The Influence of Postgraduate Education on Clinical Decision - Case Study Example

THE INFLUENCE OF POST GRADUATE EDUCATION ON CLINICAL DECISION MAKING AMONG NURSES Introduction The metamorphosis of nursing as a distinct professionswith a unique and peculiar knowledge base and approach towards healthcare has been reinforced in the past decade; in effect, it has enhanced the importance of clinical decision making (Balla, 1990). Under the realm of clinical thinking are two types of knowledge, namely, theoretical knowledge and applied knowledge, as associated with the clinical setting. The theoretical portion has been described in literature; however, the portion deduced from practice - the knowing how, has been investigated primarily mostly in the "folk" milieu of the practice setting. The intrinsic nature of this knowledge type has lead to an insufficiency in the documentation of the clinical experience. With Benner’s (1984) work, it has been suggested that a substantial portion remained hidden as tacit knowledge. Teaching the processes underlying clinical decision making has always proved difficult of not problematic. There have been numerous theoretical frameworks that have been designed to make the procedure more straightforward; however, these challenges seem to persist. The current paper intends to assess whether post-graduate education equips critical care nurses with the necessary competencies for undertaking more efficient patient management decisions. Review of Related Literature Majority of students experience difficulty in expressing and comprehending the decision making process. Aggravating the problem further is the expectation that students will garner an understanding of the theories behind the concepts and be able to apply these in real life contexts. In effect, if the student has not comprehended the concepts and fails to imbibe on the action implemented in practice, much of the knowledge in decision making processes will tend to stay vague and incomprehensible. Moreover, it is an implicit expectation that a nurse is adequately competent to be involved in diagnostic reasoning and treatment decisions in at least two areas – nursing and medicine (Carnevali, 1984). Nursing - Decision Making in Two Domains Nurses determine and resolve client issues in the nursing domain as well as being aware of, identifying and implementing treatment (under medical supervision) of client problems in the biomedical domain. Carnevali (1984) emphasizes the idea that by convention and training, nurses have been biased to direct problem solving chiefly and apparently towards the biomedical domain. This may have been the practice, but with the transition to holistic care and the dynamic mindset in health care, nurses make apt and gainful choices about when to direct their decision making and judgment to daily living as associated to health. These daily living requisites are vital to the nursing practice domain. The Nursing Practice Domain The Nursing practice domain consists of several subdomains (Benner 1984, p.46) enumerates these as follows: 1) the helping role, 2) the teaching-coaching function, 3) the diagnostic and patient-monitoring function, 4) effective management of rapidly changing situations, 5) administering and monitoring therapeutic interventions and regimes, 6) monitoring and ensuring the quality of health care practices, and 6) organizational and work-role competencies. These sub-domains depict the nursing responsibilities but both domains of clinical decision making are typically used in clinical practice contexts. Combining the Domains In the biomedical domain, nurses have delegated responsibilities to make precise and apt clinical judgments on the patients pathophysiological health states. However, the nursing domain concentrates on daily living, including the environment within which daily living takes place and functional health status of the patient. These elements are perceived in their relationship to each other and are the two major components of diagnostic reasoning in nursing (Carnevali, 1984). Nurses do not exclusively work in institutional settings. Those nurses working as autonomous practitioners, in industrial clinics, home care or midwifery make decisions on referral for medical diagnosis and treatment. They utilize clinical judgment when suggesting sustained self care, autonomous nursing action or maintenance of the client under nursing management (Carnevali, 1984). Nurses do not for the most part deal with in systematic scanning of body systems, as utilized in the biomedical domain; instead adopt a holistic approach of the client. For the nurse in an institutional context, the environment in which the data are garnered and the pre-encounter data also assists in shaping the search field. If the encounter is in an antenatal clinic, for instance, the nurse would have access to data gathered previously. She/ he would possibly have prepared and designed questions before she met the woman based on expectations of the ongoing pregnancy. On the other hand, a nurse in this setting would not be prepared for an encounter with a male patient suffering from a karate accident (Carnevali, 1984). However, early on during data organization, which will permit problem determination, he is to utilize the first recognized symptoms. There may be hardly any, and these may be imprecise but they can trigger a provisional, diagnostic hypothesis that may make clear what is experienced. It seems that the effectiveness of this step varies with experience of the person for example beginning practitioner or expert and is not specific to any practice field (Carnevali, 1984). Diagnostic hypothesis activation goes after cue recognition and is often a conscious, logical, critical-thinking maneuver although it can occur without conscious effort. Because of the tentative nature of early hypotheses it is important to avoid the manipulation of data to fit an inaccurate or imprecise diagnosis (Carnevali, 1984). The next cues may offer a challenge to rethink the hypothesis - although research has demonstrated a strong inclination for clinicians not to pay attention to these cues (Carnevali, 1984: Cox, 1993). This stage of utilizing data as the basis for yielding explanations is critical. Apparently, problem labels of diagnostic classifications that are not considered cannot be empirically examined. Cox (1993) and Carnevali (1984) express this by merely expressing that clinicians make accurate diagnosis because they think of them. The success of and the skill with the rest of the assessment-diagnostic process depends on the quality of this first and repeated phase in the process. After yielding the hypothesis, the process must start converging and refining, and review (divergent) processes involved in assessing the hypothesis. All possibilities generated must be included in this evaluative phase. The final stage of this process is to select a diagnostic classification as precisely as the available data will allow. This classification coupled the data then becomes the foundation for decisions about prognosis, goals, treatment plans and activities (Carnevali, 1984). The use of probability statements is usual in medicine with these statements having been deduced from systematic observations on numerous periods over a long period. But one may dispute that the ideas of probabilities, particularly when they are expressed in a mathematical form are futile in nursing clinical judgments. It is factual and accurate to say that probability statements are best deduced from systematic observations from numerous individuals, as the medical profession has practiced. It is also true that nursing lacks an adequate empirical data base for precise expression of probabilistic relationships at this time. However, it is argued by students of clinical decision making, that both the diagnosis and prognosis depend on at least the informal assignment of probabilities to clinical data (Tanner, 1984). Practicing in the Combined Domains The integrated domains of biomedicine and nursing utilized by nurses strongly exert influence on clinical reasoning. To demonstrate this the following example given by Tanner (1984) has been presented. This incident has at its groundwork the biomedical domain when the nurse studies the signs and symptoms of hypoglycemia, secondary to short acting insulin. The indications include modifications in behavior, irritability, cold clammy skin, tremulousness and diaphoresis. Students also discuss that the causes of such a reaction are belated or missed meals, extreme exercise or insulin overdose. Thus, if this patient exhibits behavioral change, the nurse (based on this knowledge) would surmise a hypoglycemic reaction. The cue of behavioral change was an indicator but this may also imply other diagnoses. Thus, other cues are yielded and as these are identified as positive for the initial diagnosis so is it reinforced. If other factors were observed such as the omitted meal then the diagnosis becomes almost definite. In reality the only cue that will give a positive diagnosis is a blood sugar level. The diagnosis itself however, was affirmed through accretion and casual modification of the probability hypothesis with each portion of data (Tanner, 1984). This example shows the nurse’s two-prong domains of clinical reasoning and emphasizes two major ideas. First, the determination of possible associations between cues and diagnosis, which enhances the consistency of data garnered and so increases the diagnostic accuracy. Secondly, this example reinforces that the nature of the data obtainable to the nurse both in the biomedical domain and specifically in the nursing domain, is frequently undependable. Nurses must depend almost completely on their own perceptual process, and need to be competent in the use of their senses because most frequently the precise measurement and instruments are not available. Thus, the nurses job is presented to be more cognitively complicated (Tanner, 1984). The combined domains also have the possibility to cause inconsistency for the nurse practitioner. One of the nurses most contentious roles and one of the most difficult decisions she/ he will take is that to become a patient supporter when the patient is aversive to or rejects undertaking the medical treatment. In this circumstance conflict arises between the practice domains of nursing. In the biomedical domain of clinical reasoning, the nurse may feel the treatment decision is justified; however, in the nursing domain from a helping perspective it is not. While, in some cases, working in two domains may result in personal conflict, the hardship in discussing and teaching the process is also aggravated by these variables (Conrick, 1994). Much work has been undertaken in an attempt to explain and teach Clinical Decision Making in nursing and other practice disciplines. Many attempts have been made to use paper simulation and more recently computer simulation to teach the process. Mattingly (1991) depicted clinical reasoning as mainly inferred and highly inventive. He also assesses it as a profoundly phenomenological way of thinking because one can only deduce meaning from such complicated reality through prudent analysis of narrative subjective material. It is also debated that clinical reasoning deals more with the ability to provide overt reasons that rationalize clinical decisions because it is also established on implied understanding and routine knowledge gained through experience. These factors reveal a very complex cognitive process and one that is critical for the student to grasp and become skilled in its use. Cost-effective, safe nursing requires accurate clinical judgment and decisions from the nursing domain as a basis for treatment, as surely as in any other health discipline. A fact often neglected is that the client in reality, hires health professionals, either directly or indirectly for their expertise in both diagnosis and treatment. Distinctive discipline specific perspective and expertise is therefore critical. Nursing has tried to abridge and explain the clinical decision making process and many frameworks have been drafted. However, because of the nuances of the process, the task of teaching students clinical decision making persists as a challenge. Decision Making Frameworks in the Nursing Domain The trend in nursing practice, especially in North America and to a lesser degree in Australia, has been towards the establishment of a taxonomy for clinical decision making. It is difficult however to find the term that encompasses the complete process. Dick (1991) is possibly correct when he expresses that there does not seem to be an overall term in conventional usage that covers the processes of planning, problem solving and decision making. He uses the term "problem solving" to encompass all three processes. In nursing education circles, a usual working definition for problem solving is that it is the process used to resolve or answer a proposed question or attain an answer to a client need (Pinell & de Maneses, 1986). Roy (1980) depicts problem solving as assisting within the nursing process, whereas Orem (1985) explains problem solving as the way by which clients struggle for self care. In Australia, the United States of America, Canada and the United Kingdom, clinicians reject the stringent use of frameworks such as the Nursing Process Model regarding them as misleading of the process by which experts make decisions. However, theorists and many educators see a great premium in such frameworks for hand holding the novice and student towards an comprehension of the process underlying problem solving. In many areas, it is contended that this framework is the way of the future with nursing information systems most likely to integrate these types of nursing frameworks. Truly, much work has been carried out in the United States towards this goal. However, it is the clear purpose of nursing to determine and address client problems in the nursing domain, whether it is by utilizing a problem solving approach, problem statements or the nursing process models. All these approaches are valid methods for problem solving in nursing education and clinical practice. Although practitioners have been slow to embrace the Nursing Process Model in their practice, this has not been the case with theorists and educators. According to Klaassens (1992) most of the models and strategies described the literature use the nursing process as a guide or reinforcement According to Koch and McGovern (1993), since the introduction of the Nursing Process, difficulties have been encountered by both nurse educators teaching this subject matter and practitioners trying to rationalize the process. An identified lack of knowledge of the diagnostic task, and subsequent recommendation that educators address the issue, were made by Kelly (1986) and supported by many others (Grier 1981; Field 1983). These authors speculate on the cognitive strategies used by nurses. Field (1983) saw community health nurses frequently collecting data, but failing to determine the relationships. In effect, they were seen to make disfavored judgments or they did not come up with the apt conclusions. However, Grier (1981) thought that the nurses might have lacked formal education in essential cognitive strategies. Empirical Studies on Nurses’ Decision Making After a thorough review of the issues behind teaching clinical decision making to nurses, it is worth presenting empirical data on the topic. The first study conducted by Bakalis and Watson (2005) identified the decisions nurses undertake in medical, surgical and critical care areas; the results were subsequently compared. To carry out the study, the researchers administered a clinical decision making questionnaire (CDMQ), which was composed of 15 self-constructed items. The total sample size was 60, with 20 nurses from each of the three areas of interest. The results suggest that majority of the nurses in all three areas recurrently make decisions on direct patient care, encompassing the provision of primary clinical care and psychological support, and giving instructions to patients and/ or family members. While management of the work environment was among their tasks, they did not exercise discretion over the ward or unit budget, oversee subordinates, or coach trainee nurses. Critical care nurses frequently made decisions in relation to their extended roles, including acting in crisis situations, and choosing to modify patient medication. On the other hand, surgical care nurses only undertook this intermittently. The extent of clinical experience is considerably associated with decision-making frequency. The researchers assert that the decisions that nurses make are straightforwardly related to the clinical areas to which they belong. A future twist to the study may be to determine if the nurses had specific aptitudes for certain types and levels of decision making, and if this is associated to personality, education and experience in nursing. Beeken (1997) investigated the relationship between self-concept and critical thinking ability among nurses. He utilized the CCTST to assess critical thinking; on the other hand, the Tennessee Self Concept Scale (TSCS) was used to gauge self concept. The results suggest that there were no statistically significant relationship between CCTST and TSCS scores. Nurses with a baccalaureate degree had statistically higher CCTST scores in comparison to nurses with an associate/diploma degree. These results are supported by the findings of Howenstein, Bilodeau, Brogna, and Good (1996). They gauged the critical thinking ability of nurses using the Watson Galser Critical Thinking Apprasial Tool (WGCTA), using four variables, namely age, level of education, years of nursing experience, and area of expertise in nursing. Age and years of experience negatively associated with WGCTA scores. Level of education was positively associated with WGCTA scores. Lastly, there was no significant correlation with WGCTA and area of practice. The descriptive correlational study by Polge (1995) studied the variables of self-reported level of nursing proficiency, years of clinical experience, and use of intuition, to make clinical judgments. The results suggest that as the degree or level of proficiency increased, the use of intuition to make judgments also increased. There was a positive relationship between the levels of nursing proficiency and years of clinical experience. Finally, Polge also asserts that as nursing clinical experience increased, there is an increase in the use of intuition to make clinical judgments. These results seem to support the previous studies of Beeken (1997) and Howenstein et al (1996) on the positive association between level of nursing education and critical thinking as a competency. Profetto-McFrath, Hesketh, Lang, and Estabrooks (2003) undertook a study entitled A study of critical thinking & research utilization among nurses which demonstrated the relationship between critical thinking disposition scores and research utilization habits. The results suggest a positive correlation between critical thinking disposition score and overall research utilization. Rapps, Reigel, and Glasser (2001) conducted a study was to assess if knowledge base, critical thinking skills, critical thinking dispositions, and experience could predict the cognitive development of registered nurses. Three levels of cognitive development (dualism, relativism, and commitment) were utilized. The results of the study indicate that critical thinking skill was a relevant contributor to duelism; critical thinking dispositions contributed to all three levels of cognitive development. Finally, they assert that experience contributed to commitment. Pardue (1987) upholds that a critical factor in nursing practice is the nurses ability to process information and to make decisions. One objective of majority of nursing programs is to improve students cognitive abilities and clinical decision-making skills. This study researched on the differences in critical thinking ability and decision-making skills among 121 associate degree, diploma, baccalaureate, and masters-prepared nurses. The results of the research suggested that nurses with masters and baccalaureate degrees had the highest scores in critical thinking ability. Subjects decision-making skills were gauged in relation to: 1) frequency in making decisions, 2) difficulty in making decisions, and 3) factors which influence decision making. There were no significant differences demonstrated among the four groups related to the three dimensions of decision-making skills. Moreover, experience and knowledge were the most significant determinants of decision making. The study findings suggest further investigation of the differences among nursing students related to cognitive abilities. On the con side (i.e. education does not influence critical thinking ability) a study by Hicks, Merritt and Elstein (2003) researched on the relationship of education level, years of critical care experience, and critical thinking ability and dispositions to consistency in clinical decision making among critical care nurses. The results indicate, in contrast with Beeken’s (1997) and Howenstein et al’s (1996) study, that education and experience were not associated to critical thinking ability. Moreover, critical thinking ability was not linked to decision making consistency. Notably, years of critical care experience was the only factor related to decision making consistency. Still another research undertaken by Maynard (1996) investigated the associations between critical thinking ability and professional competencies of leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal communication, and professional development. The results indicate that critical thinking ability did not change during nursing school (sophomore to senior). This seems to support the idea that education does not have any significant influence on critical thinking. A relevant increment in critical thinking ability was observed with practicing nurses. Moreover, no relationship was found between CT scores and clinical competence. The critical component of practice was the critical determinant factor competence and critical thinking development. A related research by Duchscher (2003) attempted to explain the development of critical thinking in five newly graduated BSN RNs over their first six months of nursing practice. Results both supported and questioned the practice of critical thinking among the participants. There was an apparent lack of specific factors of critical thinking among them. They could easily depict critical thinking and its elements; however, their nursing practice did not always associate with the application of these elements. They tended to manifest linear thinking and stringently brought forth ideas related to critical thinking, but were unable to integrate this into their practice. Such inadequacy, and the results of the Beeken (1997) study seem to point out that there really exist critical thinking differences among nurses attributed to level of education and experience. Given the contradictory findings of past literature regarding the effects of level of nursing education, the current study intends to investigate whether post graduate nursing education significantly enhances critical thinking ability among nurses. References Bakalis, N. & Watson, R. (2005). Nurses’ decision making in clinical practice. Nursing Standard, 19 (23), 33-39. Balla, J. (1990). Insights into some aspects of clinical education - 1 Clinical practice. Postgraduate Medical Journal, 66, 212-217. Beeken, J.E. (1997). The relationship between critical thinking and self-concept in staff nurses and the influence of these characteristics on nursing practice. Journal of Nursing Staff Development, 13(5), 272-278. Benner, P. (1984). From Novice to Expert. California, Addison-Wesley. Carnevali, D. (1984). Diagnostic reasoning in nursing. Philadelphia: J B Lippencott Company. Conrick, M. (1994). Developing computer based education software for teaching clinical decision making in nursing. Faculty of Medicine. Sydney, University of New South Wales. Cox, K. (1993). Learning Clinical Reasoning. Sydney: University of New South Wales. Dick, B. (1991). Helping Groups to be Effective. Brisbane: Interchange. Duchscher, J.B. (2003). Critical thinking: perceptions of newly graduated female baccalaureate nurses. Journal of Nursing Education, 42(1), 14-27. Field, P. (1983). An ethnography: four public health nurses perspectives of nursing. Journal of Advanced Nursing, 8 (3), 3-12. Grier, M. (1981). The need for data in making nursing decisions. Nursing Information Systems. H. Werley & M. Grier. New York: Springer Publishing. Hicks, F.D., Merritt, S.L., & Elstein A.S. (2003). Critical thinking and clinical decision making in critical care nursing: a pilot study. Heart & Lung, 32(3), 169-80. Howenstein, M.A., Bilodeau, K., Brogna, M.J. & Good, G. (1996). Factors associated with critical thinking among nurses. Journal of Continuing Education in Nursing, 27(3), 100-103. Kelly, L. (1986). Clinical inference in nursing: Part 1, a nurses viewpoint. Nursing Research, 15, 1, 23-26. Klaassens, E. (1992). Strategies to enhance problem solving. Nurse Educator, 17 (3), 28-31. Koch, B. and B. McGovern (1993). EXTEND: a prototype expert system teaching nursing diagnosis. Computers in Nursing, 11(1), 35-40. Mattingly, C. (1991). What is clinical reasoning? American Journal of Occupational Therapy, 45 (11), 979-86. Maynard, C.A. (1996). Relationship of critical thinking ability to professional nursing competence. Journal of Nursing Education, 35, 12-18. Orem, D. (1985). Nursing: Conceptions of Practice. New York: McGraw-Hill. Pardue, S. (1987). Decision-making skills and critical thinking ability among associate degree, diploma, baccalaureate, and masters-prepared nurses. Journal of Nursing Education, 26 (9). Pinell, N. & deManeses (1986). The Nursing Process: Theory Application and Related Process. Norwalk., Appleton- Century Crofts. Polge, J. (1995). Critical thinking: the use of intuition in making clinical nursing judgments. Journal of the New York State Nurses Association, 26(2), 4-9. Profetto-McFrath, J., Hesketh, K.L., Lang, S., Estabrooks, C.A. (2003). A study of critical thinking & research utilization among nurses. Western Journal of Nursing Research, 25(3), 322-337. Rapps, J., Riegel, B., & Glasser, D. (2001). Testing a predictive model of what makes a critical thinker. Western Journal of Nursing Research, 23(6), 610-626. Roy, C. (1980). The Roy Adaptation Model. Conceptual Models for Nursing Practice. Tanner, C. (1989). Clinical Decision Making Research and Teaching. Victoria, BC: Western Region Canadian Association of University Schools of Nursing. Read More