application, communication, and ongoing review. The model has been found to facilitate patient and family involvement, decision-making centered around the patient, documented justification for decisions, and transparency in the process.
2. Moral Balance model:
This model provides a streamlined approach for applying the four tenets of medical ethics at the point of care. Originally developed for intensive care medicine (ICM) students, it has broader applicability. Over the years, it has been introduced to over 300 ICM trainees and is recommended in the guidelines for end-of-life care by the Faculty of Intensive Care Medicine (FICM).
Theories of Clinical Decision Making
Clinical decision making involves input from various experts, considering multiple perspectives in a patient’s care plan. Several theories are commonly applied in clinical decision making in nursing:
1. Decision-making related to progressive medication:
In the National Health Service (NHS), patients, families, and doctors face daily challenges when making difficult decisions regarding clinical care. Good medical practice, as defined by the General Medical Council (GMC), emphasizes decision making in collaboration with patients and their families. The Mental Capacity Act mandates these discussions when determining a patient’s best interests, especially if they lack the mental capacity to make decisions for themselves.
During the COVID-19 pandemic, it is advisable to follow a systematic approach to ensure equitable access to critical care for all patients. Ethically and emotionally challenging decisions often revolve around whether to escalate, restrict, or withdraw life-sustaining treatments. Clinical decision theory emphasizes that all care decisions should align with the patient’s values and preferences, or in the absence of such agreements, with the patient’s best interests. Decision-making is not limited to choosing between life-prolonging treatment and comfort care; multiple options should be considered after thorough exploration of the issues at hand.
2. Involving other parties:
Assuming that the patient has the mental capacity to participate in decision making, clinicians should engage with family members and friends whenever possible to make decisions in the patient’s best interests. A healthcare power of attorney, a legal document granting someone the authority to make healthcare decisions on behalf of another person, can also be utilized.
For major best-interest decisions (e.g., intensive care unit admission or discontinuation of life-sustaining treatments), it is recommended that at least two senior practitioners collaborate. However, in high-pressure clinical settings, such as outside of an intensive care unit, this may not always be feasible. Healthcare organizations should consider implementing mechanisms to make collaborative decision making a reality.
3. Fostering effective patient-caregiver interactions:
Clinician-patient interactions occur in various settings, including general care, telehealth, and inpatient treatment. Illness and isolation can leave patients without the support of friends and family members to provide emotional support and advocate for their wishes when they lack mental capacity. Balancing the need for telephone or electronic contact with patients’ privacy concerns requires internal guidelines within organizations.
Importance of Clinical Decision Making in Nursing
Implementing effective clinical decision making has numerous benefits for hospitals, patients, and nurses. The process is rooted in scientific methodology and evidence-based practices. By leveraging their extensive patient care experience, nurses can make informed decisions that enhance patient outcomes. Some key benefits include:
1. Improved patient outcomes:
Clinical decision making can enhance patient outcomes, as demonstrated in the examples mentioned earlier. Nurses play a critical role in assessing patients, engaging in teamwork and communication, and determining healthcare needs. By utilizing evidence and research findings, nurses can make informed decisions. Clinical decision making in nursing has been shown to improve care quality and patient experience.
2. Benefits for hospitals and healthcare services:
As the healthcare industry shifts from fee-for-service to value-based reimbursement, patient outcome measures are becoming increasingly significant. Hospitals and healthcare providers will be rewarded based on the quality of care rather than the quantity of procedures performed. Metrics such as hospital-acquired infections, falls, and readmission rates are used to evaluate hospitals. Empowering nurses to make independent, evidence-based decisions can positively impact the financial bottom line of healthcare institutions.
3. Enhanced job satisfaction:
The nursing profession already faces a severe shortage of nurses, which has been further exacerbated by the COVID-19 pandemic. Nurses experience increased job satisfaction when given autonomy in their practice. This can lead to reduced burnout and increased retention rates. Employers
that value the clinical expertise of their nurses are more likely to retain them, which is crucial in addressing the current nursing crisis and alleviating strain on the healthcare system.
Examples of Clinical Decision Making in Nursing
Clinical decision making in nursing can be observed in various real-life scenarios. Here are a few examples:
1. Fighting COVID-19:
During the pandemic, nurses used their expertise in patient care and data analysis to quickly identify patients who required immediate medical attention. By relying on their intuition and experience rather than predetermined norms, nurses were able to respond effectively to the rapidly changing information related to COVID-19.
2. Catheter-related infections:
At Boston Medical Center, a task force composed of hospital administrators, nurse educators, urologists, and other stakeholders analyzed data and implemented awareness campaigns to reduce hospital-acquired infections caused by Foley catheters. As a result, infections related to catheter use decreased by 83% between 2013 and 2017.
3. Patient falls:
A study published in the Journal of Medical Internet Research explored the use of data analytics tools to reduce patient falls. Nurses who used the data analytics application became more aware of the risk factors associated with patient falls, resulting in fewer incidents. Evidence-based medicine studies like these guide treatment decisions in clinical practice.
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