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Griffits S, Hines S, Moloney C. Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review. JBI Evid Synth 2023; 21:713-743. [PMID: 36730096 DOI: 10.11124/jbies-21-00373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice. INTRODUCTION Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning. INCLUSION CRITERIA Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion. METHODS Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary. RESULTS The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review. CONCLUSIONS The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.
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Affiliation(s)
- Susan Griffits
- School of Nursing and Midwifery, Faculty of Health Engineering and Sciences, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Sonia Hines
- College of Medicine and Public Health, Flinders Rural and Remote SA and NT, Alice Springs, NT, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, Faculty of Health Engineering and Sciences, University of Southern Queensland, Toowoomba, QLD, Australia
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Manetti W. Sound clinical judgment in nursing: A concept analysis. Nurs Forum 2018; 54:102-110. [PMID: 30380153 DOI: 10.1111/nuf.12303] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 09/03/2018] [Accepted: 09/26/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The intent of this concept analysis is to offer a clear understanding of the definition, defining attributes, antecedents, and consequences of sound clinical judgment pertaining to nursing practice. BACKGROUND Sound clinical judgment is essential in nursing because decisions made influence patient outcomes. DESIGN This concept analysis guided by Walker and Avant's framework, dissects the concept to promote clarity and consensus. DATA SOURCE CINAHL, ProQuest for Nursing and Allied Health, ERIC, and Health Source/Nursing Academic Edition databases were searched using the keyword clinical judgment. REVIEW METHODS Articles in peer reviewed, scholarly journals written in English were considered from 1984 to 2017. RESULTS The author concluded that decision-making is a surrogate term for clinical judgment. The attributes, antecedents, and consequences are discussed and supported by evidence. Cases illustrate the essence of the concept. CONCLUSIONS Clinical judgment is an ambiguous term that is synonymous with the term decision-making. It results from critical thinking and clinical reasoning. Using these findings, educators and administrators can use valid and reliable methods to identify the presence, foster the development, and measure the existence of clinical judgment in novice nurses with an ultimate goal to improve patient care.
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Affiliation(s)
- Wendy Manetti
- Department of Nursing, University of Scranton, Scranton, Pennsylvania
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Küçük Alemdar D, Güdücü Tüfekcİ F. Effects of maternal heart sounds on pain and comfort during aspiration in preterm infants. Jpn J Nurs Sci 2018; 15:330-339. [DOI: 10.1111/jjns.12202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 09/11/2017] [Accepted: 11/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Dilek Küçük Alemdar
- Department of Midwifery, Faculty of Health Sciences; Giresun University; Giresun Turkey
| | - Fatma Güdücü Tüfekcİ
- Department of Pediatric Nursing, Faculty of Nursing; Atatürk University; Erzurum Turkey
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Trevino P, Green A, Middaugh D, Heo S, Beverly C, Deshpande J. Nursing perception of risk in common nursing practice situations. J Healthc Risk Manag 2017; 37:19-28. [PMID: 29140593 DOI: 10.1002/jhrm.21283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
As health care organizations seek to be highly reliable, systems that include layers of redundancy have been created to protect patients from harm. Many of these layers of protection are dependent on nurses making a decision to follow or adhere to the human aspects of the process. Because these decisions begin with a perception and identification of risk, understanding what nurses perceive to be a risk to patients is an essential part of designing safer health care systems. The purposes of this qualitative study were to (1) describe what nurses perceive as risky to patients in common nursing practice situations, (2) describe the effects of the perceptions of risk on clinical decision making and behavior, and (3) identify what factors nurses perceive as increasing or decreasing risk.
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Affiliation(s)
| | | | - Donna Middaugh
- University of Arkansas for Medical Sciences (Little Rock, AR)
| | - Seonghum Heo
- University of Arkansas for Medical Sciences (Little Rock, AR)
| | - Claudia Beverly
- University of Arkansas for Medical Sciences (Little Rock, AR)
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Bruschettini M, Zappettini S, Moja L, Calevo MG. Frequency of endotracheal suctioning for the prevention of respiratory morbidity in ventilated newborns. Cochrane Database Syst Rev 2016; 3:CD011493. [PMID: 26945780 PMCID: PMC8915721 DOI: 10.1002/14651858.cd011493.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endotracheal suctioning consists of the mechanical aspiration of pulmonary secretions from the endotracheal tube (ETT) to prevent obstruction. The optimal frequency of ETT suctioning has not been defined. OBJECTIVES To determine the effect of specific ordered frequency of ETT suctioning ('as scheduled') versus ETT suctioning only in case of indications ('as needed') and of more frequent ETT suctioning versus less frequent ETT suctioning on respiratory morbidity in ventilated newborns. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 10), MEDLINE via PubMed (1966 to 31 October 2015), EMBASE (1980 to 31 October 2015), and CINAHL (1982 to 31 October 2015). We checked the reference lists of retrieved articles and contacted study authors to identify additional studies. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA Randomized, quasi-randomized, and cluster randomized controlled trials comparing different strategies regarding the frequency of ETT suctioning of newborn infants receiving ventilator support. DATA COLLECTION AND ANALYSIS We used the standard methods of the Cochrane Neonatal Review Group. Two review authors independently extracted data and assessed the risk of bias of trials. The primary outcome was bronchopulmonary dysplasia or chronic lung disease. MAIN RESULTS We identified one randomized controlled study recruiting 97 low birthweight infants that met the inclusion criteria. The study was conducted in the UK in 1987 and 1988. Randomized infants received ETT suctioning every six or 12 hours during the first three days of life. The quality of reporting was limited and we rated the trial at high risk of bias. Furthermore, the trial lacked adequate power. There were no statistically significant differences in any of reported outcomes: bronchopulmonary dysplasia (defined as oxygen at more than 30 days; risk ratio (RR) 0.49, 95% confidence interval (CI) 0.20 to 1.20); incidence of pneumothorax (RR 0.70, 95% CI 0.24 to 2.05); intraventricular hemorrhage (RR 1.12, 95% CI 0.44 to 2.85); neonatal death (RR 1.40, 95% CI 0.58 to 3.37); and time on ventilation (median time 39 hours in the 12-hourly group and 28 hours in the six-hourly group; RD not applicable for this outcome as mean and standard deviation were not reported). Tests for heterogeneity were not applicable as only one study was included. AUTHORS' CONCLUSIONS There was insufficient evidence to identify the ideal frequency of ETT suctioning in ventilated neonates. Future research should focus on the effects in the very preterm newborns, that is, the most vulnerable population as concerns the risk of both lung and brain damage. Assessment should include the cases of prolonged ventilation, when more abundant, dense secretions are common. Clinical trials might include comparisons between 'as-scheduled' versus 'as-needed' endotracheal suctioning, that is, based on specific indications, as well frequent versus less frequent suctioning schedules.
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Affiliation(s)
- Matteo Bruschettini
- Lund University, Skane University HospitalDepartment of PaediatricsLundSweden
| | | | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteClinical Epidemiology UnitMilanItaly
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics and Committees UnitGenoaItaly16147
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Haghighat S, Yazdannik A. The practice of intensive care nurses using the closed suctioning system: An observational study. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2015; 20:619-25. [PMID: 26457102 PMCID: PMC4598911 DOI: 10.4103/1735-9066.164509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Endotracheal suctioning (ETS) is an essential procedure performed for mechanically ventilated patients. ETS can be either performed by open or closed suctioning system (CSS). There may be some concern on how closed-system ETS is practiced by intensive care nurses. This study was designed to investigate closed-system ETS practices of critical care nurses and to compare their practice with standard recommendations. Materials and Methods: A prospective observational study was conducted during August and December 2012 to establish how critical care nurses (N = 40) perform different steps in a typical ETS practice and to compare it with the current best practice recommendations through a 23-item structured checklist. The results were categorized into three sections: Pre-suctioning, suctioning, and post-suctioning practices. Results: Pre-suctioning, suctioning, and post-suctioning practices mean scores were 7.5, 11.75, and 8.5, respectively, out of 16, 16, and 12, respectively. The total suctioning practice score was 27.75 out of 44. Most discrepancies were observed in the patients’ assessment and preparation, infection control practices, and use of an appropriate catheter. Spearman correlation coefficient indicated a significant statistical positive correlation between suctioning education period and suctioning practice score (P < 0.0001) and between working experience and suctioning practice score (P = 0.02). Conclusions: The findings revealed that critical care nurses do not fully adhere to the best practice recommendation in CSS. We recommend that standard guidelines on ETS practice be included in the current education of critical care nurses.
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Affiliation(s)
- Somayeh Haghighat
- Department of Critical Care Nursing, Medical Students Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - AhmadReza Yazdannik
- Department of Critical Care Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
Endotracheal suctioning is an essential intervention for the care of an intubated child and is one of the most commonly performed interventions in pediatric intensive care. Despite this, much of the research related to endotracheal suctioning is dated and the bulk of it conducted in preterm infants and adults. This paper will review research related to endotracheal suctioning that involves or relates to children in intensive care to provide a current review of the literature in this field. It will conclude with recommendations for practice where possible and identify areas for further research.
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Affiliation(s)
- Lyvonne N Tume
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom.,The School of Health, University of Central Lancashire, Preston, United Kingdom
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
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Burbach BE, Thompson SA. Cue Recognition by Undergraduate Nursing Students: An Integrative Review. J Nurs Educ 2014; 53:S73-81. [DOI: 10.3928/01484834-20140806-07] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/29/2014] [Indexed: 11/20/2022]
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Davies K, Monterosso L, Bulsara M, Ramelet AS. Clinical indicators for the initiation of endotracheal suction in children: An integrative review. Aust Crit Care 2014; 28:11-8. [PMID: 24767960 DOI: 10.1016/j.aucc.2014.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 03/05/2014] [Accepted: 03/18/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Critical decisions and interpretation of observations by the nurse caring for the paediatric intensive care (PIC) patient can have dramatic and potential adverse impact on the clinical stability of the patient. A common PIC procedure is endotracheal tube (ETT) suction, however there is inconsistent evidence regarding the clinical indicators to guide and support nursing action. Justification for performing this procedure is not clearly defined within the literature. Further, a review of the literature has failed to establish clear standards for determining if the procedure is warranted, especially for paediatric patients. OBJECTIVE The objective of the review is to identify current clinical indicators used in practice to determine why ETT suction should be performed. METHOD An integrative review using a systematic approach to summarise the empirical and theoretical evidence within the literature as it relates to clinical practice was used. RESULTS Consensus of opinion indicates that ETT suctioning should only be performed when clinically indicated. There is no general consensus regarding which clinical indicators should be measured and used to guide the decision to perform ETT suctioning. CONCLUSION Research is required to identify the clinical indicators that could be used to design a valid and clinically appropriate tool to use to assist in the decision making process to perform ETT suction.
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Affiliation(s)
- K Davies
- Paediatric Intensive Care Unit, Princess Margaret Hospital for Children, Perth, Australia.
| | - L Monterosso
- School of Nursing and Midwifery, The University of Notre Dame Australia, Edith Cowan University, Australia
| | - M Bulsara
- Institute of Health and Rehabilitation Research, The University of Notre Dame Australia, Australia
| | - A S Ramelet
- Institute of Higher Education and Nursing Research, Faculty of Biology and Medicine, University of Lausanne, Switzerland
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Trevisanuto D, Doglioni N, Zanardo V. The management of endotracheal tubes and nasal cannulae: the role of nurses. Early Hum Dev 2009; 85:S85-7. [PMID: 19762171 DOI: 10.1016/j.earlhumdev.2009.08.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The management of endotracheal tubes and nasal cannulae covers a large part of work time of nurses involved in the care of very preterm infants. These procedures, although continuously performed, have not yet been scientifically demonstrated. In fact, there is limited evidence regarding several points such as the frequency of endotracheal suctioning, the level of suction pressure, the duration of suctioning, the depth of catheter insertion, the sterility, and the use of normal saline during endotracheal suction. With regard to the nasal cannulae, there is a more recent use of this device consisting in delivering end-expiratory pressure or gas flow to reduce the frequency of apneas and desaturations in preterm infants or for the management of RDS. This approach is defined high-flow nasal cannulae (HFNC). In this article, we review the literature on the airway management of intubated patients as well as of infants managed with nasal-CPAP or nasal cannulae. Potential fields of research on this topic are suggested.
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Affiliation(s)
- Daniele Trevisanuto
- Pediatric Department, University of Padua, Azienda Ospedaliera di Padova, Padua, Italy.
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A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice. Pediatr Crit Care Med 2008; 9:465-77. [PMID: 18679146 DOI: 10.1097/pcc.0b013e31818499cc] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To provide a comprehensive, evidence-based review of pediatric endotracheal suctioning: effects, indications, and clinical practice. METHODS PubMed, Cumulative Index of Nursing and Allied Health Literature, and PEDro (Physiotherapy Evidence Database) electronic databases were searched for English language articles, published between 1962 and June 2007. Owing to the paucity of objective pediatric data, all reports dealing with this topic were examined, including adult and neonatal studies. RESULTS One hundred eighteen references were included in the final review. Despite the widespread use of endotracheal suctioning, very little high-level evidence dealing with pediatric endotracheal suctioning exists. Studies of mechanically ventilated neonatal, pediatric, and adult patients have shown that suctioning causes a range of potentially serious complications. Current practice guidelines are not based on evidence from controlled clinical trials. There is no clear evidence that endotracheal suctioning improves respiratory mechanics, with most studies pointing to the detrimental effect it has on lung mechanics. Suctioning should be performed when obstructive secretions are present rather than routinely. There is no clear evidence for the superiority of closed- or open-system suctioning, nor is there clear evidence for appropriate vacuum pressures and suction catheter size. Sterility does not seem to be necessary when suctioning. Preoxygenation has short-term benefits, but the longer-term impact is unknown. Routine saline instillation before suctioning should not be performed. Recruitment maneuvers performed after suctioning have not been shown to be useful as standard practice. CONCLUSIONS Endotracheal suctioning is a procedure used regularly in the pediatric intensive care unit. Despite this, good evidence supporting its practice is limited. Further, controlled clinical studies are needed to develop evidence-based protocols for endotracheal suctioning of infants and children, and to examine the impact of different suctioning techniques on the duration of ventilatory support, incidence of nosocomial infection, and length of pediatric intensive care unit and hospital stay.
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Copnell B. Commentary: Morrow B, Futter M, Argent A. (2006). Effect of endotracheal suction on lung dynamics in mechanically-ventilated paediatric patients. Nurs Crit Care 2008; 13:54-5. [PMID: 18226055 DOI: 10.1111/j.1478-5153.2007.00256.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Beverley Copnell
- Department of Epidemiology and Preventive Medicine, Monash University, The Alfred, Commercial Road, Melbourne, Victoria 3004, Australia.
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Abstract
This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the role of knowledge in expert practice. Using grounded theory methodology, the study involved 17 registered nurses who were practicing in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participants' observations and interviews. Having extensive nephrology nursing knowledge was a striking characteristic of a nursing expert. Expert nurses clearly relied on and utilized extensive nephrology nursing knowledge to practice. Of importance for nursing, the results of this study indicate that domain-specific knowledge is a crucial feature of expert practice.
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Affiliation(s)
- Ann Bonner
- School of Nursing, Midwifery and Nutrition, James Cook University, Cairns, Australia.
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