Decision Making, Problem

Solving, Critical Thinking and

Clinical Reasoning
Rose A. Harding, MSN, RN
Reading Materials
Marquis & Huston (2021), chapter 1, Chapter 3 (p. 73)
Selected links throughout presentation
 Decision Making, Problem Solving, Critical
Thinking, and Clinical Reasoning

• Decision making: complex, cognitive process of choosing a particular

course of action; the thought process of selecting a logical choice
from available options
• Problem solving: part of decision making; systematic process focusing
on analyzing a difficult situation ____________________
• Critical thinking or reflective thinking: the mental process of actively
and skillfully conceptualizing, applying, analyzing, synthesizing, and
evaluating information to reach an answer or conclusion
 Critical Thinking and Delegation
• Effective communication is needed between registered nurses (RNs)
and unlicensed assistive personnel (UAP) for giving feedback and
clarifying tasks and patient status.
• When patients’ clinical conditions change, warranting attention by
RNs, clear directions are necessary to avoid missed care.
• Applying critical thinking can help an RN make the decision about
when to appropriately delegate care.
 Reflective Thinking
• Watching or observing oneself as one performs task or makes decision
about certain situation
• Two selves:
• ____________________
• Acts as observer and offers suggestions
• ____________________
• Active participation
 Elastic Thinking
• Differs from analytical thinking
• Allows brain to make connections without direction
• Breaks rules
• Generates novel ideas
 How to Develop Elastic Thinking?
• Cultivate a “beginner’s mind” by questioning situations as if
you have no experience in them
• Introduce discord by pursuing relationships and ideas that
challenge your beliefs
• Recognize the value of diversity
• Generate lots of ideas and don’t be bothered that most of
them will be bad
• ___________________________
• Relax when you see yourself becoming overly analytical
 Characteristics of a Critical Thinker

• Insight
• Intuition
• Empathy
• Willingness to take action
 Clinical Reasoning
• Integrating and applying different types of knowledge to weigh
evidence, critically think about arguments, and reflect on the
process used to arrive at diagnosis
• Collaborative and reflective process that involves content-specific
knowledge, engagement of the patient and family in understanding
the clinical problem, and incorporation of critical contextual factors
• Leads to deliberative decision making and sound clinical judgement
 Vicarious Learning to Enhance Decision-
Making Skills

• Case studies: provide stories that impart learning

• Simulations: provide opportunities for learning with no risk to
patients or organizational performance
• Problem-based learning (PBL): provides opportunities for learners
to address and learn from authentic problems vicariously
 Experiential Learning

• Provides mock life experiences to learn from

• Allows learners to apply leadership and management theory
• Promotes whole-brain thinking and improved problem-solving skills
 Problem-Solving versus Decision-Making Models
The Traditional Problem- ______________________
Solving Process • Determine the decision and
• Identify the problem. the desired outcome (set
• Gather data to identify the objectives).
causes and consequences of
the problem. • Research and identify options.
• Explore alternative solutions. • Compare and contrast these
• Evaluate each alternative options and their
• Select appropriate solution consequences.
• Implement solution • Make a decision.
• Evaluate results.
• Implement an action plan.
 Critical Elements in Problem
Key Problem-Solving Questions
Solving and Decision Making
• Is it important? • Identify the problem
• Is it mine? • Gather data carefully
• Am I qualified? • Take the time necessary
• Do I have the authority? • Use an evidence-based
• Do I have the resources? approach
• Can I delegate it? • Generate many alternatives
• What are the benefits of solving • Think logically
the problem?
• Choose and act decisively
 Nursing Process: A Problem-Solving
and Decision-Making Model

• Identify a problem and collect • Assess

data about the problem
• Determine the exact nature of • Diagnose
the problem
• Decide on a plan of action
• Plan
• Carry out the plan
• Implement
• Evaluate the plan
• Evaluate
 Integrated Ethical Problem-
Solving Model
• Determine whether there is an ethical issue or/and dilemma
• Identify key values and principles involved
• Rank the values or ethical principles
• Develop an action plan
• Implement the plan
• Reflect on the outcome
 Intuitive Thinking

• Innate feeling nurses develop that helps them act in certain situations
• Described as gut feeling of something wrong
• Results from unconscious assessment and analysis of data based on
individual’s past experiences
 Questions Asked in Data Gathering

• What is the setting?

• What is the problem?
• Where is it a problem?
• When is it a problem?
• Who is affected by the problem?
• What is happening?
• Why is it happening? What are the causes of the problem?
Can I prioritize the causes?
• What are the basic underlying issues? Areas of conflict?
• What are the consequences of the problem? Which of
 Evidence-Based Approach
• Use a PICO format to guide the search for the current best evidence
• Patient or population, Intervention, Comparison, and Outcome
• Need administrative support to
• Change long standing practices
• Provide resources
• Provide support personnel
• Make policies requiring adoption of new practices
 Strategies for New Nurses to Promote Evidence-
Based Practice

• Keep abreast of the evidence

• Use multiple sources of evidence
• Use evidence to support clinical interventions and teaching strategies
• Find established sources of evidence
• Implement and evaluate nationally sanctioned clinical practice guidelines
• Question and challenge nursing traditions
• Dispel myths and traditions not supported by evidence.
• Collaborate with other nurses locally and globally.
• Interact with other disciplines to bring nursing evidence to the table.
Ways of Thinking
• Overgeneralizing
• Affirming the consequences
• Arguing from analogy
 Questions Asked in Analyzing Solutions

• What factors can you influence? How can you accentuate the
positive factors and minimize the negative factors?
• What are the financial, political, time, and resource implications of
each possible solution?
• What are the weighting factors?
• What is the best solution?
• What are the means of evaluation?
• What are the consequences of each alternative?
 Variations to Decision Making
• Gender
• Personal individual values
• Life experience
• Preferences
• Willingness to take risks
• Physical, emotional, economic, time and energy
• Brain hemisphere dominance
• Left brain
• Right brain
• Predominant thinking style
 Overcoming Vulnerability in
Decision Making
• Be self-aware
• Use available resources including current evidence-based guidelines
• Involve others in decision making process
• __________________
• Evaluate decisions
• Be honest with oneself
• Be willing to take risk
• Include diverse group of thinkers
 Successful Decision Makers
• Self-aware
• Courageous
• Sensitive
• Energetic
• Creative
 Comparison of Economic &
Administrative Man
• Economic Man • Administrative Man
• Makes decisions in rational • Knowledge is fragmented
manner • Is impossible to accurately
• Has complete knowledge of predict future consequences
problem or situation • Considers multiple
• Considers all alternatives alternatives but not all
• Has systematic ordering of • Makes decisions that are
alternatives good enough
• Selects maximizing choice • Final choice is satisficing
 Group Decision Making
• May be necessary in some situations
• People affected by decision often will be involved in decision
• Involve people with information or resources that contribute to decision
• Consider size of group and personalities of members
• Major disadvantages:
• Time involved – groups can potentially waste time and be nonproductive
• May also be costly and lead to conflict
• Advantages & Disadvantages
 Decision-Making Tools

• Decision grids
• May help separate multiple factors that surround situation or decide between two choices
• Payoff tables
• Have a cost profit-volume relationship
• __________________
• A tree-like graph or model of decisions and their possible consequences, including chance event
outcomes, resource costs, and utility
• Consequence tables
• Depicts how various alternatives create different consequences
• Logic models
• Schematic of how programs are intended to operate
• Program evaluation and review technique (PERT)
• Helps determine timing of events
Example of a Payoff Table
Example of
a Decision
Tree
Example of Program and Review Technique (PERT)
 Techniques for Group Decision Making
• ____________________ • _______________________
• Ideas generated in writing • Group members do not meet
without discussion face-to-face
• Ideas presented on flip chart • Questionnaires distributed
by group members seeking opinions from group
• Group discusses, clarifies, members
and evaluates ideas • Summaries disseminated to
group members
• Group votes privately on
• Process continues until group
ideas
members reach consensus
Techniques for Group Decision Making

• _________________
• Means all group members can live with and fully support decision
regardless of whether they totally agree
• Useful because all group members participate and realize
contributions of each member to group
• Requires more time
• Should be reserved for important decisions that need strong support
Group Decision Making
• Groupthink
• Phenomenon where people tend to confirm with group decisions
to avoid feeling outcast, leading to errors in decision making
• Can potentially have problems with members feeling invincible or
stereotyping outsiders
• Can come to one solution without considering all available options
• To avoid, group leaders should encourage all members to think
independently
Examples of Groupthink
• Challenger disaster (1986)

• Enron collapse (2001)

• Madoff scandal (2008)

 Limitations to Effective Decision Making
• Obstacles to effective decision • Actions that negatively impact
making: decision making:
• Past life experience • Jumping to conclusions
• Education • Not gathering all information
• Previous decision making • Choosing too broad decisions
experience
• Failing to choose rational
• Values
solution
• Gender
• Failing to intervene or
• Personal biases
• Preconceived ideas
evaluate
Decision Making Strength

• Decision making improves with experience

• Strategies to improve critical thinking and decision making:
• Making only own decisions
• Having all information needed to make decision
• Ask “why,” “what else,” and “what if”
• Anticipate questions and outcomes