Nur3052 ch7

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Nur3052 ch7

  1. 1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 7 Patient Concerns, Choices, and Clinical Judgment in Evidence- Based Practice
  2. 2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  3. 3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  4. 4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elements of Good Clinical Judgment • Knowing the patient • Reasoning through time • Appraising and judging research evidence
  5. 5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  6. 6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  7. 7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  8. 8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.
  9. 9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.
  10. 10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  11. 11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  12. 12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Grasp • Encompasses − Making qualitative distinctions − Engaging in detective work − Recognizing changing clinical relevance − Developing clinical knowledge about specific patient populations
  13. 13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  14. 14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.
  15. 15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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
  16. 16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.
  17. 17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.
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