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?