applied clinical decision making for nurse specialists in mhc · michiel beekman, manp tobias...
TRANSCRIPT
Applied clinical decision
making for Nurse
Specialists in MHC10th ICN NP/APN Conference Rotterdam
Diana Polhuis, MANP, MSc in Nursing
Wim Houtjes, MANP, MSc in Nursing, PhdIn cooperation with
Nynke Boonstra, MANP, MSc in Nursing, Phd
Sita Roorda, MANP
Michiel Beekman, MANP
Tobias Kalverdijk, MANP
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Disclosure presenters
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Why?!
What for?
Use existing classification
models?
DSM-5 (APA, 2013)
ICF (WHO, 2017)
Functional health patterns (Gordon, 2014)
NANDA-international (Herdman & Kamitsuru, 2014)
NOC (Moorhead, Johnson, Maas & Swanson, 2012)
NIC (Bulechek, Butcher, Dochterman & Wagner, 2012)
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Facts & background Evidence for positive relationship critical thinking &
clinical decision making in nursing (Lee et al., 2017)
Good decision making = combination of intuitive & analytic aspects (Chen et al., 2016)
Good decision making = following the process & critical thinking (Van Graan, Williams & Koen, 2016; Dowden et al., 2011)
We noticed the tendency to make clinical decisions intuitively, less analytically (complexity of required skills?)
Effective teaching & training = continuing exposure to cases in several contexts, feedback, role modelling (Van
Graan, Williams & Koen, 2016; Dowden et al., 2011)
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What did we do? Uniformity in the format of complex
clinical decision making (including
existing classification models)
Uniformity in the format of a
personalised descriptive diagnose
(medical & nursing diagnostics
included)
Internalizing analytic & intuitive
clinical decision making and critical
thinking by repeatedly case
exposures, feedback, modelling in
groups
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The course
1st year: every step in detail +
practising
2nd year: refreshments of steps+
practising
3rd year: refreshments of steps+
practising +
casestudy/presentation
(Herdman & Kamitsuru, 2014)
continuing exposure in practice to cases in several contexts, feedback, role modelling
✚
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The steps Step 1: Data Collection:
Known data
Functional health patterns (Gordon)
ICF (WHO)
Psychiatric screening
Somatic screening
Extra diagnostic research
Suicidality screening
Step 2: Psychiatric & nursing diagnoses
Step 3: Validating the personalized descriptive diagnose
Step 4: Determine treatment goal & measurable outcome
Step 5: Determine interventions
Step 6: Provide treatment
Step 7: Evaluate
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Example part of step 1:International
Classification of Functioning (WHO)
Dirty home
Absence of support
system (no friends)
Withdrawn
Debts
Insomnia
Craving (for
alcohol)
Flat
affect/sombreness
Cognitive
impairments
(>stress)8
Example part of step 2: which nursing diagnosis?
- Alcohol abuse
- Dirty home
- Flat
affect/sombreness
- Absence of support
system (no friends)
- Withdrawn when
stress occurs
- Debts
- Insomnia
- Alcohol abuse
- Dirty home
- Flat
affect/sombreness
- Absence of support
system (no friends)
- Withdrawn when
stress occurs
- Debts
- Insomnia
- Alcohol abuse
- Dirty home
- Flat
affect/sombreness
- Absence of support
system (no friends)
- Withdrawn when
stress occurs
- Debts
- Insomnia
Ineffective coping?
(00069)
Ineffective protection?
(00043)
Social isolation?
(00053)
= Defining characteristics = Related factors
Clustering with
the 11 functional
health patterns
helps!
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Defining nursing diagnosis is efficient &
effective!
So, take time to define patterns (and thus nursing diagnosis) together with
patient and family!
Targets of interventions are primarily related factors, unless symptomatic
treatment is necessary
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An exercise with Tom (18 y)
1th admission on acute psychiatric ward
Shows anxiety, panic attacks,
restlessness, uneasiness
Is paranoid and hallucinates, thinks MI6
is following him, known with cannabis
use
Refuses medication
IQ 78, skipped school, no concentration
No-show during admission
…
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Example step 3: Validating the
personalized descriptive diagnose
‘Tom, born on June 23 in 2000, has been referred to the acute admission ward by his
general practitioner because of paranoid behaviour and thoughts of being followed by
MI6. Tom is living with his parents and sister (16 y). He has 2 close friends, no girlfriend.
He is not known with a psychiatric history. Physically he had an accident with his bike
when he was 6 y, that caused an concussion. The paranoid behaviour started with using
cannabis. Psychiatrically Tom suffers from a psychotic disorder, characterized by
paranoid behaviour and speaking about his conviction being an important person followed
by MI6. He also shows anxiety and panic attacks.
Physically Tom is healthy. His understanding of things is impaired, because of his IQ of 78
and his lack of concentration.12
Tom shows noncompliance (00079) characterized by missing of appointments during
admission and by non-adherence behavior as not taking medication as prescribed. The
noncompliance is related to insufficient knowledge about the treatment, which results in
anxiety.
This diagnose disables Tom in a severe way in taking care for his mental health [ICF:
activity]. His vulnerability leads to mild problems in participating in his family life [ICF:
participation].
Positive factor is that Tom would like to start school again, he is motivated to ‘get
better’. His friends support him in joining school again. Mildly obstructive is that his
friends love cannabis. [ICF: external and personal factors].
Tom describes himself as ‘a nice guy, he doesn’t understand why MI6 is following him’. He
wants help, but no medication because medication is poison according to Tom. His
parents are worried’
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Example step 4: Determine goal &
measurable outcome
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“
”
A personalised descriptive
diagnose gives direction to
measurable outcomes and
effective treatmentNOTE: shared decision making & validation!
So… use a format, train, repeat, use different contexts, expose, give feedback,
model!
Thank you for joining the workshop!
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More information American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC:
American Psychiatric Association.
Bulechek, G.M., Butcher, H.K, Dochterman, J.M. & Wagner, C. (2012) Nursing Interventions Classification (NIC), 6th ed. St.
Louis: Mosby/Elsevier.
Chen, S.L., Hsu, H.Y., Chang, C.F. & Lin, E.C. (2016). An exploration of the correlates of nurse practitioners’ clinical decision-
making abilities. Journal of Clinical Nursing, 25(7-8), 1016-1024.
Dowding, D., Gurbutt, R., Murphy, M., Lascelles, M., Pearman, A. & Summers, B. (2011). Conceptualising decision making in
nursing education. Journal of Research in Nursing, 17(4), 348-360.
Gordon, M. (2014). Manual of Nursing Diagnosis, 13th ed. Burlington, Massachusetts: Jones & Bartlett Learning.
Graan, A.C. van, Williams, M.J.S. & Koen, M.P. (2016). Professional nurses’ understanding of clinical judgement: a contextual
inquiry. Health SA Gesondheid, 21, 280-293.
Herdman, T.H. & Kamitsuru S. (2014). NANDA International Nursing diagnoses; Definitions and Classifications 2015-2017, 10th
ed. Hoboken, United States: Wiley-Blackwell.
ICF (http://www.who.int/classifications/icf/en/; website visited 29 nov. 17)
Lee, D.S., Abdullah, K.L., Subramanian, P., Bachmann, R.T. & Ong, S.L. (2017). An integrated review of the correlation
between critical thinking ability and clinical decision-making in nursing. Journal of Clinical Nursing, (ePub ahead of print),
doi: 10.1111/jocn.13901
Moorhead, S., Johnson, M., Maas, M. & Swanson, E. (2012). Nursing Outcome Classification (NOC), 5th ed. St. Louis:
Mosby/Elsevier.
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