Clinical reasoning and decision making in nursing essay


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Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events Tomlinson, The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement.

Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process Levett-Jones et al, At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction. The speed and ability by which the nurses make sound clinical judgement is affected by their experience.

clinical reasoning essay

Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

Institute of Medicine IOM report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice.


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American Nurses Association ANA , Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice p. Evans , proposes that nurses should use evidence derived from research to make a decision such as expert opinion according to quality criteria, randomised control trials and patient experience. A example of a method for EBP is a pain assessment tool for which guidance was developed by The British Pain Society has worked with the British Geriatrics Society and the Royal College of Physicians , to review the current evidence guidance to help nurses and all practitioners to use pain assessment tools to assess for the presence of pain.

The guidance helps nurses to be aware of the pain in patients, enquires about the pain by using a range of descriptive such as is it sore, hurting or aching will enable the nurse to reach decision.

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Furthermore, it helps nurse to locate the pain by asking the patient to point the area themselves to indentify the pain intensity and to identify the cause of the pain and how to treat and to re-evaluate the outcomes. Pain assessment tool helps nurses to determine the cause and provide best pain management and treatment for the patient. In order for the nurse to assess pain comprehensively, the nurse needs to address the type of pain, detailed history and assessment of the pain intensity.

It aim is to mange the pain intensity by asking the patient to match pain to a descriptor words and number. The reasoning of using the VRS is what McCaffery , defines pain should be what the patient says it is because a nurse can not measure a patient pain intensity unless the patient said so Baillie, , p According to Krohn , the nurse uses the VRS scale to ask the patients to describe their pain whether they have on pain, mild pain, moderate pain, sever or worst pain.

Once the pain intensity is assessed according to Wells et al , the nurse has to make a decision on which analgesic management and intervention to use in order to achieve optimal comfort and function with minimal side effect from analgesic therapy. The World Health Organisation WHO , suggest that nurses decision should be based on the analgesic administration ladder. Where simple analgesic such as paracetemol should be used for mild pain, weak opioids for moderate pain if not contraindication to renal dysfunction Ballantye et A sever or worst pain should be review and a strong opioids analgesic such as morphine should be administer to improve the comfort of the patient.

The nurse should monitor and be caution about the safety of the patient because first time analgesia patient will be susceptible to adverse effects such sedation and respiratory depression National Patient Safety Agency Time management is a factor that hinder the use of pain assessment tool. A randomly studies carried out by Manias et al They added that due to this interruption patient are unable to request pain relief for the fear of being regarded as a nuisance and it have impact on their emotional, physiological and physical function aspect of their lives.

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Knowledge of pharmacology and analgesic also enhance to decrease anxiety, improve the mood and promote comfort to the patient. Although using pain assessment tools in adult who speak English and understand the pain score is very effectively are able to give consent about their treatment, but in elderly adult with cognitive impairment will be confuse and not be to able give a reliable measurements of pain intensity, which is likely to result in inappropriate intervention. According to Weiner and Herr , assess pain in patient with impaired communication such as learning disability and mental health patient represent the most significant challenges in pain management and nurses have difficulty knowing when those patient are in pain and when they are experience pain relief.

They added that nurse have to depend on their facilitators to describe the pain in which the nurse have to query the reliability during decision. Pain assessment tools used in children is complex for example babies who are unable to communicate, decision and consent has relays on their parent.

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So during decision making about interventions, the nurse have to use ethical principles of beneficence and non-maleficence to select best pain assessment to provide pain comfort for all the patient Nursing and Midwifery Council NMC According to Wood , nurses in the health care sectors encounter multiple challenges when providing quality care to diverse patient population.

This creates ethical dilemmas resulting form the combination of increasing of patients acuity and limited of resources. She added that professional code of practice as a method will enable nurses to make an ethical decision to provide a patient centred care. Ethical decision making as explain by Ian et al , is when a nurse carefully rational the available evidence by asking a question such as what is the context of the dilemma or the data. Consider the relevant moral principles such as what alternatives exist and the purpose of each alternative, the consequences of our actions such as what are the social and legal constraints.

Serious games SGs are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care.

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This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease COPD in home healthcare settings. A prototype SG was developed. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory.

Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation.

Clinical Judgement and Decision Making for Nursing Students Transforming Nursing Practice Series

The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users.