1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 7
Patient Concerns, Choices, and
Clinical Judgment in Evidence-
Based Practice

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Research and Patient Concerns
• Research evidence needs to be considered in light of the
patient’s concerns and preferences
• Good clinical judgment is required, not only research
evidence
− Critical judgment requires two components
• The validity of the evidence itself needs to be
examined carefully
• How the evidence is applied to clinical decision
making must be examined

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Applying Evidence
• The fit between evidence and clinical reality is rarely
perfect
− Every patient is different
− Patients never exhibit only one problem
• Nurses must judiciously consider relevant patient
particularities and concerns in making clinical decisions
• Ethics must also be considered
• A “narrative understanding” of each patient is necessary

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Elements of Good Clinical Judgment
• Knowing the patient
• Reasoning through time
• Appraising and judging research evidence

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Clinical Judgment and Self-Improving
Practices
• The goal is for practice to be self-improving through
science and experiential clinical learning and correction
• Dependent on experiential learning
− Turning around preconceptions, expectations, sets,
and routines or adding new insights to a particular
practical situation

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Experiential Learning
• Techne
− Producing outcomes by a means-ends strategy,
whereby the maker or producer governs the outcome
by mastering the means of its production
• Phronesis
− Reasoning across time about changes in the
particular patient’s condition and changes in the
clinician’s understanding

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The Risks of “Leveling”
• Above-average performance is harmed when it is brought
down to the clinical “standard,” even if the standard is
evidence-based
• Variation below the standard must be brought up to the
standard, but variation above the standard should not be
brought down

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Tell whether the following statement is true or false.
• An evidence-based standard of practice represents the
best possible outcomes that can expected in a particular
clinical context.

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
• Rationale: A standard of practice may represent a
baseline or average level of outcomes that is significantly
below what is possible in some settings.

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Expertise
• Not every aspect of nursing practice is “formalizable”
• The ethos (i.e., ethics or notions of good) of practice
influences what is considered relevant science
• Knowledge alone is not sufficient to ensure that nurses
will form helpful relationships with patients or that nurses
will notice and correctly identify early signs and
symptoms
− Formal measurements cannot replace perceptual
skills

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
How Narratives Inform Clinical
Understanding
• A narrative mode of description best captures clinical
judgment and experiential learning
• A narrative can capture chronology, the concerns of the
actor, and the ambiguities and puzzles as the story
unfolds
− Nurses’ clinical narratives can reveal their taken-for-
granted clinical understandings
− Narratives reveal clinical wisdom that other nurses
can identify with, and appropriate for, their own
clinical practices

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Clinical Grasp
• Encompasses
− Making qualitative distinctions
− Engaging in detective work
− Recognizing changing clinical relevance
− Developing clinical knowledge about specific patient
populations

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• A nurse who provides care on the renal unit of a hospital
has developed a skilled clinical grasp that allows her to
provide highly competent care. The nurse’s clinical grasp
has been primarily enhanced by:
a. Making qualitative distinctions
b. Engaging in detective work
c. Recognizing changing clinical relevance
d. Developing clinical knowledge about specific patient
populations

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• d. Developing clinical knowledge about specific patient
populations
• Rationale: Refinement of clinical judgment is possible
when nurses have the opportunity to work with specific
patient populations. The nurse’s opportunity to provide
care exclusively to patients with kidney disease will foster
skilled clinical judgment in this area.

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Clinical Forethought
• Refers to at least four habits of thought and action
1. Future think is the practical logic of the practitioner
situated in practice
2. Clinical forethought about specific patient
populations
3. Anticipation of risks for particular patients
4. Seeing the unexpected

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Tell whether the following statement is true or false.
• A consistently high level of clinical performance is
necessary in order for a nurse to engage in experiential
learning.

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
• Rationale: Focusing only on performance and on “being
correct” and not on learning from breakdown or error
dampens the curiosity and courage to learn
experientially. Experiential learning requires engagement
with complex clinical realities, which nurses will
sometimes interpret or respond to incorrectly.