Clinical Diagnosis (Essential Clinical Skills for Nurses)

The role and function of the nurse is rapidly changing. Some nurses are now required to undertake clinical diagnosis of the patient, a responsibility traditionally.
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Evidence Based Care Sheets provide summaries outlining what is known about a disease or condition and the best way to treat the patient. This information can be referenced at the point-of-care, keep nurses up-to-date on the latest evidence and refresh clinical nursing skills. See a sample Evidence Based Care Sheets document. Nurses can improve their nursing skills with continuing education modules which provide contact hours.

Nurses who successfully complete the modules can obtain CEUs. Read more about continuing education. Nurses can increase their skills with additional resources including practice guidelines, research instrument information and legal cases. Resources also include full text for books covering a wide range of topics including drug information, nursing communication skills, critical thinking skills and more. Home Benefits Improves Nursing Skills. The goal is to create a living self-improving tradition. Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning.

Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought. We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching.

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To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training. Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment.

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Clinical experience is good, but not everybody has it. The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined.

Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning. Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention. Clinical grasp describes clinical inquiry in action.

Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Four aspects of clinical grasp, which are described in the following paragraphs, include 1 making qualitative distinctions, 2 engaging in detective work, 3 recognizing changing relevance, and 4 developing clinical knowledge in specific patient populations.

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient.

Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Clinical situations are open ended and underdetermined. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

Effective case presentations--an important clinical skill for nurse practitioners. - PubMed - NCBI

For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors.

The meanings of signs and symptoms are changed by sequencing and history. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments. Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population.

The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: Future think is the broadest category of this logic of practice.

Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment.

Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients. Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time.

This aspect of clinical forethought is central to knowing the particular patient, family, or community. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting.

For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:. Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. She asked what tubes here have you seen? Well, I know peripheral lines.

The site, check the site. He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning.

One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates.

Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:.

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. But she shared that. One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning.

If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open.

Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action.

Effective case presentations--an important clinical skill for nurse practitioners.

Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention.

MedSurg Assessment

A hallmark of expertise is the ability to notice the unexpected. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition.


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Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.


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    7. Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. Turn recording back on. National Center for Biotechnology Information , U. Show details Hughes RG, editor. Chapter 6 Clinical Reasoning, Decisionmaking, and Action: Background This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Critical Thinking Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years.

    Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition: Course work or ethical experiences should provide the graduate with the knowledge and skills to: Use nursing and other appropriate theories and models, and an appropriate ethical framework;. Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;. Critical Reflection, Critical Reasoning, and Judgment Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case.

    Techne and Phronesis Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. Thinking Critically Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation.

    As Dunne notes, A practice is not just a surface on which one can display instant virtuosity. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them: Experience One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit ICU nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories.

    Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response: Intuition and Perception Intuition is the instant understanding of knowledge without evidence of sensible thought. Evaluating Evidence Before research should be used in practice, it must be evaluated.

    Evidence-Based Practice The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. When Evidence Is Missing In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. The Three Apprenticeships of Professional Education We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching.

    Making Qualitative Distinctions Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. Recognizing Changing Clinical Relevance The meanings of signs and symptoms are changed by sequencing and history. Developing Clinical Knowledge in Specific Patient Populations Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population.

    Clinical Forethought Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Future think Future think is the broadest category of this logic of practice. Anticipation of crises, risks, and vulnerabilities for particular patients This aspect of clinical forethought is central to knowing the particular patient, family, or community. In the following example, an anonymous student recounted her experiences of meeting a patient: One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference: Seeing the unexpected One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices.

    Conclusion Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. Dressel P, Mayhew L. General education exploration in evaluation. American Council on Education; Scriven M, Paul R.

    Bittner N, Tobin E. J Nurses Staff Dev. A consensus statement on critical thinking in nursing. Facione N, Facione P. Externalizing the critical thinking in knowledge development and clinical judgment. American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice.

    American Association of Colleges of Nursing; Foundation for Critical Thinking; Expertise in nursing practice, caring, clinical judgment and ethics. Back to the rough ground Practical judgment and the lure of technique. University of Notre Dame Press; The wisdom of practice. On the vital role of fluid movement in organisms and cells: Clinical reasoning strategies during care planning. Explores the assessment skills required for a rapid response to a patient at risk of becoming acutely unwell.

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