Clinical Judgement/Reasoning

[gemmi999]

I am a new grad working in a small community ED. We have about 12 beds but are a *very* busy ER with about 100 - 150 patients a day. I am just off preceptorship/orientation and have had my first four shifts alone. I am just now realizing that developing clinical judgement and reasoning comes at a heavy price, and it's sobering.

I had a 16 year old patient who came in with DKA, a wbc count of 54,000 and a bicarb of 2. She was GCS of 9, maybe 8. Not good. I followed the physicians instructions to the letter and within 5 hours had her shipped off to a PICU at a large children's hospital. It was during the transfer report that I realized that my small-community hospital physician didn't know a lot about peds or DKA, apparently. He'd even told the PICU doctor that the patient had a GCS of 15! It was because of the discrepancies between my report to the transport nurse and his report to the PICU doctor that the transport team decided to fly out instead of drive, cutting a 2 hour journey into 30 minutes. This probably helped save the patient's life.

Long story short, because I'm a new nurse and have only had adult DKA patients, I didn't question treating the pt. like an adult--fluid resuscitation, insulin, etc. The transport team helped educate me on the differences but now I can't help but feel bad because I didn't know that the doctor's orders weren't correct because it was a ped's patient. I spoke with my former preceptor and a couple other nurses and they said that I did what I was supposed to do--followed the doctor's orders, questioned them within the confines of my knowledge, and followed up with them about the situation. My preceptor said that experiences like this are what help form and build clinical judgement and reasoning.

He specifically said that he doubted I'd *ever* not think to question a ped's dosage amount now, or even look up treatment online to make sure of something makes sense before giving the treatment.

I was wondering if anybody else had that sinking feeling in their stomach when they realized that clinical judgement and reasoning comes from bad or potentially bad outcomes. It's just hitting home today, and it's sobering to finally realize the lives that hang in my hands. My job isn't just a place to get experience and maybe some cool stories, it's literally a place of life or death decisions; decisions that I am literally making every day.

[HouTx, BSN, MSN, EdD]

The only way to become an "expert" is via experience.... And even then, that is not sufficient. Studies of expertise have shown that 'experts' engaged in quite a bit of reflection after each new experience - analyzing their actions and determining what they will do differently next time. So, they LEARN from their experiences. It has been described as an effortful process. It doesn't just happen automatically. And it never stops -- if you stop putting forth the effort, the expertise begins to degrade - basically, use it or lose it. Here is a nice overview of research on this issue.

In a nutshell, experience is necessary, but not sufficient to produce expertise. Some people just float with a "oh well" attitude... taking things as they come. They never beat themselves up, even after an upsetting event because "things happen". OTOH, they probably have much less job-related stress.

So - bottom line. Believe your preceptors and mentors. Each misstep provides you with a learning opportunity - but it's your choice to take advantage of them.