II: IMPLEMENTATION OF THE APRN ROLE
ADVANCED CLINICAL DECISION MAKING
Clinical decision making in advanced practice nursing occurs as a continuous, purposeful, theory- and knowledge-based process of assessment, analysis, strategic planning, and intentional follow-up. It is both a cognitive and affective problem-solving activity for defining patient problems and selecting appropriate management approaches (Buckingham & Adams, 2000). Lunney (2009) states, "The personal strengths of tolerance for ambiguity and reflective practice need to be developed because decisions are so complex in nursing and the use of clinical judgment needs to be an ongoing learning process. Each decision is relative to context of situation and specific nature of the individual, family, or community" (p. 7).
The role of the advanced practice registered nurse (APRN) is multifaceted, and the scope of decision making is similarly complex. It incorporates health promotion, disease prevention, risk reduction, management of functional health needs, subjective concerns, program planning, biomedical diagnostics, and disease management. Large amounts of data are elicited, sorted, and organized into meaningful patterns. Conducted within the context of nurse-patient relationships, APRN clinical decision making is frequently characterized by changing health circumstances and complex social variables. The nursing and biomedical decision making involved may be straightforward or of low, moderate, or high complexity. The level of patient health risk may range from very low to very high. These parameters are used to direct allowable and appropriate billing charges in clinical practice. Reimbursement is higher for increased decision making complexity and increased patient health care risk.
PROCESSES, FOCUS, AND FRAMEWORKS
To understand clinical decision making at the APRN level, it is necessary to examine at least three interrelated aspects of practice: decision-making processes, the focus of APRN practice, and APRN frameworks for practice. Each of these components contributes essential elements to the process of clinical decision making in advanced practice nursing, resulting in a unique and valuable clinical practice role.
Decision-Making Processes: Research in Clinical Reasoning
Research in clinical judgment and decision making has been an important area of study for more than 50 years. Much of the decision-making and problem-solving research began in the cognitive sciences (Newell & Simon, 1972; Tversky & Kahneman, 1974), with early application to diagnostic reasoning and clinical problem solving in nursing and medicine (Elstein, 1976; Elstein, Shulman, & Sprafka, 1978; Hammond, 1964; Hammond, Kelly, & Castellan, 1966). Strong interest in this field of study has continued with distinctions more clearly discerned between clinical problem solving in nursing and medicine. Nursing problem solving frequently focuses on expert judgment about changes in a patient's overall status; anticipating and preventing potential problems; ensuring safe passage through uncertain health-illness trajectories; addressing the functional needs and capacities and quality-of-life issues for the whole person; understanding and responding to complex human responses; and protecting individuals and groups in their health-illness vulnerabilities (Benner, Hooper-Kyriakidis, & Stannard, 1999; Carnevali & Thomas, 1993; Tanner, Benner, Chesla, & Gordon, 1993). Medical reasoning, in contrast, focuses more specifically on the management of illness, pathology and disease, biomedical hypothesis generation with probability determination, and medical treatment decisions (Schwartz & Elstein, 2008). In medicine, a very different set of problem-solving skills and knowledge bases are required: pathophysiologic causal reasoning, use and interpretation of diagnostic tests, prognostic determination, and disease-oriented therapeutic decision making (Kassirer & Kopelman, 1991). Advanced practice nursing involves a complex blending of both nursing and medical decision making. It is important to be able to synthesize decision-making skills from both fields.
