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NUR4153CBE Rasmussen Factors That Influence Clinical Decision Making Discussion

NUR4153 Deliverable 1ScenarioYou are working as a charge nurse on a medical-surgical unit in an acute healthcare facility. One of the staff nurses who recently from bereavement leave has been assigned to care for an elderly client, newly diagnosed with stage IV pancreatic cancer. While you are visiting with the client, the nurse is completing her assessment. The client requests assistance to set up hospice care, complete an advanced directive, and reach out to his estranged daughter. The nurse stated, “I can get you the paperwork for the advance directive, but I can’t call your child for you, I am not a social worker.” The nurse leaves the room and asks to speak with you stating, “I can’t care for this client, I need my client assignment changed now or else I will go home.”As the charge nurse, you step in and change the nurse’s client assignment and offer to assist the client with his requests. Later, you have the opportunity to debrief with the nurse regarding her reaction and decisions regarding the client’s requests and make some recommendations on how the nurse could have responded differently. You write up a summary of the events and include the follow-up conversation with the nurse.InstructionsCompose a written memo of the situation and debrief for the employee’s personnel file. Include the following in the summary:Analysis of the internal and external cues impacting the responses of the staff nurse and the charge nurse.Describe how these factors influenced the clinical decision making of both nurses.Emotional intelligence action plan for the nurse based on interactions observed with the client and the charge nurse.Include self-compassion and compassion toward others.Include an alternative response from the staff nurse and charge nurse.ResourcesHow do you compose a memo?How can I make a Research Appointment with a Rasmussen College Librarian?Rasmussen Writing GuideAPA Guide

NUR4153CBE Clinical Reasoning Material
Grading Rubric
Internal and External Factors
Before 1950, the apprenticeship model informed nursing practice with the
focus on learning through interactions with individual and situations
rather than cognitive processing and problem-solving. Between 1950 and
1970, the nursing process was developed and emphasized structured
clinical problem-solving skills in a four-step process: assessment,
planning, intervention, and evaluation. Over time nurses realized
perspectives of nursing practice were different from medical practice and
led to the recognition of unique nursing phenomena and knowledge
taxonomies known as nursing diagnoses. Eventually, nursing scholars
questioned how nurses blended scientific knowledge with unique
characteristics and contexts of client care. The progressive building of a
scholarly body of nursing knowledge led a movement away from simple
problem-solving to outcomes-based nursing practice, the basic structure
for clinical reasoning. Subsequently, the American Nursing Association
identified six steps essential to reflective clinical reasoning:
1.
2.
3.
4.
5.
Assessment
Diagnosis
Outcomes Specification
Planning
Implementation (includes coordination of care, health teaching and
promotion, consultation, and prescriptive authority and treatment),
6. Evaluation
Current nursing practice guidelines recognize clinical reasoning as
cognitive and metacognitive thinking to process through complex
relationships between internal and external factors within a specific
context (Kupier, 2017).
Internal Factors
Self-regulation is a process for purposeful clinical reasoning in nursing
practice and involves awareness of how a person thinks when applying
self-monitoring and self-reflection. Self-monitoring occurs when a nurse
recognizes individual strengths, weaknesses and habitual behaviors
when considering goals for performance. Self-reflection is the
intersection of personal, behavioral and environmental processes within
a contextualized situation affecting outcome based decisions (Kupier,
2017). In the Nursing Clinical Judgment Model, internal factors that
contribute to a nurse’s ability to process information and make decisions
are education, knowledge, emotions, confidence, personal values,
professional orientation, and experiential learning (Dickison et al., 2016).
External Factors
Gathering evidence is key to effective clinical reasoning in nursing
practice and begins when a nurse is exposed to the context of a
situation. Nurses gather external cues as part of information processing
and integrate memories from prior reference points with relevant external
factors as the first step to creative problem solving. External or
environmental factors in the Nursing Clinical Judgment Model include
task complexity, time pressure, distractions interruptions and
professional autonomy (Dickison, et al., 2016).
Clinical Reasoning
In the practice setting, nurses gather internal and external factors as
cues influencing cognitive processing and the generation of expected
behaviors aligned with expected client outcomes. Clinical reasoning is
“the process used to assimilate information, analyze data and make
decisions regarding patient care” (AACN, 2008, p. 36).
To examine clinical reasoning in context, consider this scenario:
The nurse assigned to care for this client has worked for eight years in
Labor and Delivery, recently transferred to the emergency department,
and is currently orienting with a Preceptor with ten years prior experience
as a critical care nurse. To examine the relationship of how internal and
external factors impact clinical reasoning, review these tables comparing
how the nurse new to the area versus the nurse with years of prior
experience process cognitive decisions and expected behaviors.
New Nurse vs. Nurse with Prior Experience
Expected
Internal Factors
External Factors
Behaviors
NEW NURSE




No established
prior education
directly related
to critical care
with adults.
May have
critical care
experiences
but only
related to labor
and delivery
and not with
older adults.
Limited to no
confidence
communicatin
g with an
elderly adult
client.
Expected
higher than
normal levels
of stress and
emotional
perceptions of
consequences
and risks
based on
personal
experiences
NEW NURSE



High task
complexity
due to client
status
declining
evident by
objective
evidence
leading to
time
pressure to
determine
the
appropriate
course of
action.
In the role
of
preceptee
with limited
professional
autonomy.
Emergency
Department
typical
chaotic
atmosphere
is leading to
multiple
distractions.
NEW NURSE


Recognize
the strength
of value for
ethical
nursing
practice and
admit
weaknesses
related to
internal cues
related to
education
and
experience.
Defer
decisions for
care to
experienced
nurse
recognizing
external
cues
indicating
the need to
timely,
appreciate
client care.

with elderly
family
members.
Self-awareness
of limited
ability to
determine
professional
care decisions
due to limited
experience
specific to the
situational
context.
NURSE WITH PRIOR
NURSE WITH
NURSE WITH
EXPERIENCE
PRIOR
PRIOR
EXPERIENCE
EXPERIENCE



Prior
education and
experience
directly related
to critical care
with adults.
High degree of
confidence
paired with low
stress and
emotional
responses
based on the
history of the
common
situational
context within
the emergency
department.
Self-awareness
of need to


Low task
complexity
and time
pressure
with
expected
objective
data for a
typical older
adult client
presenting
with a
history of
vomiting
and
diarrhea.
Distractions
and
interruption
s present



Recognize
hypovolemia
.
Recognize
hypotension.
Recognize
the need for
quick
retrieval of
more data.

react quickly in
this situation
and knowledge
of appropriate
decisions.
Professional
self-orientation
high based on
designation as
Preceptor, an
expert in this
area of nursing
practice.

but not an
external
factor as
expected
after years
in this
practice
setting.
Professiona
l autonomy
high due to
assignment
as
Preceptor
viewed as
external
recognition
of expertise.
References:
AACN (2008). The essentials of baccalaureate education for professional
nursing practice. Retrieved from
https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.p
df.
Dickison, P., Luo, X., Kim, D., Woo, A., Muntean, W., and Bergstrom, B.
(2016). Assessing higher-order cognitive constructs by using an
information-processing framework. Journal of Applied Testing in
Technology. 17(1). p. 1-19. Retrieved from
https://ncsbn.org/AssessingHigherorder CognitiveConstructs_2016.pdf.
Kuiper, R., O’Donnell, S. M., Sigma Theta Tau International, Pesut, D. J.,
& Turrise, S. L. (2017). The Essentials of Clinical Reasoning for Nurses.
Indianapolis, IN Sigma Theta Tau International. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/logi
n.aspx?direct=true&db=nlebk&AN=1525699&site=eds-live.
Emotional Intelligence Action Plan
Emotional intelligence is the ability to recognize, appropriately express
and effectively manage emotions. Characteristics necessary to design
and maintain an effective plan for emotional intelligence in nursing
include:




motivation to engage emotionally with self and others through
empathy and compassion
self-control to integrate cognitive processing with emotions
self-awareness to recognize the impact of emotions on clinical
judgment
adeptness to form appropriate personal and professional
relationships (Schub and Smith, 2017).
Often nurses are expected to remain distant from complex emotional
situations to maintain objectivity, yet practice compassion as a way to
share suffering. This dichotomy of relating to self and others can be
exhausting and lead to diminished emotional intelligence in nursing
practice unless an emotional intelligence plan exists. Research regarding
the impact of emotional intelligence on clinical reasoning and decision
making revealed three key components of a nursing specific emotional
intelligence plan:
1. emotional capacity
2. emotional motivation
3. emotional reasoning (Hutchinson, Hurley, Kozlowski and
Whitehair, 2017).
References:
Hutchinson, M., Hurley, J., Kozlowski, D., & Whitehair, L. (2018). The
use of emotional intelligence capabilities in clinical reasoning and
decision-making: A qualitative, exploratory study. Journal of Clinical
Nursing, 27(3/4), e600–e610. doi: 0.1111/jocn.14106.
Schub, T. B., & Smith, N. R. M. C. (2017). Emotional Intelligence in
Nursing Practice. CINAHL Nursing Guide. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/logi
n.aspx?direct=true&db=nup&AN=T903079&site=eds-live
Emotional Intelligence Plan Example

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