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Effects of reflection on clinical decision-making of intensive care unit nurses
Accepted Manuscript Effects of reflection on clinical decision-making of intensive care unit nurses
Shahrokhi Razieh, Ghafari Somayeh, Haghani Fariba PII: DOI: Reference:
S0260-6917(18)30134-5 doi:10.1016/j.nedt.2018.03.009 YNEDT 3804
To appear in: Received date: Revised date: Accepted date:
22 October 2017 18 February 2018 13 March 2018
Please cite this article as: Shahrokhi Razieh, Ghafari Somayeh, Haghani Fariba , Effects of reflection on clinical decision-making of intensive care unit nurses. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ynedt(2018), doi:10.1016/j.nedt.2018.03.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Effects of Reflection on Clinical Decision-Making of Intensive Care Unit Nurses Word count: 3383
Shahrokhi Razieh department of nursing , Isfahan university of medical science, Isfahan, Iran
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Ghafari Somayeh (corresponding author)
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Assistant professor, nursing and midwifery care research center, faculty of nursing and midwifery, Isfahan University of medical science, Isfahan, Iran. PO: 81746-73461
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Tel: 03137927544
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E-mail: [email protected]
Haghani Fariba
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Department of Medical Education, Medical Education Research Center, Isfahan University of
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Medical Sciences, Isfahan, Iran
Acknowledge: The researcher appreciates the authorities of Amin Hospital (affiliated to Isfahan
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University of Medical Sciences) and all nurses participating in this study..
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Funding: This research was supported by Isfahan University of Medical Science (grant number: 396150).
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Abstract
Background: Nurses are one of the most influential factors in overcoming the main challenges
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faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. Objective: This study evaluated the effects of implementing Tanner’s reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). Design: This study used an experimental, pretest, posttest design. Setting: The setting was the intensive care unit of Amin Hospital Isfahan, Iran).
ACCEPTED MANUSCRIPT Participants: The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). Methods: This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic
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characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-
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14). The questionnaire was completed before and one week after the intervention. The data were
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analyzed using SPSS 21.0.
Results: The two groups were not significantly different in terms of the level and mean scores of
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clinical decision-making before the intervention (P = 0.786). Based on the results of independent t test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann
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Whitney test showed that one week after the intervention, the nurses’ level of clinical decision-
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making in the case group rose to the next level (P = 0.001). Conclusion: Reflection could improve the clinical decision-making of ICU nurses. It is, thus,
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recommended to incorporate this method into the nursing curriculum and care practices. Clinical decision-making is a fundamental concept in the field of nursing which affects the
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course of patient care and recovery
The validity of important clinical decisions depends on proper and thoughtful judgment
Reflection helps individuals use the critical analysis of their performance and integrate
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their thoughts and actions when facing different situations The results of this study showed that the implementation of Tanner’s reflection could
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significantly increase the mean score and level of clinical decision-making in ICU nurses Keywords: Reflection, clinical decision-making, nurse, intensive care unit
ACCEPTED MANUSCRIPT Introduction Clinical decision-making is a fundamental concept in the field of nursing which affects the course of patient care and recovery (Johansen and O'Brien, 2016). It can be regarded as interventions and strategies improving patients’ clinical status from their current conditions to favorable conditions (shahraki moghaddam et al., 2016). Due to their role as one of the most influential factors in
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overcoming the main challenges faced by health systems throughout the world, nurses should
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receive relevant education to enhance their clinical judgment and decision-making skills (Thompson et al., 2013). Under the dynamic and changing conditions of their work environment,
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nurses have to deal with the uncertain and changing status of the patients. They should, hence, be competent at decision-making to make precise and appropriate decisions about patients’ health
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status by combining their technical skills and professional knowledge (Musavi, 2016).
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Literature
Considering the complexity and rapid changes in the clinical status of patients and the need for
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urgent measures in intensive care units (ICUs), making timely and rational clinical decisions is of critical importance for ICU nurses (Ramazanibadr et al., 2010). Therefore, ICU nurses need greater
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clinical decision-making skills. The validity of important clinical decisions depends on proper and thoughtful judgment (Rostamniya et al., 2014). However, previous studies have indicated low-
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moderate clinical decision-making skills among nurses (Ramazanibadr et al., 2010, Sedaghati and Ezadi, 2014). Karimi et al. reported the intuitive level of decision-making among nursing students
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and working nurses as 0% and 1.5%, respectively (Karimi Noghondar et al., 2013). Despite increased attention to clinical decision-making in nursing curriculum, no efficient training
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intervention has been presented to improve nurses’ clinical decision-making skills (Thompson et al., 2013). Johansen emphasized the need for nurses to learn different methods facilitating appropriate decision-making in various fields (Johansen and O'Brien, 2016) Structures deepening nurses’ thinking and analysis ability, such as reflection, can enhance their clinical decision-making skills. Reflection helps individuals use the critical analysis of their performance and integrate their thoughts and actions when facing different situations. Considering the importance of this subject
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ACCEPTED MANUSCRIPT matter and the number of studies in this regard, this study evaluated the effects of reflection on clinical decision-making of ICU nurses. Analytical Framework The present study examined the effect of Tanner's guide for reflection on the clinical decision
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making of nurses who work in ICUs. Tanner's guide for reflection, specially designed for nurses
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in the clinical setting, uses clinical experience and their processing and analysis to save the gained
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knowledge for better performance in similar or more complex empirical situations in future.
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Aim
This study evaluated the effects of implementing Tanner’s reflection method on clinical decision-
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making of nurses working in an intensive care unit (ICU).
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Methods Design
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This study used the Guide for Reflection based on Tanner's Clinical Judgment Model (2007) which is a framework for nurses’ reflection in clinical environments .Tanner’s reflection guide
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uses clear open-ended questions to analyze every clinical situation nurses face based on not only the context, but also noticing, responding, and reflecting in action and reflecting on action. It aims
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to turn the experience into new knowledge which can be used by nurses in future situations. The findings of the systematic review generally support Tanner's original model, although the role of experience in clinical reasoning and judgment is still not well understood or fully established. In recent literature, researchers have furthered their knowledge by using tools for improving these skills in both nursing students and practicing nurses, although no one strategy has been identified as being more effective. (Nielsen et al., 2007, Cappelletti et al., 2014). The researcher scores the participants’ level of reflection after each reflection based on Laster Clinical Judgment Rubric (a feedback measure designed for Tanner’s reflection guide). Feedback is the heart of the reflection process and encourages people to more actively involve in reflection. The rubric scores reflection
ACCEPTED MANUSCRIPT in four levels including beginning (11 points), developing (12-22 points), accomplished (23-33 points), and exemplary (34-44 points) (Miraglia and Asselin, 2015). In order to prevent the propagation of the information, the control group completed Laurie’s Clinical Decision-Making Scale twice (pretest and posttest) with a one-month interval. Afterward, the case group filled out the same questionnaire and attended a one-day workshop on Tanner’s reflection method. During the workshop, specialized professors instructed the nurses to use scenario planning and group
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discussions and to participate in the analysis process based on Tanner’s guide. Every week (for
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four weeks), each participant recorded a reflection in the reflection book and the researcher
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reviewed each reflection, scored it based on Lasater Clinical Judgment Rubric, and returned it to the participant. The participants recompleted the scale one week after the end of the intervention.
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Setting and Practitioner
In this clinical trial, 60 eligible nurses working in the ICU of Amin Hospital, Isfahan, Iran were
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selected by census sampling. The participants were randomly allocated to either the case or the control group. The inclusion criteria were willingness to participate and having at least six months
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Ethical Considerations
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of work experience in the ICU.
The present study was approved by the Ethics Committee of Isfahan University of Medical
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Sciences, Isfahan, Iran (IR.MUI.REC1396.3.150) and the hospital authorities’ permission was sought as well. The study was also registered at the Iranian Registry of Clinical Trials(
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IRCT2017070434896N1) .Moreover, the participants signed the written informed consents for voluntarily taking part in the study before completing the questionnaires. Questionnaires were
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anonymized and the participants’ information was collected privately by the researchers. The participants who completed the questionnaire received a small gift for their participation. Data Collection
A two-part questionnaire was administered to collect data. The first part included demographic characteristics (i.e. age, sex, clinical work experience, and ICU work experience). The second part was Laurie and Salantera’s standard clinical decision-making scale (NDMI-14) which is a structured 24-item measure of clinical decision-making. The items are scored on a five-point Likert scale (Always = 5, Often = 4, Sometimes = 3, Rarely = 2, and Never = 1) and the total scores of
ACCEPTED MANUSCRIPT the scale range between 24 and 120. The scale measures clinical decision-making at three levels including systematic analytical (24-67 points), intuitive analytical (68-77 points), and intuitive interpretive (78-120 points). Nouhi et al. (Nouhi et al., 2014), Karimi et al. (Karimi Noghondar et al., 2013), and Philips et al. (Phillips, 2015) confirmed the validity and reliability of the scale. The scale was reported to have adequate internal consistency (Cronbach’s alpha = 0.85). Analytical and intuitive decision-making are the two ends of the decision-making spectrum. Systematic
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analytical decision-making is a step-by-step time-consuming linear analysis. Intuitive interpretive
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decision-making involves a rapid analysis within a short period of time based on the individual’s
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skills, power of thinking, and ability to associate previous and present knowledge, senses, and information perceived from multiple sources. Intuitive analytical decision-making is a
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combination of the two kinds (Phillips, 2015). According to Benner’s theory, nurses with higher levels of clinical competency make decisions more intuitively. Benner states that nurses' judgment
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and decision making determines their clinical competence. According to Benner, nurses in terms of clinical competency are categorized into five groups of novice, advanced beginner, competent,
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proficient and expert. The more the person has the clinical competence, intuitive aspect of his judgment and decision is more. (Abdi et al., 2015, Benner et al., 2009).
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Data Analysis
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The collected data were analyzed using descriptive statistics (mean and frequency) and inferential statistics (paired and independent t tests, Mann Whitney test, and Wilcoxon test). Wilcoxon test
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was used to measure the clinical decision-making levels within the group before and after the intervention. Independent t tests used to measure the mean score of clinical decision-making for intergroup before and after the intervention. Mann-Whitney test was used to measure the clinical
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decision-making levels between groups after the intervention. All analyses were performed in SPSS 21.0 (SPSS Inc., Chicago, IL, USA). A limitation of this study was that the reflection process required thinking and time to learn and implement (it will be more easily implemented when learnt and turned into a habit). Moreover, the nurses’ shortage of time and confrontation with various questions made the intervention progress difficult. The researcher tried to solve the abovementioned problems through spending more time with the participants and preparing scientific materials. Results
ACCEPTED MANUSCRIPT The participants’ mean age, clinical work experience, and work experience in the ICU were 31.2 ± 5.16, 7 ± 4.42, and 4.84 ± 3 years, respectively. Most participants were female. According to the results of independent t and Fisher’s exact tests, the case and control groups were identical in terms of demographic and occupational characteristics (Table 1). The results of independent t tests for intergroup differences before the intervention showed that
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the two groups were not significantly different in the mean score of clinical decision-making (P =
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0.786). However, one week after the intervention, the mean score of clinical decision-making was
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significantly higher in the case group than in the control group (P = 0.009) (Table 2). According to the results of Mann-Whitney test, after the intervention, the nurses’ level of clinical decision-making was significantly higher in the case group than in the control group (P < 0.001).
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In fact, the case group’s level of clinical decision-making improved to the next level (Table 3).
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Discussion
The results of this study showed that the implementation of Tanner’s reflection could significantly
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increase the mean score and level of clinical decision-making in ICU nurses. In fact, the nurses’ mean score of clinical decision-making before the intervention was 73.66 ± 6.77 in the case group
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and 74.1 ± 6.44 in the control group. One week after the intervention, the scores increased to 80.5 ± 7.07 in the case group (P < 0.05) and 75.8 ± 6.4 in the control group (P > 0.05). Furthermore,
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according to Mann-Whitney test results, the case group’s clinical decision-making moved to the next level one week after implementing Tanner’s reflection method. The most important finding
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of this study was that the frequency distribution of the level of intuitive interpretive decisionmaking in the case group increased from 23.3% to 60.0% after the intervention. In the control
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group, 26.7%, 46.6%, and 26.7% of the participants had systematic analytical (24-67 points), intuitive analytical (68-77 points), and intuitive interpretive (78-120 points) levels of clinical decision-making, respectively. These values remained unchanged after the intervention. In the case group, the frequency of systematic analytical and intuitive analytical levels decreased from respectively 20% and 56.7% to respectively 0% and 40%. In contrast, the frequency of the intuitive interpretive level increased from 23.3% to 60%. Reflection encourages people to search and explore for solutions for difficult and doubtful situations. Following the use of reflection in clinical environments and nursing training, nurses
ACCEPTED MANUSCRIPT obtain knowledge through creative methods and focus on their own experiences. They, hence, develop a sense of ownership to the obtained knowledge. Reflection is a fundamental method which effectively promotes knowledge and expertise in clinical situations (Dehghany et al., 2013). According to previous studies, 84.3% of nursing students found that reflection enhanced their sense of empowerment and self-confidence. Moreover, 82% of them believed that performing reflection in clinical environments improved the students’ learning (Sedaghati and Ezadi, 2014,
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Naber and Wyatt, 2014). These results confirmed the implemented method and environment of
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reflection in this study. According to Lasater, the structure of Tanner’s reflection suits clinical
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environments, facilitates learning from nurses’ clinical experiences, and enhances deep and critical thinking in clinical environments. Naber examined the effects of written reflection on critical
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thinking and concluded that reflection served as a valuable skill to improve nurses’ critical thinking. This finding is also in line with the results of the present study (Naber and Wyatt, 2014).
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Thinking skills are a major prerequisite for decision-making and allows nurses to make appropriate decisions under critical conditions. In order to promote nurses’ sensible clinical actions, their
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thinking, judgments, and decision-making skills should be developed. Reflection is a method for development of deep thinking in nurses (Bulman and Schutz, 2013). It enhances thinking skills
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through promoting critical thinking. In an interventional study, Dehghani evaluated the effects of reflection on nurses’ clinical competency and reported that reflection teaching strategy in clinical
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skills could promote nursing students’ clinical competency(Dehghany et al., 2013). They introduced reflection as evidence for professionalism. According to Abdi, nurses’ type of clinical
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judgment and decision-making might be a determinant of their level of clinical competency. Moreover, nurses with higher levels of clinical competency made clinical decisions more
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intuitively (Abdi et al., 2015). Ramezanibadr et al. suggested intuitive decision-making as a main characteristic of clinically competent ICU nurses(Ramazanibadr et al., 2010). Since Tanner’s reflection method could enhance the intuitive interpretive aspect of clinical decision-making among ICU nurses, it might be effective in their clinical competency. WainWright qualitatively examined physiotherapists’ use of reflection in clinical decisionmaking. Similar to our findings, they indicated that reflection could promote the participants’ clinical decision-making skills (Wainwright et al., 2010).
ACCEPTED MANUSCRIPT In line with our findings, studies on the levels of clinical decision-making among nurses have shown intuitive interpretive and systematic analytical levels to have the minimum and maximum frequencies, respectively (Karimi Noghondar et al., 2013, Parker, 2014, Phillips, 2015). It should be noted that no reports of the inefficiency of reflection was found in the review of the available literature. Moreover, none of the previous studies have measured the effects of reflection
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on clinical decision-making.
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Since Tanner’s reflection method significantly increased the level and mean scores of clinical
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decision-making, it can serve as a valuable and strategic technique for improving nurses’ decisionmaking skills. One of the strengths of this study was the use of Tanner’s reflection guide that has
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been developed specifically for nurses’ reflection in clinical environments and can be implemented both individually and collectively in different wards. In this study, the reflection method was implemented individually. After practicing reflection, each participant received feedback from the
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researcher based on Lasater Clinical Judgment Rubric. In order to help the participants evaluate themselves, they were informed about the feedback and its scoring. Numerous studies have sought
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to find methods for improving nurses’ clinical decision-making (Manzari et al., 2015, Nouhi et al.,
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2014, Jodat and Sharifzadeh, 2014). These studies faced with limitations, including the need for suitable training environments, insufficient time for attending various workshops, and the need for the development of specialized scenarios. However, none of these limitations occur when using
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Tanner’s reflection guide as this method does not require a training environment or frequent workshops. In fact, Tanner’s reflection guide has a certain structure and a set of questions for
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analyzing individuals’ experience or future situation based on contextualization, noticing, responding, reflecting in action, and reflecting on action. Therefore, individuals can use this
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method in every situation. Conclusion
Considering the results of this study and the importance of clinical decision-making, it is critical to use novel theoretical and clinical training methods for improving nurses’ clinical decisionmaking skills, particularly in clinical environments. ICU nurses focus on caring for patients who experience life-threatening conditions, they should use all aspects of nursing knowledge to manage the crisis and life threatening of the patients at any moment. This critical care, in addition to basic knowledge of nursing, requires critical thinking and creativity in thinking so that it can achieve the
ACCEPTED MANUSCRIPT highest quality professional performance by making the right decision. Tanner's reflection as the heart of critical thinking and workgroup counseling and individual promotion is a suggestion for nurses in the intensive care units to promote nursing profession, and care process for their patients by increasing their analytical, evaluation, deductive and inductive reasoning. On the other hand, ICU nurses are constantly experiencing complex clinical situations, these experiences are the most significant factors enhancing the clinical decision-making skill. Tanner’s reflection guide is a
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review of experiences identifying nurses’ experiences as a source of knowledge which can be
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expanded by analysis and reflection. While most nurses are unaware of the goals of reflection,
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successful reflection depends on the fact that learners recognize the importance of reflection for their individual and professional growth (Chaffey et al., 2012). Therefore, in order to improve
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nurses’ clinical decision-making skills, Tanner’s reflection should be incorporated into clinical and
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academic nursing education.
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Acknowledgements
This study was derived from a research project approved under the Research Deputy of Isfahan
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University of Medical Sciences (#396150). The researcher appreciates the authorities of Amin Hospital (affiliated to Isfahan University of Medical Sciences) and all nurses participating in this
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study.
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Table 1 frequency distribution of participants demographic characteristics Groups Experimental Control Mean ± SD
Mean ± SD
31/20 ± 5/16 31/50 ± 5/81 Age 5/5 ± 3/75 4/84 ± 3 precedent of experience in icu 7 ±4/42 7/3 ± 4/92 precedent of total experience 27(90 %) 26 (86/4 %) Gender Male 3(10 %) 4 (13/3 % ) Female Table 2 The mean of CDM score in both groups before and after the intervention
The chi-square and the Fishers exact tests* P
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0/83 0/45
0/21 0/76
0/804
0/25
P*=0/5
ACCEPTED MANUSCRIPT Groups score of cdm
Control
The independent – samples t tests*
Mean ± SD
Mean ± SD
P
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73/66 ± 6/77
74/1 ± 6/44
0/786
0/273
80/5 ± 7/07
75/8 ± 6/4
0/009
2/69
P< 0/009 t =15/1
P = 0/13 t = 1/25
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Pre intervention One week post intervention The paired samples t test
Experimental
References
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8 (26/7)
17 (56/7)
14 (46/6)
0/11
1/60
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8 (26/7)
12 (40)
14 (46/6)
18(60) P<0/001 Z=-4/12
8 (26/7) P=1 Z=0
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1/07
8 (26/7)
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7 (23/3) 0 (0)
0/278
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6 (20)
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Pre intervention Analyticsystematic Analyticintuition intuition One week post intervention Analyticsystematic Analyticintuition intuition Wilcoxon test
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Table 3 Frequency distribution of level of CDM in both groups before and after the intervention Time Experimental Control Mann Whitney test level of CDM N (%) N (%) P Z
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Abdi, A., Assadi, P., Mohammadyari, T. & Miri, J. 2015. General decision-making style and clinical competence of nurses working in the educational hospitals affiliated to Kermanshah University of Medical Sciences in 2014. Journal of Nursing Education, 4.29-19 , Benner, P. E., Tanner, C. A. & CHesla, C. A. 2009. Expertise in nursing practice: Caring, clinical judgment, and ethics, Springer Publishing Company. Bulman, C. & Schutz, S. 2013. Reflective practice in nursing, John Wiley & Sons. Cappelletti, A ,.Engel, J. K. & Prentice, D. 2014. Systematic review of clinical judgment and reasoning in nursing. Journal of Nursing Education, 53, 453-458. CHaffey, L. J., DE Leeuw, E. J. J. & Finnigan, G. A. 2012. Facilitating students' reflective practice in a medical course: literature review. Education for Health, 25, 198. Dehghany, Z., Abaszadeh, A., Moattari, M. & Bahreini, M. 2013. Effective reflection on clinical competency of nursing students. Payesh, 12, 63-70.
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Shahrokhi Razieh, Ghafari Somayeh, Haghani Fariba PII: DOI: Reference:
S0260-6917(18)30134-5 doi:10.1016/j.nedt.2018.03.009 YNEDT 3804
To appear in: Received date: Revised date: Accepted date:
22 October 2017 18 February 2018 13 March 2018
Please cite this article as: Shahrokhi Razieh, Ghafari Somayeh, Haghani Fariba , Effects of reflection on clinical decision-making of intensive care unit nurses. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ynedt(2018), doi:10.1016/j.nedt.2018.03.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Effects of Reflection on Clinical Decision-Making of Intensive Care Unit Nurses Word count: 3383
Shahrokhi Razieh department of nursing , Isfahan university of medical science, Isfahan, Iran
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Ghafari Somayeh (corresponding author)
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Assistant professor, nursing and midwifery care research center, faculty of nursing and midwifery, Isfahan University of medical science, Isfahan, Iran. PO: 81746-73461
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Tel: 03137927544
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E-mail: [email protected]
Haghani Fariba
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Department of Medical Education, Medical Education Research Center, Isfahan University of
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Medical Sciences, Isfahan, Iran
Acknowledge: The researcher appreciates the authorities of Amin Hospital (affiliated to Isfahan
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University of Medical Sciences) and all nurses participating in this study..
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Funding: This research was supported by Isfahan University of Medical Science (grant number: 396150).
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Abstract
Background: Nurses are one of the most influential factors in overcoming the main challenges
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faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. Objective: This study evaluated the effects of implementing Tanner’s reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). Design: This study used an experimental, pretest, posttest design. Setting: The setting was the intensive care unit of Amin Hospital Isfahan, Iran).
ACCEPTED MANUSCRIPT Participants: The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). Methods: This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic
T
characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-
IP
14). The questionnaire was completed before and one week after the intervention. The data were
CR
analyzed using SPSS 21.0.
Results: The two groups were not significantly different in terms of the level and mean scores of
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clinical decision-making before the intervention (P = 0.786). Based on the results of independent t test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann
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Whitney test showed that one week after the intervention, the nurses’ level of clinical decision-
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making in the case group rose to the next level (P = 0.001). Conclusion: Reflection could improve the clinical decision-making of ICU nurses. It is, thus,
ED
recommended to incorporate this method into the nursing curriculum and care practices. Clinical decision-making is a fundamental concept in the field of nursing which affects the
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course of patient care and recovery
The validity of important clinical decisions depends on proper and thoughtful judgment
Reflection helps individuals use the critical analysis of their performance and integrate
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their thoughts and actions when facing different situations The results of this study showed that the implementation of Tanner’s reflection could
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significantly increase the mean score and level of clinical decision-making in ICU nurses Keywords: Reflection, clinical decision-making, nurse, intensive care unit
ACCEPTED MANUSCRIPT Introduction Clinical decision-making is a fundamental concept in the field of nursing which affects the course of patient care and recovery (Johansen and O'Brien, 2016). It can be regarded as interventions and strategies improving patients’ clinical status from their current conditions to favorable conditions (shahraki moghaddam et al., 2016). Due to their role as one of the most influential factors in
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overcoming the main challenges faced by health systems throughout the world, nurses should
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receive relevant education to enhance their clinical judgment and decision-making skills (Thompson et al., 2013). Under the dynamic and changing conditions of their work environment,
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nurses have to deal with the uncertain and changing status of the patients. They should, hence, be competent at decision-making to make precise and appropriate decisions about patients’ health
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status by combining their technical skills and professional knowledge (Musavi, 2016).
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Literature
Considering the complexity and rapid changes in the clinical status of patients and the need for
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urgent measures in intensive care units (ICUs), making timely and rational clinical decisions is of critical importance for ICU nurses (Ramazanibadr et al., 2010). Therefore, ICU nurses need greater
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clinical decision-making skills. The validity of important clinical decisions depends on proper and thoughtful judgment (Rostamniya et al., 2014). However, previous studies have indicated low-
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moderate clinical decision-making skills among nurses (Ramazanibadr et al., 2010, Sedaghati and Ezadi, 2014). Karimi et al. reported the intuitive level of decision-making among nursing students
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and working nurses as 0% and 1.5%, respectively (Karimi Noghondar et al., 2013). Despite increased attention to clinical decision-making in nursing curriculum, no efficient training
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intervention has been presented to improve nurses’ clinical decision-making skills (Thompson et al., 2013). Johansen emphasized the need for nurses to learn different methods facilitating appropriate decision-making in various fields (Johansen and O'Brien, 2016) Structures deepening nurses’ thinking and analysis ability, such as reflection, can enhance their clinical decision-making skills. Reflection helps individuals use the critical analysis of their performance and integrate their thoughts and actions when facing different situations. Considering the importance of this subject
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ACCEPTED MANUSCRIPT matter and the number of studies in this regard, this study evaluated the effects of reflection on clinical decision-making of ICU nurses. Analytical Framework The present study examined the effect of Tanner's guide for reflection on the clinical decision
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making of nurses who work in ICUs. Tanner's guide for reflection, specially designed for nurses
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in the clinical setting, uses clinical experience and their processing and analysis to save the gained
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knowledge for better performance in similar or more complex empirical situations in future.
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Aim
This study evaluated the effects of implementing Tanner’s reflection method on clinical decision-
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making of nurses working in an intensive care unit (ICU).
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Methods Design
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This study used the Guide for Reflection based on Tanner's Clinical Judgment Model (2007) which is a framework for nurses’ reflection in clinical environments .Tanner’s reflection guide
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uses clear open-ended questions to analyze every clinical situation nurses face based on not only the context, but also noticing, responding, and reflecting in action and reflecting on action. It aims
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to turn the experience into new knowledge which can be used by nurses in future situations. The findings of the systematic review generally support Tanner's original model, although the role of experience in clinical reasoning and judgment is still not well understood or fully established. In recent literature, researchers have furthered their knowledge by using tools for improving these skills in both nursing students and practicing nurses, although no one strategy has been identified as being more effective. (Nielsen et al., 2007, Cappelletti et al., 2014). The researcher scores the participants’ level of reflection after each reflection based on Laster Clinical Judgment Rubric (a feedback measure designed for Tanner’s reflection guide). Feedback is the heart of the reflection process and encourages people to more actively involve in reflection. The rubric scores reflection
ACCEPTED MANUSCRIPT in four levels including beginning (11 points), developing (12-22 points), accomplished (23-33 points), and exemplary (34-44 points) (Miraglia and Asselin, 2015). In order to prevent the propagation of the information, the control group completed Laurie’s Clinical Decision-Making Scale twice (pretest and posttest) with a one-month interval. Afterward, the case group filled out the same questionnaire and attended a one-day workshop on Tanner’s reflection method. During the workshop, specialized professors instructed the nurses to use scenario planning and group
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discussions and to participate in the analysis process based on Tanner’s guide. Every week (for
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four weeks), each participant recorded a reflection in the reflection book and the researcher
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reviewed each reflection, scored it based on Lasater Clinical Judgment Rubric, and returned it to the participant. The participants recompleted the scale one week after the end of the intervention.
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Setting and Practitioner
In this clinical trial, 60 eligible nurses working in the ICU of Amin Hospital, Isfahan, Iran were
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selected by census sampling. The participants were randomly allocated to either the case or the control group. The inclusion criteria were willingness to participate and having at least six months
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Ethical Considerations
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of work experience in the ICU.
The present study was approved by the Ethics Committee of Isfahan University of Medical
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Sciences, Isfahan, Iran (IR.MUI.REC1396.3.150) and the hospital authorities’ permission was sought as well. The study was also registered at the Iranian Registry of Clinical Trials(
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IRCT2017070434896N1) .Moreover, the participants signed the written informed consents for voluntarily taking part in the study before completing the questionnaires. Questionnaires were
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anonymized and the participants’ information was collected privately by the researchers. The participants who completed the questionnaire received a small gift for their participation. Data Collection
A two-part questionnaire was administered to collect data. The first part included demographic characteristics (i.e. age, sex, clinical work experience, and ICU work experience). The second part was Laurie and Salantera’s standard clinical decision-making scale (NDMI-14) which is a structured 24-item measure of clinical decision-making. The items are scored on a five-point Likert scale (Always = 5, Often = 4, Sometimes = 3, Rarely = 2, and Never = 1) and the total scores of
ACCEPTED MANUSCRIPT the scale range between 24 and 120. The scale measures clinical decision-making at three levels including systematic analytical (24-67 points), intuitive analytical (68-77 points), and intuitive interpretive (78-120 points). Nouhi et al. (Nouhi et al., 2014), Karimi et al. (Karimi Noghondar et al., 2013), and Philips et al. (Phillips, 2015) confirmed the validity and reliability of the scale. The scale was reported to have adequate internal consistency (Cronbach’s alpha = 0.85). Analytical and intuitive decision-making are the two ends of the decision-making spectrum. Systematic
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analytical decision-making is a step-by-step time-consuming linear analysis. Intuitive interpretive
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decision-making involves a rapid analysis within a short period of time based on the individual’s
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skills, power of thinking, and ability to associate previous and present knowledge, senses, and information perceived from multiple sources. Intuitive analytical decision-making is a
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combination of the two kinds (Phillips, 2015). According to Benner’s theory, nurses with higher levels of clinical competency make decisions more intuitively. Benner states that nurses' judgment
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and decision making determines their clinical competence. According to Benner, nurses in terms of clinical competency are categorized into five groups of novice, advanced beginner, competent,
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proficient and expert. The more the person has the clinical competence, intuitive aspect of his judgment and decision is more. (Abdi et al., 2015, Benner et al., 2009).
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Data Analysis
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The collected data were analyzed using descriptive statistics (mean and frequency) and inferential statistics (paired and independent t tests, Mann Whitney test, and Wilcoxon test). Wilcoxon test
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was used to measure the clinical decision-making levels within the group before and after the intervention. Independent t tests used to measure the mean score of clinical decision-making for intergroup before and after the intervention. Mann-Whitney test was used to measure the clinical
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decision-making levels between groups after the intervention. All analyses were performed in SPSS 21.0 (SPSS Inc., Chicago, IL, USA). A limitation of this study was that the reflection process required thinking and time to learn and implement (it will be more easily implemented when learnt and turned into a habit). Moreover, the nurses’ shortage of time and confrontation with various questions made the intervention progress difficult. The researcher tried to solve the abovementioned problems through spending more time with the participants and preparing scientific materials. Results
ACCEPTED MANUSCRIPT The participants’ mean age, clinical work experience, and work experience in the ICU were 31.2 ± 5.16, 7 ± 4.42, and 4.84 ± 3 years, respectively. Most participants were female. According to the results of independent t and Fisher’s exact tests, the case and control groups were identical in terms of demographic and occupational characteristics (Table 1). The results of independent t tests for intergroup differences before the intervention showed that
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the two groups were not significantly different in the mean score of clinical decision-making (P =
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0.786). However, one week after the intervention, the mean score of clinical decision-making was
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significantly higher in the case group than in the control group (P = 0.009) (Table 2). According to the results of Mann-Whitney test, after the intervention, the nurses’ level of clinical decision-making was significantly higher in the case group than in the control group (P < 0.001).
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In fact, the case group’s level of clinical decision-making improved to the next level (Table 3).
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Discussion
The results of this study showed that the implementation of Tanner’s reflection could significantly
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increase the mean score and level of clinical decision-making in ICU nurses. In fact, the nurses’ mean score of clinical decision-making before the intervention was 73.66 ± 6.77 in the case group
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and 74.1 ± 6.44 in the control group. One week after the intervention, the scores increased to 80.5 ± 7.07 in the case group (P < 0.05) and 75.8 ± 6.4 in the control group (P > 0.05). Furthermore,
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according to Mann-Whitney test results, the case group’s clinical decision-making moved to the next level one week after implementing Tanner’s reflection method. The most important finding
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of this study was that the frequency distribution of the level of intuitive interpretive decisionmaking in the case group increased from 23.3% to 60.0% after the intervention. In the control
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group, 26.7%, 46.6%, and 26.7% of the participants had systematic analytical (24-67 points), intuitive analytical (68-77 points), and intuitive interpretive (78-120 points) levels of clinical decision-making, respectively. These values remained unchanged after the intervention. In the case group, the frequency of systematic analytical and intuitive analytical levels decreased from respectively 20% and 56.7% to respectively 0% and 40%. In contrast, the frequency of the intuitive interpretive level increased from 23.3% to 60%. Reflection encourages people to search and explore for solutions for difficult and doubtful situations. Following the use of reflection in clinical environments and nursing training, nurses
ACCEPTED MANUSCRIPT obtain knowledge through creative methods and focus on their own experiences. They, hence, develop a sense of ownership to the obtained knowledge. Reflection is a fundamental method which effectively promotes knowledge and expertise in clinical situations (Dehghany et al., 2013). According to previous studies, 84.3% of nursing students found that reflection enhanced their sense of empowerment and self-confidence. Moreover, 82% of them believed that performing reflection in clinical environments improved the students’ learning (Sedaghati and Ezadi, 2014,
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Naber and Wyatt, 2014). These results confirmed the implemented method and environment of
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reflection in this study. According to Lasater, the structure of Tanner’s reflection suits clinical
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environments, facilitates learning from nurses’ clinical experiences, and enhances deep and critical thinking in clinical environments. Naber examined the effects of written reflection on critical
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thinking and concluded that reflection served as a valuable skill to improve nurses’ critical thinking. This finding is also in line with the results of the present study (Naber and Wyatt, 2014).
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Thinking skills are a major prerequisite for decision-making and allows nurses to make appropriate decisions under critical conditions. In order to promote nurses’ sensible clinical actions, their
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thinking, judgments, and decision-making skills should be developed. Reflection is a method for development of deep thinking in nurses (Bulman and Schutz, 2013). It enhances thinking skills
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through promoting critical thinking. In an interventional study, Dehghani evaluated the effects of reflection on nurses’ clinical competency and reported that reflection teaching strategy in clinical
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skills could promote nursing students’ clinical competency(Dehghany et al., 2013). They introduced reflection as evidence for professionalism. According to Abdi, nurses’ type of clinical
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judgment and decision-making might be a determinant of their level of clinical competency. Moreover, nurses with higher levels of clinical competency made clinical decisions more
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intuitively (Abdi et al., 2015). Ramezanibadr et al. suggested intuitive decision-making as a main characteristic of clinically competent ICU nurses(Ramazanibadr et al., 2010). Since Tanner’s reflection method could enhance the intuitive interpretive aspect of clinical decision-making among ICU nurses, it might be effective in their clinical competency. WainWright qualitatively examined physiotherapists’ use of reflection in clinical decisionmaking. Similar to our findings, they indicated that reflection could promote the participants’ clinical decision-making skills (Wainwright et al., 2010).
ACCEPTED MANUSCRIPT In line with our findings, studies on the levels of clinical decision-making among nurses have shown intuitive interpretive and systematic analytical levels to have the minimum and maximum frequencies, respectively (Karimi Noghondar et al., 2013, Parker, 2014, Phillips, 2015). It should be noted that no reports of the inefficiency of reflection was found in the review of the available literature. Moreover, none of the previous studies have measured the effects of reflection
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on clinical decision-making.
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Since Tanner’s reflection method significantly increased the level and mean scores of clinical
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decision-making, it can serve as a valuable and strategic technique for improving nurses’ decisionmaking skills. One of the strengths of this study was the use of Tanner’s reflection guide that has
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been developed specifically for nurses’ reflection in clinical environments and can be implemented both individually and collectively in different wards. In this study, the reflection method was implemented individually. After practicing reflection, each participant received feedback from the
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researcher based on Lasater Clinical Judgment Rubric. In order to help the participants evaluate themselves, they were informed about the feedback and its scoring. Numerous studies have sought
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to find methods for improving nurses’ clinical decision-making (Manzari et al., 2015, Nouhi et al.,
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2014, Jodat and Sharifzadeh, 2014). These studies faced with limitations, including the need for suitable training environments, insufficient time for attending various workshops, and the need for the development of specialized scenarios. However, none of these limitations occur when using
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Tanner’s reflection guide as this method does not require a training environment or frequent workshops. In fact, Tanner’s reflection guide has a certain structure and a set of questions for
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analyzing individuals’ experience or future situation based on contextualization, noticing, responding, reflecting in action, and reflecting on action. Therefore, individuals can use this
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method in every situation. Conclusion
Considering the results of this study and the importance of clinical decision-making, it is critical to use novel theoretical and clinical training methods for improving nurses’ clinical decisionmaking skills, particularly in clinical environments. ICU nurses focus on caring for patients who experience life-threatening conditions, they should use all aspects of nursing knowledge to manage the crisis and life threatening of the patients at any moment. This critical care, in addition to basic knowledge of nursing, requires critical thinking and creativity in thinking so that it can achieve the
ACCEPTED MANUSCRIPT highest quality professional performance by making the right decision. Tanner's reflection as the heart of critical thinking and workgroup counseling and individual promotion is a suggestion for nurses in the intensive care units to promote nursing profession, and care process for their patients by increasing their analytical, evaluation, deductive and inductive reasoning. On the other hand, ICU nurses are constantly experiencing complex clinical situations, these experiences are the most significant factors enhancing the clinical decision-making skill. Tanner’s reflection guide is a
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review of experiences identifying nurses’ experiences as a source of knowledge which can be
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expanded by analysis and reflection. While most nurses are unaware of the goals of reflection,
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successful reflection depends on the fact that learners recognize the importance of reflection for their individual and professional growth (Chaffey et al., 2012). Therefore, in order to improve
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nurses’ clinical decision-making skills, Tanner’s reflection should be incorporated into clinical and
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academic nursing education.
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Acknowledgements
This study was derived from a research project approved under the Research Deputy of Isfahan
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University of Medical Sciences (#396150). The researcher appreciates the authorities of Amin Hospital (affiliated to Isfahan University of Medical Sciences) and all nurses participating in this
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study.
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Table 1 frequency distribution of participants demographic characteristics Groups Experimental Control Mean ± SD
Mean ± SD
31/20 ± 5/16 31/50 ± 5/81 Age 5/5 ± 3/75 4/84 ± 3 precedent of experience in icu 7 ±4/42 7/3 ± 4/92 precedent of total experience 27(90 %) 26 (86/4 %) Gender Male 3(10 %) 4 (13/3 % ) Female Table 2 The mean of CDM score in both groups before and after the intervention
The chi-square and the Fishers exact tests* P
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0/83 0/45
0/21 0/76
0/804
0/25
P*=0/5
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Control
The independent – samples t tests*
Mean ± SD
Mean ± SD
P
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73/66 ± 6/77
74/1 ± 6/44
0/786
0/273
80/5 ± 7/07
75/8 ± 6/4
0/009
2/69
P< 0/009 t =15/1
P = 0/13 t = 1/25
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Pre intervention One week post intervention The paired samples t test
Experimental
References
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8 (26/7)
17 (56/7)
14 (46/6)
0/11
1/60
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12 (40)
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18(60) P<0/001 Z=-4/12
8 (26/7) P=1 Z=0
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1/07
8 (26/7)
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7 (23/3) 0 (0)
0/278
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6 (20)
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Pre intervention Analyticsystematic Analyticintuition intuition One week post intervention Analyticsystematic Analyticintuition intuition Wilcoxon test
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Table 3 Frequency distribution of level of CDM in both groups before and after the intervention Time Experimental Control Mann Whitney test level of CDM N (%) N (%) P Z
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