Nursing Process and Clinical Decision-Making
The nursing professional faces a myriad of decisions on a daily basis. The effectiveness of the decision-making process is crucial to ensuring positive outcomes in the clinical setting. If the nursing process is misunderstood or misapplied to the decision-making process by a failure to use critical thinking skills, the results can be catastrophic to the anticipated outcomes. Furthermore, an immaturity in critical thinking may influence decisions because of insufficient knowledge and experience. This paper will explore the role of critical thinking and the nursing process in making clinical decisions. Additionally, clinical maturity will be addressed as a key component of critical thinking and making-clinical decisions. Finally, these elements will be applied to a case scenario to demonstrate the progression of clinical decision-making by applying critical thinking skills through the nursing process.
When faced with a clinical problem, the nurse must go through an ordered series of steps to arrive at a sound clinical decision. While there are many versions of these steps, they can be summarized as follows. First, the problem must be identified and stated (e.g., the patient is bleeding from a laceration). Second, the goal must be stated. This many be multi-tiered (e.g., the goals would be to stop the bleeding and prevent shock). Third, the goals must be prioritized (e.g., stopping the bleeding must take precedence over preventing shock). Fourth, interventions must be developed to accomplish the goals (e.g., direct pressure, elevation, arterial pressure, and tourniquet). Fifth, the interventions must be evaluated and ranked according to recognized standards of care (e.g., direct pressure is first, then elevation, then arterial pressure, and as a last resort, a tourniquet). Sixth, the interventions must be evaluated as to any negative effect that may arise in the situation and appropriate steps determined to minimize any negative outcome (e.g., if the pressure bandage is too tight, peripheral blood flow may stop causing damage to tissue distal to the laceration; therefore, the bandage will only be tight enough to allow two fingers beneath the dressing and distal pulses or capillary refill will be monitored). Finally, the intervention must be evaluated for effectiveness. If the intervention fails to achieve the desired outcome, then the process returns to the fourth step and the selection process for the next intervention is initiated. (Kozier, Erb, Berman, & Burke, 2000, p.261)
Closely linked to this decision-making model is the ubiquitous nursing process. The nursing process includes data collection and documentation, analysis of the data to determine current condition and real or potential health related issues, development of an individualized plan of care to deal with these issues, implementation of that plan of care, and evaluation of the plan of care to determine its effectiveness and adjust the plan as needed. (Blais, Hayes, Kozier, & Erb, 2006)
Underlying both the clinical decision-making process and the nursing process is the skill of critical thinking. Critical thinking has been described as the ability to gather and process data in such a way as to arrive at the best conclusion using the filters of prior knowledge, experience and external resources to overcome personal emotions, biases, and assumptions. (This description was developed during NUR/300 class, University of Phoenix, S. Colorado, March 16, 2006) Note that critical thinking is described as a skill. As with all skills, there may be some innate ability to think critically; however, as with all skills, achieving a high degree of proficiency as a critical thinker requires study and practice. As stated above, data must be filtered through prior knowledge and experience which only come through time and hard work. Just as a baseball player may have some natural ability to play the game, he can only attain proficiency through learning the game and practice. The same principle is true in the nursing profession. As the nurse increases in experience and knowledge, the lenses of prior knowledge and experience begin to sharpen the focus on the data collected and the possible conclusions become at once narrower and broader: narrower in the sense that many considerations can be quickly eliminated; broader in the sense that new possibilities can now be considered that may not have been previously evident.
The journey to gain this knowledge and experience has been mapped out by Benner in her book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Benner applies the Dreyfus model of skills acquisition to delineate a series sequential phases through which a nurse must pass to attain the highest degree of nursing expertise. The stages are novice, advanced beginner, competent, proficient, and expert. As the nurse passes through each stage, the base knowledge and experience grows equipping the nurse with sharper honed instruments that can be applied to the critical thinking process. (Benner, 1984)
To illustrate how a nurse in each stage may think and act differently along this continuum, consider the following scenario. A 41 year-old African-American, slightly obese female presents to the Emergency Department complaining of sharp back pain under her left scapula. She also complains of some shortness of breath, but no other symptoms. Her vital signs are T-984, P-92, R-22, B/P-116/68. She appears to be mildly distressed and states that the pain has been constant for about one hour and is a 4/10. She also states that she has smoke a pack a day for 25 years and experiences mild dyspnea on exertion.
The novice would have no experience with this type of situation. There may be recognition that pain is not a normal condition for a healthy person and aside from perhaps simple positioning there would be no plan to alleviate the pain. Data collection in the novice stage may be limited to vital signs and questions governed by protocols. The novice may be able to recognize data that is outside of norms, but does not know how to develop a plan of care. The novice can; however, be directed to certain tasks under the guidance of a more experienced nurse.
The advanced beginner has seen this situation before and has observed the process of developing and implementing a plan of care. However, the advanced beginner is still quite rudimentary in the critical thinking process and does not see beyond the fact that this patient has back pain. The plan of care that is seen in this stage is governed by principles that have been observed in previous situations. The advanced beginner may think that perhaps ice to the back and some muscle relaxant medication would be needed to treat the pain and make the patient more comfortable.
The competent nurse has been working in the Emergency Department for two to three years and has seen this situation many times. The competent nurse broadens the scope of data collection to include the possibility of injury, exacerbating and alleviating activities, precipitating events, history of this pain. The long-range goal is no longer simply to assuage the pain but to prevent further occurrences. The plan of care is broadened to include the possibility of exercise and therapy, cessation of smoking, a weight loss program, these interventions will lead to a healthier back and a prevention of further back pain.
The proficient nurse takes a holistic approach and looks beyond the presenting symptoms. Data collection would be expanded to include further physical assessments such as lung sounds, measuring lung capacities, perhaps blood gases and chest x-rays. The proficient nurse recognizes that the type of pain and the medical history of the patient and realizes that these symptoms may be attributed to asthma or COPD. The plan of care would be directed at ensuring a stable airway and good oxygenation of this patient as well as patient teaching about the need to stop smoking and increase exercise to build up respiratory endurance.
The expert nurse has taken all the previous possibilities into consideration, is not bound by protocols and guidelines. The expert nurse instinctively senses that there may be more to this situation. Data collection is again expanded to include an EKG and cardiac enzymes because the expert nurse knows that even though this is not a classic cardiac presentation the interpretation of these symptoms as cardiac is certainly within the possible alternatives. The EKG and enzymes confirm the expert nurseâ€™s suspicions; the patient is having a heart attack.
Through increased knowledge and experience the critical thinking process is honed to razor sharp proficiency. As the basis for the nursing process and clinical decision-making, all nurses should be motivated to gain as much knowledge and experience as they can. Nurses should never become complacent or comfortable with their knowledge and level of experience the life of a patient may depend upon it.
Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley.
Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2006). Professional nursing practice : concepts and perspectives (5th ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall.
Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2000). Fundamentals of nursing (6th ed.). Upper Saddle River, N