Overview: Clinical decision making

Clinical decision making allows nurses to make informed choices about patient care. Effective clinical decision making helps nurses navigate patient needs within various clinical scenarios, and is essential for providing safe, quality care and improving patient outcomes. Clinical decision making requires clinical reasoning, which is a complex cognitive process that uses nursing knowledge to assess, analyze, and interpret the significance of patient data. Clinical judgment is the result of this complex, iterative process, where the nurse chooses a course of action from several options and makes decisions about patient care.

Alright, let’s look at concepts and frameworks nurses use to make decisions, including clinical judgment models; Maslow’s hierarchy of needs; airway, breathing, and circulation, or the ABCs; safety; distinguishing between acute and chronic conditions; and providing the least restrictive and least invasive care.

Two primary models used to explain the process of making clinical judgments include Tanner’s Clinical Judgment Model and the Clinical Judgment Measurement Model, or CJMM.

Tanner’s Clinical Judgment Model guides both novice and expert nurses in developing clinical judgment, and includes four main components: noticing, interpreting, responding, and reflecting.

On the other hand, the CJMM explains the process of arriving at clinical judgments and is made of several layers. Layer 3 contains six tangible tasks, which guide the nurse to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. These steps help make clinical decisions and support nurses in managing complex patient conditions.

Switching gears, Maslow's Hierarchy of Needs is a framework for understanding and prioritizing patient care based on ascending levels of human needs. Maslow's hierarchy of needs organizes a patient’s needs by priority, typically illustrated as a five-tier pyramid. Since fundamental needs must be met before higher-level needs can be pursued, these needs are at the pyramid base, while higher-level needs are at the top. So, at the base of the pyramid are physiological needs essential for human life, such as oxygen, fluids, nutrition, body temperature regulation, and elimination. Once these needs are satisfied, the focus shifts to safety and security needs, including physical and psychological safety. Next is the need for love and belonging, which refers to having social relationships, like friends and family. Moving higher in the pyramid is the need for self-esteem, which encompasses a patient’s sense of self-worth and positive self-image, as well as feeling valued and respected by others. Finally, at the top of the pyramid is self-actualization, which involves reaching one's full potential and achieving personal goals through continuous self-improvement.

Like Maslow’s hierarchy of needs, the ABCs help nurses prioritize care when making clinical decisions to ensure the most critical issues are addressed first. A, for airway, involves evaluating whether the patient's airway is open, patent, and clear. This has the highest priority because without an open airway, oxygen can’t reach the lungs, which can quickly lead to oxygen deprivation, brain injury, and eventually death. If the patient’s airway is secure, the next priority is B, for breathing, or the process of ventilation to support gas exchange. After ensuring a patient’s breathing is effective, the focus shifts to C, for circulation, or the movement of blood, oxygen, and nutrients essential for vital organs and tissues.

Exceptions to the ABC sequence occur in emergency situations when cardiopulmonary resuscitation is required or when massive, uncontrolled external bleeding is present. In these cases, addressing impaired circulation through hemorrhage control and chest compressions are the highest priority, and the order changes to circulation or compressions, airway, and breathing, also called CAB, to ensure blood flow to vital organs is maintained.

Similarly, distinguishing between acute and chronic conditions can guide nurses when prioritizing patient care and making clinical decisions. Acute conditions have a sudden onset of symptoms that last a short time, usually days or weeks, and typically require immediate or urgent care to treat illness and prevent complications. In contrast, chronic conditions have a gradual onset of symptoms and can worsen over time. Symptoms last more than 6 months, can impair the functioning of multiple body systems, and require ongoing care and monitoring. When making clinical decisions, nurses consider the urgency of treating acute conditions and usually prioritize these over chronic conditions.

Nurses prioritize care during clinical decision-making using methods that are the least restrictive and least invasive as possible. Restrictive care involves methods that limit a patient's movement, like physical or chemical restraints. Invasive care involves diagnostic procedures or other methods of care that require entering the body in some way, like through an incision, puncture, or by placing medical equipment inside the body.

Finally, patient safety involves protection from psychological and physical injury by minimizing the risk of harm to individuals seeking health care. Healthcare organizations adopt evidence-based practices to enhance patient safety, such as using at least two methods to identify patients, implementing fall precautions, and infection control practices. Patient safety is considered during clinical decision making as nurses plan and prioritize care that will promote patient safety and minimize risk of harm.

Now, let’s look at a scenario where a nurse uses these frameworks to make decisions and prioritize care.

Nurse Priya is caring for Charlie, a 78-year-old man with a history of hypertension and heart failure, who was admitted to the cardiac unit with shortness of breath.