clinical decision making nursing essay

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Effective decision-making: applying the theories to nursing practice.

Samantha Watkins

Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley

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Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Decision-making is a fundamental concept of nursing practice that conforms to a systematic trajectory involving the assessment, interpretation, evaluation and management of patient-specific situations ( Dougherty et al, 2015 ). Shared decision-making is vital to consider in terms of patient autonomy and professional duty of care as set out in the Nursing and Midwifery Council (NMC) (2018) Code, which underpins nursing practice. Consequently, the following assessment and decision-making processes were conducted within the remits of practice as a student nurse. Decision-making is a dynamic process in nursing practice, and the theories emphasise the importance of adaptability and reflective practice to identify factors that impact on patient care ( Pearson, 2013 ). Three decision-making theories will be explored within the context of a decision made in practice. To abide by confidentiality requirements, the pseudonym ‘Linda’ will be used throughout. Patient consent was obtained prior to writing.

Linda was a 71-year-old who had been admitted to the cardiac ward following an episode of unstable angina. She was on continuous cardiac monitoring as recommended by the National Institute for Health and Care Excellence (NICE) (2016) guideline for chest pain of recent onset. During her stay on the ward, the tracing on the cardiac monitor indicated possible ST-segment elevation ( Thygesen et al, 2018 ). It was initially hypothesised that she might be experiencing an ACS ( Box 1 ) and could be haemodynamically unstable.

Box 1. Acute coronary syndrome

• Acute coronary syndrome is an umbrella term that includes three cardiac conditions that result from a reduction of oxygenated blood through the coronary arteries, causing myocardial ischaemia. An ST-segment elevation myocardial infarction (STEMI) connotes the complete occlusion of one or more of the coronary arteries, which is demonstrated by patient symptoms and ST-segment elevation seen on an electrocardiogram (ECG)
• A non-ST-segment elevation myocardial infarction (NSTEMI) results from a partial occlusion of a coronary artery. Patient symptoms often present alongside dynamic ST-segment depression, T-wave inversion or a normal ECG
• Unstable angina is a result of a transient occlusion of the coronary arteries causing symptoms at rest or on minimal exertion, which may be eased/resolved with rest with or without glyceryl trinitrate (GTN)
• Signs and symptoms of ischaemia experienced by patient include: chest pain with or without radiation to jaw, neck, back, shoulders or arms, which is described as squeezing or crushing. Associated symptoms of lethargy, syncope, pre-syncopal episodes, diaphoresis, dyspnoea, nausea or vomiting, anxiety or a feeling of impending doom often also prevail

Source: Deen, 2018

The possibility that Linda was experiencing ST-segment elevation myocardial infarction (STEMI) meant that she needed rapid assessment of her condition. Stephens (2019) recommended the use of the ABCDE assessment as a timely and effective tool to identify physiological deterioration in patients with chest pain. The student nurse's ABCDE assessment of Linda is shown in Box 2 .

Box 2. ABCDE assessment * of ‘Linda’

• Airway: patent, no audible sounds of obstruction; however, unable to speak in full sentences due to dyspnoea
• Breathing: dyspnoeic, respiratory rate of 27, saturations of 85% on room air—with guidance from the senior charge nurse, 80% oxygen via non-rebreathe mask was administered ( O'Driscoll et al, 2017 )
• Circulation: tachycardia of 112 beats per minute, hypotensive at 92/50 mmHg, oliguric, diaphoretic, and with cool peripherals and a thready radial pulse
• Disability: She was alert on the AVPU scale, but anxious and feeling lethargic. Blood glucose was 5.7 mmol/litre
• Exposure: no erythema or wounds noted. She stated she had central chest pain, which was radiating to her jaw and back, described as ‘pressure’, and rated as a seven out of ten

* in line with Resuscitation Council (2015)

NICE (2016) recommends that the first investigation for patients with chest pain is to conduct an ECG as a rapid and non-invasive assessment for a cardiac cause of the pain. This was carried out and 2 mm ST-segment elevation in the precordial leads V1-V3 was noted, indicating a possible anterior STEMI ( Amsterdam et al, 2014 ). The student nurse had had basic ECG interpretation training as part of the nursing degree undertaken, but had also received informal teaching from registered nursing staff in cardiology. The ECG findings were confirmed by the senior charge nurse after they were alerted to Linda's condition, symptoms, and National Early Warning Score 2 (NEWS 2) ( Royal College of Physicians, 2017 ). The senior charge nurse escalated her care to the cardiology team. A diagnosis of STEMI was made by the cardiology team using the ECG findings and her physiological signs of deterioration from their assessment, within the context of her initial presentation to hospital for unstable angina. This diagnosis, coupled with the deterioration in her condition, meant that she required primary percutaneous coronary intervention (PCI). The NICE (2014) quality standard for acute coronary syndromes and the clinical guideline on STEMI ( NICE, 2013a ) recommend that primary PCI is initiated within 120 minutes to reperfuse the myocardium and prevent further myocardial cellular necrosis. This improves long-term patient outcomes ( Thygesen et al, 2018 ).

Decision-making theories

The recognition of an evolving STEMI on the cardiac monitor corresponds with the model of hypothetico-deductive reasoning ( Pearson, 2013 ) within the descriptive and normative theories ( Box 3 ). Thompson and Dowding (2009) highlighted that this model recognises that decision-making comprises four stages, beginning with cue acquisition. The specific pre-counter cues can be identified as the recognition of the abnormal tracing on the cardiac monitor ( Pearson, 2013 ), suggestive of ST-segment elevation, that indicated Linda might be experiencing haemodynamic deterioration with a cardiac cause. Subsequently, the decision to assess Linda formed the hypothesis generation phase of the decision and the recognition of the clinical signs as indicating STEMI ( Nickerson, 1998 ; Johansen and O'Brien, 2016 ). This hypothesis focused the assessment to identify and examine pertinent factors that supported this conjecture ( Pearson, 2013 ). However, the student nurse required more data to formulate a robust hypothesis thereby initiating the cue interpretation phase by conducting an ABCDE systematic assessment, including ECG. Lindsey (2013) argued that during cue interpretation, the health professional uses prescriptive guidelines to direct the assessment process and provide a rationale.

Box 3. Decision-making theories considered

• Descriptive theory: is concerned with each individuals’ moral beliefs regarding a particular decision
• Normative theory: connotes what decisions individuals should make logically
• Prescriptive theory: encompasses the policies that govern the remits of a decision within the evidence base that informs practice

Source: Pearson, 2013

Arguably, however, clinical knowledge of the pathophysiology of ACS is fundamental to effective cue interpretation, not simply the individual's knowledge of the NICE guidance ( NICE, 2013a ; 2013b ; 2014 ; 2016 ). The student nurse's existing knowledge of the symptoms of ACS supported the cue interpretation with assessing Linda's condition and possible diagnosis of ACS. This knowledge enriched the student nurse's understanding of the guidance, which could then effectively be applied as the central aspect of cue interpretation ( Deen, 2018 ).

Elstein and Schwartz (2002) conceded that the prescriptive theory knowledge synthesised for the decision must be accurate and evidence-based for hypothetico-deductive reasoning to be effective. Courtney and McCutcheon (2009) argued that reliance solely on clinical guidelines can limit decision-making and result in erroneous outcomes and should consequently be used in collaboration with the evidence base. By combining normative theory with prescriptive guidance, clinical decisions can be enriched and validated. Stevens (2013) highlighted that it is vital that the guidance used in corroboration with decision-making models is valid and reliable and therefore prescriptive theory must be critically evaluated against the evidence-base. The guidance published by NICE (2013a) is supported by the American College of Cardiology ( O'Gara et al, 2013 ), European Resuscitation Council ( Nikolaou et al, 2015 ), European Society of Cardiology ( Steg et al, 2012 ) and Cardiac Society of Australia and New Zealand ( Chew et al, 2016 ). Accordingly, these guidelines highlight the clinical signs of STEMI and the diagnostic investigations pertinent to this condition. Within the remits of practice as a student nurse, this evidence supported the decision to escalate Linda's condition.

Antithetically, during cue interpretation and the hypothesis generation phases, Pearson (2013) emphasised the importance of considering multiple hypotheses extrapolated from the clinical data, resulting in the selection of the most appropriate hypothesis when more data are obtained. Despite this, during the interpretation of the cues for the hypothesis, the student nurse failed to consider differential diagnoses, such as pneumothorax or pulmonary embolism, which have similar presentations to STEMI ( Deen, 2018 ). Consequently, this hypothesis generation had an element of uncertainty ( Bjørk and Hamilton, 2011 ), which could have impeded Linda's care by erroneously considering only one potential diagnosis and therefore focusing the assessment on that diagnosis. Student nurses can be considered ‘novice’ health professionals, demonstrating limitations in knowledge regarding differential diagnoses and therefore in potential hypotheses. Pearson (2013) argued that this is because student nurses lack the requisite experience to cluster information as effectively as an ‘expert’ health professional. Consequently, the presentation of one hypothesis is permissible within the remits of practice as a student nurse.

Assessment tools such as ABCDE ( Resuscitation Council UK, 2015 ) ensure that all factors indicative of deterioration are recognised. Consequently, by using a systematic assessment, any potential erroneous hypothesis can be precluded. Therefore, as Carayon and Wood (2010) state, the assessment tool was a barrier to active failure to recognise alternative diagnoses thus circumventing any serious consequences, highlighting the importance of comprehensive assessment to avoid error and safeguard the ethical principle of non-maleficence ( Beauchamp and Childress, 2013 ) fundamental to nursing. Antithetically, Benner et al (2008) argued that even the novice nurse should be able to consider multiple hypotheses within a situation, although they may not be able to reflect on these decisions within the moment. However, as Keller (2009) noted, the hypothetico-deductive model is based on presuppositions recognised by the health professional, such as the evolving cardiac tracing and history of pain, indicating that STEMI was the higher probable cause ( Deen, 2018 ). Consequently, a limitation of hypothetico-deductive reasoning is sufficient experience to aid in generating hypotheses.

Thereafter, in the hypothesis generation phase, the decision-making process evolved to include elements of pattern recognition theory ( Croskerry, 2002 ). The clinical decision that focuses on a single hypothesis can be compared to the use of pattern recognition ( Pearson, 2013 ) where existing knowledge is used to establish the hypothesis. Pearson (2013) commented that hypothetico-deductive reasoning is based on the synthesising and analysing of information whereas the formulation of one hypothesis is suggestive of pattern recognition, where the nurse uses previous experience to evaluate the situation. Consequently, the student nurse's previous experience of assessing a patient in acute STEMI may have guided practice to recognise ST-segment elevation on the telemetry, and then subsequently to conduct an ECG, and to recognise the associated clinical signs of STEMI and to gather a history of the pain using NICE (2013b) guidance on unstable angina, in line with Linda's initial presentation. Croskerry (2002) identified that health professionals who rely on pattern recognition initially recognise visual cues that are then supplemented with more in-depth data, often using assessment tools such as NEWS (and now NEWS 2) and ABCDE. Arguably, the recognition of similarities in clinical presentation, past medical history, and cardiac monitoring tracing of Linda's case to the previous case and use of ABCDE and NEWS 2 to further assess her condition and extrapolate data, identifies that previous experience can facilitate decision-making outcomes.

Finally, in the last phase of the decision-making in the hypothetico-deductive model, the student nurse evaluated the hypothesis and by using the merits from the cues ( Banning, 2008 ) established that STEMI was the most probable cause of Linda's deterioration and could escalate her care appropriately using the prescriptive theory tools described above.

Arguably, by using previous experience to guide practice, an element of confirmation bias may have affected the selection of data ( Thompson and Dowding, 2009 ) and consequently the student may have neglected other important data ( Croskerry, 2003 ). For instance, student nurses are inexperienced with chest auscultation and consequently could not have ruled out differential respiratory diagnoses. Stanovich et al (2013) acknowledged that confirmation bias can be circumvented when evidence is assimilated with hypothesis generation. The consideration that Linda may have been at an increased risk of myocardial infarction due to her age, history of smoking and admission to hospital for unstable angina ( Piepoli et al, 2016 ), indicated that the cause of her deterioration would most likely be cardiac. Thus, an evidence-based approach could inform practice and consequently, any limitations as a ‘novice’ would be minimised through rationalisation and critical thinking. Indeed, Stanovich et al (2013) argued that rationalising and critical thinking are markedly more important than existing knowledge. This is because even an ‘expert’ in a specific field does not have completely comprehensive knowledge, and therefore relies on a critical thought process to make rational decisions.

Conclusively, health professionals must be able to rationalise their decisions ( Johansen and O'Brien, 2016 ) and justify these decisions within the context of each presentation as a central concept of nursing ( NMC, 2018 ).

Communication is vital to establishing consent to treatment where the patient is regarded as having capacity under the Mental Capacity Act 2005. This is particularly significant when conducting investigations and escalating care to ensure that the patient's wishes are respected, and that the patient is empowered with knowledge regarding their condition and care ( Coultier and Collins, 2011 ). Linda was informed that her care required escalation to the appropriate clinical team, and then subsequently recommended to have PCI intervention as the most effective treatment for STEMI ( NICE, 2013a ; 2014 ). Presenting a default decision and using choice architecture can be construed as methods of liberal paternalism used to avoid impeded decision-making from choice overload ( Rosenbaum, 2015 ) or irrational decision bias ( Marewski and Gigerenzer, 2012 ). To escalate Linda's care within the recommended timeframe ( NICE, 2013a ; 2014 ), it was important to use elements of liberal paternalism ( Beauchamp and Childress, 2013 ) while preserving Linda's autonomy of choice ( Kemmerer et al, 2017 ). Linda had a right to make a decision against medical advice as per Re B (Adult, refusal of medical treatment) [2002] and these choices were presented to her by the cardiology team. As a health professional, a duty of care was owed to the patient to escalate concerns regarding her condition under the Code ( NMC, 2018 ).

Conclusively, all three theories of decision-making pertained to this patient's effective care. Nurses must be accountable for their decisions and act within the remits of the NMC (2018) Code. Patient care must consequently be effective, evidence-based and patient-centred. Accountability requires the health professional to act within the remits of their role to ensure safe care is delivered to the patient. This is a fundamental aspect of patient-centric care and principal to effective decision making. Demonstrably, the use of descriptive and normative theories can be interchangeable, however, the use of prescriptive theory is pivotal to validate clinical decision-making. The decision-making process can be further facilitated by use of structured assessment tools to reduce margin of error and improve outcome. Collaborative decision making is pivotal to advancing patient autonomy and empowerment but certain decisions require elements of paternalism to improve the process and uphold the ethical principles of beneficence and non-maleficence. Nevertheless, health professionals have a duty of care to adhere to decisions made by patients established to have capacity to give informed consent, irrespective of the personal beliefs of the professional.

• This article is a reflection on a case scenario where decisions were made in the care of a patient admitted for cardiac monitoring
• Nursing decision making is complex and involves a multitude of processes based on experience, knowledge and skill.
• Understanding the importance of decision-making theory and how these theories apply to practice can be effective in reflecting on practice, and the application of theory to practice can inform patient care

CPD reflective questions

• Consider the three different theories of decision making outlined here—which theory do you deem the most important to your practice? How does this affect your practice?
• Consider how reflecting on your own decision making can improve practice
• What can you do to enrich your own knowledge regarding patients with chest pain?

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Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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• Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. [Nurse Educ Today. 2016] Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Lee J, Lee YJ, Bae J, Seo M. Nurse Educ Today. 2016 Nov; 46:75-80. Epub 2016 Aug 15.
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15.2 Evidence-Based Clinical Decisions

Learning objectives.

By the end of this section, you will be able to:

• Analyze the foundations for evidence-based decision-making
• Apply the Institute for Healthcare Improvement (IHI) bundles to evidence-based nursing practice

Most nurses do not spend their day-to-day lives engaging in evidence-based research (EBR). However, all nurses make evidence-based clinical decisions daily as part of the ordinary course of their work. An evidence-based decision-making (EBDM) involves using evidence-based practice (EBP) when making decisions about caring for individual patients (Belita et al., 2020). Examples of EBDM include preventing falls by encouraging a patient to call before getting up to use the bathroom, asking a physician to order a medication in a liquid rather than pill form to make it easier for a patient to swallow, and determining what kind of dressing to put on a new wound. EBDM draws on the nurse’s experience, intuition, understanding of EBP, and knowledge of the patient (Nibbelink & Brewer, 2018).

Foundations for Evidence-Based Decision-Making

EBP and EBDM look similar because they both rely on the EBP triad of scientific evidence, clinical experience, and patient values Figure 15.7 . However, EBDM must also include an understanding of the setting and environment in which the decision is made. The practical consequence of this understanding is that nurses always have a limited number of options to choose from (Nibbelink & Brewer, 2018). For example, even if the gold standard of care has excellent evidence to support it, aligns with a nurse’s clinical expertise, and meets a patient’s preferences, it still may be impossible to provide based on the agency’s policies, procedural concerns, or resource limitations. Thus, decisions must be made based on the EBP triad and the situational reality of what is possible within a given setting.

The EBP movement has decreased gaps between what nurses and other healthcare professionals do in practice and what they should do based on the best evidence. As a result, several tools are now available to bring the best EBPs to the bedside and make them easily accessible for clinicians and agencies. One commonly used tool is the ISBAR (sometimes abbreviated to SBAR) strategy for communicating information between healthcare team members. ISBAR stands for introduction, situation, background, assessment, and recommendation. It has been implemented effectively in many agencies throughout the United States as a way to communicate necessary patient information rapidly and succinctly among healthcare workers in a variety of situations (such as end-of-shift reporting and transferring patients between units or facilities). Figure 15.9 shows an example of an ISBAR communication between an emergency room nurse sending a patient to a unit and the nurse who is receiving the patient.

It can be confusing to apply the EBP triad in practice. Let’s further explore this process for each component of the triad.

Patient Preference

The importance of honoring patient preferences is a key tenet of both patient-centered care and shared decision-making. Patient-centered care (PCC) is the inclusion of patient preferences, values, and needs in healthcare activities. Nursing is always patient centered because our standard of practice encourages partnering and working collaboratively with our patients and considering their culture, beliefs, and values when making decisions (American Nurses Association, 2021). Thus, incorporating patient preferences and values into EBDM is a natural behavior for nurses and an expected standard of practice.

What does it mean to include patient preferences and values in decision-making? It may be as simple as asking patients what they want or need and hearing what they say and do not say (Nibbelink & Brewer, 2018). Alternatively, it may consist of learning about the expectations of a patient’s culture or ensuring the presence of a certified medical language translator when discussing their preferences or providing education. Some patients may have religious beliefs that influence their preference for one intervention. Others may have difficulty accessing outside resources, so decisions must include only resources the nurse can provide at the point of care. In short, incorporating patient preferences and values into EBDM requires assessing and understanding what matters to the patient (American Speech-Language Hearing Association, 2021).

Patient Conversations

How to identify patient preferences.

Scenario: Nurse enters the patient’s room shortly after the medical team has made their rounds. The patient is frowning and has balled his hands into fists.

Nurse: Mr. Hernandez, are you okay? You seem distressed.

Patient: Dr. Colling wants me to stay in the hospital for two more weeks for IV antibiotics. I don’t understand it. I’m feeling much better and can move around without pain. Why do I need to be here for that long?

Nurse: I know that staying here longer is disappointing. You have a bad case of cellulitis on your leg that has spread quite far. That takes a long time to heal.

Patient: My leg is starting to look better. Why can’t they switch me to an oral medication?

Nurse: In my experience, cellulitis is challenging to treat. IV antibiotics are stronger than oral ones because the medication goes directly into the bloodstream.

Patient: Oh, I didn’t realize that. But I really can’t stay here that long. I need to get back to work, and I help my mom out a lot. She doesn’t drive anymore, you know. She lives alone, and I don’t like her being alone for so long.

Nurse: Oh, I do understand that won’t be easy. Did you discuss any of these concerns with Dr. Colling?

Patient: No, he just seemed too busy today.

Nurse: Well, why don’t I call him and ask him to stop by again later? We can explain your situation and see if there are any other options.

Patient: Thank you. I would appreciate it. Can you help me talk to him? He makes me nervous.

Nurse: Of course I will.

Scenario follow-up: Dr. Colling came and spoke with Mr. Hernandez. When he realized the issue, he offered an additional treatment option, going home with a central line and having home health come daily to give the IV medication. While he was unwilling to have Mr. Hernandez return to his construction job due to the danger posed by having a central line in place, he agreed that Mr. Hernandez could provide his usual care for his mother.

The process of shared decision-making (SDM) empowers patients to actively make decisions and state their needs and limitations in conjunction with healthcare providers rather than passively receive care (Skelly et al., 2020). SDM should involve clear, comprehensible education and encouragement of patients and their families to be open and accurate about their abilities and skills in self-management (Nibbelink & Brewer, 2018). For example, sending a patient home with the expectation that they will give themselves shots mandates that the nurse supply thorough education about the process and evaluate the patient’s ability to perform the task satisfactorily. Failure to do so sets up the patient for a poor healthcare outcome.

The Agency for Healthcare Research and Quality (AHRQ) has developed a SHARE decision-making model to guide SDM. Many of the components are similar to those of other decision-making models; however, the SHARE model emphasizes the inclusion of the patient in the process (AHRQ, 2023a; Skelly et al., 2020). As Figure 15.10 shows, the SHARE model is a five-step process.

Link to Learning

The AHRQ offers extensive resources for using the SHARE model, including a video showing the SHARE Approach in action.

Best Evidence

One of the pitfalls nurses can fall into when seeking best evidence is an unconscious bias toward information that aligns with their clinical experience, regardless of the evidence for it (Nibbelink & Brewer, 2018). Locating high-quality evidence can be difficult and time consuming, but systematic and metareviews are excellent starting points (Pubrica, 2020). As discussed previously, these reviews are generally at the top levels of evidence hierarchies. Because they are rigorous in their methodology and provide an in-depth exploration of a given topic, they can be both a high-quality and quick resource—a one-stop shop, so to speak, of the best evidence compiled from many other researchers.

Clinical Expertise

Several components make up clinical expertise . In addition to critical thinking, it includes a nurse’s ability to recognize patterns based on their experiences over time and to evaluate those patterns and extrapolate alternative solutions or appropriate interventions based on similar but not identical experiences (Nibbelink & Brewer, 2018). Nurses must recognize their limitations and know when to ask for assistance if they do not have the clinical experience to make an informed clinical decision (Nibbelink & Brewer, 2018). Asking for help is never a flaw. It is a sign of a strong, self-confident nurse who recognizes their limitations, and it protects their patients—and their nursing license.

It has been previously mentioned that a nurse’s ability to make decisions about most issues becomes almost second nature. Nurses make many daily clinical decisions that become part of the muscle memory of nursing—practically automatic, like driving a car or riding a bike. However, other situations require reflection to determine the best course of action. Even with the decisions that nurses make every day, they must guard against cognitive bias : an unintentional error in judgment due to incorrect thought processes ( The Joint Commission , 2016; Thirsk et al., 2022). Nurses must be aware of their own biases and seek to avoid them by engaging in regular self-reflection, particularly in situations that felt uncomfortable. Also, nurses must be willing to change, as nursing, medicine, and health care are constantly changing.

Clinical Decision Support and the Institute for Healthcare Improvement (IHI)

Due to the time-consuming nature of EBR and the structural difficulties associated with changing the practices of all healthcare workers within an agency, several clinical decision support tools are available to help nurses and other healthcare professionals access information about best practices more quickly (Pubrica, 2020). These tools combine evidence about specific best practice into an organized body of knowledge that is easily accessible. Many are electronic and integrated into electronic medical records or point-of-care informatics tools to enhance decision-making (HealthIT, 2018). Others are integrated into care pathways in different ways. The key advantage is that they provide a structured approach that is reproducible and repeatable across practice settings and patients.

The Institute for Healthcare Improvement (IHI), a not-for-profit organization, has been at the forefront of developing clinical decision support tools, particularly care bundles, to allow all patients in all environments to have the same high-quality level of care. For over three decades, the IHI has been working to improve the quality and safety of health care, both in the United States and globally (IHI, 2017).

Evidence-Based Practice Bundles

The evidence-based practice bundles are like nursing toolkits: small sets of evidence-based interventions that are used together to improve patient outcomes. They are rooted in EBR and have been shown to positively impact patient care (IHI, 2017). The IHI pioneered these bundles to address some common causes of hospital-based morbidity and mortality, such as ventilator-associated pneumonia (VAP), central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections, and surgical site infections. The use of bundles has expanded to other groups and even individual institutions. Bundles do not include all possible interventions for given situations or conditions; instead, they recommend a subset of highly effective interventions easily integrated into most hospitals (IHI, 2012a). All elements of a bundle should be used regardless of the specific situation: for example, a bundle for patients on ventilators in the intensive care unit should be used for all such patients, and all the components that make up the bundle should be used each time. Otherwise, the staff cannot count the bundle as complete. It is an “all-or-none measurement” (IHI, 2017).

Real RN Stories

New bundle implementation.

Nurse: Becky, RN Clinical setting: ICU Years in practice: 20 Facility location: Rural community hospital in Tennessee

We introduced the ICU Liberation bundle a few years ago. The ICU Liberation bundle has six parts—A to F—designed to improve our outcomes. My ICU is small, with many nurses entirely set in their ways, so it was an uphill struggle. We were asked to do things differently than we ever had. Some of us were intrigued because we had the opportunity as nurses to be part of a huge change in the treatment of our patients.

Six of us volunteered to be champions of the bundle for our unit, each taking one piece of it. The pieces of the bundle include A (assess, prevent, and manage pain), B (both spontaneous awakening trials and spontaneous breathing trials), C (choice of analgesia and sedation), D (prevent and manage delirium), E (early mobility and exercise), and F (family engagement and empowerment). I took piece F: family engagement and empowerment.

My part of the bundle encouraged a deeper relationship with the patient’s family. So often in the ICU, we had limited visitation and patient disruption to a minimum. By implementing the bundle, we encouraged families to be involved and present with patients in their rooms during rounds and many aspects of patient care. We could still ask family members to leave if it was clear they were bothering the patient or disrupting care, but the bundle reminded us to view families as our partners. Their presence usually helped the loved ones in our care. I learned all I could about my part of the bundle and taught it to the other nurses on the unit. While it brought many changes, implementing the ICU Liberation bundle helped our patients a lot. I am glad we did it.

Institute for Healthcare Improvement Ventilator Bundle

The IHI collaborated with thirteen Veterans Health Administration (VHA) ICUs to develop a bundle to decrease the risk of VAP in ICU settings. VAP is a healthcare-associated infection (HAI) —it is caused by medical treatments—that occurs as a new finding after a patient has been placed on a ventilator. Characteristics of VAP include abnormal chest x-ray findings, fever, leukocytosis (elevated white blood cell count), and thick tracheal secretions (Roch et al., 2017). Ventilator-associated pneumonia is the leading cause of death from HAIs. For patients who survive, it often increases the length of stay in the ICU, the length of time on the ventilator, and the overall costs of care (Roch et al., 2017). One incidence of VAP causes an estimated $40,000 in additional healthcare costs (IHI, 2012a).

The VAP bundle includes five elements of care (IHI, 2012a):

• Maintain the head of the bed elevated between 30° and 45°.
• Perform daily sedative interruption and assessment of readiness to extubate.
• Provide peptic ulcer prophylaxis (such as a proton pump inhibitor) to intubated patients.
• Provide deep vein thrombosis prophylaxis (such as sequential compression devices) on the lower legs.
• Provide daily oral care with chlorhexidine.

Using a daily checklist, maintained at the bedside, in the patient’s paper chart, or in their electronic health record ensures completion of these steps.

Even though VAP continues to be a problem in health care, the VAP bundle has been proven to reduce the incidence of VAP by 45 percent or more, resulting in improved patient outcomes and lower overall costs (Taplitz et al., 2017).

To learn more about VAP and the Ventilator bundle, explore this How-to Guide from IHI.

Institute for Healthcare Improvement Central Line–Associated Bloodstream Infection Bundle

A central line is a catheter with a tip that ends (terminates) in a major vessel such as the aorta, superior vena cava, or femoral vein. While their use has become increasingly common in the last few decades, they are also the source of many HAIs and a great contributor to hospital-associated mortality rates, In the early 2000s, CLABSIs caused over 30,000 deaths yearly in U.S. hospitals (IHI, 2012b). In response, IHI developed a bundle to reduce the number of CLABSIs in the hospital setting; the bundle includes hand hygiene, barrier precautions, optimal catheter site selection, and daily review of need. Hospitals that have implemented this bundle have seen up to a 65 percent decrease in their rates of CLABSIs (IHI, 2012b; Taplitz et al., 2017).

The AHRQ provides guidelines to prevent CLABSIs in their CLABSI bundle.

Surviving Sepsis Campaign and Bundles

Sepsis is a life-threatening inflammatory condition in which the body starts attacking its tissue and organs in response to an infection. Historically, the fatality rate of sepsis has been very high (van der Poll & Wiersinga, 2017). In the early 2000s, the IHI began to work on the Surviving Sepsis Campaign (SSC) in conjunction with the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) (SCCM, 2021). (SCCM and ESICM have subsequently taken over the SSC entirely.) Two sepsis-related bundles were initially developed from their work. However, as of the 2020 revision of the SSC guidelines, only one is being used: the Hour-1 bundle, for initial resuscitation for sepsis and septic shock (SCCM, 2021).

The Hour-1 bundle should be initiated immediately upon recognition of sepsis or septic shock (SCCM, 2021). The hour begins when providers recognize sepsis or septic shock (SCCM, 2021). While all components may not be completed within an hour, they should begin in the first hour. There has been some pushback concerning using this bundle, particularly from emergency room physicians concerned about unnecessary antibiotic treatment. However, the data strongly suggest that the sooner treatment begins, the better chances patients have of survival (SCCM, 2021).

Here are resources produced for the Surviving Sepsis Campaign (SSC):

• This video about the SSC illustrates how practitioners should use the Hour-1 bundle to help patients survive sepsis.
• This Hour-1 bundle infographic illustrates how to provide initial resuscitation for sepsis and septic shock.

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8.7: Critical Thinking, Clinical Judgment and the Nursing Profession

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Figure 8.12 Image by Moondance from Pixabay

Critical thinking involves the skillful analysis of information to make informed judgments. To engage in critical thinking, it's crucial to recognize and address personal biases and assumptions when encountering information, and to consistently apply standards for evaluating sources.

Critical Thinking in Nursing

Critical thinking is indispensable in nursing as it empowers caregivers to make decisions that optimize patient care. During education, educators and clinical instructors introduced critical-thinking examples in nursing, emphasizing tools for assessment, diagnosis, planning, implementation, and evaluation.

The cultivation of these skills continues into practice. Critical thinking is pivotal in delivering quality patient care and evolves throughout a nursing career, eventually becoming instinctive. Critical thinking in nursing involves identifying problems, determining optimal solutions, and executing effective resolutions through clinical decision-making. Reflection follows action to assess outcomes and consider alternative approaches where necessary.

Nurses play a crucial role as primary patient advocates, often the first to detect changes in status. Critical thinking enables unbiased interpretation of these changes based on evidence rather than conjecture. Anticipating patient needs through critical-thinking skills significantly influences care quality and outcomes.

Key elements of critical thinking in nursing include:

• Clinical judgment: Prioritizing patient needs, interpreting data, and anticipating complications.
• Patient safety: Recognizing deviations and taking preventive actions.
• Communication and collaboration: Fostering interdisciplinary teamwork.
• Problem-solving skills: Analyzing issues and implementing effective solutions.

Developing critical-thinking skills involves continuous learning, reflection on practice, openness to diverse perspectives, and structured problem-solving approaches like SWOT analysis. These skills mature with experience, enabling nurses to navigate complex healthcare scenarios effectively.

In conclusion, critical thinking is indispensable for safe, patient-centered care in nursing. Its ongoing development equips nurses to navigate challenges and uphold standards of excellence in an evolving healthcare landscape.

Clinical Judgement

Clinical judgment is the application of critical thinking to the clinical setting, which includes assessing, analyzing, and synthesizing complex patient data to develop and implement effective patient care plans. It involves interpreting patient information, drawing conclusions, and making decisions about patient care. Clinical judgment centers on interpreting and synthesizing patient data to make informed decisions about nursing interventions. It aims to make accurate and timely clinical decisions that positively impact patient outcomes. Nurses use clinical judgment to prioritize patient needs, anticipate complications, and adapt care plans based on patient responses. It integrates critical thinking skills into real-time clinical situations.

Clinical Decision Making

Clinical decision making refers to the process of choosing the best course of action among various alternatives to achieve a desired patient outcome. It involves selecting appropriate interventions based on a synthesis of clinical judgment, evidence-based practice, patient preferences, and available resources. Clinical decision making is focused on choosing the best action to meet specific patient needs and goals. It aims to provide safe, effective, and patient-centered care. Nurses engage in clinical decision making to determine treatment plans, prioritize care activities, and manage patient responses. It relies on critical thinking and clinical judgment to weigh options and select the most appropriate intervention.

In nursing practice, critical thinking, clinical judgment, and clinical decision-making are interrelated and essential:

• Critical thinking underpins both clinical judgment and decision-making by guiding the analysis and evaluation of information.
• Clinical judgment utilizes critical thinking to interpret patient data and make informed decisions about care priorities and interventions.
• Clinical decision-making integrates critical thinking and clinical judgment to choose effective interventions and strategies for achieving positive patient outcomes.

While critical thinking focuses on the process of reasoning and evaluating information, clinical judgment applies this thinking to clinical situations to interpret and prioritize patient needs. Clinical decision-making then uses critical thinking and clinical judgment to select the best course of action for optimal patient care. Together, these elements form the foundation of professional nursing practice, ensuring safe, effective, and patient-centered care delivery.

Differentiating Between Critical Thinking and Clinical Judgment in Caring for a Patient with Pneumonia

Instructions:

Review the patient scenario provided below. For each action taken by the nurse, determine whether it demonstrates critical thinking or clinical judgment. Write "CT" for critical thinking and "CJ" for clinical judgment next to each action. Explain why you classified each action as either critical thinking or clinical judgment.

Patient Scenario:

Mrs. Johnson, a 68-year-old woman, is admitted to the hospital with pneumonia. She presents with a fever of 101.8°F, productive cough, shortness of breath, and chest pain. Her medical history includes hypertension and type 2 diabetes.

1.Reviewing Mrs. Johnson’s Medical History and Lab Results: - Action: The nurse reviews Mrs. Johnson’s past medical history and her recent lab results to understand her overall health status. - Classification: ___ - Rationale: ___

2. Administering Prescribed Antibiotics: - Action: The nurse administers the prescribed antibiotics as ordered by the physician. - Classification: ___ - Rationale: ___

3. Monitoring Vital Signs: - Action: The nurse frequently monitors Mrs. Johnson’s vital signs, including temperature, blood pressure, respiratory rate, and oxygen saturation. - Classification: ___ - Rationale: ___

4. Evaluating the Effectiveness of Interventions: - Action: After administering antibiotics, the nurse assesses Mrs. Johnson’s response, including a reduction in fever and improvement in breathing. - Classification: ___ - Rationale: ___

5. Prioritizing Care: - Action: The nurse prioritizes interventions, ensuring that Mrs. Johnson receives oxygen therapy before other less urgent tasks. - Classification: ___ - Rationale: ___

6. Educating the Patient and Family: - Action: The nurse educates Mrs. Johnson and her family about pneumonia, its treatment, and how to manage symptoms at home. - Classification: ___ - Rationale: ___

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Effective decision-making: applying the theories to nursing practice

Affiliation.

• 1 Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley.
• PMID: 31972119
• DOI: 10.12968/bjon.2020.29.2.98

Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Keywords: Decision-making; Deteriorating patient; Hypothetico-deductive reasoning; Myocardial infarction; Patient assessment.

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