Perception requires skillful engagement both with the problem and the person(s). Perceptual acuity is much less studied than judgment, yet one can only make judgments about what is perceived (Vetleson, 1994). The skills of problem engagement and interpersonal involvement require experiential learning. For example, clinicians talk about problems of overidentifying with the patient and becoming flooded with feelings. It is equally a problem to wall off feelings so that the possibilities of attunement are blunted or shut down. The beginning nurse can feel a generalized anxiety over the demands of learning or the fear of making errors. At this beginning stage, dampening emotional responses can lower anxiety and improve performance. But with the gaining of skilled know-how and good clinical judgment, emotional responses can become more differentiated. The practitioner begins to feel comfortable and “at home” in familiar situations and uneasy in situations that are unfamiliar. This differentiated emotional response is the beginning of gaining a sense of salience and developing attunement to the situation. At the competent stage, clinical learners can safely pay attention to vague or global emotional responses as a sign that they do not fully understand a situation. This global understanding of the clinical situation is at the heart of practical clinical reasoning that we call clinical grasp (Benner, Hooper-Kyriakidis, & Stannard, 1999). At the competent level of skill acquisition, nurses have a developing sense of when they do or do not have a good clinical grasp of the situation. This emotional sense is crucial to early problem search and identification. Perceptual acuity and an acute clinical grasp of the situation are the sources of discovery and early warnings of changes in patients.

Traditionally, emotion has been seen as the opposite of cognition and rationality. But increasingly it is recognized that emotions play a key role in perception and even act as a moral compass in learning a practice (Benner, Tanner, & Chesla, 1996; Dreyfus, Dreyfus, & Benner, 1996). For example, at the competent stage, clinical learners feel “good” when they perform well and when they take the risks inherent in making sound clinical judgments. Nurses at this level feel disappointment and regret when an error in judgment causes a patient to suffer a negative outcome (Dreyfus & Dreyfus, 1986). These are essential aesthetic and ethical responses that guide the development of perceptual acuity and problem identification. And it is the ongoing background sense of whether the nurse has a good grasp of a clinical situation or whether the situation is ambiguous and puzzling that guides problem recognition and clarification.

DIAGNOSTIC DISCERNMENT AND ATTENTIVENESS

Interpersonal engagement is not synonymous with problem engagement, although the two are linked. Bearing witness to another’s distress can cause anxiety, and nurses may distance themselves for their own emotional protection. If nurses selectively attend to some problems more than others, such as attending to a patient’s dysrhythmias or cardiac output, they may not be able to engage with the patient’s overall clinical situation. They must learn to carry out comprehensive assessment of the patient’s changes over time.

Anxiety can disrupt attentiveness and helping relationships. Extreme disengagement may prevent the nurse from experiencing personal responsibility and agency in a clinical situation (Rubin, 1996). Thus attentiveness as disrupted by system constraints, such as low nurse-to-patient staffing ratios, may prevent sufficient nurse-patient contact to ensure attentiveness. It cannot be considered an error of “clinical judgment” if system constraints have prevented the nurse from having sufficient contact with a patient to make an adequate assessment of the patient’s condition. For reasoning-in-transition (or practical clinical reasoning) to occur, the nurse must use the interpersonal skills of engaging with the clinical and human situation at hand but he/she must also have the opportunity to interact with the patient. The relational skills of listening to and clarifying the patient’s concern create effective disclosure spaces for understanding the patient’s situation and needs.

Thus attentiveness is related to skills of involvement or engagement. Attentiveness and skills of involvement require the imperative of an open and attentive engagement with a clinical situation or problem and the skill of applying the right kinds and amounts of interpersonal engagement with patients and their families (Benner, Hooper-Kyriakidis, & Stannard, 1999).

CASE STUDY—BEWARE: One Emergency May Hide Another!

A hospital submitted a report to the State Board of Nursing reporting that an RN had been terminated after the death of a patient following surgery for a tubal pregnancy.

THE NURSE’S STORY—SALLY SIMMS, RN

I had worked the medical-surgical units at the General Hospital ever since graduating from my nursing program 4 years before. This was the worst night, the worst shift, of my nursing career.

I was assigned to care for eight patients that night, which is not an unusual number of patients, but they all were either fresh post-ops or so very sick. Four patients had just had surgery that day. One patient was on a dopamine drip to maintain his blood pressure, so he needed frequent monitoring. One patient was suspected to have meningitis, one patient had pneumonia, and a patient with suspected histoplasmosis completed my assignment.

One of my post-op patients was Betty Smith, a young woman in her early thirties who had laparoscopic surgery late in the day. She had been transferred from the recovery room late in the evening shift and was very uncomfortable when I first made my rounds. At 12:05 AM, I called Betty’s physician because she was vomiting and thrashing in bed. Per his order, I medicated the patient with Phenergan.

The next time I checked on Betty, she seemed to be more comfortable, but I realized that her IV had infiltrated. I was really overwhelmed with meeting the needs of all my patients, so I asked Joan Jones, the charge nurse, to restart Betty’s IV. It was about 2:00 AM when Nurse Joan restarted the IV.

I had been able to pretty much stay on top of everything at that point in the shift, and by 2:30 AM I had assessed all my patients, given pain medications, and called four physicians to update them regarding their patients and for various orders. I thought things were settling down. I thought wrong.

Mrs. Holmes, the patient with histoplasmosis, seemed a bit off from when I had cared for her the previous two nights. Mrs. Holmes’ vital signs were unstable and her O₂ saturation was only 80%. I notified her physician and he ordered stat arterial blood gases. The lab called with the results, and they were alarming. Mrs. Homes was losing ground, and her physician ordered us to transfer her to the ICU. I was preoccupied with accomplishing the transfer and accompanied Mrs. Holmes to the unit. I returned from the ICU at about 3:50 am.

On my return, I first checked the patient who was on dopamine, medicated another patient for pain, and did visual checks on the rest of the patients who all seemed to be sleeping. I began my charting.

At 6:05 AM, I went to start IV antibiotics on Betty’s roommate, and to my horror discovered Betty was not breathing. I called the code. The first time I discovered that Betty had had a low blood pressure and elevated pulse was when I checked the vital signs sheet when the ER physician (who responded to the code) asked how Betty’s vital signs had been during the shift. The nurse’s aide who was assigned to monitor Betty had not informed me, and I had not checked the vital signs sheet.

It was such a terrible night; I was so busy with the transfer and caring for the other patients. Betty just had an outpatient procedure; if she had been earlier on the surgical schedule, they would have sent her home. I did not physically check her vital signs, and the aide did not report the elevated pulse and low blood pressure. I depended on the aide—my mistake. I know I was responsible.

I was terminated from employment and reported to the board of nursing. I have taken myself out of nursing; something died in me when I found my patient.

EMPLOYMENT EVALUATIONS

An evaluation conducted a few weeks before the incident showed mostly good ratings (11) with three excellent ratings. The hospital would consider reemployment if Ms. Simms improved her critical thinking skills.

PATIENT MEDICAL RECORD

Surgery Notes—Laparoscopy to remove unruptured ectopic pregnancy from distal portion of the fimbriae with estimated blood loss of 150 cc, three references to homeostasis, two references to cautery, patient “… to recovery room in excellent condition.”

Recovery Room Nurse’s Notes—In recovery 2110 to 2300, initial post-op flow sheet noted at 2210 BP 124/74, pulse 94; at 2225 BP 123/65; at 2240 BP 107/85, pulse 123. Assessment signed at 2220 “abdomen distended with few faint bowel sounds … patient shivering, c/o [complained of] abdominal pain, medicated ×3 [three times] with IVP Demerol, total of 50 mg. Patient awake, three dressings dry. No c/o N/V/D.” [No complaints of nausea, vomiting or diarrhea.]

Medication Record—Patient received Demerol 50 mg. with 25 mg Phenergan IM at 2215 and 0200.

Cardiopulmonary Resuscitation Record—Compressions noted at 6:08 am. [RN had initiated code at 5:55 AM], MD arrived at 6:15 AM, patient intubated at 6:20 AM, patient administered atropine ×3, Eppy [epinephrine] ×5 [five times], bicarbonate [of sodium] ×2 [two times]. Pacemaker never captured. Patient never had return of spontaneous pulses and pronounced dead at 6:38 AM.

Death Certificate—Immediate cause of death was hemoperitoneum due to postoperative hemorrhage of placental tissues after salpingotomy for a right tubal ectopic pregnancy.

BOARD ACTION

Ms. Simms entered into a consent agreement with the board of nursing, admitting that her conduct constituted a failure to practice in accordance with acceptable and prevailing standards of safe nursing care. Nursing standards cited were failure to assess and document the health status of the patient, failure to provide ongoing patient monitoring, and failure to communicate appropriately with members of the health care team.

Ms. Simms’ license was probated with stayed suspension for 2 years, with requirements for successful completion of ordered education including an advanced assessment course at an educational/collegiate institution, continuing education hours in risk management/legal issues in nursing (in addition to continuing education hours required for license renewal). Order noted RN’s voluntary evaluation by a mental health care professional and her compliance with all aspects of the treatment plan. Other terms included quarterly reports from nursing employer and self-reports. Ms. Simms was required to appear in person (as requested) for an interview with the Board or a board-designated representative.

COMMENTARY

This case example illustrates a cascade of clinical events that caused errors in clinical judgment, all of which are related to work overload and consequent lack of surveillance and monitoring of the patient. Nurse Simms made faulty assumptions that the young patient with a tubal pregnancy was her least acute patient. Of course the patient is the primary victim, but Nurse Simms also suffered greatly from this tragic incident, which was precipitated by a collection of untoward events and work overload. The following TERCAP® categories under “Inadequate Clinical Judgment” are appropriate:

Clinical implications of signs, symptoms, and/or interventions not recognized: The abdominal pain was extreme for the procedure and was most likely related to internal hemorrhage.

Clinical implications of signs, symptoms, and/or interventions misinterpreted: The nurse assumed that the primary problem was nausea and vomiting. Other vital signs and symptoms were ignored.

Lack of appropriate priorities: In this case there were at least three competing high-priority situations occurring at once.

Poor judgment in delegation and the supervision of other staff members: Delegation and supervision were problems on several levels. The charge nurse and supervisor failed to provide appropriate support for the RN with a patient in a full-blown crisis. The nurse gave the nurse’s aide faulty supervision in not requesting full vital signs at 5:00 AM.

Inappropriate acceptance of assignment or delegation beyond the nurse’s knowledge, skills, and abilities (given the critical and unstable condition of the eight patients): Eight patients were too many patients to care for given the critical acuity of these particular eight patients. Backup support should have been requested and/or just sent when one patient went into crisis. The nursing supervisor is mistaken in waiting for reports only as a means of knowing what is needed, especially when a patient crisis arises.

CLARIFYING CONCEPTS

During the initial examination of many of the study cases, poor clinical judgment was identified as the cause of the practice breakdown. Often, however, the cause for the practice breakdown was lack of attentiveness. Nurses were not able to begin to engage in a clinical situation and begin to use their clinical judgment because of staffing shortages and competing high priorities among patients. Recommendations to remediate nurse clinical judgment skills in such situations would be nonproductive. Also, a unit can have a very hectic day with more patients admitted than usual, or more patient crises than usual, causing many disruptions to many nurses’ work on the unit. Nurses are called to watch over patients for other nurses and may not have a good grasp of the patient’s ongoing clinical condition and needs. Thus, as discussed in Chapter 4, the issue of attentiveness needs to be addressed in ways that allow the nurse adequate time for attentiveness or awareness of the clinical situation to prevent practice breakdown. If the unit is unusually pressed, short staffed, or the nurse is interrupted frequently because of a heavy workload, a patient in crisis, or new patient admissions, the root cause of the problem may not be clinical reasoning but a system-induced lack of adequate patient monitoring.

All nursing actions contain within them some form of judgment. For the purposes of TERCAP classification of nursing practice breakdown, we are using a restricted definition of clinical reasoning (as described above) because we want to identify situations where knowledge and skill related to clinical judgment are absent or obsolete. In these instances the nurse misinterprets or makes a mistake in judgment about a patient’s needs or concerns, even though he/she has had the opportunity to observe the patient. Common, routine interventions that are required for all patients should not be considered an issue or a problem of clinical judgment, since the primary problem is an omission of routine, standardized practice that requires knowledge. For example, although it is always poor judgment to omit preventive interventions, it is really not an issue of clinical reasoning about a particular patient to omit standard nursing procedures to avoid the hazards of mobility. Likewise, standard infection preventive measures require little latitude or room for judgment and should not be classified as clinical judgment.

Poor clinical judgment will impact the ability of the nurse to advocate for the patient, but if the nurse makes an appropriate clinical judgment but does not follow through with adequate advocacy for the patient, (e.g., calling the physician for an appropriate intervention), then the primary area of practice breakdown is Professional Responsibility and Patient Advocacy. Clinical judgment is always situated. Good clinical judgment requires the possibility of attentiveness. In the one clinical situation above, a nurse had an extremely heavy assignment with the same-day postsurgical patients, one of whom required a vasopressor to maintain his blood pressure. To complicate the situation further, another patient with histoplasmosis developed poor oxygen saturation and required an immediate transfer to the ICU. The transfer of the patient with poor oxygen saturation took the nurse away from the unit at a critical time for the patient after she had had a tubal pregnancy removed; she was now showing all the signs of a postoperative hemorrhage. As a result of information overload and poor backup support, the nurse did not receive or could not attend to the 30-year-old patient who was experiencing a postoperative hemorrhage and extreme pain.

There are human limits to the span of control and the ability to attend to multiple urgent and cognitively complex demands. Many system and practice breakdowns came together at the same time to create this tragic outcome of patient death. The nurse’s aide was not appropriately respectful and attentive to the patient’s requests to call her husband and her physician. The patient was labeled “whiny” and her complaints, as well as the patient’s authority, were devalued and dismissed. The charge nurse did not adequately assess the nurse’s workload. The supervisory practice in the hospital was substandard in that clinical supervisors did not proactively observe and supervise the unit’s workload, changing conditions, and the nursing needs of the patients. Rather, supervisory staff waited until they received an explicit request for help from very busy nurses. There was no Fast Response Team to come to the unit. It may seem obvious that busy, overloaded nurses would automatically call for help, but there is little support for this assumption, because the nurse who is busy phoning physicians and carrying out emergency interventions may be so occupied with urgent, multiple demands that making one more phone call in the moment does not occur to him or her. If help is seldom provided when requested, it may also seem futile to take the time to call.

An intervention at the system level would be a predetermined “SOS” number that requires no explanation or rationale and that receives immediate supervisory attention. Such a signal would require an immediate, mandatory response from nursing supervisory staff, including the immediate nursing staff on the unit. Patients should be routinely given a supervisory number to call 24 hours a day, whenever they feel that their needs are not being adequately attended to on any nursing unit. In this situation, such a routine “fail-safe” backup strategy for patients could have possibly prevented this patient’s death. The patient tried to call her husband for help, and she tried to call her physician. The patient did not imagine that there was any available help in the hospital because her requests were being ignored by the nurse’s aide, and the busy registered nurse had little first-hand contact with the patient.

No doubt the nurse’s information and task overload caused her to deviate from the professional standard of care of closely monitoring the patient’s vital signs postoperatively, checking for potential hemorrhage, and assessing the patient’s pain. In the context of two competing patients’ urgent care needs, the nurse did not make a direct assessment of the postoperative patient’s condition on receiving information from the nurse’s aide about the patient’s changing vital signs. The period of decreased surveillance and monitoring prevented adequate clinical observation, assessment, and thus detection of postoperative hemorrhage that, if recognized, would have saved this patient’s life. In this instance, a critical lack of surveillance occurred during which time the nurse instructed the nurse’s aide not to awaken the patient and check her vital signs at 5:00 AM. It is unknown whether the patient was indeed sleeping, unconscious, or dead at 5:00 AM. when the nurse’s aide reported that the patient was sleeping quietly.

Good clinical reasoning requires knowledge about the patient’s particular condition and therapies being used. Clinical reasoning also requires the ability to perceive and recognize changes in patients’ clinical conditions and responses to ongoing therapy. Unlike scientific reasoning that can be established using formal criteria and decision points at prescribed points in time, clinical reasoning is ongoing about the particular in relation to the general. Clinical reasoning is reasoning across time, about the particular, through changes in the patient’s condition and/or changes in the clinician’s understanding of the patient’s condition over time (Benner, Hooper-Kyriakidis, & Stannard, 1999).

Benner, Hooper-Kyriakidis, & Stannard (1999) state:

Critical care nursing practice is intellectually and emotionally challenging because it requires quick judgments and responses to life-threatening conditions where there are narrow margins for error. Developing expertise in this practice requires experiential learning under pressure and “thinking-in-action” (thinking linked with action in ongoing situations) (p. 2).

The nurse’s overload and focused concern for the patient whom she considered to be at greatest risk, clouded her thinking-in-action about her other patient’s potential for hemorrhage, and therefore caused her to ignore warning signs of changes in the patient’s condition.

Clinical judgment requires clinical reasoning across time about the particular. Clinical reasoning is very different from scientific reasoning in conducting clinical or bench research. Research uses formal criteria to develop “yes” and “no” judgments. Research is closer to a static, snapshot reasoning than clinical reasoning which, as noted, is reasoning across time about the particular through changes in the clinician’s understanding or changes in the patient’s condition.

Nursing, like medicine, involves a rich, socially embedded, clinical know-how that encompasses perceptual skills, transitional understandings across time, and understanding of the particular in relation to the general. Clinical knowledge is a form of engaged reasoning that follows modus operandi thinking in relation to patients’ and clinical populations’ particular manifestations of disease, dysfunction, response to treatment, and recovery trajectories. Clinical knowledge is necessarily configurational, historical (by historical, we mean the immediate and long-term histories of particular patients and clinical populations), contextual, perceptual, and based upon knowledge gained in transitions…[Through articulation], clinical understanding becomes increasingly articulate and translatable at least by clinical examples, narratives, and puzzles encountered in practice (Benner, 1994, p. 139).

Clinical reasoning also requires engaged reasoning across time about the particular through changes in the patient’s condition and changes in the clinician’s understanding of the patient’s situation (Benner, 1984, 2001). Aristotle called attention to practice or praxis that requires phronesis, something qualitatively distinct from techne (the know-how and skill of producing things). This was in addition to the narrower “rational calculation” or snapshot account of rationality handed down in the Cartesian tradition and captured in early Greek thought by Plato as techne or technique. A practice is a socially embedded form of knowledge that has notions of the good internal to the practice (Benner, 1984, 2001). Aristotle’s example was that of a statesman who had to develop character, skilled know-how, practical reasoning, and comportment that included appropriate emotional responses and relationships. This contrast form of rationality and skill-based character called phronesis is similar to clinical judgment. A rational-technical mode, techne (sometimes called “rational technicality”), separates means and ends and focuses on achieving prespecified outcomes.

Rational technical thought is a powerful strategy for those areas of science and technology that can be standardized and made routine. But where clinical reasoning, relationship, perception (or noticing), timing, and skilled know-how are involved, more than techne or rational calculation is required. Guignon (1983) points out that separating means and outcomes often devalues or does violence to the means, especially where means and ends are closely interwoven. For example, it is not sensible to separate means and ends in birth, comfort, health promotion, or end-of-life care. In each of these caring practices, means and ends are in many ways not separable, since most often there are multiple means and ends at stake in any clinical encounter.

Caregiving relationships may open up possibilities or close them down. But even with the best intentions and comportment, the one cared for may not be able to respond to care. “Outcomes” in caregiving relationships are necessarily interdependent and mutual. Some types of influence are morally unacceptable. Manipulation, coercion, or misuse of professional influence in persuading a patient to accept a treatment is unethical. When things go well and the patient/family is able to respond to caring practices, the practitioner cannot attribute the good outcome solely to the efficacy of some technique they may have used.

In the recent past, nursing practice on “prespecified outcomes” identified and evaluated nursing outcomes in case management based on the premise that only technique is involved in health care, that one knows the outcomes to expect, and that all things can be “fixed.” The problem is further complicated by institutional constraints to effective caregiving. Meeting and responding to the other may clash with the bureaucratic goals of care for the many in the most cost-efficient manner. For all these reasons, developing moral agency and the skills of involvement present ongoing demands for experiential learning and character development. Viewing nursing as a basic human encounter and as a practice that requires phronesis has major implications for nursing education and the moral development of practitioners.

Technical cure and restorative care must not become mutually exclusive for the nurse. One way to create more equal dialogical partners between technical health care and everyday social existence or lifeworlds (defined as a person’s everyday way of being in a particular culture, subculture, and nexus of interpersonal relationships and social roles) is to understand medicine, nursing, and other health care practices as practices that encompass more than the science and technologies they use to effect cures.

Developing expert practice in local, specific settings requires experiential learning as well as communicating that experiential learning to others so that clinical knowledge is continually developed and evaluated. This experientially gained clinical knowledge is held collectively by a local group of practitioners who extend local knowledge through dialogue with larger practice communities. Communities of practitioners must find ways to make their experiential learning collective and cumulative in order for nursing practices in local settings to grow and improve. It is wasteful and harmful when experiential learning is not shared with other clinicians. Experiential learning is expensive to acquire for patients and for nurses. Improving systems and enhancing individual performance and responsibility requires a community of local practitioners who collectively work to improve their clinical practice.

The two dominant approaches to reducing errors in health care, a systems approach and individual practitioner learning and responsibility, both depend on local practice communities and on the larger tradition of good practice. Improving practice systems and performance of individual clinicians both depend on the socially embedded knowledge and teamwork of practitioners in local practice settings. This is another contrast between theory and practice.

Theory derives its power from the ability to be abstract and applicable over a range of particular situations. Practice is local and particular. Excellent practice is lodged in a tradition of fostering good practice and ongoing experiential learning in local settings. The book Clinical Wisdom and Interventions in Critical Care: A Thinking-in Action Approach (Benner, Hooper-Kyriakidis, & Stannard, 1999) describes two major habits of thought and action involved in clinical reasoning: clinical grasp and clinical forethought. Parts of the book illustrate the ways in which these pervasive habits of thought and action “work” in relation to major goals of critical care nursing practice. However, these same habits of thought, clinical grasp, and clinical forethought can be found in all domains of nursing practice. Table 5.1 draws heavily on the original research reported in the book on clinical wisdom.

TABLE 5.1 Habits, Clinical Grasp, Inquiry, and Forethought
Habits of Thought and Action

1. Clinical grasp and clinical inquiry: Problem identification and clinical problem-solving

2. Clinical forethought: Anticipating and preventing potential problems

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