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Evidence-based principles should unquestionably play a key role in decision making. However, we must recognize that gaps in both knowledge and evidence occur in daily clinical practice. Subjective judgment can be a constructive component in making clinical decisions. The use of heuristics has been used both purposely and instinctively to help fill gaps and assist in solving complex dilemmas. A goal of this article is to encourage clinicians to assess their own decision-making skills as well as the skills of novices and experts with whom they work with.
Keywords: heuristics; clinical decision making; clinical reasoning; checklists
"Medicine is a science of uncertainty and an art of probability."
-William Osler (1849-1919) (Bean, 1961)
That same quote also pertains to all spheres of nursing. The amount of information we have available to make clinical decisions is vast. Yet, humans have limited i nformation-processing abilities related to memory and attention, thus often rely on simplifying heuristics (Patel, Kaufman, & Arocha, 2002). Gaps remain between information that we have learned and how it should be applied. For example, because we are aware of certain information doesn't mean we know what to do with that information. Understanding the human genome is a current example of this.
Despite the application of evidence-based principles, gaps in care remain. Clinical decision making is complex and incorporates several factors that cannot be easily measured or integrated into guidelines. With the current emphasis on evidence, we often minimize the i nfluence of experience, beliefs, time constraints, and affective influences on clinical decision making. Interruptions, stress, ergonomics, economic incentives, and geography all contribute to practice patterns (Phua & Tan, 2013). We must accept uncertainty and learn to make decisions in this context, reevaluating situations as new information arises.
Clinical Reasoning Theories
Clinical decision making involving individual patients will always have some degree of uncertainty and unavailable information; clinical expertise rather than formal clinical rules must sometimes be given emphasis to (Luchins, 2012; Muoni, 2012). Research has shown that statistical techniques may not be superior to clinical judgment (Gigerenzer & Gaissmaier, 2011), because statistical models "overfit" past observations and although they have some degree in predicting events cannot intervene and change outcomes (Luchins, 2012).
Wegwarth, Gaissmaier, and Gigerenzer (2009) point out that although limited cognitive...