Assignment Task:
Giovanna P
For APNs, effective decision-making is crucial for patient care. The scenario presented involves a 69-year-old lady who has sustained a fall and presents with wrist and shoulder concerns. The complexities of her case, along with the pressures of a busy ED, highlight the intricate balance between patient needs, clinical judgment, and time constraints.
Psychological and Contextual Complexities
In this scenario, the NP faces several psychological and contextual challenges. Firstly, the patient's anxiety about spending extended time in the ED adds emotional pressure on the NP to expedite care. This anxiety can influence the NP's decision-making process, potentially leading to a rush in diagnosis and treatment rather than a thorough evaluation. Additionally, the patient's insistence on minimizing her time in the ED may lead the NP to subconsciously prioritize the patient's desire over comprehensive clinical evaluation (Bijani et al., 2021).
Moreover, the context of a busy ED creates a constraint on time and resources. With the NP's shift ending soon, there is a risk of overlooking critical assessments due to the urgency of the situation. The awareness of potential delays in care if the ANP does not act swiftly can create further stress, complicating the decision-making process. The NP must navigate these emotional and situational pressures while ensuring that patient safety and thoroughness remain paramount (Featherston et al., 2020).
Decision-Making Models
Intuitive Decision-Making
This model relies on gut feelings, past experiences, and subconscious processing. It is often fast and automatic, making it suitable for situations requiring quick decisions (Ruzsa et al., 2020). In this scenario, the NP's intuition regarding the swelling in the patient's humerus and her past medical history of a proximal humerus fracture may prompt a more immediate concern about potential complications, such as a fracture or a hematoma (Brorson et al., 2019).
Rational Analytic Decision-Making
This model involves a systematic approach to problem-solving. The NP should gather all available data, perform a thorough clinical examination, and use evidence-based guidelines to determine the best course of action. This would include further imaging of the humerus and a detailed assessment of the shoulder stiffness (Villiger, 2023).
In this scenario "the patient is anxious to minimize her time in the ED, indicating a desire to return home, possibly due to travel or family obligations" which could suggest an environment where she feels pressured to minimize her healthcare needs, and it could be a red flag for abuse or neglect. The presence of multiple injuries (the wrist and humerus) raises questions about the mechanisms of these injuries and whether they are consistent with the patient's account of falling. Moreover, the patient did not initially disclose her previous shoulder injury or the swelling in her arm, which could indicate either a lack of understanding of the seriousness of her condition or possible neglect in monitoring her recovery (Patel et al., 2021).
Comparison of Intuitive and Rational Analytic Decision-Making Models
The benefits of the Intuitive Decision-Making model include allowing for rapid decisions which can be crucial in emergency settings like the ED, and utilizing the clinician's accumulated knowledge and expertise, which can enhance accuracy in familiar scenarios (Ruzsa et al., 2020). While, the consequences could be risk of bias because decisions may be influenced by biases or emotions, potentially leading to errors, and the lack of rigor by overlooking systematic evaluation of evidence or alternative options, risking incomplete assessments (Villiger, 2023).
The benefits of the Rational Analytic Decision-Making model include ensuring thorough consideration of all relevant data and options, which can enhance decision quality, and relying on evidence by minimizing the influence of personal biases and emotions (Villiger, 2023). While its consequences could be time-consuming which can delay decisions that could be detrimental in time-sensitive situations like the one described, and it may lead to paralysis by analysis, where the decision-maker becomes overwhelmed by options and data (Viale et al., 2023).
Best Decision-Making Approach for Advanced Practice Nurses
The best decision-making approach for advanced practice nurses (APNs) typically combines elements of both intuitive and rational analytic models, often termed as a hybrid approach which balances the need for quick responses in acute settings with the necessity of comprehensive assessments, ultimately leading to improved patient outcomes. Scarffe et al. (2024) displayed that APNs should trust their clinical intuition based on previous encounters with similar cases, which allows for quick assessments and interventions. Simultaneously, Viale et al. (2023) explained that ANPs should engage in a thorough assessment of the patient, including gathering data, considering differential diagnoses, and utilizing protocols and guidelines. According to Bendowska and Baum (2023), involving interdisciplinary teams can provide diverse perspectives and expertise, enhancing decision quality. Ruzsa et al. (2020) displayed that engaging in reflective practice allows APNs to learn from past experiences and improve future decision-making.
Intuition can guide the NP toward pertinent clinical issues quickly (Ruzsa et al., 2020), while rational analysis ensures that decisions are grounded in evidence and are patient-centered, reducing the risk of errors (Viale et al., 2023). The NP should prioritize obtaining a radiograph of the humerus to assess the swelling and potential complications, while also ensuring that the patient receives appropriate pain management and education about her condition (Brorson et al., 2019). According to Villiger (2023), based on rational analytic decision-making, the evidence does not definitively indicate elder abuse, but it raises important flags and questions that warrant further investigation such as if the patient is indeed experiencing long-term issues from her previous injury that were not addressed adequately, this could indicate neglect by caregivers or a lack of appropriate follow-up care. Additionally, it would be prudent for the healthcare team to conduct a more comprehensive evaluation of the patient's living situation and support systems. This includes assessing any potential caregiver interactions that may contribute to her current state, as well as ensuring that all injuries and their histories are thoroughly documented and investigated (Patel et al., 2021).
Metacognition and Its Role in Guiding Decision-Making for the APN
Metacognition refers to the awareness and understanding of one's own thought processes. It involves self-regulation and reflection on how one thinks, learns, and makes decisions (Liu et al., 2024). In this context, metacognition plays a crucial role in decision-making by enhancing self-awareness by making APNs to recognize their biases, strengths, and weaknesses in clinical judgment, which allows for more informed decision-making (Wokke et al., 2020). Metacognitive strategies encourage APNs to reflect on past decisions, analyze outcomes, and adjust future approaches based on what was learned. By continuously evaluating their thought processes, APNs can develop critical thinking skills that enable them to approach complex clinical situations more effectively (Liu et al., 2024).
Finally, metacognition helps APNs identify when a situation requires a more analytical approach versus when quick intuition may be appropriate, leading to more effective and adaptive decision-making (Wokke et al., 2020).
In conclusion, decision-making in nursing, especially within the advanced practice realm, is complex and multifaceted. The scenario of the 69-year-old lady underscores the need for NPs to navigate psychological pressures and contextual constraints while employing diverse decision-making models. While there may not be clear evidence of abuse, the patient's situation reflects complexities that could involve neglect or inadequate care. A thorough assessment and supportive inquiry based on analytic decision-making model into her living conditions and healthcare management would be essential to ensure her safety and well-being. Finally, the hybrid approach that incorporates both intuitive and rational analytic models, allows NPs to make swift, informed decisions while ensuring comprehensive care by emphasizing the importance of clinical judgment shaped by experience, combined with evidence-based practices to safeguard patient outcomes.
References:
Bendowska, A., & Baum, E. (2023). The Significance of Cooperation in Interdisciplinary Health Care Teams as Perceived by Polish Medical Students. International Journal of Environmental Research and Public Health, 20(2), 954.
Bijani, M., Abedi, S., Karimi, S., & Tehranineshat, B. (2021). Major challenges and barriers in clinical decision-making as perceived by emergency medical services personnel: a qualitative content analysis. BMC Emergency Medicine, 21(1), 11.
Brorson, S., Alispahic, N., Bahrs, C., Joeris, A., Steinitz, A., & Audigé, L. (2019). Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions. BMC Musculoskeletal Disorders, 20(1), 91.
Featherston, R., Downie, L.E., Vogel, A.P., & Galvin, K.L. (2020). Decision making biases in the allied health professions: A systematic scoping review. PLoS One, 15(10), e0240716.
Liu, C., Wang, K., & Yu, R. (2024). The neural representation of metacognition in preferential decision-making. Human Brain Mapping, 45(6), e26651.
Patel, K., Bunachita, S., Chiu, H., Suresh, P., & Patel, U.K. (2021). Elder Abuse: A Comprehensive Overview and Physician-Associated Challenges. Cureus, 13(4), e14375.
Ruzsa, G., Szeverenyi, C., & Varga, K. (2020). Person- and job-specific factors of intuitive decision-making in clinical practice: results of a sample survey among Hungarian physicians and nurses. Health Psychology and Behavioral Medicine, 8(1), 152-184.
Scarffe, A., Coates, A., Brand, K., & Michalowski, W. (2024). Decision threshold models in medical decision making: a scoping literature review. BMC Medical Informatics and Decision Making, 24(1), 273.
Viale, R., Gallagher, S., & Gallese, V. (2023). Bounded rationality, enactive problem solving, and the neuroscience of social interaction. Frontier in Psychology, 14, 1152866.
Villiger, D. (2023). Rational transformative decision-making. Synthese, 201(3), 87.
Wokke, M.E., Achoui, D., & Cleeremans, A. (2020). Action information contributes to metacognitive decision-making. Scientific Reports, 10(1), 3632.