CLINICAL DECISION MAKING AS UNDERSTOOD FROM PRACTICE

In addition to influences from nursing research, theory, and professional organizations, much has been learned about APRN clinical decision making directly from clinical practice as well as research and practice experiences from other disciplines.

Skilled communication and interaction are essential components of clinical decision making at all levels, whether the APRN is posing wide-field or focused inquiries, clarifying diverse perspectives, providing guidance for lifestyle health behaviors, or evaluating a patient's responses to treatment. As Chase (2011) points out, clinical decision making is not a process that occurs with the APRN in isolation. It occurs as dialogue and interaction between the patient and provider, with experiences of satisfaction significantly influenced by the quality of communication and engagement with the clinical situation (Benner, Stannard, & Hooper, 1996).

Most descriptions of APRN clinical decision making begin with an expanded nursing process model that integrates elements of hypothetic-deductive reasoning. Carnevali and Thomas (1993) describe the diagnostic reasoning process in nursing as reviewing pre-encounter data, entering into the assessment situation, collecting the database, coalescing cues into working clusters, selecting pivotal cues or cue clusters, determining possible diagnostic explanations, further comparing the clinical situation with diagnostic categories, and assigning the diagnosis.

White et al. (1992) outlined a clinical decision-making framework for APRNs that adds elements from hypothetic-deductive reasoning. Hypotheses formed are used to guide the process of inquiry (i.e., decisions about how to focus the history, examination, and diagnostic testing). The process outlined by White et al. adds many of these elements to nursing clinical decision making: reviewing pre-encounter data, generating early hypotheses, engaging in clinical inquiry, determining working hypotheses, conducting diagnostic testing, testing the final hypothesis, specifying the diagnosis, determining patient management, and evaluating the total clinical situation.

Chase (2004) configures this process specifically for nurse practitioner practice. She lists the phases of clinical judgment as follows: conducting an early wide-field search for the primary concerns; generating an early hypothesis on probable causes of the concerns; engaging in focused data acquisition related to supporting the active hypotheses and ruling out other serious conditions; evaluating various hypotheses by clustering and analyzing the data for the appropriate fit with diagnostic categories; naming the priority problems; determining appropriate therapeutic goals; determining an appropriate management plan; evaluating the effectiveness of the clinical process; and confirming or revising the diagnoses and plans. Table 8.1 provides a comparison of these three approaches.

In advanced practice nursing, each of these approaches might be appropriate for differing clinical scenarios or problems and stages. The decision-making processes can be used with both disease- and non-disease-based concerns, as well as with medical or nursing diagnoses. Hypothetic-deductive models are perceived generally to be more useful during data collection and implementation. Intuitive-interpretive models are reported in use more during data processing, whereas during planning both models are perceived to be equally in use (Bjork & Hamilton, 2011). Clinical nurse specialists might place less relative emphasis on the biomedical diagnostic content, tending more often to work collaboratively with medical care providers for these decision-making components. Nurse practitioners emphasize greater autonomy in medical diagnostic and treatment elements but place less overall emphasis on specialty nursing care and system-level thinking. With either role, however, keys to the process are clinician characteristics of perception and engagement, discipline-specific knowledge, commitment to quality

TABLE 8.1 Comparison of Nursing and APRN Clinical Decision-Making Frameworks

practice, and know-how related to "think clinically" under differing clinical role expectations. Skilled clinical decision making occurs as an intentional process of problem solving, critical thinking, and reflection in action (Benner et al, 1996). It is guided by content expertise and deliberate decisions about how to proceed through the current clinical encounter as well as reasoning through the anticipated trajectory of the health concern.