Nursing Documentation Project

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Nursing Documentation Project

• Keith Ward

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Nursing Documentation

• Nurses who exercise good clinical decision
  making improve significantly the quality of the
  patient experience Boney and Baker 1997 and
  clinical decision making skills are
  internationally recognised as a generic
  competence in pre-registration nursing programmes
  Standing 2007.

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Clinical Decision Making Models

• Two Models Proposed
• Intuitive humanist model
• Information processing model

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Intuitive Decision Making

• Clinical decision making based on intuition has
  been variously described as
• understanding without a rationale Benner
  Tanner, 1987 p.24,
• a perception of possibilities, meanings and
  relationships by way of insight. Gerrity 1987
  p.64,
• immediate knowing of something without the
  conscious use of reason (Schrader Fischer
  1987, p.45).

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Information Processing

• The information processing model is the preferred
  model in medical decision making and is typically
  represented through a four stage scientific
  hypothetico-deductive process.

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Four Stages

• Cue recognition gathering preliminary clinical
  information about the patient (also called the
  cue acquisition stage)
• Hypothesis generation diagnosis These are
  related to previously gathered data.
• Cue Interpretation do the cues support, reject
  or make no contribution to the diagnosis?
• Hypothesis evaluation which if any of the
  hypotheses are favoured by the evidence?

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Information Processing Model

• Nurses found to have difficulty with the
  information processing model based on
  difficulties in generating appropriate hypothesis
  Banning 2006.

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CfH

• CfH systems model on the information processing
  model
• Not possible in current systems to
  model/represent intuitive based decisions which
  are reported to be difficult to articulate and
  thus capture.

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CfH

• Nurses need to develop further towards a
  information processing model for patients to make
  the gains expected in patient outcomes.
• Information processing model wrongly describe as
  medical model widely used by other professional
  groups.

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Other Model

• If clinical decisions are not based on
  information processing then the default position
  assumed by many is that they must be based on
  intuitive process, there was very little evidence
  that this was the case in the documentation
  reviewed.

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Other Model

• The majority of observed nursing activity was
  found to be driven by core care plans, integrated
  care pathways and medical orders.
• Very little evidence of evaluative type reports
  evidencing clinical decision making process.
• That is not to say it was not going on.
• 96 of free text nursing entries found to be
  status type reports.

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Status Reports

• A nursing entry in the free text nursing
  documentation record set characterised by a date
  and time stamp indicating a patient event or
  intervention has been carried out and typically
  but not always has at its root a medical
  instruction e.g. catheter removed, mobilised,
  commenced free fluids etc.

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Nursing Documentation

• Other considerations
• Algorithmic approach to care deskilling nurses
• Cumulative unreasonableness
• Running faster to stand still need for
  weighting
• models for key targets

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What might be done?

• Pre-registration nursing curricula to emphasise
  clinical decision making process.
• Core skills for clinical decision making include,
  critical thinking, information literacy skills,
  broad nursing knowledge etc. Core skills need to
  be unbound from academic process and developed
  in context of patient, clinical and service
  delivery contexts.
• CfH initiative to act as catalyst for changes in
  qualified workforce

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• Thank you