The Different Approaches To Clinical Decision-Making In Nursing

Clinical Decision-Making as a Contextual, Continuous and Evolving Procedure

Clinical decision-making can be defined as the contextual, continuous act and an ever evolving procedure. In the procedure, data is gathered and is there by interpreted and then evaluated to select an evidence-base of a particular action for a task (Johansen and O’brien 2016). During the time of making clinical judgments, nursing professionals are seen to draw different types of information from many different sources that would also include their formal nursing education as well as from their experience that is usually gained over a period in their practice. The clinical decision-making can be therefore defined as the effective choosing between different alternative and can be considered as a skill, which helps in improvement of the nurses gain of experiences both as a nurse and in a specific specialty (Standing 2017). Researchers are of the opinion that clinical decision making mainly needs good quality judgment that should include critical thinking. The definition of critical thinking in nursing is therefore described as “Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge” (Yeates et al. 2016). Many of the researchers have also define decision making as the procedure where professionals use to gather information about the patients and thereby evaluate them and make judgments which result in the provision of the nursing care. Qualified nurses should be able to use effective decision-making skills to provide safe and effective nursing care. Over the course of time, researchers have put different types of decision-making theories forward. This assignment would mainly be discussing about the different types of decision-making theories that can be used by nurses in different scenarios to make effective decision and thereby help patients to get proper treatment and expect better quality life.

The basic concept of the information processing theory is that individual human beings have minds that are like computers or information processors. They can simply not be considered to provide responses to stimulus that are present in the environmental surrounding. The human brain is seen to receive information just like a computer. Information that is gathered from the senses as input can then be processed and then stored by the brain (Decoux et al. 2016). This information then helps in delivering output that mainly comes out with the process of behavioral response. The information-processing model is also called the psychological theory and is much used in the research of the medical decision-making. It is also referred to as the scientific approach to for effective decision-making and is also termed as the hypothetic-deductive approach. In the nursing profession, there are four main stages of this process. The first one is the gathering of preliminary clinical information about the patient and then generating tentative hypothesis about the condition of the patient (Garner, Boyard and Gray 2015). Then the professionals interpret the initially registered cues in the light of the tentative hypothesis and then weight the decision alternatives. This is then followed by the choosing of the one that seems to fit best in the light of the evidence collected. One of the drawbacks of this hypothesis deductive approach is that it may result in inaccurate structures sometimes that may have wrong probabilities that may remain attached with the  with the results in the invalidation of the outcomes. Sometimes the hypothesis may be wrong and this may lead to a rise of a proposition, which may be fundamentally incorrect.

The Information Processing Theory in Clinical Decision-Making

A model of working memory or short-term memory was introduced that mainly comprises of three important components. These are the selection of the information, effective method of processing, meaning and then ultimately deciding the components of the information that had to be transferred to the long-term memory or to forget it. Two of the counterparts of this system is the auditory loop where the auditory information is saved and the visual-spatial checkpad where the visual information is proceeded. The information that is obtained is maintained in the short-term memory mainly by two procedures. The first is the maintenance process that occurs through repetition of the information and the other is elaboration that refers to the organization of the information through chunking (Sliakbari et al. 2015). This mode of information processing theory cannot be depended by the nursing professionals for decision-making.  Different nurses have different varying levels of cognitive load. Therefore, those nurses who cannot take enough cognitive loads in the rehabilitation department, it may lead to negative outcomes (Cocks et al. 2016). Again, one of the features is that when the information is repeated many times, the information becomes automatic. At that time, it does not require cognitive resources. Moreover, this system helps in focusing on particular information and that is really important and relevant. Often nurses in the rehabilitation ward have to conduct many activities that are physically and mentally strenuous. Starting from manual handling to making of beds, medication, conducting activities of daily lives of the patient and many others are also the duties of nurses in rehabilitation wards (Tiffen et al. 2014). Therefore, in such times of cognitive load where different information is poured from different members of the multidisciplinary team in the wards, the nurse may become filled with cognitive load and hence the information may slip resulting in issue in decision-making (Krishnan 2018). However, one of the good features is that information, which is often repeated in the ward like importance of effective documentation about the progression of health of the patient is often declared by nurse managers. Hence, this information may remain stored and thus not require cognitive resources. With the help of this short-term memory model, nurses can specifically focus on particular information that is highly relevant and necessary.

Long-term memory is different from the short-term memory with the fact that it has unlimited space. It include proper encoding which is the elaboration process to the long term memory and the other is the retrieval process which is the scanning of the information and the transferring to short term memory or the working memory so that it can be used. Often a nurse is seen to conduct excessive literature review and learn different evidence based information to develop their skills in the rehabilitation ward (Toplak et al. 2014). This is then stored in the long-term memory. As per requirement of the situation, information from here is transferred to short-term memory for effective application. Therefore, in way this model is highly beneficial in decision making for the nurses. However, this model is yet under arguments about how parallel information can be collected and processed and recollected dieting the times of need. Researchers argue that nurses need to be highly skilled to achieve this (Chen et al. 2014). Therefore this model can then never be applied to all nurses especially who are novices as they may fail to undertake parallel processing of information. Therefore, it cannot be considered as an effective source.

The Role of Short-Term Memory in Decision-Making

Approaches of decision-making can be quite diverse and many range from classical, rationalistic and even decision making procedures to a less structured, intuitive as well as decision making style. Rational decision-making procedures are seen to consist of sequence of step that are designed rationally for development of desired solution (Melin et al. 2017). However, intuitive decision-making is entirely different which is being more instinctive subjective as well as subconscious in nature. Often it is seen that the decisions of the nursing professionals are made on judgments that are affected by a range of factors. These may include experiences, values, emotions as well as attitudes. Many of the researchers also name it as the judgment heuristic decision-making. This system is mainly seen to use simple rules as well as approximate short cuts that help the professionals in arriving at decisions. Many of the researchers are of the opinion that by adapting to this form of decision-making, they mainly rely on experiences and attitudes and they mainly do so by helping to cut through excessive information that can overload as well as result in delay of decisions (Payne 2015). Although this procedure helps the professionals in simplifying complex situations, the nature of this form of decision-making can also result in the introduction of the bias. Different types of judgment heuristic can be representative heuristic. Here, the judgments are based on things with which the professionals are familiar with or are inferred from representative characteristics. Another is the anchor heuristics where the professionals are seen to take decisions that are based on the anchor like a typical value and then different adjustments are made from that starting point. Another one is the availability heuristics where judgments are mainly built on the information that is readily available or on the easily called memory experience. Another study had given an explanation s the main foundation of the decision-making procedures. It is mainly seen that in many cases making a decision becomes difficult because it’s not poplar but mainly due to the reason as it come from the “gut” and defines a clinical or the technical rationale. It is seen that professionals are sometimes observer of things so many times that they become s capable to understand what is going on this time. In this scenario, the facts may be incomplete and the data may be also limited but the professionals can very well feel aligned or can recognize the outcome seven before the situation reaches to completion (Hassani et al. 2016). Therefore, in simple terms it can be stated in case of intuition theory of decision making, the professional is mainly believing on something that had been already known and is also perceived, understood  as well as believed by instinct, feelings of the nature without undertaking the help of actual evidence but by the utilisation of thought, rational processes or reasons. Researchers are of the opinion that brain researches point to different regions of the brain that are seen to work simultaneously with the conscious though processes of the human beings  and act as parallel intelligent systems . These systems are mainly seen to create responses that are seen to compete with each other in determination of the response of the person.  However on the other hand, when human beings are guided by the experience with a previous pattern, then the responses are said o be a result of the intuition.

The Benefits and Drawbacks of Long-Term Memory in Decision-Making

However, in many cases, it is seen to have a number of drawbacks, as this form of decision-making can often be a source of the significant errors. Sometime sot may result in flawed information. Intuition making is mainly seen to respond quickly to inaccurate, unreliable, insufficient as well as incomplete information on patterns on previous experiences that might not always yield similar results as previous time and may contribute to flawed information. short term emotional basis may also take place as any researchers state that decisions of professionals are influenced by the unrelated emotions during the time of making a decision. Moreover, it also results in insufficient considerations of alternatives. Researchers are of the opinion that as mainly this intuition generally bases on pattern recognition, it mainly points to solutions that have already worked with current perceived patterns (Cork 2014). This in turn limits considerations of other options although the alternative may give more fruitful it better results. Prejudices may also creep in as emotions help in formation of intuitions and thereby it can allow flawed experiences for overruling sound facts and evidences.

The intuition of the nurses is an important component in relation to patient care and intuition decision making guides the nurses in various types of nursing procedures. Knowledge, experiences, skill levels, personal characteristics as well as relationships with the patients all play an important role in the nursing ability for development and application of the intuitive abilities. However when the nurses are not well experienced, this process of decision-making may have negative impacts on the patients. Nurses are therefore seen to integrate intuition as well as analysis or synthesis alongside objective data when decision-making.  They need to be alert of their sense of intuition that may in turn expand their knowledge and experience and therefore develop the quality of patient care.

In the rehabilitation ward, a patient was seen to be suffering from abdominal pain and was feeling confused and did not want to lie down. He continued to stay so even after pain medication was given. Diagnostic tests like ECG showed that he had normal heart rhythms and other members could not understand how to ease the patient. The senior nurse called for the cardiac arrest team and within very hours, the patient had a cardiac arrest. After the patient was saved , the team asked her what made her understand so. She exclaimed that it was her intuition that advised her to do so. This can be considered a judgment on over analysis because no cues from the situation indicated that such a situation could have taken place.

Classical and Intuitive Approaches to Decision-Making in Nursing

Expected utility theory is of the opinion that every decision maker should choose between the risky or uncertain prospects of a task with the help of comparison of the expected utility values that is the weighted sum obtained by addition of the utility values of outcomes multiplied by their respective probability (Guistinelli 2016). Researchers are of the opinion that expected utility theory is mainly helpful as a tool for analysis of situations where individuals must make a decision without knowing which of the outcomes of the task will result from the decision and that are decision-making takes place under uncertainty. The professional would choose that particular option which will result in the highest expected utility that is which is the sum of the products of the probability and utility over all possible outcomes. One of the important thing is that the decision which will be made also depends on the risk aversion of the agent as well as the utility of the other reasons (Gerard et al. 2015). To make it simpler, it can be stated as a Theory that helps in estimating the likely validity of an action when the professional faces uncertainty about the outcome. Which theory suggests that the rational choice is to choose an answer that will have the highest expected utility in the situation. A number of disadvantages are associated with this theory. Researchers have conducted surveys that have show that people are very risk averse towards any form of gambles especially in cases that involves their health related outcomes (Fischer, Pelka and Riedl 2015). The survey also indicated that there is significant variability in the risk attitudes across different professional pertaining any given gamble and that there is significant variability in the risk attitude of a given individual across gambles. It has been also found from the survey that the variability of this risk attitude of a given individual suggests that the risk attitudes are not absolute but are in the functions of the parameters that are present in the   gamble.

 Patient of 75 years was admitted in the rehabilitation ward after facing a fall in the garden following a stroke. He was a patient for about stage 5 chronic kidney diseases and was taking dialysis for above ten years. After the emergency treatment that cured his stroke chances and helped in dressing the wounds, the patient and family requested to conduct a kidney transplant so that the patient can get over having a proper quality life. In such a situation, the senior nurses and the physicians were seen to conduct an analysis of the risks that are associated with it so that the utility of the intervention that would be taken can be judged. They came to discussion where it was revealed that the patient is already having dialysis to more than 10 years and evidences show that such patients do not have extra benefits and higher mortality after transplantation in comparison to those who have started dialysis recently or taking them for little number of years. Again it was seen that the donor was supposed to be his wife who was also old and this also increases the risk of failure of transplantation success. Age also plays an important factor in ensuring success of this process. Hence, the nursing professionals and physicians decided not to undertake transplantation surgery as better utility and success remains associated with dialysis for the patient.

The information processing theory is a systematic procedure of decision-making process that can be used by both new nurses and experienced nurses. They are able to find solutions of the of the problems by creating hypothesis of the decision maker based on knowledge that had been already gathered (Reyna et al. 2015). On the other hand, intuition theory is very different because of the fact that it is not based on any form of rationale. It is entirely based on the intuition that the nurses develop at that particular moment from her previous experiences that might not have any steady logic to defend the decisions. Expected utility theory is again based on another rationale and is mainly help in situations when there is uncertainty like when there are number of risks associated with the different ways of performing a task (shabn 2015). This theory helps to decides which of the intervention along with the risk would help in providing more benefit in comparison to the other modes of interventions with the risks that would result in more harm and less benefits. Therefore, in a way those theories are helpful in different situations and help to decide with different angles that may help professionals to come to a decision that brings out success.

This theory is one of the best theories of decision-making as it follows a systematic procedure that provides very little scope of resulting in conducting mistakes. This theory addresses the basic psychological concepts of memory, cognitive processing and problems solving. The theory has also been successful in acting as framework for many of the studies based on clinical decision-making (Nestel and beardman 2015). It is one of the best theories that help in describing the processes of problem solving behavior based on the interaction of the between the task and that of the problem solver. Clinical decision making mainly give rise to situations that require considering huge amount of data to be gathered properly followed by their documentation and then acting upon them. Here, the potential for cognitive strain is very high. Here the professionals can develop their capacity of working memory or the short-term memory by the clustering of the data into the familiar chunks for information processing (Lin et al. 2016). The four steps that the professionals should undertake to complete it successfully are quite easier. Firstly, the professionals need to gather and attend to the initially available cues and symptoms. Then the professionals with the help of the cues activate some of the hypotheses that may satisfy the initial cues that had been selected. Then the professional need to gather additional data that is usually that are hypotheses directed (Brinol et al. 2015) . Then the professionals need to evaluate the hypothesis  by weighing the likelihood of each  in the light of the new cue until the diagnosis is accepted. Therefore, this systematic procedure helps the professionals to link their theoretical knowledge taught in their classes and training to relate with the real life situations that give very little scope of errors and mistakes. Therefore, it results in fewer changes of the patient harm and better patient safety than the other decision-making skills (Niedtfeldt et al. 2017).

From the above discussion, it becomes clear that the nurses can utilize different types of decision-making theory in different situations in order to reach a conclusion. The decisions making theory help the nurses take the correct decisions in order to provide the care that is not only safe but also ensures better quality life for the patients. Different types of decision-making theories have been put forward by different researchers out of which the information processing theory is one of the most important and helps nurses to develop a hypothesis against the cues obtained from the initial assessment of the patient. This hypothesis is then tested with the cues with the help of already learnt information and knowledge prior to the occurrence of the task and this knowledge helps the nurses to decide up number of particular interventions according to the authorities of the patients. In addition, other important decision making theory is the intuition decision-making theory. Here the nurses do not follow particular knowledge but take decisions from the intuition, which does not remain, based on prior knowledge but usually remains based on prior experiences. However, one negative point about this is that it may result the nurse to conduct mistake even when the same decision had resulted in success in the previous cases. Another decision-making theory is the utility theory where the nurse mainly takes judgment about the utility of the different interventions that are associated with the task. Then the nurses take sides of that particular intervention which has less risks and most number of benefits to the patients in comparison to the other interventions. This type of theory is mainly helpful in the cases of uncertainty. Therefore, the nurses might use the different types of decision-making theories in different cases and develop decisions that bring them success in their careers.

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