Page 30 - ACCCN's Critical Care Nursing

Scope of Critical Care Practice 7

The analytical approaches arise from a positivist or ratio- Other studies indicated that experienced and inexperi-
nalist perspective and focus on analysing behaviours enced nurses differ in their decision making skills, 67,70,71
and the steps involved in problem solving. Some of the and that role models or mentors are important in assist-
specific theories that fall into this category include infor- ing to develop decision making skills. 72
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mation-processing theory (IPT) and decision analysis
theory (DAT). 60 RECOMMENDATIONS FOR DEVELOPING
Fundamental to IPT is the premise that reasoning consists CLINICAL DECISION MAKING SKILLS
of a relationship between the problem solver and the Several strategies can be used to help critical care nurses
context within which the problem occurs. This theory to develop their clinical decision-making abilities (Table
asserts that relevant information is stored in one’s memory 1.2). 73-75 These strategies can be used by nurses at any
and that problem solving occurs when the problem solver level to develop their own decision-making skills, or by
retrieves information from both short- and long-term educators in planning educational sessions.
memory. Additionally, IPT claims that there are limits to
the amount of information that can be processed at any In summary, clinical decision making is a component of
given time. Thus, IPT focuses on understanding how the clinical reasoning process that is part of everyday criti-
information is gathered, stored and retrieved. DAT focuses cal care nursing practice. It involves gathering and analys-
on the use of decision trees, mathematical formulas and ing information in order to arrive at a decision about a
other techniques to determine the likelihood of meaning- particular course of action. The analytical or rationalist
ful clinical data. These rationalist approaches focus on perspective of clinical decision making focuses on analys-
diagnosing a problem, intervening and evaluating the ing behaviours and the steps in solving a problem, while
outcome. 61 the intuitive or humanistic approach centres on intuitive
knowledge and the context of the decision. In this spe-
Contrary to the analytical approaches, intuitive approaches cialty area nurses are making clinical decisions at a rate
(also termed humanistic, hermeneutic or phenomeno- of two to three per minute. 61,68 Given this, it is important
logical) focus on the importance of intuitive knowledge that clinical decision-making skills be developed through
and context in clinical decision making. 40,62,63 That is, experience, training and education. Previous research has
expert intuition develops with experience and can be demonstrated that a number of strategies, such as case
used to make complex decisions. Both intuitive knowl- studies and reflection on action, can be used to assist
edge and analytical reasoning contribute to clinical deci- nurses in developing these important skills.
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sions. Intuitive approaches to decision making therefore
focus on understanding the development of intuition, the LEADERSHIP IN CRITICAL
role of experience and articulating how nurses use intu-
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ition to make a decision. In addition, Australian authors CARE NURSING
have described a naturalistic framework to examine criti- Effective leadership within critical care nursing is essen-
cal care nurses’ decision making, describing it as a way tial at several organisational levels, including the unit and
of considering how people use their experience when hospital levels, as well as within the specialty on a broader
making real-life decisions.
professional scale. The leadership required at any given
RESEARCH ON DECISION MAKING IN time and in any specific setting is a reflection of the sur-
rounding environment. Regardless of the setting, effective
CRITICAL CARE NURSING leadership involves having and communicating a clear
Critical care nursing practice has been the focus of many vision, motivating a team to achieve a common goal,
studies on decision making. As multiple, complex deci- communicating effectively with others, role modelling,
sions are made in rapid succession in critical care, it is an creating and sustaining the critical elements of a healthy
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ideal setting for studying clinical decision making. The work environment and implementing change and inno-
seminal work by Benner and colleagues 40,63,65 focused on vation. 76-79 Leadership at the unit and hospital levels is
critical care nurses. Table 1.1 summarises 10 studies (11 essential to ensure excellence in practice, as well as ade-
publications) conducted on critical care nurses’ decision quate clinical governance. In addition to the generic strat-
making over the past decade. egies described above, it is essential for leaders in critical
care units and hospitals to demonstrate a patient focus,
Of note, 7 of the 10 studies were conducted in Australia, establish and maintain standards of practice and collabo-
with two multinational studies also including Australia. rate with other members of the multi-disciplinary health-
All but two studies 66,67 used qualitative approaches such care team. 76
as observation, interviewing and thinking aloud. Two
studies reported the types and frequency of decisions Leadership is essential to achieve the growth and develop-
made during the time period and identified that critical ment in our specialty and is demonstrated through such
care nurses’ decisions were related to interventions and activities as conducting research, producing publications,
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communication, 61,68 evaluation, assessment, organisa- making conference presentations, representation on
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tion and education. A further study demonstrated that relevant government and healthcare councils and com-
critical care nurses generate one or more hypotheses mittees, and participation in organisations such as the
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about a situation prior to decision making. All three ACCCN and the WFCCN. As outlined earlier in this
studies highlighted the importance of enabling expert chapter, we have seen the field of critical care grow from
nurses to provide a narrative account of their practice. early ideas and makeshift units to a well-developed and