Other investigations of clinical decision making have shown an intuitive pattern of knowing in nurse clinical decision making (Benner, 1984; Benner & Tanner, 1987; Phillips & Rempusheski, 1985; Pyles & Stern, 1983; Hew, 1988, 1990). From novice to expert. For example, during an observation one nurse explained that her decision making during that day *would not be at her normal level of excellence because she had been off for several days and did not know her patients. Nurse informants were instructed to write down two personal experiences in which they made a decision about a patient's problem or need prior to the focus group sessions. 315-323). Yet, as they describe situations in which collaboration with physicians is requested, the request made by the nurse is often intended to influence the physician to do something, rather than to request the physician's collaboration in decision making. Padrick, K., Tanner, C-, Putzier, D., & Westfall, U. As the nurse proceeded she interacted differently with each patient. Whether your encounters are brief or longer, you're in and out of their room for the eight or 12 hours that you're on that shift. This type of knowledge comes to us through the process of observation, reflection, and self-actualization. The nurse informants said they desire equal relationships with physicians in which each is a co-partner in decision making. The following situation is an example. An experienced nurse describes a situation in which she is caring for a patient on a psychiatric unit who had been admitted for treatment of depression. Bevis, E. (1988). Personal Knowing: Carper (1978), describes personal knowing as striving to know the self and to actualize authentic relationship between the nurse and the one nursed. The role of experience, narrative, and community in skilled ethical comportment. Personal knowledge or knowing is one of those patterns. Along with empirics, aesthetics and ethics, personal knowing was understood as an essential attribute of nursing knowledge evolution, setting the context for the nurse to become receptively attentive to and engaged within the interpersonal processes of practice. The result is a description of the pattern of personal knowledge in nurse clinical decision making. Hypothesis evaluation: A component of diagnostic reasoning. Four focus group sessions were used for data collection during Phases I and II of the study. ), Classification of nursing diagnosis: Proceedings of the seventh national conférence (pp. Clinical decisions for informants are influenced by relationships between and among nursing staff. Nurse informants label the pattern of personal knowledge as knowing, and describe their success in making clinical decisions as highly dependent upon the quality of interpersonal relationships with patients, peer nursing staff, and physicians. The nurse was caring for a patient in the immediate postoperative period following a laryngectomy. Personal knowing is the reflection on past challenges. She then uses the interaction as a method to motivate the patients to cooperate in their rehabilitative process. The investigator spoke with the nurse informants during or immediately following each observation to clarify the intent of actions observed. Another nurse says, "I think it is very important to talk with them [physicians] each day to get their plan of care, and also to give them my ideas about how a patient has been responding to the plan so that I can best help the patient.". This pattern covers fundamental values and aspects in the nursing code of ethics such as self-, respect, value for human dignity, accountability, among others. However, our understanding of nurse clinical decision making remains incomplete, especially in view of the fact that it occurs within the context of complex human organizations. ", Nurses in the study give a variety of reasons for needing to collaborate with physicians for the purpose of decision making. Becoming Whole: The Role of Story for Healing Show details . "Pattern of knowing in nursing" is used to examine the kind of knowing in nursing that provides the discipline with its particular perspective and significance. (1988). One nurse said, "It's a good feeling when you know that someone respects your opinion and respects your assessment of the patient also. Peacekeeping behaviors were observed in nurses when they recognized a conflict and acquiesced to another's opinion or wishes to resolve it. Intuition in decision-making. Observations and informant experiences include many examples of group decision making. A decision-making model for diagnosing and intervening in elder abuse and neglect. It demands a caregiver to have intimate knowledge to approach patients as a person to form an authentic relationship. On the other hand, it is an essential pattern of understanding the meanings of health terms of the well-being of individuals. Knowing patients, fellow staff, and, in some instances, physicians was a major influencing factor in the nurses' clinical decision-making ability. Then when they understand what's going on they're not so nice anymore and the whole relationship changes. Investigators have also demonstrated that nurses' decision making is characterized by acquisition and cognitive organization of vast amounts of patient-generated cues (Cianfrani, 1984; Fitzmaurice, 1987; Itano, 1989; Tanner, Padrick, Westfall, Putzier, 1987). Additional scientific rigor was assured through careful identification of the source of all data in the study. New York: NLN. Knowing the patient: One aspect of clinical knowledge. St. Louis, MO: C.V. Mosby Co. Corcoran, S.A. (1986a). New York; NLN. Additional qualitative studies of the knowing theme would facilitate a deeper understanding of this important aspect of nurse clinical decision making. No interview guide was used. She questions whether it is right or wrong to give the medication, yet she still does as her peers persuade her to do instead of following her belief. Focus group discussion and participant observation were two methods of data collection used. All these studies emphasize the knowledge gained from a personal relationship with patients and the importance ofthat knowledge in clinical decision making. The present investigation was designed to provide insight into additional intelligences or patterns of knowing beyond cognition, intuition, and experience inherent in nurse clinical decision making. Dimensions of Critical Care Nursing, 9, 30-33. The ratio of male to female (1:22) informants parallels the ratio of male to female nurses in the hospital. Many factors have been identified that diminish nurses' ability to establish the necessary interpersonal relationships. However, as the above example points out, nurses do not always take information communicated in report at face value. From beginner to expert: Gaining a differentiated clinical world in critical care nursing. Holistic Nursing Practice, 1, 52-62. This report describes knowing, which is one of those themes. At first she called the first-year resident covering the patient to ask for assistance. Personal knowing reflects in the engagement between a nurse and patients. All units were general, non-intensive care units. In A. McLane (Ed. In A. McLane (Ed. A thorough practice-based understanding of clinical decision making helps nurse educators to develop teaching methodologies that are more reflective of clinical practice, which narrows the education-practice gap. Personal. This article reconsiders the fundamental patterns of knowing in nursing in light of the challenge of narrow empirics in the form of evidence-based practice.Objections to the dominance of evidence-based practice are reviewed, and the reasons for it are examined. Understanding four fundamental patterns of knowing makes possible an increased awareness of the complexity and diversity of nursing.knowledge.” (page 21). Menlo Park, CA: Addison-Wesley Publishing Company. Gardner (1985) and Sternberg (1988), however, propose that intelligence is a multifaceted entity extending beyond the traditional view of pure cognition. In this paper the relevance of personal knowledge is discussed with respect to nursing practice, especially in older adult care. The nurse in this vignette describes how she goes about establishing the interpersonal relationship with the patient. The informants represent a range of work experience (1 to 21 years) and basic educational preparation (13 baccalaureates, four associate degrees, six diplomas). The investigator first read each transcript to gain an appreciation of the text as a whole. She said she didn't know this intern well because "he was new on the service." Educational efforts focused on effective clinical decision making should include skill building in cognitive, intuitive, and interpersonal skill. Units of information ranged in length from a short phrase to five paragraphs in length. Nurse clinical decision making requires multiple intelligences or patterns of knowing. Armed with an understanding of nurse's and physician's roles, students should then be taught skills in negotiation and conflict resolution so they can effectively solve conflicts as they arise. Six fundamental ways of knowing underpin nursing science. The dynamic of this relationship was influenced by nurses' resentment toward first-year residents as they became confident in their new role. American Journal of Nursing, 87, 23-31. Nurses were then directed to begin their contributions in each focus group by sharing stories. Examining further the perceptions of both parties in the relationship would also be important factors to study.
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