Nur3052 ch7

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 7Patient Concerns, Choices, and Clinical Judgment in Evidence-

Based Practice


Research and Patient Concerns Research evidence needs to be considered in light of the

patient’s concerns and preferences

Good clinical judgment is required, not only research evidence

Critical judgment requires two components

The validity of the evidence itself needs to be examined carefully

How the evidence is applied to clinical decision making must be examined


Applying Evidence

The fit between evidence and clinical reality is rarely perfect

Every patient is different

Patients never exhibit only one problem

Nurses must judiciously consider relevant patient particularities and concerns in making clinical decisions

Ethics must also be considered

A “narrative understanding” of each patient is necessary


Elements of Good Clinical Judgment

Knowing the patient

Reasoning through time

Appraising and judging research evidence


Clinical Judgment and Self-Improving Practices The goal is for practice to be self-improving through

science and experiential clinical learning and correction

Dependent on experiential learning

Turning around preconceptions, expectations, sets, and routines or adding new insights to a particular practical situation


Experiential Learning

Techne

Producing outcomes by a means-ends strategy, whereby the maker or producer governs the outcome by mastering the means of its production

Phronesis

Reasoning across time about changes in the particular patient’s condition and changes in the clinician’s understanding


The Risks of “Leveling”

Above-average performance is harmed when it is brought down to the clinical “standard,” even if the standard is evidence-based

Variation below the standard must be brought up to the standard, but variation above the standard should not be brought down


Question

Tell whether the following statement is true or false.

An evidence-based standard of practice represents the best possible outcomes that can expected in a particular clinical context.


Answer

False

Rationale: A standard of practice may represent a baseline or average level of outcomes that is significantly below what is possible in some settings.


Clinical Expertise

Not every aspect of nursing practice is “formalizable”

The ethos (i.e., ethics or notions of good) of practice influences what is considered relevant science

Knowledge alone is not sufficient to ensure that nurses will form helpful relationships with patients or that nurses will notice and correctly identify early signs and symptoms

Formal measurements cannot replace perceptual skills


How Narratives Inform Clinical Understanding A narrative mode of description best captures clinical

judgment and experiential learning

A narrative can capture chronology, the concerns of the actor, and the ambiguities and puzzles as the story unfolds

Nurses’ clinical narratives can reveal their taken-for-granted clinical understandings

Narratives reveal clinical wisdom that other nurses can identify with, and appropriate for, their own clinical practices


Clinical Grasp

Encompasses

Making qualitative distinctions

Engaging in detective work

Recognizing changing clinical relevance

Developing clinical knowledge about specific patient populations


Question

A nurse who provides care on the renal unit of a hospital has developed a skilled clinical grasp that allows her to provide highly competent care. The nurse’s clinical grasp has been primarily enhanced by:

a. Making qualitative distinctions

b. Engaging in detective work

c. Recognizing changing clinical relevance

d. Developing clinical knowledge about specific patient populations


Answer

d. Developing clinical knowledge about specific patient populations

Rationale: Refinement of clinical judgment is possible when nurses have the opportunity to work with specific patient populations. The nurse’s opportunity to provide care exclusively to patients with kidney disease will foster skilled clinical judgment in this area.


Clinical Forethought

Refers to at least four habits of thought and action

1. Future think is the practical logic of the practitioner situated in practice

2. Clinical forethought about specific patient populations

3. Anticipation of risks for particular patients

4. Seeing the unexpected


Question

Tell whether the following statement is true or false.

A consistently high level of clinical performance is necessary in order for a nurse to engage in experiential learning.


Answer

False

Rationale: Focusing only on performance and on “being correct” and not on learning from breakdown or error dampens the curiosity and courage to learn experientially. Experiential learning requires engagement with complex clinical realities, which nurses will sometimes interpret or respond to incorrectly.

Health & Medicine

Nur3052 ch7