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Introduction
Decision-making is the essence of nursing practice, as nurses must make choices about treatment and patient care countless times a day. Levett-Jones et al. (2010) note that nurses make 1428 decisions during a 12-hour shift in critical care. In turn, according to Razieh et al. (2018), about one hundred thousand patients die each year due to poor healthcare decision-making. In this regard, clinical decision-making is crucial for nursing practice.
Experience as Clinical Decision-Making Factor
Researchers identify various factors that influence clinical decision-making. Tenham et al. (2017) assert that these include nursing experience, organizational culture, education, understanding of patient status, environment, and autonomy. Nibbelink and Brewer (2018) confirm the importance of nursing experience in decision-making. Experience is related to time spent in clinical practice. Standing (2020) argues that nurses’ clinical judgments depend more on previous experience than on the actual clinical situation. Thus, previous clinical experience serves as a valuable guide to decision-making.
When making decisions, experience is associated with confidence. Nibbelink and Brewer (2018) note that communication and patient care, and intervention skills that form clinical experience contribute to good decision-making in nursing practice. Time spent as a nurse positively affects nurses’ decision-making as it increases self-confidence. Moreover, the problem of decision-making is connected not only with one’s own experience but also with the experience of colleagues. Collaboration with experienced colleagues influences clinical decision-making by nurses. According to Waters (2020), nurses prefer information provided by experienced colleagues or their own experience over other sources of information. Furthermore, Guerrero (2019) reinforces this idea by arguing that information from associates is a more applicable source in patient care situations than protocols, which is especially relevant when decision time is limited.
However, there is an opposing view regarding the positive impact of experience on clinical decision-making. According to Guerrero (2019), the length of clinical practice is not related to the effectiveness of clinical solutions. While experience gives confidence, it is not related to the quality of patient care. Thus, the problem of the influence of experience on decision-making remains open and needs further research.
Electronic Health Records
Information technology in the modern world is used everywhere, and healthcare is no exception. According to Bergey et al. (2019), back in 2016, the digital e-health market was US$23 billion and will increase to US$33 billion by 2025. Modern IT progress impacts the development of new ways of organizing medical care for the population. Conducting teleconsultations of patients and staff, exchanging information about patients between different institutions, remote recording of physiological parameters, and real-time monitoring of operations – all these opportunities are provided by introducing information technology in medicine. It brings healthcare informatization to a new level of headway.
One of the most common health information technologies is electronic medical records. They are currently being introduced into the health systems of developed countries as an alternative to paper medical records. An electronic medical record contains the full amount of personal medical data related to all types of medical care for a patient in healthcare facilities. This information system is a multifunctional base for the long-term accumulation and storage of information about what happened to the patient or was done for recovery in a particular period of life. Electronic medical record systems allow control of the organization of the treatment and diagnostic process and make recommendations for further examination and treatment of patients. The EHR records the results of working with the patient, including the collected anamnesis, the results of examination and research, appointments, and recommendations. What’s more, EHRs include clinical decision support systems that can provide medical and clinical information, alerts, alerts, and reminders that can help nurses make decisions and improve healthcare delivery.
This technology positively impacts the quality of clinical assessment of patients and clinical decision-making in nursing care. The key advantage of electronic medical records is convenience and ease of use. The nurse only needs to find the patient in the computer program to enter data into them. After that, you can not only enter all the necessary data but also study the patient’s history in detail at any time without turning over a huge number of pages of a paper medical record. An equally significant advantage of EHR is legibility. Illegible handwriting is a major source of medication errors. Haldane et al. (2019) note that over 60% of hospital medication errors are due to poor handwriting. Moreover, many EHRSs include tools that support clinical judgment and decision-making, as well as care coordination and health information sharing.
EHRs increase efficiency while reducing paperwork. According to Nesheva (2019), using EHR can significantly reduce the time spent maintaining medical records compared to the manual execution of entries on the card. Accordingly, nurses have more time to care for patients. Moreover, referrals and prescriptions can be sent quickly, reducing waiting times. Automatic reminders can let patients know when it’s time for their annual checkups or alert them as they approach milestones that require regular checkups. With integrated patient tracking, billing and insurance claims can be filed promptly.
However, some shortcomings of EHR hurt the quality of clinical assessment of patients and clinical decision-making in nursing care. Vehko et al. (2019) note that one of the most significant negative aspects is data inaccuracy. If the EHRs are not updated immediately as new information becomes available, anyone viewing this EHRS may receive incorrect or incomplete information. It can lead to subsequent errors not only in patient care by nurses, but also in diagnosis, treatment, and health outcomes by physicians and other professionals. According to Nesheva (2019), an equally significant disadvantage of EHR is the potential for misunderstanding of patients. When a patient has access to their medical information, there is a possibility of misinterpretation. The ability to access information that a person does not fully understand can lead to many misunderstandings. These include panicking and taking inappropriate and potentially dangerous actions.
Another disadvantage of using EHRs is related to the issue of liability for negligence. The introduction of an EHR system opens the door to several liability issues, such as ensuring that precious medical records are not destroyed or lost when moving from paper to electronic records. In turn, it can lead to treatment errors. Medical professionals, including nurses, may be held liable for any failure to access all medical data in their possession, especially when it is believed that this data is more accessible given its electronic nature.
Electronic health records offer many valuable benefits for both healthcare providers and patients. However, they also have many potential drawbacks. Ultimately, by weighing the benefits of EHRs against their drawbacks, researchers agree that once EHRs are accepted and meaningfully used on a broad basis, they can significantly benefit patients, providers, and society.
Conclusion
Therefore, clinical decision-making depends on nurses’ experience and is directly related to the use of the EHR.
References
Bergey, M. R., Goldsack, J. C., & Robinson, E. J. (2019). Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team. Social Science & Medicine, 235, 112387.
Guerrero, J. (2019). Practice rationale care model: The art and science of clinical reasoning, decision making and judgment in the nursing process. Open Journal of Nursing, 9, 79-88. Web.
Haldane, V., Tan, Y. G., Teo, K. W. Q., Koh, J. J. K., Srivastava, A., Cheng, R. X., Yi Cheng Yap, Y.C., Ong, P., van Dam, R.M., Foo, J.M., Müller-Riemenschneider, F. Klecun, E., Zhou, Y., Kankanhalli, A., Wee, Y. H., & Hibberd, R. (2019). The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: A tale of two countries. Journal of Information Technology, 34(4), 292-332.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y., Noble, D., Norton, C. A., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515–520.
Nesheva, D. (2019). Introduction to health and health information technologies. IOP Conference Series: Materials Science and Engineering, 618, 12033.
Nibbelink, C. W., & Brewer, B. B. (2018). Decision‐making in nursing practice: An integrative literature review. Journal of Clinical Nursing, 27(5-6), 917-928.
Razieh, S., Somayeh, G., & Fariba, H. (2018). Effects of reflection on clinical decision-making of intensive care unit nurses. Nurse Education Today, 66, 10-14.
Standing, M. (2020). Clinical judgement and decision making in nursing. Sage.
Ten Ham, W., Ricks, E. J., van Rooyen, D., & Jordan, P. J. (2017). An integrative literature review of the factors that contribute to professional nurses and midwives making sound clinical decisions: Clinical decision-making factors. International Journal of Nursing Knowledge, 28(1), 19-29.
Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., Tuukkanen, J., Aalto, A. M., & Heponiemi, T. (2019). Experienced time pressure and stress: Electronic health records usability and information technology competence play a role. BMC Medical Informatics and Decision Making, 19(1), 160.
Waters, V. L. (2020). Theory, nurse decision-making, and practice. Nursing Management, 51(2), 22-28.
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