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Discussion Question:
Describe components of a clinically based decision-making model impacted by clinical expertise and explain how clinical expertise informs evidence-based practice.
Your initial posting should be at least 400 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 200 words in length.

1 -Amy Ruble posted Dec 5, 2019, 4:26 PM

Applying the best evidence to our clinical decision making involves examining, critiquing, and synthesizing the available research evidence. However, we must consider the science along with our clinical experience and patients’ values, beliefs, and preferences (Ginex, 2018) In addition to patient preferences, practitioners need to consider the patients’ clinical state, setting, and circumstances. Another component of clinical decision making is the availability of healthcare resources. Sometimes, even the best evidence cannot be used because the interventions is too costly. Finally, it is the practitioners’ responsibility to identify current, high-quality research evidence to inform his or her clinical decisions. Not all research is of sufficient quality to inform clinical decision making. Therefore, it is important to critically appraise evidence before using it to inform your clinical decision making. (Melnyk & Fineout-Overholt, 2015).
Evidence-based practice (EBP) models help address clinical problems; translate relevant research to practice; and improve care, outcomes, and systems quality. Evidence-based decision making is influenced by the practitioners’ experience and skills. Practitioner skills include the expertise that develops from multiple observations of patients and how they react to certain interventions. In the clinical decision-making model, clinical expertise is the mechanism that provides for the integration of the other model components. The practitioner’s clinical expertise will influence the initial assessment of the patient’s clinical state and circumstances; problem formation; decisions about whether the best evidence and availability of healthcare resources substantiate a new approach; exploration of patient preferences; delivery of the clinical evidence; and evaluation of the outcome for that particular patient (Melnyk & Fineout-Overholt, 2015).
Good clinical judgment integrates our accumulated wealth of knowledge from patient care experiences as well as our educational background. Our clinical expertise, combined with the best available scientific evidence, allows us to provide patients with the options they need. Patients cannot have a preference if they are not given a choice, and they cannot make that choice if they are not presented with all options. Using the best-available scientific evidence by itself is not enough to care for our patients in an evidence-based environment. We must also incorporate our clinical expertise and patient preferences and values to include the art with the science to see patient outcomes improve. Evidence-based practitioners must combine understanding the science of health, illness, and disease with the art of adapting care to individual patients and situations, all while thinking critically to improve patient outcomes (Ginex, 2018).

Ginex, P., (2018). Integrate Evidence with Clinical Expertise and Patient Preferences and
Values. Oncology Nursing Foundation. Retrieved from https://voice.ons.org/news-and-views/integrate-evidence-with-clinical-expertise-and-patient-preferences-and-values
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing &
Healthcare a Guide to Best Practice (3rd ed.). Philadelphia, PA: Wolters Kluwer.

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2- Lauren Mischke posted Dec 5, 2019 3:01 PM

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Throughout nursing school, and as I am continuing with my nursing education, I often reflect back on my previous career as a kindergarten teacher. As an educator, my “patients” were students and the teachers were frequently being directed to changes in instruction and curricula which were analogous to healthcare clinical practice guidelines. As with any evidence-based practice, much research went into determining what would help children learn “best” just as nurses look for the practices that will optimize the health of our patients.
Essentially, various theories and clinical based decision-making models are necessary in many vocations to give a framework and help implement change. Melnyk and Fineout-Overholt (2015) list eight models for implementing evidence-based practices in the healthcare environment. Each has strengths and many have similar facets; however, as a bedside nurse practicing in Baltimore, the Johns Hopkins Nursing Evidence-Based Practice caught my eye. I appreciate this model because it acknowledges that a culture of evidence-based practice must exist in order for nurses to fully embrace and implement changes. There are 18 steps in the model, five related to practice questions, five related to evidence and eight related to translation. There are also tools to support each stage of the model (Melnyk & Fineout-Overholt, 2015). Kudos to John Hopkins for involving actual bedside nurses in the creation of the tools and in the evaluation of each stage of the model!
Education is key to providing the clinical expertise nurses need to bring about positive change and implement evidence-based practices because they understand the value and are vested in the results. Green et al. (2014) recommend mentors to assist in implementing evidence-based practice. Through mentoring, nurses learn from other nurses the value of the changes they are implementing. Green et al. (2014) give examples of how multidisciplinary education and multidisciplinary rounding helped reduce the number of urinary catheter infections by motivating healthcare providers to decrease the unwarranted and unnecessary use of urinary catheters. White-Williams et al. (2013) also contend that the provision of continuing education for nurses is imperative to giving nurses the knowledge and confidence to understand and use evidence-based best practices. In my own healthcare organization, the way I learn best is from my peers. In-person workshops in which I am taught about evidence-based practice and, most importantly, and educated on the research and data that support the change, are motivating and inspiring to me. Having other nurses to mentor and act as evidence-based practice “champions” also helps build confidence in me when new clinical practice guidelines are being piloted.

Green, A., Jeffs, D., Huett, A., Jones, L. R., Schmid, B., Scott, A. R., & Walker, L. (2014). Increasing capacity for evidence-based practice through the evidence-based practice academy. The Journal of Continuing Education in Nursing, 45(2), 83-90.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare a guide to best practice (3rd ed.). Philadelphia: Wolters Kluwer.
White-Williams, C., Patrician, P., Fazeli, P., Degges, M.., Graham, S., Andison, M., & McCaleb, K. (2013). Use, knowledge, and attitudes toward evidence-based practice among nursing staff. The Journal of Continuing Education in Nursing, 44(6), 246-54; quiz 255-6.

Discussion Question:
As nurses, we complete physical assessment on a routine basis, but typically these are focused assessments. Which components of the head-to-toe physical assessment are not routine for you (ones you do not use on a regular basis)? Why is it important for you to still be familiar with these components and skilled at completing them?
Your initial posting should be at least 400 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 200 words in length.

3- Alexa Cameron posted Dec 3, 2019 9:35 PM

As a nurse navigator in neuro-oncology, I work with patients who are newly diagnosed with primary brain tumors who have undergone surgical resection and are about to begin adjuvant treatment with chemotherapy and radiation. I serve as one of the first points of contact for these patients as they transition from in-patient care to the out-patient world. The majority of what I do is provide education to the patient and their family and loved ones over the phone. I teach them about what the gold standard of care is for first-line treatment, what to expect in terms of side effects, and what resources the hospital offers to provide support. I meet with patients briefly at their first clinic appointment so they can place a face to my name, but the majority of all my follow-up with them is again over the phone. This is the way my clinic designed my role to function. And, due to space constraints at my rapidly-growing hospital, I am only on campus two days a week and I work from home the other days. I say all of this to explain that this is an interesting discussion question to answer. Due to the nature of my role and its limited in-person interaction with patients, the physical assessment is not a part of my job responsibilities. However, though sight and touch are not what I use, I must very adeptly use other senses and means to assess my patients. For example, before I call a patient for the first time, I thoroughly read through their medical record to understand their history and current health status, including their new post-surgery baseline and how this differs from their pre-surgery baseline. This helps me to anticipate their needs and tailor my teaching style and techniques to target the patient’s strengths and navigate around their deficits. I must also quickly assess the patient’s status from the phone call as the information in the chart is only as accurate as the note writer and the patient’s status as captured on a particular note. For example, a discharge summary may fail to mention the patient has poor short term memory or word-finding difficulty following surgery. These are things I must try to catch in speaking with the patient. Family members and loved ones may be reluctant to share or discuss the patient’s deficits in front of the patient, so I must rely on my assessment skills to catch these sometimes subtle clues over the phone or briefly in person.
I do worry about losing the skill of performing physical assessments as the health assessment is a critical element in the nursing process. It is by assessing patients that nurses determine their care needs and select and prioritize appropriate nursing interventions. By detecting subtle changes in the patient, nurses can detect the first signs of a change/deterioration in the patient’s condition and intervene before a larger problem or adverse event occurs (Adib-Hajbaghery & Safa, 2013; Watson, 2006). Simply put, the more accurate the assessment, the higher the quality of care provided.
When I was a nurse on the burn intensive care unit, we performed head-to-toe physical assessments on our patients every four hours. At that point in my career, I was very comfortable and efficient at full body exams. Now, being out of practice, heart sounds are intimidating. I had to revisit the four areas for auscultation. Palpating for tactile fremitus is a completely new skill for me (I have zero recollection of this from nursing school). And, if I am being honest, the art of percussing was something I never even tried to learn. According to research, it is common for nurses to only use a fraction of assessment skills. A study evaluating American nurses found that, of 120 health assessment skills, 29 percent reported using these skills daily or weekly, 34 percent reported using these skills monthly or occasionally, and 37 percent reported using them rarely. A study of Australian nurses found similar trends with 34 percent reporting regular use of assessment skills, 35 percent reporting occasional use, and 31 percent saying the used them rarely (Adib-Hajbaghery & Safa, 2013; Birks et al., 2013).

References
Adib-Hajbaghery, M., & Safa, A. (2013). Nurses’ evaluation of their use and mastery in health assessment skills: Selected Iran’s hospitals. Nursing and Midwifery Studies, 2(3), 39-43. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228544/
Birks et al. (2013). The use of physical assessment skills by registered nurses in Australia: Issues for nursing education. Collegian, 20(1), 27-33. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1322769612000170
Watson, D. (2006). The impact of accurate patient assessment on quality of care. Nursing Times, 106(6). Retrieved from https://www.nursingtimes.net/clinical-archive/haematology/the-impact-of-accurate-patient-assessment-on-quality-of-care-07-02-2006/
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4- Joyce Hart posted Dec 5, 2019, 4:47 PM

In the healthcare industry, there is a variety of specialties in nurses’ practice. Ambulatory care nursing is a specialized practice setting that is defined by nurses reacting rapidly to high quantities of patients in a short period while handling matters that are not always anticipated. Although ambulatory care nursing crosses all groups of patients and care varies from wellness/prevention to sickness and comfort of the dying, there is a demand for an ambulatory care nursing conceptual structure that defines the unique ideas into ambulatory care nursing. The core theories are connected to the ambulatory care nursing discipline. Ambulatory care nursing offers various opportunities, as well as challenges for nurses( American Academy of Ambulatory care nursing,2019).
As a nurse that works in the ambulatory care specialty of an urgent care environment, I find that every day can be different. As mentioned above, I treat patients for various reasons. As the patient is triage and place in an exam room, I focus on the problem that is currently affecting the patient. Being that the environment is fast-paced and patients are often in and out, a focused assessment is not typically performed by the nurse except for vital signs and for an emergency patient that comes to the urgent care for treatment. I often have to triage the patient based on the symptoms that he or she tells me to determine if they should seek emergency care or not. In my practice, the provider performs the focused assessment on each patient, and I would perform many different tasks such as nebulizer treatments, vaccine applying hand and foot splints, and removing stitches along with discharging and providing education. Each portion of a head-to-toe examination for me is not performed regularly. One day I may perform a focused assessment of the eyes such as visual acuity. It is typically done because the patient seeks treatment for eye issues, and the next day I may not. It is essential to be familiar with performing each component of a head-to-toe assessment to ensure that you, as the nurse, are aware of any developments that the patient is encountering and report them to the provider immediately. Distinguishing the difference between what is normal and what is abnormal provides the nurse with data to assist the provider in doing a more thorough assessment and address the problem as needed. Knowing how to perform a head-to-toe assessment helps nurses to generate clinical judgment into how to address the patient’s needs and care for the patient accurately.
American Academy of Ambulatory care nursing. (2019).
Understanding ambulatory care nursing practice.
Retrieved from
https://www.aaacn.org/understanding-ambulatory-care-nursing-practice
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Discussion Question:
This week you will shadow and interview a nurse leader. Please post your questions for the interview and offer some background as to why these questions were chosen.
Your initial posting should be at least 400 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 200 words in length.

5- Yaydagni Arduengo posted Dec 5, 2019, 2:33 PM

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Conducting an interview takes more than skills. Getting a unit manager as a mentor was not an easy task. I wanted to find someone that was client-oriented as well as budget-conscious. I offered the opportunity to a manager at a primary care physician’s clinical facility. The doctor has hospital privilege, so I was able to dig a bit into the coding-billing-reimbursement world. Through the course of this class, we learned than sometimes clinicians and managers don’t look eye to eye, so I was determined to demonstrate the opposite.
I shadowed her on November 29 for the whole day. Using the opportunity that I was off for Thanksgiving week, I coordinated this experience. The day started early; opening time was at 7:00 am, and for the first thirty minutes, we got the place ready for the day. Lights on, rooms open, computers on printer paper, and checking the room have supplies needed were the most natural part. She makes sure all the coffee machines are clean, and she brews the coffee for the waiting area and the employee’s lunchroom.
According to Frangenberg (2016) “You have a limited amount of time to make an impression with your questions and learn about the realities of your desired job, “When interviewing either a possible new employee or a mentor, the most important step is how to break the ice. Inspire confidence and from the first moment, make the interviewee feel comfortable to get ideas flowing. First, I choose her because she is different, and while her manager skills seem odd to some people, I think she goes above and beyond her duties. She has been in the position for over 10 years. After so much experience, I can understand how she has all the answers to the medical facility. Talking to few staff members, they express how grateful they are to be working under her supervision, and they recall several occasions where the manager steps up to help them regardless of her work was getting behind or not. Based on that information, I decided to use the questions below.
Tell me, how did you hear about this position?
How did you get to where you are today?
How would you describe your working style?
How did you bounce back after a failure?
How do you feel about a risk-taking approach?
If I had the power to change one thing in this place, what would that be?
How can you overcome daily challenges?
What particular skill makes you the perfect fit for the job?
In three words describe an ideal work environment
What do you find most challenging in leadership?
Can you recall the first accomplishment you had in this practice?
What skill would you like to improve, and how are you planning to do so?
What excites you the most about this position?
Do you ever feel like a specific task is impossible to complete
My day went by fast, and we did not sit down to talk. I probably forgot more than fifty percent of her answers, but I did enjoy this opportunity.
Reference

Frangenberg, E. (2016). What to Ask During an Interview – And What Questions to Avoid. Chemistry, Engineering– Chemical Engineering, 112(3). DOI: 1776156048

6- Michelle Rowlen posted Dec 3, 2019 6:25 PM

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For this week’s assignment, I have the opportunity to shadow the soon-to-be chief nursing officer (CNO) and the hospital where I work: Carle Foundation Hospital. Carle as a Magnet designated hospital; our current CNO plans to retire in two years, however, the CHO cannot change during a magnet term. Our current magnet term ends December 31st so the decision was made to start grooming a new CNO to start on Jan first, 2020, her name is Elizabeth Angelo.
In our interview I plan to ask the following questions:
Please describe your role at Carle and what tasks you do in your everyday routine
This will set up an understanding of what the CNO position entails and will drive any extra improvisation questions.
Please describe the nursing and inter-professional teams that operate at Carle.
This question, as you all know, was on the list of example questions. I have chosen to ask this question in regards to the administrative staff and what teams the nursing administration work alongside.
Please provide an example of practice change brought about by EBP within the last year
I am particularly interested in the CNO’s answer to this question as the culture of each unit and department at Carle has an EBP project going each year.
What obstacles have you had to overcome to get to your current position?
This question is being posed as Elizabeth had held multiple leadership positions in the past and is a great resource for learning what obstacles are in the way and how to overcome them.
What do you love most about your job?
This question is being asked because as a direct patient care nurse I know what I love about nursing, however, I am interested in hearing what a member of not only leadership but administration sees as the love of the job.
What is your nursing background?
This question will help me understand the steps taken before becoming the CNO and how a nurse can achieve a leadership position.
What drew you to your current position?
I am particularly interested in the question because I do not wish to be in an administration and I am curious what draws a person to that type of role.
How would you best describe Carle’s culture?
The culture of an organization is one factor that drives the organization’s goal. I am curious how the CNO perceives the organization’s culture in comparison with my view of the culture.
What is your role in staffing?
This question is to assess what the CNOs job in regard to the proper staffing of a hospital.
How would you describe your leadership style?
To be the CNO takes good leadership, I am curious how Elizabeth describes her style of leadership.
What advances in informatics have you seen at Carle in the last year?
This question is being asked to complete the requirement of having at least one informatics question.
What sources of resistance have you encountered in your current role?
This question is to assess what resistance she has encounter and is to be followed by asking how she has overcome that resistance.
Please explain the role that nurses at each level of leadership play in budgeting
When I was an emergency room nurse I did not see how my practice directly impacted budgeting. I am curious how budgeting is perceived from the top
What advances are being made in regard to patient safety at Carle?
This question is to see how she perceives patient safety and the nurse’s role
I have already completed my interview and ended up adding in questions as other topics arose. Elizabeth and I spent quite a bit of time discussing informatics as we both seem to have interests in how it can be utilized in nursing. We discussed big data, patient portals, the recent expansion of Carle’s EMR to include a large local clinic, and also what her predictions are for informatics in the future of healthcare. I feel very privileged to be able to shadow a nurse at the very top level of administration and enjoyed the experience very much!
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