1. Analyzing Complex Situations in an Emergency Department or a Department of Surgery Course prepared for training given at Coimbra Hospital in Portugal By Margot Phaneuf, R.N., Ph.D.

2. Which steps of the critical thinking process are required to analyze a complex situation?

3. A complex situation requires complex tought, combining ones intuition with thinking that is:. Inductive,. Systematic,. Dialectical and critical,. Hypothetical-deductive, and. Creative.

4. The care process remains the best strategy for dealing with a complex situation, since it calls on several aspects of critical thinking.

5. The nursing process The nursing process Data gathering Analysis Planning Intervention Evaluation Clinical judgment Nursing diagnosis

6. Hypotheses Inductive thinking Intuition Systematic thinking Hypothetical-deductive thinking Dialectical and critical thinking Clinical judgment Contributions to the formation of a clinical judgment Choices

7. Inductive thinking: for collecting data Intuition: for structuring a more targeted search for data Systematic thinking: for taking into account all aspects of a situation Hypothetic-deductive thinking: for identifying and analyzing hypotheses Types of thinking used in the overall nursing process Dialectical and critical thinking: for selecting the hypothesis or nursing diagnosis and evaluating the process Creative thinking: for planning interventions

8. What to avoid in a complex situation Simplistic reasoning that moves directly from cause to effect

9. Analysis of a complex situation Inductive thinking Systemic thinking Critical thinking: I look at both sides. I look for other factors. I reconsider what I know about the subject. I consider different aspects of the person. Deductive reasoning I confirm my intuitions. I validate the facts and the symptoms. I analyze and integrate my observations. (Dialectical thinking) Choices Hypotheses Inductive reasoning Clinical judgment Deductive thinking I observe signs and facts; I have certain perceptions. Intuitive thinking I ask myself questions.

10. Various dimensions of a complex situation

11. The complexity of a situation may result from a variety of factors. Factors: Physiological, Psychological (discouragement, depression, lack of motivation, suicidal thoughts), Social (family socio-economic status), Cultural (habits, hygiene), Religious (values, taboos), Linguistic (barriers to communication), Moral and ethical, Legal

12. Observations and data to be gathered Explanation of the CQAST model

14. Two main types of data collection Data related to independent role Data relate to cooperative role

15. ConceptExplanationExample CCause What causes the symptom to emerge? What makes it go away? How did the pain first appear? Are you using an analgesic? Q Quality, quantity Description of the symptom Frequency What does it feel like: a burning sensation, a pounding, etc.? How bad is it, on a scale of 1 to 10? A Area affected by irradiation Area where the symptom is located Other affected areas Tell me where it hurts, or point to it with a finger. Does it hurt anywhere else? S Related symptoms Other symptoms associated with the main symptom Do you have any other related problems? T Time, duration When it appears, duration How long have you had this problem? Is it constant or does it come and go? How often in a week or a month? CQAST Model Source: Mario Brûlé et Lyne Cloutier Lexamen clinique, Erpi 2001.

16. Situation 1 Physiological complexity

17. Situation 1: Serious abdominal injury Car accident, 50-year- old single male Significant bleeding, multipe fractures in the thorax and the cervical spine

18. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? Do I get the feeling that its serious? Does it remind me of anything that Ive already seen or learned about? What do I know about this subject? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

19. Issues General nursing plan What are the patients emotional, psychological and social needs? What are the patients reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

20. Anticipating physiological complications: hypovolemic shock and cardiogenic shock

21. Situation 1. Potential complication: State of shock Anxiety, prostration or agitation Intense thirst capillary refill time = 5 sec. Blood pressure = 80mm Hg If septic shock: shivers, fever, sharp rises in temperature or hypothermia Skin mottling Cold extremities, cyanosis Oliguria:- 30 ml or anuria Tachypnea Tachycardia, weak pulse Nausea, vomiting Cold sweats

22. Severed spinal chord Obstructive shock Drop in cardiac output, vascular trauma Vasogenic (distributive) shock Hypovolemic shock Pneumothorax, cardiac tamponade Cardiogenic shock Bleeding External-internal (liver, spleen, or retroperitoneal) Cardiac failure Circulatory distress mechanisms Situation 1. Complications

23. IssuesPhysiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? Do I get the feeling that its serious? Does it remind me of anything that Ive already seen or learned about? What do I know about this subject? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

24. Issues General nursing plan What are the patients emotional, psychological and social needs? What are the patients reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

25. Situation 2 Mixed complexity involving physiological risks and little motivation to get better and live Model for analyzing motivation

26. Situation 2. Suicide attempt: Antipsychotic poisoning 30-year-old woman, mother of a young child Difficult situation in terms of family support and living conditions

27. Model of relative motivation (McEwen) Individual perceptions:. Severity of the problem. Subjects vulnerability. Value of acting Change factors:. Personal circumstances: age, situation. Internal and external obstacles to assistance Prior knowledge Motivation to change behaviour Trigger

28. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? What are her problems? What does my intuition tell me? Does it remind me of anything that Ive already seen are learned about? What should be checking or monitoring? Is there an intervention model that would apply? What is the treatment? What do I need to plan?

29. Issues General nursing plan What are the patients emotional, psychological and social needs? What are the patients reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

30. Issues Physiology Is the patient motivated to live, to get better? Is the patient motivated to live, to get better? Where does this motivation come from? Love (spouse, children, family), personal interests (nature, work, art), fear of having a serious problem, fear of dying? Where does this motivation come from? Love (spouse, children, family), personal interests (nature, work, art), fear of having a serious problem, fear of dying? What is getting in the way? Depression, problems in her love life, family or work, not having a job, other problems? What is getting in the way? Depression, problems in her love life, family or work, not having a job, other problems? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to plan? What do I need to plan?

31. Situation 3 Mixed complexity involving cultural issues Transcultural analytical model

32. Situation 3. A miscarriage at 3 months, South American patient Age: 38 years State of health: suffering from malnutrition Support network: In-laws who are a bit hostile and very disappointed at losing the child.

33. Adapted from the transcultural models of L. Purnell and M. Leininger Person Family Cultural community Receiving society Communication Family Spirituality Maternity Death rituals Nutrition Hygiene Health-related habits Organization of work Authority and community organization Biological differences Risky behaviours Values Place of originEducation Leasure Reciprocal perceptions Perceptions of the health system

34. Data collection: A transcultural approach Cultural differences: food, hygiene, etc. Variations, biological frailties Communication problems: language, mode Concept of space Concept of time Social organization structures The idea of the family and the environment Identify

35. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What do I know in this area? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

36. Issues General nursing plan What are the patients emotional, psychological and social needs? What are the patients reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

37. Issues Culture Culture What cultural factors are interfering with care? What cultural factors are interfering with care? What are her eating habits? What are her eating habits? Ignorance of what the treatment involves? Ignorance of what the treatment involves? What authority do her husbands and her in-laws exercise? What authority do her husbands and her in-laws exercise? Do they have a different approach to personal hygiene? Do they have a different approach to personal hygiene? What role do women play in their society? What role do women play in their society? What is the importance of a child and, above all, a male child, in this family? What is the importance of a child and, above all, a male child, in this family? What are my nursing diagnoses? What are my nursing diagnoses?

38. Situation 4 Mixed complexity involving cultural, religious and family issues

39. Situation 4. Uterine bleeding in a Muslim woman 25 years old, mother of three children Devout Muslim family, domineering husband.

40. Issues Physiology What signs and symptoms have I seen? What signs and symptoms have I seen? (CQAST) What is the patient saying about it? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What does my intuition tell me is going on? What do I know in this area? What do I know in this area? What should be checking or monitoring? What should be checking or monitoring? Is there an intervention model or protocol that Is there an intervention model or protocol that would apply? would apply? What is the treatment? What is the treatment? What do I need to plan? What do I need to plan?

41. Issues General nursing plan What are the patients emotional, psychological and social needs? What are the patients emotional, psychological and social needs? What are the patients reactions, expectations, fears and complaints? What are the patients reactions, expectations, fears and complaints? What is bothering her: sadness, despair, physical pain? What is bothering her: sadness, despair, physical pain? Are there family members who need to be contacted or who need support? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to explain to or teach the patient? What do I need to plan? What do I need to plan?

42. Issues Culture and religion What specific factors apply to this situation? Religious taboos? Religious taboos? Need to preserve modesty? Need to preserve modesty? Eating habits? Eating habits? Ignorance of treatment methods? Ignorance of treatment methods? Husbands authority? Husbands authority? Different approach to personal hygiene? Different approach to personal hygiene? The role of women in this society? The role of women in this society? What are my nursing diagnoses? What are my nursing diagnoses? What should I do? What should I do?

43. Situation 5 Mixed complexity with physiological, psychological and social factors

44. cardiomyopathy Individual: 77-year-old man, Severe diabetes Social background: Retired, poor Family: Takes care of his wife, who has cancer

45. Issues Physiology What signs and symptoms have I seen? What signs and symptoms have I seen? (CQAST) What is the patient saying about it? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What does my intuition tell me is going on? What do I know about the related problems? What do I know about the related problems? What should I be checking or monitoring? What should I be checking or monitoring? Is there an intervention model or protocol that would apply? Is there an intervention model or protocol that would apply? What is the treatment? What is the treatment? What do I need to plan? What do I need to plan?

46. Issues General nursing plan What are the patients emotional, psychological or social needs? What are the patients emotional, psychological or social needs? What are the patients reactions, expectations, fears and complaints? What is bothering him? What are the patients reactions, expectations, fears and complaints? What is bothering him? Are there family members who need to be contacted or who need support? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to explain to or teach the patient? What do I need to plan? What do I need to plan?

47. Issues Psychology What social and family factors are interfering What social and family factors are interfering with care? with care? How has he reacted to the situation? How has he reacted to the situation? Responsibility of caring for his wife? Responsibility of caring for his wife? Economic constraints? Economic constraints? Absence of a support network? Absence of a support network? Ignorance of treatment methods? Ignorance of treatment methods? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to plan? What do I need to plan?

48. Situation 6 Mixed complexity with physiological, cultural, social and religious factors Aggression curve and hallucination-related behaviour

49. Complication: Respiratory problems Obstructed airways Inhalation of foreign object Contusion to the brainstem Intracranial hypertension Cervical trauma Thoracic pneumothorax Quadriplegia Hypoventilation Respiratory arrest Car accident, multiple fractures 17-year-old man, Hindu, delinquent, schizophrenic, aggressive and hallucinating

50. Trigger event Refusal to cooperate Panic reaction Attempt at intimi- dation Acting out: agitation, aggression, violence Recovery phase Stabili- zation Curve of growing anxiety and aggression Structure of an outburst

51. Signs of an attack Disjointed speech Raised voice Refusal to cooperate Mistrustful look Rising anxiety Agitation, excitement Arrogant comments Hostility, threats Clenched teeth or fists Hyperactivity Rigid posture Hallucination, disorientation Delirious remarks Pale or flushed face

52. Issues Physiology What signs and symptoms have I seen? What signs and symptoms have I seen? (CQAST) What is the patient saying about it? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What does my intuition tell me is going on? What do I know about the related problems? What do I know about the related problems? What should I be checking or monitoring? What should I be checking or monitoring? Is there an intervention model or protocol that would apply? Is there an intervention model or protocol that would apply? What is the treatment? What is the treatment? What do I need to plan? What do I need to plan?

53. Issues General nursing plan What are the patients emotional, psychological or social needs? What are the patients emotional, psychological or social needs? What are the patients reactions, expectations, fears and complaints? What is bothering him? What are the patients reactions, expectations, fears and complaints? What is bothering him? Are there family members who need to be contacted or who need support? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to explain to or teach the patient? Do I have reason to fear in his behaviour? Do I have reason to fear in his behaviour? What do I need to plan? What do I need to plan?

54. Issues Psychology What factors stemming from his psychiatric problem and his culture are interfering with care? What factors stemming from his psychiatric problem and his culture are interfering with care? His personality and his reaction to the situation? His personality and his reaction to the situation? Religious prescriptions or taboos? Religious prescriptions or taboos? Eating habits? Eating habits? Ignorance of treatment methods? Ignorance of treatment methods? Different approach to personal hygiene? Different approach to personal hygiene? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to plan? What do I need to plan?

55. Situation 7 Mixed complexity with physiological, cultural and legal factors Gypsy woman injured in a criminal fire that she set

56. Family context: Single mother with 2 young children Burns over 40% of her body Pale, clammy skin Tachycardia, tachypnea State of shock Loss of plasma Cultural context: gypsy woman, Legal context: procedures for act of pyromania Pressure when seated Hypovolemic shock Weakness, weak pulse Anxiety, Thirst Urinary output Symptoms Other factors Serious burn victim, 30 years old

57. Issues Physiology What signs and symptoms have I seen? What signs and symptoms have I seen? (CQAST) What is the patient saying about it? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What does my intuition tell me is going on? What do I know about the related problems? What do I know about the related problems? What should I be checking or monitoring? What should I be checking or monitoring? Is there an intervention model or protocol that would apply? Is there an intervention model or protocol that would apply? What is the treatment? What is the treatment? What do I need to plan? What do I need to plan?

58. Issues The nursing plan What are the patients emotional, psychological or social needs? What are the patients emotional, psychological or social needs? What are the patients reactions, expectations, fears and complaints? What is bothering her? What are the patients reactions, expectations, fears and complaints? What is bothering her? Are there family members who need to be contacted or who need support? Are there family members who need to be contacted or who need support? How will the legal issues affect the situation? How will the legal issues affect the situation? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to explain to or teach the patient? What do I need to plan? What do I need to plan?

59. Issues Psychology What factors stemming from her problem and her culture interfere with her care? What factors stemming from her problem and her culture interfere with her care? Her personality and her reaction to the situation? Her personality and her reaction to the situation? Religious and social beliefs, understanding of rules and the law? Religious and social beliefs, understanding of rules and the law? Eating habits? Eating habits? Ignorance of treatment methods? Ignorance of treatment methods? Different approach to personal hygiene? Different approach to personal hygiene? What are my nursing diagnoses? What are my nursing diagnoses? What do I need to plan? What do I need to plan?

60. Situation 8 Mixed complexity with physiological, cultural, legal and ethical issues: a young man who has had an industrial accident and is in a deep coma Suggestions for analyzing the ethical issues

61. Neurological distress: Cerebral anoxia Young man, 22 years old, industrial accident Father of 2 children Very devout catholic family Very poor prognosis, coma

62. Intracranial bleeding or hematoma Respiratory distress Circulatory arrest Increase in central venous pressure Edema Intracranial pressure Cerebral anoxia Neurological distress Cranial fracture, significant compression

63. Issues What signs and symptoms have I seen? What signs and symptoms have I seen? (CQAST) What is the patient saying about it? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What does my intuition tell me is going on? What do I know about the related problems? What do I know about the related problems? What should I be checking or monitoring? What should I be checking or monitoring? Is there an intervention model or protocol that would apply? Is there an intervention model or protocol that would apply? What is the treatment? What is the treatment? What do I need to plan? What do I need to plan?

64. Issues What decision will need to be made if there is respiratory arrest? What decision will need to be made if there is respiratory arrest? What line of reasoning or principles can be used for this decision and its supporting arguments? What line of reasoning or principles can be used for this decision and its supporting arguments? What does the family say? What does the family say? What does the medical team think? What does the medical team think?

65. Suggestions for analyzing situations with ethical issues

66. ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES What are the facts? What are the facts? In physical, psychological and mental terms and in terms of the persons future opportunities and quality of life? In physical, psychological and mental terms and in terms of the persons future opportunities and quality of life?

67. ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES (page 2) What values are at play? What values are at play? What are the values of: What are the values of: The patient (moral, cultural values)? The patient (moral, cultural values)? The family values? The family values? The professionals (personal and The professionals (personal and professional values)? professional values)?

68. ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES (page 3) How has this problem come up? How has this problem come up? Is there a conflict of values (a dilemma)? Is there a conflict of values (a dilemma)? What are the possible solutions? What are the possible solutions? What legal issues may be involved? What legal issues may be involved? What would be the consequences? What would be the consequences?

69. ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES (page 4) For each alternative solution, what is the most important value? How can priorities be determined? How can priorities be determined? What decision should be made? What decision should be made? What recommendations and justifications What recommendations and justifications can be made? can be made?

70. A dilemma?

72. The ethical dilemma: Some food for thought

73. QUESTIONS FOR ETHICAL REASONING QUESTIONS FOR ETHICAL REASONING There are times when caregivers face ethical dilemmas and must respond by making a decision to act, to express an opinion or to voice their disagreement. Asking the following questions can help you reach that decision. There are times when caregivers face ethical dilemmas and must respond by making a decision to act, to express an opinion or to voice their disagreement. Asking the following questions can help you reach that decision. What is the goal of this action or of not acting? Is it to bring an end to the persons suffering? To hasten their death and end a life considered impossible? What is the goal of this action or of not acting? Is it to bring an end to the persons suffering? To hasten their death and end a life considered impossible?

74. QUESTIONS FOR ETHICAL REASONING (page 1) Is it for the greater good of the Is it for the greater good of the patient? patient? Is the underlying motive: Is the underlying motive: An economic motive (such as the An economic motive (such as the cost of care)? cost of care)? One of compassion? One of compassion? A social motive (for example, because A social motive (for example, because organizational or family problems are organizational or family problems are standing in the way of care delivery)? standing in the way of care delivery)? Does the patient suffer as a result? Does the patient suffer as a result?

75. QUESTIONS FOR ETHICAL REASONING (page 2) QUESTIONS FOR ETHICAL REASONING (page 2) Is the pain or the situation intolerable? Is the pain or the situation intolerable? Intolerable for whom? Intolerable for whom? For the patient? For the patient? For family and friends? For family and friends? For the caregivers? For the caregivers? Who lacks courage? Who lacks courage? The patient? The patient? Family and friends? Family and friends? The caregivers? The caregivers?

76. QUESTIONS FOR ETHICAL REASONING (page 3) QUESTIONS FOR ETHICAL REASONING (page 3) What rights do health professionals have over patients? Parents over their children? Children over their parents (in terms of making decisions for them)? What rights do health professionals have over patients? Parents over their children? Children over their parents (in terms of making decisions for them)? Does this act represent being faithful and loyal to the person? Does this act represent being faithful and loyal to the person? Is respect being shown for the patients independence, right to self-determination, integrity, privacy and dignity? Is respect being shown for the patients independence, right to self-determination, integrity, privacy and dignity?

77. Illustrations of physiology inspired by: Illustrations of physiology inspired by: Jean-Pierre Carpentier (2002), Soins infirmiers aux urgences et en réanimation, 4th Ed., No 21, Paris, Masson.

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