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Decision Making

A 69-year-old lady presented to the ED at 17.30 h following a fall the previous day while out walking. She had stumbled over an uneven patch of walkway and landed on her outstretched extended hand. When reviewed by the ANP, her arm was elevated in a sling and relatively comfortable and she was mobilizing independently. She had been travelling with her family most of the day and was anxious to minimize her time in the ED and be back home before midnight and she still had long way to travel. She had expressed this desire to the Triage nurse who was cognizant that the ANP shift ﬁnished at 20.00 h, and as the department was very busy and it was very likely that this lady would have a long wait for medical staff once the ANP service had ﬁnished for the day. So the Triage nurse immediately requested a wrist X-ray in order to try and speed up the patients’ treatment process.

ANP Clinical Examination

Clinical examination by the ANP revealed a 69-y old lady, healthy and well in appearance. She declared no signiﬁcant previous medical history. She had no known allergies and had a pain score 3/10. Analgesia had been administered in Triage with good effect. Detailed examination of her left non-dominant wrist revealed a grossly swollen deformity, with bruising and swelling extending up the forearm and tenderness over the distal radius and ulna.

While examining the wrist the ANP noted that the patient’s left shoulder appeared somewhat ‘‘stiff” and the patient was asked to remove upper arm garments for further evaluation. She had not mentioned any previous medical history in the initial history-taking episode. She insisted that the shoulder stiffness was due to an old injury from six months previously where she had sustained a left proximal humerus fracture in a fall. She was conﬁdent that the ongoing physiotherapy on her upper arm was still going well and she had just ‘‘rattled things” a little bit again. However, on further examination of her upper arm a large swelling was noted on the mid-shaft of the humerus which the patient felt was there ‘‘all the time” since the previous fall. She complained of only slight pain and tenderness over this swelling and had a reduced range of motion in her left shoulder and elbow. There was no evidence of any neurovascular injury in the left arm or wrist. The initial left wrist radiograph was negative.

Describe some psychological and contextual complexities and constraints that may face the NP while making decisions in the above scenario
Describe intuitive and rational analytic decision-making models (thinking) that would serve to guide the ANP's decision in this scenario (making sure to provide the decision the NP should make). Are both required, why or why not?
Compare and contrast the two decision-making models applied and discuss the benefits and consequences of using these decision-making methods in the above scenario.
What is the best decision-making approach/strategy for advanced practice nurses generally? Be sure to provide a well-supported response.
What is metacognition and how does it help to guide decision-making for the APN?

Full Answer Section

Decision-Making Models

Intuitive Decision-Making:

Strengths: Quick and efficient, especially in familiar situations.
Weaknesses: Can be prone to biases and errors, particularly when dealing with complex or novel situations.

Rational Analytic Decision-Making:

Strengths: Systematic and logical, reducing the risk of errors.
Weaknesses: Can be time-consuming and may not be practical in fast-paced clinical settings.

In this scenario, a combination of both intuitive and rational analytic decision-making is necessary:

Intuitive Decision-Making: The ANP can use intuition to quickly assess the patient's overall condition, identify potential red flags, and prioritize immediate concerns.
Rational Analytic Decision-Making: The ANP should systematically gather information, consider multiple hypotheses, and weigh the potential risks and benefits of different treatment options.

Best Decision-Making Approach for APNs

A hybrid approach that combines both intuitive and rational analytic decision-making is optimal for APNs. This approach allows for rapid decision-making in urgent situations while also considering all relevant factors and potential consequences.

Metacognition and Decision-Making

Metacognition, or thinking about thinking, is essential for effective decision-making. It involves:

Self-awareness: Recognizing one's own cognitive biases and limitations.
Critical Thinking: Evaluating the quality of information and evidence.
Problem-Solving: Breaking down complex problems into smaller, more manageable steps.
Reflection: Reflecting on past decisions to identify lessons learned and improve future decision-making.

By developing strong metacognitive skills, APNs can enhance their ability to make sound clinical judgments and provide high-quality care.

Sample Answer

The ANP in this scenario faces several psychological and contextual complexities:

Patient Anxiety: The patient's desire for rapid treatment and return home can influence the ANP's decision-making, potentially leading to a rushed assessment.
Time Constraints: The approaching end of the ANP's shift and the busy ED environment can put pressure on the clinician to make quick decisions.
Patient's Minimization of Symptoms: The patient's initial underreporting of symptoms, particularly regarding the shoulder injury, can complicate the assessment process.
Diagnostic Uncertainty: The initial negative wrist X-ray and the patient's history of a previous shoulder injury can create uncertainty about the extent of the current injuries.