Structuring Clinical Decisions NUR 603 Dr. Julie Sebastian

Decision-making is “the operationalisation of nursing knowledge.” (Luker & Kenrick, 1992, p. 458)

Why might it be important to understand how nurses make clinical decisions?

Structured care approaches* Protocols –guides to action Clinical pathways –optimize care for a popln. & reduce costs Decision analysis –determination of optimal outcomes based on analysis of probabilities & expected values Algorithms –If-then branching logic; useful when greater variance is likely *From: O’Neill & Dluhy, 2000, p. 132.

Approaches to decision making Process vs. outcome

Process approaches* Descriptive –systematic-positivist (empirical) esssentially a linear, information-processing model –intuitive-humanist Benner; novice to expert gestalt of the situation helps expert link data cues to judgements Normative –probabilistic –based on Bayesian logic (incremental comparisons between theory & evidence) * From: Hamers et al., 1994 & Thompson, 1999

Outcome approaches OPT; Outcome-Present State-Test Pesut & Herman keys are framing problems and juxtaposing present state against desired state

How does the client fit into this model? Pesut and Hermann would recommend that nurses take into account the patient’s story, or total life situation.

Decision-making process Initiating the process Structuring the process Evaluating the process

Process Diagnostic decision Desired goal Management decision Patient outcome

Diagnostic decision-making Hypothesizing Collecting data Diagnosing Validating the dx

How would you validate your diagnosis (judgement)?

Goal-setting Etiology-related Realistic Measurable Timed

Treatment Decision-making Alternative actions Consequences –Utilities (u) –Probabilities (P) Expected values –EV=u*P –Approximations Choose & prioritize interventions

Determining the outcome Measure intervention result Calculate variance Decision feedback

How do the patient problem and outcome relate and differ?

What started your thinking?

Initiating the process Chief complaint Diagnosis Problem Client story Goal Other

Structuring the process Did you use a theory? If so, what?

Structuring cognition Frameworks Systematic Objective Variations In the decision-making you described today, did you use deductive or inductive reasoning, or a combination of both?

Evaluating decisions Process –proficiency –efficiency Feedback

Rational decisions are: Made efficiently Made using a systematic thinking procedure Supported with objective evidence Reasonably accurate (proficient) Do you agree that this is how good decisions are made? Why or why not?