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What is clinical decision making?

Internal and external variables such as the nurse's personal experience, knowledge, creative thinking ability, education, self concept, as meshed with the nurses' working environment, and situational stressors all can work to enhance or inhibit effective clinical decision making for a nurse. (O'Reilly, 1993) Clinical decision-making is defined as the ability to sift and synthesize information, make decisions, and appropriately implement those decisions within a clinical setting. Practicing nurses must effectively identify and solve the problems of patient diagnosis and treatment by using such a model. One means of doing so, paradoxically, is to identify the barriers to decision making so they can be overcome by the use of more effective decision-making tools. The nursing process itself involves the need for quality decision-making at every sage of assessment, diagnosis, planning, implementation, and evaluation of patient needs and demands. ("Nursing process,' 2006, Wikipedia) Thus, both processes are interrelated; as to be a good nurse a nurse must be a good decision-maker.

Describe Patricia Benner's stages of clinical judgment

According to the nursing theorist Patricia Benner (2004), the novice nurse has little experience, and must essentially proceed by rote to function as an effective nurse in the clinical setting, such as a first year nursing student who needs constant guidance from other hospital staff members. A recent graduate nurse or advanced beginner possesses some minimal clinical practice and can grasp attributes but not aspects of the clinical setting without constant assistance. In contrast, a competent nurse has a filtering device of experience to know what to ignore and what to assimilate in the clinical setting, based upon greater levels of experience than the advanced beginner nurse. A proficient nurse has made the leap beyond basic competence into a more holistic assessment of understanding of patient needs. Finally, the expert nurse no longer relies upon clearly articulated analytical rules of judgment regarding patient diagnosis and treatment at all, but can proceed to judgment on a more intuitive, but still rational level. The expert can deploy both creative thinking and rational thinking simultaneously and effectively in the clinical environment.

Discuss the ways in which the nursing process contributes to effective clinical decision-making

The nursing process of assessment, diagnosis, planning, implementation, and evaluation are dependant upon both the nurse's personal qualities as well as upon the setting of the assessment. (Quan, 2006) For example, during the assessment, increased knowledge on the part of the nurse practitioner leads to greater clinical accuracy in judgment. The more experienced nurse knows what to look for, based upon clinical knowledge and personal experience, and can use that observed and filtered knowledge in making a more competent diagnosis. A more competent diagnosis leads to a better-planned and implemented course of treatment, and a better assessment of how and if the treatment is working. (O'Reilly, 1993)

But treatment is not merely a checklist. Intuition is also said to be the hallmark of expert judgment, where intuitively on a subconscious level accumulated knowledge 'kicks in' in helping the nurse understand what, if anything, in the patient's state of health may be wrong. Creative thinking when assessing the patient's psychological and physical state, the ability to fuse emotion and reasoning in the mind of the seasoned nurse, can lead to a better mental selection of important data and a more effective diagnostic conclusion. (O'Reilly, 1993)

Also, self-concept, the empowered use with confidence of one's knowledge that comes with experience and the practice of years can increase the speed and efficacy of the planning of the treatment and its implementation and evaluation. However, it is important to remember that even in expert nurses, stresses such as less then optimal staffing or undercutting confidence through interpersonal staff conflicts can increase anxiety, and can threaten the ability to make an effective diagnosis. A lack of sleep, an overwhelming patient load, or staff condescension, especially in less confident novice nurses can all inhibit the use of one's personal assessment tools and thus disrupt the process of effective nursing in the clinical environment. (O'Reilly, 1993)

Provide examples of how planning for the provision of nursing care might differ at each stage of clinical judgment.

Nursing processes are thus always in a dialogue between the nurse's own personal competence (internal factors) and the external stressors of the environment. For example, take a highly contentious situation in the ER when a patient may come in, late at night, complaining of chest paints, agitated, and certain that he or she is suffering a heart attack. A novice nurse, in her process of assessment, diagnosis, planning, implementation, and evaluation might merely register the patient's emotional distress and immediately call for a doctor specializing in cardiac care, accepting the patient's own assessment and diagnosis as if it were valid. The nurse's lack of confidence and fear of the possible consequences of an untreated attack might drive her to seek immediate assistance to help in the planning and implementation of a plan to aid a heart attack victim. 

An advanced beginner nurse, less shaken by the emotion of patient, but proceeding by rote and by the knowledge given to her by professional mentors during her minimal previous clinical experience, might go down a checklist of evaluating the patient's pain, such as where is the pain localized, when the pain began, then asking the patient to describe and rate the pain, and based upon such an assessment, diagnosis the cause and severity of the case before seeing assistance in planning and implementing a treatment plan either for a cardiac condition or for heartburn. 

A competent nurse might, by sight, be able to evaluate if the patient's pain was nausea, as in heartburn, or if the clutching pain seemed to affect the patient's breathing or numb the patient's limbs as might be typical of an oncoming heart attack. A proficient nurse might be able to assess the immediate severity of the condition-even if the pain was heart-related, she or he might be able to offer a finer-tuned diagnosis and plan. For example, if the patent's angina was life threatening and required immediate care, or if the pain could be taken care of through a nitroglycerin tablet, for example, and patient rest, before a doctor was called for to evaluate the patient's physical health and provide advice regarding future heart care. 

Finally, an expert nurse might be able to assess, having seen many heart attacks and heart burn patients go through the ER, might know what was needed almost by sight. The expert nurse would likely be also better skilled in comforting the patient and thus lessening the trauma of the patient's trip to the ER and the final diagnosis. 

However, it is important to remember at all junctures of this decision-making process, that a crowded or understaffed ER can interfere with such holistic judgment, although the more experienced a nurse is in high-pressure situations, the better able he or she will be to filter out such unnecessary environmental static such as an argument with a colleague, the lateness of the hour, or an uncooperative patient. Experience is not a panacea, but combined with an effective use of clinical decision making and the nursing process, experience combined with the simultaneous and effective deployment of rational and intuitive judgment is the best personal asset a nurse offer to a patient.

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