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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?
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