is decision making that uses critical thinking skills and considers patient preferences

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

The role of patient preferences in nursing decision-making in evidence-based practice: excellent nurses' communication tools

Affiliations.

• 1 Christian University of Applied Sciences, Ede, Netherlands.
• 2 Fontys University of Applied Sciences, Tilburg, Netherlands.
• PMID: 31148233
• DOI: 10.1111/jan.14083

Abstract in English, Chinese

Aim: To develop an understanding of how nurses take account of patient preferences in nursing decision-making in evidence-based practice to provide individual tailored nursing care.

Design: Qualitative grounded theory.

Methods: Semi-structured interviews were conducted with 27 nurses in four medium-sized hospitals in the Netherlands. Furthermore, seven nurses were observed during their shift. Constant comparative analysis underpinned by Strauss and Corbin's framework was used.

Results: Three communication tools of nurses were identified to discern and attend to patient preferences: (a) a click-making tool enables to build rapport instantly; (b) antennae monitor individual patient's needs; and (c) asking empathic questions to fine-tune to individual patient preferences. Participants emphasized that giving individual attention enhances the patient's experienced quality of life.

Conclusions: Excellent nurses in evidence-based practice consciously spend time to discover patient preferences using the set of implicit and intuitive communication tools to attune their professional care. The use of these tools leads to individual tailored nursing care and appears to be part of the nurses' practical wisdom. Further studies on how nurses balance patient preferences in nursing decision-making in the evidence-based practice are recommended.

Impact: The findings fill a gap in the literature on how nurses discover and balance all three aspects of the evidence-based practice in their decision-making: evidence derived from science, best practice, and patient preferences. Moreover, the use of this implicit knowledge in nursing deserves further research and attention in practice and education.

目的: 了解护士在基于证据的实践下的护理决策中如何考虑患者的偏好因素,以提供个性化的护理服务。 设计: 定性的基础理论。 方法: 在荷兰,对四家中型医院的27名护士进行了半结构式访谈。此外,在轮班期间还观察了7名护士的情况。采用了Strauss完善的常数比较分析方法和Corbin框架方法。 结果: 确定了护士的三种沟通工具,以辨别和照顾患者的偏好:(a)一个点击工具可以立即建立融洽的关系;(b)监测个别患者的需要;(c)提出感性化问题,以调整患者的个人偏好。参与者强调,给予个性化关注可提高患者的生活质量。 结论优: 秀的护士在基于证据的实践中,有意识地花时间去发现患者的偏好,使用隐性和直觉的沟通工具来协调他们的专业护理。这些工具的使用导致了个性化的护理,似乎是护士的实用智慧的一部分。建议进一步研究护士在基于证据的实践下,如何平衡患者在护理决策中的偏好。 影响: 这些发现弥补了文献中关于护士如何发现和平衡,在其决策中基于证据的实践下的所有三个方面的缺乏:科学性的证据、最佳实践和患者偏好。此外,值得在实践和教育中进一步研究和重视这种隐性知识在护理中的应用。.

Keywords: antennae; click or instant connection; empathic questions; evidence-based practice; grounded theory; nursing; nursing decision-making; patient preferences; quality of life.

© 2019 John Wiley & Sons Ltd.

PubMed Disclaimer

Similar articles

• Taking into account patient preferences in personalised care: Blending types of nursing knowledge in evidence-based practice. den Hertog R, Niessen T. den Hertog R, et al. J Clin Nurs. 2021 Jul;30(13-14):1904-1915. doi: 10.1111/jocn.15743. Epub 2021 Mar 25. J Clin Nurs. 2021. PMID: 33763940
• Canadian hospital nurses' roles in communication and decision-making about goals of care: An interpretive description of critical incidents. Strachan PH, Kryworuchko J, Nouvet E, Downar J, You JJ. Strachan PH, et al. Appl Nurs Res. 2018 Apr;40:26-33. doi: 10.1016/j.apnr.2017.12.014. Epub 2017 Dec 18. Appl Nurs Res. 2018. PMID: 29579495
• Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions. Florin J, Ehrenberg A, Ehnfors M. Florin J, et al. J Clin Nurs. 2006 Dec;15(12):1498-508. doi: 10.1111/j.1365-2702.2005.01464.x. J Clin Nurs. 2006. PMID: 17118072
• Straddling the fence: ICU nurses advocating for hospice care. Borowske D. Borowske D. Crit Care Nurs Clin North Am. 2012 Mar;24(1):105-16. doi: 10.1016/j.ccell.2012.01.006. Crit Care Nurs Clin North Am. 2012. PMID: 22405716 Review.
• Nurses' autonomy: influence of nurse managers' actions. Mrayyan MT. Mrayyan MT. J Adv Nurs. 2004 Feb;45(3):326-36. doi: 10.1046/j.1365-2648.2003.02893.x. J Adv Nurs. 2004. PMID: 14720250 Review.
• Perceiving the Role of Communication Skills as a Bridge between the Perception of Spiritual Care and Acceptance of Evidence-Based Nursing Practice-Empirical Model. Panczyk M, Iwanow L, Musik S, Wawrzuta D, Gotlib J, Jaworski M. Panczyk M, et al. Int J Environ Res Public Health. 2021 Nov 29;18(23):12591. doi: 10.3390/ijerph182312591. Int J Environ Res Public Health. 2021. PMID: 34886316 Free PMC article.
• Allen, D., & Cloyes, K. (2005). The language of ‘experience’ in nursing research. Nursing Inquiry, 12, 98-105. https://doi.org/10.1111/j.1440-1800.2005.00259.x
• Argyle, M., & Trower, P. (1979). Person to Person: Ways of Communicating. New York: Harper & Row.
• Avis, M., & Freshwater, D. (2006). Evidence for practice, epistemology and critical reflection. Nursing Philosophy, 7(4), 216-224. https://doi.org/10.1111/j.1466-769X.2006.00267.x
• Barelds, D. P. H., & Dijkstra, P. (2007). Love at first sight or friends first? Ties among partner personality trait similarity, relationship onset, relationship quality and love. Journal of Social and Personal Relationships, 24, 479-496. https://doi.org/10.1177/0265407507079235
• Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley.
• Search in MeSH

LinkOut - more resources

Full text sources.

• Ovid Technologies, Inc.
• MedlinePlus Health Information

Miscellaneous

• NCI CPTAC Assay Portal

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• - Google Chrome

Intended for healthcare professionals

• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Margaret McCartney:...

Nurses are critical thinkers

Rapid response to:

Margaret McCartney: Nurses must be allowed to exercise professional judgment

• Related content
• Article metrics
• Rapid responses

Rapid Response:

The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., 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.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

ANA Nursing Resources Hub

Search Resources Hub

Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

Related Resources

Item(s) added to cart

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Week 6: Clinical Judgment Part A

Unit Learning Outcomes

At the end of this chapter, the learner will:

1. Compare and contrast three approaches to problem solving.

2. Describe models of clinical judgment for critical thinking and decision-making judgments.

3. Discuss clinical judgment and decision-making necessary to provide quality care.

Overview of this Chapter

This chapter will introduce the concept of clinical judgement, a vital  process where nurses make decisions using their knowledge, clinical  reasoning and critical thinking.  It is important to understand concepts related to clinical judgement(CJ) in nursing practice. This chapter is the part A of this concept and will include concepts related to clinical judgement, models of CJ and how important it is to provide safe nursing care to patients.

Nurses make decisions while providing patient care by using critical thinking  and clinical reasoning . Let’s review what is critical thinking, clinical reasoning and clinical judgement.

Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. “Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought:  Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Exercises: Pre-class:

Watch the video prior to class and be ready to discuss in the class. See the task below the video .

In-class discussion:

 Give an example of how you have used critical thinking, decision making & clinical reasoning in everyday life.  

I. Clinical Judgment and Nursing

When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate  clinical judgment , which is defined as:

• A determination about a client’s health and illness status.
• Their health concerns and needs.
• The capacity to engage in their own care. AND
• The decision to intervene/act or not – and if action is required, what action (Tanner, 2006).

The nursing process is the foundation of clinical judgment. However, clinical judgment is more comprehensive, action-oriented, and guided by the philosophy of client safety. Thus, it is important to learn when to act to prevent  clinical   deterioration , a worsening clinical state related to physiological decompensation (Padilla & Mayo, 2017).

To facilitate clinical judgment, you must determine if the collected data represent normal findings or abnormal finding. When findings are abnormal, you must act on these cues as they signal a potential concern and require action. Failing to recognize abnormal findings and act on these cues can lead to negative consequences including sub-optimal health and wellness – and more importantly,  clinical   deterioration . Some abnormal findings are considered critical finding that place the client at further risk if the nurse does not act immediately.

The process leading to clinical judgment is described as  clinical   reasoning . This process involves:

• Thoughtfully considering all client data as a whole, whether each piece of information is relevant or irrelevant, and how each piece of information is related or not related.
• Recognizing and analyzing  cues. Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment?
• Interpreting problems. What is the priority problem and what are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment?

The clinical reasoning process is encompassed by  critical thinking . This means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error.

Clinical Judgement 

A client tells you “I have a headache.” As the nurse, you immediately recognize the cue: headache. However, you do not have sufficient information to analyze this cue and identify the significance. Thus, you may ask a series of subjective questions such as “When did the headache start? What were you doing when it started? Have you ever had this type of headache before?” The client’s response will provide you detailed information to facilitate your critical thinking and the process of hypothesizing what is going on, and thereby helping you determine what actions to take.

Clinical judgement is facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration; see  Table 6.1 . Like the nursing process, these steps should be performed in an iterative manner as per the client situation and your clinical reasoning process.

Table 6.1 : Clinical judgment steps (developed based on NCSBN, 2020)

Exercises:  Check Your Understanding

Discussion: Watch the video below and Discuss

 Video: NCSBN (National Council of State Boards of Nursing) : Clinical Judgment -The Next Generation NCLEX (NGN) – Right Decisions Come from Right Questions.

Discuss relevance of Clinical Judgment in nursing practice.

II. Priorities of Care

Why is clinical judgment important? How does it guide the provision of care?

Clinical judgment is important to ensure the nurse’s actions are based on the client’s most important needs. Clients often have several needs, and some are more important than others. As such, nurses need to assess and evaluate the  priorities   of care:  what actions are most important to take first, and then what actions can follow. Typically, priority actions are those that prevent clinical deterioration and death.

Exercises: CURE Hierarchy

• The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

You are the nurse caring for the patients in the following table.  For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

III. Maslow’s Hierarchy of Needs

Priorities of care can be determined using several frameworks such as  Maslow’s Hierarchy of Needs.  For example, at the most basic level, life requires an open airway to breathe, the physiological process of breathing, and the circulation of blood and oxygen throughout the body. Airway, breathing, and circulation are the ABCs, which you might have learned if you have taken a cardiopulmonary resuscitation (CPR) course.

Maslow’s Hierarchy of Needs was developed to consider  basic human needs  and motivations of healthy individuals (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). Although not well known, Maslow’s work was closely influenced by the Blackfoot tribe in Canada (James & Lunday, 2014). One version includes  five  levels of needs: those related to  physiological, safety, love, esteem,  and  self-actualization  (Maslow, 1943), which can help prioritize care in nursing.  Figure 6 .2  presents one adapted version of Maslow’s Hierarchy.

Figure 6.2 : Maslow’s Hierarchy of Needs (see attribution statement at bottom of page)

Drawing upon this framework, a nurse can use health assessments to explore five levels of needs:

• Are these basic physiological needs being met? Is the client’s breathing and circulation supported?
•  Does the client feel safe and secure in general in life? Does the client feel safe and secure in the healthcare environment? Is the bed lowered to the lowest position when you finish your assessment? Is the call bell in reach?
• Does the client feel love and belongingness in general in their relationships? More specifically, does the client feel cared for by nurses and other healthcare providers?
• Does the client feel respected and valued in general by others? Does the client feel respected and valued within the healthcare environment?
• What is important to the client in terms of what they want to achieve in life in general? What are the client’s goals that they may have for themselves in their own health and healing journey? Does the client feel satisfied, confident, and accomplished?

You can use Maslow’s Hierarchy of Needs as a guide, but it is important to be aware of the  critiques  and possible limitations in its application. See  Video 6.1  of a conversation between Dr. Lisa Seto Nielsen and Mahidhar Pemasani.

Video 6.1 : A discussion about Maslow’s Hierarchy of Needs

Criticisms of Maslow’s hierarchy  are related to it being ethnocentric, based on individualistic societies, and not necessarily taking into account diversity in culture, gender, and age (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). It should not be arbitrarily applied to all healthcare encounters. Although you may initially focus on physiological needs to ensure the client is stable, the client may have different priorities that are more important to them. By drawing upon Indigenous knowledge, it is vital to recognize the role of community and advocacy in reaching self actualization at every level (Bennett & Shangreaux, 2005). This is particularly important in the context of systemic racism and oppression and the existing disparities among racialized populations including Black communities and Indigenous People.

IV. Levels of Priority of Care

Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to the set of physiological needs that are important to maintain life and prevent death. These priorities of care are related to the ABCs – airway, breathing, and circulation – introduced above. These priorities of care are often categorized as first, second, or third level, with the first level taking a priority (see  Table 6.2 ).

Table 6.2 : Priorities of care

With regard to levels of care, it is essential to consider what is  most important to the client . You should treat the client as the expert in their own life – and also as the expert in decisions about their own healthcare, if they choose. Although a client may have plummeting blood pressure, you need to consider tailoring the intervening action to their wishes. Some clients may not wish for intervention in a life-threatening circumstance. Therefore, you always need to be open to the client’s wishes, but also consider whether they are able to weigh the consequences of their decision (i.e., are they competent to consent?).

Urgent Priorities of Care: Mental Health 

In practice, mental health is typically not categorized as a first- or second-level priority of care unless the client is showing signs of clinical deterioration based on the examples noted in  Table 6.3 . In some situations, mental health may be positioned as a third-level priority of care, for example when a client is experiencing anxiety, depression, grief, but shows no signs of suicidal ideation. These symptoms should be addressed, but according to this framework, they are considered less urgent compared to first- and second-level priorities of care. However, sometimes, you should think differently about how  mental health   is a priority of care .

In some situations,  mental health may take precedence.  For example, a client who has attempted suicide or has just overdosed will probably have other physical symptoms as a result and therefore require urgent intervention and constant observation as per  Table 6.3 . However, the descriptions of the priorities of care presented in the table do not account for a client who has voiced a specific plan for suicide and has identified when and how. This client is at very high risk and requires urgent intervention regardless of what may be viewed as their physical health state or history. The description of priorities of care listed above does not account for this except as a third-level priority – but a client with suicide ideation or has voiced wanting to hurt others requires urgent action to protect their own wellbeing and others and the possibility of clinical deterioration as a result of their actions.

V. Intervention Types

As illustrated by the text box above, you will need to use your own judgement to determine how to act when a cue presents itself and how to categorize these interventions. This could involve four general  types of interventions  that you need to be aware of (see  Table 6.3 ) including  effective, ineffective, unrelated,  and  contraindicated.  These types of interventions will become more clear as you begin to learn about normal, abnormal, and critical findings for various body systems, and how interventions and actions will affect these findings and the client.

Table 6.3:  Types of interventions

Exercises: In-Class

2. SPOTLIGHT APPLICATION: https://wtcs.pressbooks.pub/nursingmpc/chapter/2-6-spotlight-application/

Sam is a novice nurse who is reporting to work for his 0600 shift on the medical telemetry/progressive care floor. He is waiting to receive handoff report from the night shift nurse for his assigned patients. The information that he has received thus far regarding his patient assignment includes the following:

• Room 501:  64-year-old patient admitted last night with heart failure exacerbation. Patient received furosemide 80mg IV push at 2000 with 1600 mL urine output. He is receiving oxygen via nasal cannula at 2L/minute. According to the night shift aide, he has been resting comfortably overnight.
• Room 507:  74-year-old patient admitted yesterday for possible cardioversion due to new onset of atrial fibrillation with rapid ventricular response. Is scheduled for transesophageal echocardiogram and possible cardioversion at 1000.
• Room 512:  82-year-old patient who is scheduled for coronary artery bypass graft (CABG) surgery today at 0700 and is receiving an insulin infusion.
• Room 536:  72-year-old patient who had a negative heart catheterization yesterday but experienced a groin bleed; plans for discharge this morning.

Based on the limited information Sam has thus far, he begins to prioritize his activities for the morning. With what is known thus far regarding his patient assignment, whom might Sam plan to see first and why? What principles of prioritization might be applied?

  Clinical Judgment Review:  Think, Pair, Share

Read the case scenario and complete the activity below.

Case Scenario

Client admitted to orthopedic unit following an open reduction internal fixation of right lower tibia and fibula. Client was brought to the emergency department by family after falling on the stairs at home. Client reports pain currently 4 out of 10 and tolerable. Right lower leg in cast, elevated on pillows. Toes warm, capillary refill < 3 seconds, client denies numbness or tingling. Client reminded of non-weight bearing status on the right leg. Reviewed prescriptions and expectations for hospital stay. Client asks, “Why do I need insulin? I don’t have diabetes. The last time I saw my doctor, I was just told to eat less sweets and try to walk more often.”

  Instructions:

Pair with another student and complete the following activity on a 3×5 card.

Share your answers with the class.

Lab values are numbers (example: 2.5, 80, etc.)

• List three lab values that indicates your patient’s condition is improving
• List three lab values that indicates your patient’s condition is worsening
• List a priority nursing intervention based on one of these lab values

VI. Reflections

Prepare for the librarian visit.

• Have few EBP articles ready to discuss with the librarian
• Choose an EBP article for the EBP assignment

Key Takeaways

Type your key takeaways here.

Assignment: Review Blackboard for details

• MC Library Tutorial APA Format and Quiz (90%) 2.5 points.
• Library Tutorial- Academic Integrity & Avoiding Plagiarism Quiz (90%) 2.5 points.

VII. Recommended Resources

CLINICAL JUDGMENT MEASUREMENT MODEL: https://www.nclex.com/clinical-judgment-measurement-model.page

Getting Ready for the Next-Generation NCLEX ® (NGN): How to Shift from the Nursing Process to Clinical Judgment in Nursing: https://evolve.elsevier.com/education/expertise/next-generation-nclex/ngn-transitioning-from-the-nursing-process-to-clinical-judgment/

References and Attributes

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.
• Dickison, P., Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks.  Journal of Nursing Education ,  58 (2), 72-78.  https://doi.org/10.3928/01484834-20190122-03
• NCSBN (2020, Spring). Next Generation NCLEX news .  https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf
• Padilla, R., & Mayo, A. (2017). Clinical deterioration: A concept analysis. Journal of Clinical Nursing ,  27 , 1360-1368.  https://doi.org/10.1111/jocn.14238
• Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education ,  45 (6), 204-211.  https://doi.org/10.3928/01484834-20060601-04
• Maslow, A. (1943). A theory of human motivation. Psychological Review ,  50 (4), 370-396.  https://doi .org/ 10.1037/h0054346
• Bennett, M., & Shangreaux, C. (2005). Applying Maslow’s Hierarchy Theory. First Peoples Child & Family Review: a Journal of Innovation and Best Practices in Aboriginal Child Welfare Administration, Research, Policy & Practice ,  2 (1)89-116. https://doi.org/10.7202/1069540ar
• Bouzenita, A. I. & Wood Boulanouar, A. (2016). Maslow’s hierarchy of needs: An Islamic critique. Intellectual Discourse ,  24 (1), 59-81.
• Francis, N.H. & Kritsonis, W.A. (2006). A brief analysis of Abraham Maslow’s original writing of self-actualizing people: A study of psychological health. Doctoral Forum: National Journal of Publishing and Mentoring Doctoral Student Research , 3(1), 1-7. 
• Critical Thinking and Clinical Reasoning: https://med.libretexts.org/Bookshelves/Nursing/Nursing_Management_and_Professional_Concepts_(OpenRN)/02%3A_Prioritization/2.04%3A_Critical_Thinking_and_Clinical_Reasoning
• Open Resources for Nursing (Open RN) Nursing Management and Professional Concepts   by Chippewa Valley Technical College 

The Novice Nurse's Guide to Professional Nursing Practice Copyright © by Kunjamma George, PhD, RN, CNE and Raquel Bertiz, PhD, RN, CNE, CHSE-A is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

Share This Book

Students also viewed

• Online DNP Overview
• BSN to DNP-AGACNP
• BSN to DNP-FNP
• BSN to DNP-PMHNP
• DNP Careers
• Online MSN Overview
• MSN Careers
• Online PMC Overview
• Micro-Credentials
• Tuition and Fees

Clinical Decision-Making in Nursing Practice

August 29, 2023

View all blog posts under Articles | View all blog posts under Doctor of Nursing Practice

Clinical decision-making is one of the most important skills that nurses bring to the profession. When nurses have the authority to make evidence-based care decisions that follow best practices, a host of benefits accrue. Patients have better outcomes, nurses have higher job satisfaction, and hospitals benefit by improving their patient care metrics and reducing their risk profile.

Therefore, nursing education coursework and practicums should teach both critical thinking and clinical decision-making in order to prepare nurses for their role as leaders in patient care quality.

What Is Clinical Decision-Making in Nursing?

Nurses are the experts in patient care. They have a more in-depth understanding of a patient’s current condition than doctors and hospital administrators do. They’re the first to recognize that a patient is in pain or that a patient’s condition is deteriorating. That’s why nurses need to be problem-solvers and decision-makers with regard to patient outcomes.

Clinical decision-making in nursing is an active approach to assessing a patient’s condition and basing care decisions on the evidence. It’s a collaborative approach, with a team of health care providers weighing in and determining the best course of action. Clinical decision-making also includes patients and families in the process, which recognizes patients as their own best advocates and experts on their physical and mental health needs.

Critical thinking skills, teamwork, communication, collaboration, and knowledge of best practices are all essential parts of the clinical decision-making process. Nurses, colleagues, and patients keep the lines of communication open, make sure that everyone is on the same page with regard to decisions, and follow the evidence when caring for patients.

Examples of clinical decision-making by nurses include the following:

COVID-19 Interventions

During the pandemic, the health of hospitalized patients infected with COVID-19 could deteriorate quickly. Experienced nurses combined their knowledge of patient care and their analysis of COVID-19 patients whom they’d already treated to identify patients who were in the most danger of requiring rapid response. Nurses often followed their intuition and experience rather than relying on rules-based decision-making, allowing them to respond to complex and rapidly changing information more quickly.

Catheter-Associated Infections

Boston Medical Center identified Foley catheters as the source of 9% of hospital-acquired infections in its patients, according to a BMJ Open Quality article. The medical center set up a task force, including nurse managers, nurse educators, urologists, and other stakeholders. This team identified the issues and created education programs to prevent infections. The initiative resulted in an 83% reduction in catheter-caused infections between 2013 and 2017.

Patient Falls

Falls are a common source of inpatient injuries. In a 2021 study published in the Journal of Medical Internet Research, researchers analyzed the effectiveness of a data analytics tool for preventing falls among elderly and other patients. The data showed that use of the data analytics tool increased nurses’ awareness of fall risk and decreased the number of falls overall. Studies such as these become part of the evidence that support clinical decision-making.

Why Should We Care About Clinical Decision-Making?

Clinical decision-making has a number of advantages for hospitals, patients, and nurses. At its core, the process is rooted in science and the scientific method (hypothesis, test, repeat). It allows nurses to use all of their clinical experience, education, and professional knowledge of patient care, rather than following a set workflow or checklist. Nurses are clinicians; therefore, they should make clinical decisions. Health care organizations that support nursing judgment and critical thinking benefit in the following ways:

Patient Outcomes

The above examples show how clinical decision-making can improve patient outcomes. Nurses assess their patients, work with their colleagues, communicate with patients and their families, and identify patient health requirements. They can base their decisions on research and data. They can use critical thinking skills to identify when a patient’s treatment needs to be adjusted. The research increasingly shows that clinical decision-making by nurses can improve quality of care and patient satisfaction.

Hospital Advantages

As health care payment models move from fee-for-service reimbursement models to value-based care, patient outcome metrics have become more important. That’s because hospitals and doctors will soon largely be reimbursed based on the quality of the care they provide rather than by procedure. Medicare is using data such as hospital-acquired infections, falls, and readmissions to penalize hospitals. As a result, allowing nurses to use their clinical judgment can help boost hospital revenues.

Job Satisfaction

The nursing shortage has worsened under pressure from COVID-19. Nurses report that when their employers give them authority to make clinical decisions, they are more likely to be satisfied in their jobs. They may be less susceptible to burnout and more likely to stay in the profession. When employers treat nurses as clinicians, they are more likely to retain staff, which can help stem the nationwide nursing shortage that the health care system faces.

Multidisciplinary Care

By its nature, clinical decision-making is a multidisciplinary process. Health care providers can apply it at the patient level, because it accounts for the views of all professionals involved in a patient’s care plan. It also applies at the organizational level, as leaders can incorporate the knowledge and experience of all clinical and administrative staff members when making operational decisions.

Coordinated Care

The coordinated care pathway is a hallmark of clinical decision-making at the patient level. It connects health care providers (doctors, nurses, and support staff) and makes sure that everyone communicates through transition points, such as when patients are handed off to specialists or other care teams or throughout the length of their medical condition.

Organizational Decision-Making

At the organizational level, nurses, nurse managers, physicians, administrators, and chief nursing and chief medical executives are part of the decision process. This was found to be especially effective during the pandemic. According to the American Association of Critical Care Nurses, direct care nurses, nurse leaders, and organizational leaders came together to support clinical care best practices at all levels, starting with the nursing process (assess, diagnose, plan, and evaluate).

A Comprehensive Nursing Education for Your Future

The future of nursing is in the hands of clinicians who are just now coming into the workforce. This is a time of great change in health care. Hawai‘i Pacific University’s online Bachelor of Science in Nursing to Doctor of Nursing Practice program prepares nurses to excel in this new world with a curriculum that supports clinical decision-making and critical thinking. Take the first step into your future today.

Recommended Reading:

The Importance of a Nurse’s Role in Patient Safety

What Is Evidence-Based Practice in Nursing?

Nursing Advocacy: The Role of Nurses Advocating for Patients

Agency for Healthcare Research and Quality, "Chapter 2. What Is Care Coordination?"

American Association of Critical-Care Nurses, Effective Decision Making

American Association of Critical-Care Nurses, "Effective Decision-Making During the Pandemic"

American Association of Nursing Colleges, "Hospitals Innovate Amid Dire Nursing Shortages"

BMC Nursing, "Shared Clinical Decision-Making Experiences in Nursing: A Qualitative Study"

BMJ Open Quality , "Catheter-Associated Urinary Tract Infection Reduction in Critical Care Units: A Bundled Care Model"

JMIR Publications, "Clinical Impact of an Analytic Tool for Predicting the Fall Risk in Inpatients: Controlled Interrupted Time Series"

Nursing-Writing, "Clinical Decision Making in Nursing Scenarios"

PLoS One , "Identifying Factors That Nurses Consider in the Decision-Making Process Related to Patient Care During the COVID-19 Pandemic"

RN.org, "Critical Thinking in Nursing: Decision-Making and Problem-Solving"

Do More With HPU

Critical Thinking

High quality, safe patient care is dependent upon the healthcare provider’s ability to reason, think, and make judgments about care. Critical thinking, clinical reasoning and judgment are integral to quality clinical decisions and actions. Today’s healthcare landscape has transitioned towards an environment where patients are more medically complex, an aging population with chronic illness, and increased socioeconomic diversity. In order to provide quality patient-centered care, nurses need to develop CT skills in order to provide patients with expert care (Brunt, 2005).

Developing CT is an ethical responsibility of professional nursing practice, and a component for sound clinical judgments and safe decision-making. Thinking in a logical, systematic way, being open to questioning current practice, and reflecting on one’s practice regularly are some key features that strengthen nurses’ CT skills.

The quality of clinical decision-making is influenced by a number of factors, including experience, level of education, time pressures, and also the culture of the nursing unit (Johansson, Pilhammar, & Willman 2009). Developing critical thinking skills has the potential to improve personal practice and patient outcomes.

Critical thinking (CT) is a process used for problem-solving and decision-making. CT is a broad term that encompasses clinical reasoning and clinical judgment. Clinical reasoning (CR) is a process of analyzing information that is relevant to patient care. When data is analyzed, clinical judgments about care is made. The process of analyzing the data, making decisions is the result of CT—thinking critically throughout the entire patient situation, weighing all relevant options and using CT skills to make the best decision for the patient.

While many definitions have been cited for CT (see below), there is a general agreement that CT is a purposeful action that includes analysis, logical reasoning, intuition, and reflection. Making a concerted effort to critically think during patient care leads to safe, effective decisions. Developing CT skills is key for all nurses, they spend the most time with patients, and are able to recognize subtle changes in their patients and are positioned to make quick, precise decisions, often lifesaving. Using effective CT skills allows nurses to shape the outcome of a patient’s experience with the healthcare system.

The concept of critical thinking has been an integral part of professional frameworks for generations, yet scholars still debate a universal accepted definition. Dozens of CT definitions have been published, with each of them sharing some common features, such as reflection, contemplation, holism, and intuition. The list below shares a variety of CT definitions:

“The rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, ideas, statement beliefs and action” (Bandman & Bandman, 1995, p. 7)

A reflective skepticism; “reflecting on the assumptions underlying our and others’ ideas and actions and contemplative alternative ways of thinking and living” (Brookfield, 1987, p. 18)

“The process of purposeful self-regulatory judgment . . . gives reasoned consideration to evidence, context, conceptualization, methods and criteria: (Facione, 2006, p. 21)

“Reasonable and reflective thinking that is focused upon deciding what to believe or do” (Kennedy, Fisher, & Ennis, 1991, p.46)

“An investigation whose purpose is to explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusion about it that integrates all available information and that, therefore, can be convincingly justified” (Kurfiss, 1988, p. 37)

“The propensity and skill to engage in an activity with reflective skepticism” (McPeck, 1961, p. 8)

“The deliberative nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting and evaluating information that is both factual and belief based” (National League for Nursing Accrediting Commission, 2000, p. 8)

“A unique kind of purposeful thinking in which the thinker systematically and habitually imposes criteria and intellectual standards upon the thinking, taking charge of the construction of thinking, guiding the construction of the thinking according to the standard, and assessing the effectiveness of the thinking according to the purpose, the criteria and the standards” (Paul, 1993, p. 21)

“In nursing . . . an essential component of professional accountability and quality nursing care [that exhibits] confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance and reflection.” (Scheffer & Ruberfeld, 2000, p. 357)

Concepts Related to Critical Thinking

Clinical Reasoning

• A process where nurses integrate and analyze patient data to make decisions about patient care (Simmons, Lanuza, Fonteyn, & Hicks, 2003)

Clinical Decision-Making

• A process of choosing between different options or alternatives (Thompson & Stapley, 2011)

Clinical Judgment

• A cognitive process used to make judgments based on patient data and cues. Nurses interpret a patient’s concerns, needs, and health problems for proper decision-making (Tanner, 2006, p. 204)
• Outcome of critical thinking in nursing practice; judgments begin with the end goal in mind; outcomes are met, involves evidence (Pesut, 2001)

Logical Reasoning

• Arriving at a conclusion based on relatively small amounts of knowledge and/or information (Westcott, 1968)
• “Drawing inferences or conclusions that are supported in or justified by evidence (Alfaro-LeFevre, 2015, p. 232)
• A purposeful analysis of one’s current and past actions (Schon, 1987)

Experience and Clinical Reasoning

According to Benner’s (1984) novice to expert model, expert nurses have an intuitive grasp of their patients’ problems, their approach is fluid, flexible, and proficient. Compared to novice nurses, they are more task oriented and require frequent verbal and physical cues to provide care.

Novice nurses are challenged with overcoming a knowledge gap, leading to less effective decisions and actions. Compared to experienced nurses, who are challenged with traditional thinking, leading to less effective clinical judgments and decisions (Cappelletti et al., 2014). Successful CR and decision-making require a balance of intuition and evidence-based thinking to make effective clinical decisions (Simmons et al., 2003).

Andersson et al. (2012) found nurses who were specialized in their setting (more experience) used a more holistic approach to making decisions (p. 876), compared to less experienced nurses who used a “task-and action-oriented approach” (p. 873). Gaining experience and knowledge is one way to improve thinking and decision-making, though improving CT skills can close the gap. Being open-minded, self-aware, and reflective offers nurses important information that can improve CR and decision-making. Clinical judgment (akin to CR) improves over time with nurses who uses reflection as a guide for decisions and actions (Cappelletti et al., 2014).

Critical Thinking and Clinical Decision-Making

Lee et al. (2017) conducted an integrated review on nine studies to determine whether effective CT impacted clinical decision-making. Four studies found CT impacted decision-making, though five studies did not find a correlation. Due to poor study designs, Lee et al. (2017) could not come to a clear decision on whether there was as significant correlation.

CT continues to be an important factor for problem-solving, regardless if studies can confirm a correlation to decision-making. Developing CT skills, such as reflection, intuition, and logical reasoning, are essential behaviors that lead to a patient-centered approach. Nurses who stop and think about what worked for a patient in the past, may consider the same option again, or may choose an alternative. Considering all possibilities with the patient’s best interest in mind is part of CT and making clinical decisions.

Researchers will continue to study the impact of CT on nursing care. Nurse educators will continue emphasize CT in the curriculum and assist students in developing CT skills throughout all levels of education as they offer students tools and methods for problem-solving.

Rubenfeld and Scheffer (2001) explain the essence of CT in nursing practice:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (2001, p. 125).

Standards of Practice

Critical thinking and clinical reasoning are weaved throughout the Nursing Scope and Standards of Practice and Code of Ethics (American Nurses Association [ANA], 2021). The nursing process itself, Standards 1-6, are essentially a tool used for clinical reasoning. The standards require core cognitive competencies and guide nurses to use patient data to make effective clinical decisions.

The  Essentials

Clinical Judgement is one of the eight featured concepts within The Essentials (American Association of Colleges of Nursing [AACN], 2021, p.12). The process of clinical judgement, as earlier in this section, is the outcome of critical thinking.

The Essentials explains how a liberal arts education is critical to exposing nurses to a broad worldview, giving them a holistic perspective that engages them in promoting health equity and social justice, , and “forms the basis for clinical reasoning and subsequent clinical judgments” (AACN, 2021, p. ).

Problem-Solving A pproaches

Reflective thinking.

Reflection is a powerful tool for recognizing errors in judgment, questioning one’s response, and ultimately improving outcomes. Below are two practice examples that illustrate the power of reflective thinking with interprofessional communication and patient care:

Novice and senior nurse communication

• Problem: A novice nurse is struggling with inserting IVs just about every shift. One day, the nurse asks the same more experienced nurse for help again. The nurse listens though does not turn around to face the nurse when questioned, and responds in a swift, aggressive way, “I’m swamped, we have no aides today and I’m falling behind with everything. I’ll help you when I get time, but it’s going to be a while.”
• Impact: The nurse’s patient is at risk for injury without an IV line. The patient may be upset and unsatisfied with care knowing the IV was out for an extended period of time. The nurse feels dejected, does not feel like she is a valued team member, and loses further confidence in her abilities. She considers quitting her job or transferring to another unit.
• Reflection: The experienced nurse realizes she was not empathetic to the nurse’s needs and impatient and aggressive in her response. She realizes the nurse is new and doesn’t have much confidence in her skills yet. She also knows the nurse is probably disappointed in the lack of teamwork and camaraderie. Most of all, she feels bad about disrespecting her coworker.
• Impact of reflection : After reflection of the situation, the nurse apologizes for her poor behavior. She states she will work with her each shift they work together, she will share personal tips and review educational materials. Additionally, she will offer to have her observe her IV insertions until she has mastered the skill. She will also make sure the new nurse feels like she is part of the team, not just the new nurse.

Shift report

• Problem: The oncoming nurse enters his patient room for the first time and finds the foley bag is full and the patient is complaining of abdominal discomfort.
• Impact: The patient is at risk for infection and may be disappointed with the quality of nursing care.
• Reflection: The oncoming nurse realizes there is always one or two problems or inconsistencies when he assesses his patients for the first time. He knows the outgoing nurses are skilled and provide quality care and considers another reason for the errors. After thinking about this for a while, he believes the process for shift report can help reduce change of shift errors. The nurse realizes there needs to be a better way for sharing patient information during change of shift.
• Impact of reflection: The nurse researches evidence-based practices to improve safety and quality during shift change. The nurse shares a copy of the review article on bedside report with his manager. The nurse offers to be a change champion on the unit to implement a new process for shift report.

L ong-term impact of reflection :

• Improved team cohesiveness, nurse retention and job satisfaction
• Improved patient satisfaction experience and quality of care, leading to higher insurance reimbursement

Glynn (2012) states reflective thinking enhances clinical judgment and gives nurses the opportunity to learn from actual or perceived errors. In regard to the communication scenario, it’s through reflection that nurses can think about their behaviors and responses. Reflect on the message for clarity, and whether it was shared in an empathetic and respective way.

As discussed in the communication chapter, poor communication is the number one reason for medication errors and sentinel events. Through reflection, miscommunication can be identified, solutions found, and implemented. In order for this process to come to fruition, nurses must take the initiative to reflect on their practice.

Creative Thinking

Creative thinking helps nurses generate alternative approaches to clinical decision-making. This type of thinking works especially well with medically complex patients, where care needs to be individualized to reach desired outcomes.

Akin to the concept of “thinking outside the box”, finding a novel approach to patient care prevents traditional, stagnant thinking. Choosing alternatives based solely on creative thinking can negatively impact outcomes unless it is paired with the skill of critical thinking. Critical thinking requires the nurse to view the patient holistically,

Nurses access knowledge unconsciously and trust this information as fact. Often referred to as a “gut feeling”, intuition comes naturally. Intuition is not a tool that is sought out at will, instead the knowledge emerges naturally during a care experience, resulting in firm actions and decisions. Intuition is a measure of professional expertise (Smith, Thurkettle, & Cruz, 2004), a type of clinical judgement that develops over time (Benner, 1984). Since this knowledge is considered intangible or irrelevant, some disregard it, though many studies have shown its positive influence in making accurate decisions and improving the quality of care (Robert, Tilley & Petersen, 2014).

• Nurses will recognize something about their patient that they can’t explain, and will make decisions on care without concrete evidence to back up their actions. Such actions can be lifesaving (Billay, Myrick, Luhanga & Yonge 2007). Each clinical experience acts as a learning experience for which lessons are learned and applied to the next experience (McCutcheon & Pincombe, 2001).
• Holtslander (2008) states Carper’s (1978) seminal work on the fundamental ways of knowing was published as a reaction to the overemphasis of empirical (scientific) knowledge in nursing practice. One of the four ways of knowing , called aesthetic knowing , explains the component of art within nursing practice, an, awareness of the patient, viewing the patient as unique. This viewpoint allows nurses to consider more than just empirical knowledge to guide practice.

Critical Thinking Skills

As discussed earlier, CT encompasses a broad range of reasoning skills that lead to effective decision-making. Through the process of clinical reasoning and judgment, nurses make best choice after assembling and analyzing patient data.

White (2003) studied senior baccalaureate nurses and found the following five themes were essential to developing clinical decision-making skills:

• Gaining confidence in clinical skills
• Building relationships with staff
• Connecting with patients
• Gaining comfort in self as a nurse
• Understanding the clinical picture

Scheffer and Rubenfeld (2000) found CT is comprised of affective and cognitive components. Affective components refer to an individual’s feelings and attitudes, and cognitive components refer to thought processes. The CT components include 10 habits of the mind (affective components) and seven skills (cognitive components), as follows:

Habits of the mind

• Confidence : assurance of one’s reasoning abilities
• C ontextual perspective : considerate of the whole situation, including relationships, background and environment relevant to some happening
• C re a tivity : intellectual inventiveness used to generate, discover, or restructure ideas; imagining alternatives
• F lexibility : capacity to adapt, accommodate, modify or change thoughts, ideas, and behaviors
• I nquisitiveness : an eagerness to know by seeking knowledge and understanding through observation and thoughtful questioning in order to explore possibilities and alternatives
• I ntellectual integrity : seeking the truth through sincere, honest processes, even if the results are contrary to one’s assumptions and beliefs
• I ntuition : insightful sense of knowing without conscious use of reason
• O pen-mindedness : a viewpoint characterized by being receptive to divergent views and sensitive to one’s biases
• P erseverance : pursuit of a course with determination to overcome obstacles
• R eflection : contemplation upon a subject, especially one’s assumptions and thinking for the purposes of deeper understanding and self-evaluation (Scheffer & Rubenfeld, 2000, p. 358)
• Analyzing : separating or breaking a whole into parts to discover their nature, function and relationships
• A pplying standards : judging according to established personal, professional or social rules or criteria
• D iscriminating : recognizing differences and similarities among things or situations and distinguishing carefully as to category or rank
• I nformation seeking : searching for evidence, facts or knowledge by identifying relevant sources and gathering objective, subjective, historical, and current data from those sources
• L ogical reasoning : drawing inferences or conclusions that are supported in or justified by evidence
• P redicting : envisioning a plan and its consequences
• T ransforming knowledge : changing or converting the condition, nature, form, or function of concepts among contexts (Scheffer & Rubenfeld, 2000, p. 358)

Development of CT is a lifelong process that requires nurses to be self-aware, and to use knowledge and experience as a tool to become a critical thinker. As nurses move along the continuum from novice to expert, one’s competence and ability to critically think will expand (Brunt, 2005).

• Transitions to Professional Nursing Practice. Authored by : Jamie Murphy. Provided by : SUNY Delhi. Located at : https://courses.lumenlearning.com/suny-delhi-professionalnursing . License : CC BY: Attribution

Privacy Policy

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• HHS Author Manuscripts

Engaging patients in decision-making and behavior change to promote prevention

Effectively engaging patients in their care is essential to improve health outcomes, improve satisfaction with the care experience, reduce costs, and even benefit the clinician experience. This chapter will address the topic of patient engagement directly and review the relationships between health literacy and patient engagement. While there are many ways to define patient and family engagement, this chapter will consider engagement as “patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policy making – to improve health and health care [ Health Aff (Millwood) 32 (2013), 223–231].” We will specifically focus on the patient engagement and health literacy needs for three scenarios (1) decision-making, (2) health behavior change, and (3) chronic disease management; we will include the theoretical underpinnings of engagement, the systems required to better support patient engagement, how social determinants of health influence patient engagement, and practical examples to demonstrate approaches to better engage patients in their health and wellbeing. We will close by describing the future of patient engagement, which extends beyond the traditional domains of decision-making and self-care to describe how patient engagement can influence the design of the healthcare delivery system; local, state, and national health policies; and future research relevant to the needs and experiences of patients.

1. Introduction

This chapter addresses the topic of patient engagement directly and reviews the relationships between health literacy and patient engagement. While there are many ways to define patient and family engagement, this chapter considers engagement as “patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policy making – to improve health and health care.” The authors specifically focus on the patient engagement and health literacy needs for three scenarios: (1) decision-making, (2) health behavior change, and (3) chronic disease management. The chapter addresses the theoretical underpinnings of engagement, the systems required to better support patient engagement, how social determinants of health influence patient engagement, and practical examples to demonstrate approaches to better engage patients in their health and wellbeing. The chapter closes by describing the future of patient engagement, which extends beyond the traditional domains of decision-making and self-care to describe how patient engagement can influence the design of the healthcare delivery system; local, state, and national health policies; and research relevant to the needs and experiences of patients. The specific subtopics covered in the chapter are: the need for patient engagement; engaging patients to better understand decisions; engaging patients to improve health behaviors; engaging patients to improve chronic disease management; the influence of health’s social determinants on engagement; health information seeking behaviors and engagement; as well as future directions.

2. The need for patient engagement

Several US studies recently reported coordinated care trials that actively engaged patients with chronic disease resulted in significant mortality reductions compared to a control group who only took appropriate medications [ 18 , 19 , 55 ]. The studies suggest chronically ill patient who are engaged in their care live longer than unengaged peers who otherwise receive similar treatment [ 18 , 19 , 55 ]. In other words, health and wellbeing are fostered by engaged and activated patients, who collaborate with their clinician to better manage care. In summarizing the hypothetical impact of widespread patient engagement on contemporary health care, Kish described the influence would be analogous to the introduction of a once-in-a-century blockbuster drug [ 38 ].

In addition, patient engagement demarcates an increasing shift from more paternalistic models of care in which clinicians tell patients what they should do (and often ineffectively), to one in which clinicians partner with patients. The collaborative partnership is intended to: help make better medical decisions; educate patients about how to stay healthy and manage conditions; develop systems and supports to activate patients; and sustain patient interest in their ongoing care.

The US Institute of Medicine’s landmark report, Crossing the Quality Chasm, emphasized healthcare providers should be “respectful of and responsive to individual patient preferences, needs, and values,” and ensure “patient values guide all clinical decisions [ 14 ].” In the US, the idea of engaging patients also has been advanced by the research funded by the Patient Centered Outcomes Research Institute (PCORI) and it is at the heart of national healthcare initiatives, such as Meaningful Use and the Medicare shared-savings program for Accountable Care Organizations [ 20 , 67 ].

So why is patient engagement important in health care? What additional evidence is there to support the need to engage patients? What is the effect of varied health literacy on effective engagement? To begin, the need for patient engagement is posited as foundational because most adults spend little time in health care facilities and frequently are on their own to make appropriate, daily health decisions. This means patients need to be in control and the drivers of their health. Patient engagement further has an (a) ethical basis – engagement supports patient autonomy and self-determination, (b) interpersonal basis – engagement promotes confidence and trust in the clinician-patient relationship, and (c) educational basis – engagement improves knowledge, sets reasonable expectations, and reduces decisional conflict.

There is a practical need for engaging patients in their care as well. Many medical decisions have a trade-off of benefits and harms and sometimes there is a close balance of benefit to harm. Only by including patient values and preferences can a good decision be made [ 72 ]. Chronic disease management and health behavior change both must be done by the patient. Without complete buy-in and understanding of care and needed changes, a patient will not be able to effectively manage their health. Ultimately, the patient must suffer or enjoy the outcomes associated with any medical decision, test, treatment, or health behavior change.

In an international study of patients with “complex health needs” spanning 11 industrialized countries and focusing on the relationship between engagement and health care quality, substantial differences in the level of patient engagement between countries was identified. Consistently, countries with higher levels of engagement had better quality of care, lower medical error rates, and greater satisfaction in the experience of care [ 64 ]. Four case studies in diverse countries and health care settings further show the importance of engaging patients and the resulting improvements in health care quality and outcomes [ 44 ]. Collectively these findings demonstrate how patient engagement shifts the clinical paradigm from “what is the matter?” to more meaningfully discovering “what matters to you?”

There is a growing literature on how patient engagement impacts the experience and delivery of care. Minority patients frequently receive lower rates of preventive services. They suffer delays in diagnosis of diseases such as cancer, and once identified they even suffer delays in treatment. In a recent study, Sheppard has found that medical mistrust may contribute to these problems, something that could be overcome through effective patient engagement [ 71 ]. Survey data collected by Arora from cancer survivors demonstrates that better engagement increases the perception of personal control, increases trust, and decreases uncertainty [ 4 ]. Torres demonstrated that clinician communication styles are critically important to effective patient engagement and “good” communication creates a sense of not being rushed, a feeling like the clinician understands the patient, and a partnership built on trust [ 86 ]. Effective communication to better engage a diverse spectrum of patients with varying levels health literacy needs to be learned by all clinicians.

A review of proven strategies to enhance patient engagement identified three focus areas for engagement: improving health literacy, helping patients make appropriate health decisions, and improving the quality of care processes [ 16 ]. The Health Literate Care Model is an important tool to inform how attention to health literacy can improve patient engagement [ 39 ]. This model encourages clinicians to approach “all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients’ understanding.” Across the spectrum of healthcare delivery, full engagement of the patient requires the patient to be able to obtain, process and communicate health information. Strategies to ensure that engagement activities are appropriate for a patient’s health literacy can include adapting and simplifying language to decrease the risk of misunderstanding, providing examples that are relevant to the individual’s lifestyle and cultural context, using visual representations of data, and integrating decision aids into care [ 22 ]. In a health literate care model, information needs to be presented in a manner that is congruent with a patient’s ability to understand the material and span the domains in which health care occurs – the clinical setting, home, and community.

3. Engaging patients TO better understand decisions

3.1. the evolution of patient engagement for decision-making.

Engaging patients in health care decision-making has significant benefits. Patients who participate in their decisions report higher levels of satisfaction with their care; have increased knowledge about conditions, tests, and treatment; have more realistic expectations about benefits and harms; are more likely to adhere to screening, diagnostic, or treatment plans; have reduced decisional conflict and anxiety; are less likely to receive tests or procedures which may be unnecessary; and, in some cases, even have improved health outcomes [ 60 , 61 , 77 ].

Engaging patients in decisions has its basic grounding in the Nuremburg code which originated, mandated, and defined informed consent as a requirement for involving participants in research. Informed consent is the concept that individuals must be aware and understand what will be asked of them if they choose to participate and the risks and benefits of participating in a study. The information must be presented in a way that facilitates complete understanding – irrespective of the person’s health literacy. In the mid-1970s, informed consent was extended to clinical practice requiring clinicians to disclose the risks and benefits of a medical procedure and then obtain patient permission before the procedure rather than patients simply yielding to, or complying with proposed medical care [ 6 ]. While this represents an improvement in patient engagement, it was mainly applied to surgical procedures and most efforts focused on getting signed consent rather than ensuring patient involvement in decision-making or even ensuring full comprehension of the procedure and alternatives [ 2 , 3 ].

3.2. Key components of shared and informed decision-making

In the mid-1980’s, informed consent evolved in to a more collaborative relationship between patients and clinicians, where both parties shared information and came to joint decisions. The closely related concepts of informed decision-making and shared decision-making emerged. Shared decision-making has been defined as, “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences [ 21 ].” In this model, the clinician’s role is to elicit the patient’s understanding, values, or reasoning and serve as a partner in decision making. According to the US Preventive Services Task Force (USPSTF), shared decision-making within the patient-clinician partnership universally encompasses a process in which both the patient and clinician share information with each other, take steps to participate in the decision-making process, and agree on a course of action [ 72 ].

Braddock defined seven elements that informed decision-making: (1) discussion of the patients role in decision making, (2) discussion of the clinical issue, (3) discussion of alternatives, (4) discussion of the pros and cons of alternatives, (5) discussion of uncertainties, (6) assessment of patient understanding, and (7) exploration of patient preference [ 9 ]. Braddock acknowledged that medical decisions vary in complexity and these elements will be employed to varying degrees depending on how straight forward or complex the decision. Embedded in each element is a recognition that in order for a patient to fully engage in any discussion there is need for the patient to have some health literacy. Clinicians should approach decision steps with attention to the patient’s literacy needs and assess the patient’s knowledge and understanding throughout.

3.3. Implementing patient engagement for decision-making

While some medical decisions are straightforward with one clear “right” choice, most decisions have multiple options each with a different set of advantages and disadvantages for patients and clinicians to consider. For some decisions, it is important to incorporate clinical information such as individual patient risks, the specifics of the condition, comorbidities, and potential prognoses. While this may be done by clinicians without much patient engagement, often patients may be the only source that knows, or has at least experienced all their medical history. Patient engagement is critical to ensure that all the medical information is being incorporated into these decisions. For other decisions, it may be more important to include patient’s values, preferences, likelihood for adherence, and life circumstances. This scenario clearly involves patient engagement as only patients know this information. Effective discussions include both clinicians sharing clinical information about the options and patients sharing information about themselves.

Common examples of medical decisions include whether and how to make a health behavior changes, when to start and how to get preventive screening, management for acute or chronic conditions, how to prioritize competing health needs, and even when to change or stop a treatment. Some decisions are routine and occur frequently in practice such as when to start screening for breast cancer or how to be tested for colorectal cancer [ 7 , 63 , 75 , 76 ]. In one US primary care setting, nearly one in five patients seen for an office visit faced a routine decision about preventive care [ 43 ]. Other more major decisions, such as how to treat localized breast cancer or manage an abdominal aortic aneurysm, may only occur once in a patient’s lifetime.

Traditionally, clinicians engage patients in decision-making during in-person visits. This may work well for major decisions, which occur infrequently, have obvious consequences, and may be amenable to clinicians and patients meeting on several occasions to make the decision. More routine decisions that are part of an office visit during which multiple issues are discussed are often overlooked by patients and clinicians. When asked, more than two thirds of patients report that they would like to share decisions with their clinician – routine and major. Sadly, this happens less than half the time [ 93 , 96 ]; conversations between clinicians and patients rarely include all elements of a good decision [ 48 , 56 , 96 ]; and while patients consider themselves knowledgeable about decisions, patients frequently have a poor understanding of the medical facts and often over-estimate the value of medical care [ 32 ].

One solution is to use decision aids and supports to help patients make medical decisions. These tools can ensure patients receive information in a standardized format that includes all critical content, presents information in a culturally appropriate manner, and uses language and images to ensure understanding across a range of health literacy needs. Decision aids are not routinely used in clinical care [ 31 , 35 , 45 , 47 , 62 ]. Key barriers include time, expense, perceived legitimacy, capacity, ability to integrate into workflow, lack of clinician training and comfort with decision aids, and an environment that has not made routine use a cultural norm [ 73 ]. Despite these barriers many good decision aids have been developed. A host of organizations have cataloged and made available a range of high quality decision aids tailored to a range of literacy levels and cultural norms as well as trainings and resources to help clinicians better implement shared decision-making (see Table 1 ).

Organizations and resources that promote and support informed and shared decision-making for patients and clinicians

Krist proposes that to be effective, decision aids must also be integrated into the clinical workflow – realistically, patients undergo a “decision journey [ 43 ].” This journey requires support over time, allowing patients to contemplate options, gather additional information, confer with family and friends, consider individual preferences, and address their personal worries or concerns. Clinicians can serve as trusted advisors during this decision journey. One example of systematically supporting decision journeys is how a group of practices used their patient portal to promote cancer screening decisions ( Fig. 1 ). The system anticipated the patients’ decision needs; delivered decision support prior to visits; allowed patients to tailor decision supports to their interests and needs; collected patient-reported information about where they were with their decision journey, what they wanted to discuss with their clinician, and their fears; shared the patient reported information with their clinician; set a decision-making agenda; and even provided follow-up on next steps [ 43 ]. Routine implementation of similar workflows and processes, whether technology-based or not, has great potential to improve care, address health literacy issues, and better engage patients in decision-making.

A workflow to better engage patients throughout their decision-making journeys. To better engage patients in their decisions, this workflow, which several practices programmed into their patient portal and electronic health record, guides patients and clinicians through a series of seven steps: (1) based on electronic health record data, patients with decision needs are identified, and the patient portal reaches contacts patients outside the confines of an office visit to start considering decision options; (2) the patient portal walks patients through an intake that assesses personal preferences, knowledge, needs, and readiness to make a decision; (3) the portal provides personalized educational material tailored to the patient’s stated preferences and decision stage; (4) the portal allows the patient to share their preferences and decision needs with their clinician; (5) the clinician reviews the information prior to a visit, priming the discussion so the clinician is aware of the patient’s needs; (6) the patient and clinicians are able to make a more informed and shared decision; and (7) the electronic health record and patient portal can follow-up with both the clinician and patient to make sure the decision is acted upon consistent with the patient’s wishes (modified from [ 43 ]).

4. Engaging patients to improve health behaviors

Similar to increasing patients’ participation in medical decision making, clinicians need to engage patients to effect desired health behavior changes. Research has shown that incorporating patient’s goals and motivations into planned behavior change increases the likelihood that a patient will be successful with behavior change. Multiple strategies have been developed to increase patient involvement in health behavior change, including the 5 As, the 5 Rs, and Motivational Interviewing. Similar to shared decision-making, each of these strategies require the clinician to elicit the patient’s reasons for change and incorporate those reasons into the behavior change plan. Through this process the clinician can also ascertain a patient’s understanding of their health care and address any misconceptions.

The 5 As is a framework that can help guide clinician actions to better engage patients who are working towards health behavior change [ 1 , 27 , 92 ]. The major steps to the five As include: (1) Ask every patient about health behaviors, (2) Advise patients with an unhealthy behavior in a clear, strong, and personalized manner to modify the behavior, (3) Assess the patient’s willingness to change the health behavior (sometimes referred to instead as seeking Agreement on the patient’s willingness to change the health behavior), (4) Assist the patient in modifying the health behavior, and (5) Arrange for follow-up. For many behaviors, A1 through A3 can occur during one encounter and may take only a few moments. Conversely, A4 and A5 – assisting patients and arranging follow-up – often require intensive support extended over a period of time. For example, interventions to help patients eat right, exercise, or lose weight often take dozens of hours of face to face contact over a period of months from multiple members of a multidisciplinary team [ 88 , 89 ]. The exception to the intensive time and resource requirement for A4 and A5 is counseling patients to quit smoking and counseling patients against risky drinking behaviors (not treating alcoholism). A4 and A5 can be done effectively in a matter of minutes during one encounter with brief follow-up and support. While more intensive interventions to help patients quit smoking and limit risky drinking are more likely to result in lasting heath behavior changes, brief interventions for these two behaviors do have some efficacy [ 23 , 59 ].

For patients that are not ready to make a health behavior change, the five Rs is a tool that clinicians can use to help patients move to a stage of readiness to change their health behavior. The 5 Rs prompts the clinician to: (1) discuss the Relevance of the change for the patient (e.g. smoking may be contributing to your getting so many colds and missing work so often), (2) discuss the Risks of continuing the unhealthy behavior, (3) discuss the Rewards of adopting a healthy behavior, (4) identify Roadblocks to changing the behavior, and (5) Repetition of the personalized five Rs message at each visit [ 25 , 26 ]. The last R, Repetition, stresses the importance of reiterating the 5 Rs to help motivate patients to change behaviors whenever possible, so that when the patient is ready to make changes, the assistance and support is available.

Motivational Interviewing is a third strategy that leverages a patients’ values and goals to initiate and maintain behavior change. Motivational Interviewing is defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence [ 57 ].” One of the key components of this definition is a patient’s ability to develop intrinsic motivation which requires that he/she has a knowledge of how the behavior change directly relates to personal goals. In order to enhance intrinsic motivation, the patient must be able to relate the behavior change to their sense of self, their self in the context of family and community, and their other values and roles. Effective patient education and support tailored to the patient’s needs and health literacy can increase their sense of self-efficacy. This education can help patients leam how diseases progresses and how changing behaviors can make a clear impact on their health. Making the behavior change relevant to the patient’s experience may alleviate shame and guilt and instill hope that change is possible.

Sadly, unhealthy behaviors account for nearly 40% of premature deaths and substantial morbidity in the US [ 58 ]. Engaging patients in health behavior change has been clearly shown to improve health and patients commonly report a clinician’s advice to change an unhealthy behavior as a key motivating factor for change [ 28 , 79 ]. Yet few patients report being asked regularly about their health behaviors; only 10–20% of smokers report being told to quit smoking by their clinician; less than 20% of obese patients report being told by their clinician that they are overweight; and only 2–5% of patients in need of intensive diet, exercise, and weight loss counseling actually receive assistance [ 46 , 69 ].

There are many reasons why health behavior counseling is done poorly in practice including lack of time, competing demands, inadequate resources and support, limited training in health behavior counseling, and even lack of confidence in effecting change in patients [ 12 , 34 , 78 ]. Exceptional practices and health systems are increasingly trying to better address health behavior counseling by building the infrastructure support necessary for intensive assistance and follow-up, creating multidisciplinary teams that can address the range of patient needs, and having dedicated staff to follow-up and provide ongoing assistance and motivation [ 8 , 68 ]. To be successful all care team members must have defined roles, be effective patient communicators, understand the patient’s information and social needs, and pay attention to each individual’s health literacy. New payment models that reward improved outcomes and value-based care may further support and enhance these practice efforts. Alternatively, practices can form partnerships with existing community programs designed to help patients improve health behaviors. These clinical community linkages can often more effectively address patient’s needs by building on the strengths of each partner – clinicians to Ask, Advise, and Assess patient’s readiness to change and community programs to provide the intensive Assistance and follow-up in the places that patients live, work, and play [ 41 , 42 , 94 ]. One framework, proposed by Krist, depicts how clinical practices and community programs can work together to better engage patients in health behavior change and care in general ( Fig. 2 ).

A Framework for How Clinical Practices and Community Programs Can Partner to Better Engage Patients in Care. A framework depicting how funders, policy makers, communities, and clinicians can work together with the support of personnel and infrastructure to link the care delivery systems. Funders, payers, and purchasers are tasked with financing the infrastructure needed to support integrating the clinical and community care systems. National and state leadership are empowered with the authority, resources, and responsibility to foster integrations across regions. Local leaders are the regional organizations that step forward to oversee and support local tailoring and integration activities. Community is the setting where individuals live work, and play and where the stakeholders who serve them are located. Community organizations are care providers that deliver the community elements of a clinical-community integration. Clinicians are care providers that deliver the clinical elements of a clinical-community integration. Spanning personnel are staff who specialize in helping people traverse the clinical and community settings to obtain care. Spanning support (which includes policies, delivery system design, information systems, decision support, and management support) are essential ingredients to support integrations at all levels depicted in the framework (modified from [ 41 ]).

5. Engaging patients for chronic disease care

Understanding how patients can be engaged in self-management of chronic conditions is also important given today’s growing prevalence of chronic disease. For example, an estimated 70 million Americans live with hypertension and 29 million live with type 2 diabetes mellitus. Another significant proportion of the US population have the precursors to these chronic diseases – 70 million have prehypertension and 86 million have prediabetes. The number and prevalence of chronic conditions that patients must live with continues to expand.

One commonly promoted model for designing systems to better address chronic conditions is the Chronic Care Model (CCM). Developed in the mid-1990s by Wagner, the CCM identifies key health system elements needed to provide effective chronic disease management and prevention [ 90 ]. These elements include (a) the community, (b) the health system, (c) self-management support, (d) delivery system design, (e) decision support, and (f) clinical information systems. When these elements function synergistically they result in a more informed, engaged, and activated patient as well as a more prepared, proactive practice team. The patient and the practice team can have more productive interactions, clinicians can better assist patients, and patients can better manage their health – all leading to improved outcomes. Use of the CCM to inform and guide the care delivery system has been evaluated extensively and is demonstrated to both improve health outcomes and cost-effectiveness [ 13 ].

When designed effectively, the healthcare and community delivery systems can provide the tools to help patients to become more informed, engaged and activated in their care. Engaged patients are more likely to practice healthy behaviors, eating right, exercising, and not smoking, mitigating any harms from their chronic condition. They seek and use more health information from a wide range of sources to learn about their condition and ways to manage it. And they better self-manage their condition by following up with their primary care clinician and specialists, getting needed tests to monitor their condition, adhering to daily medications, and participating in self-monitoring activities. Effective healthcare and community delivery systems should encourage and support these activities in a manner attentive to the patient’s health literacy and health information needs.

6. The influence of social determinants on engagement and literacy

There is growing attention to the relationship between social determinants and whether clinicians can effectively engage patients in their care. It has long been known that health outcomes are affected by the social determinants of health, including socioeconomic status, education, ethnicity, race, and community of residence. The Institute of Medicine first drew attention to this problem, with a focus on racial and ethnic disparities, in their 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care [ 81 ]. The report highlighted that health outcome disparities could not be explained by merely lack of access to care, such as insurance status or availability of care. In addition, inherent stereotyping of patients and biases of clinicians contributed to poorer quality of care for minority patients. While concordance between clinician and patient in ethnicity, race, and gender have been shown to be important contributors [ 82 ], patient engagement barriers extend beyond these factors. Several studies have reported that clinicians are verbally dominant and engage less in patient centered communication in encounters with ethnic minority patients [ 15 , 36 ]. This lack of engagement with patients is even worse when a language barrier exists between the clinician and patient.

Clinicians are often also unable to fully comprehend the struggles with transportation, finances, housing and other economic barriers that patients of lower socioeconomic status may face. While patients with higher income may often live in the same communities as their clinicians, poorer patients either have to travel long distances to receive health care from clinics where they may be stereotyped or are served in clinics by clinicians who drive in from higher income communities. Unless directly asked, patients may often hesitate to bring up structural barriers to receipt of care and clinicians may not be aware of their barriers.

These barriers, whether created from ethnic differences, income disparities, geographic barriers, or inherent communication gaps, are often not addressed through intentional efforts to better engage patients in their care processes. In fact, special efforts need to be made since those who face barriers from social determinants have traditionally been disenfranchised within the health care system. A recent report published by the National Academies of Science, A Framework for Educating Health Professionals to Address the Social Determinants of Health , discusses processes in which some of these issues may be addressed. The framework includes three pillars: education, community and organization.

In terms of education, increased efforts to train clinicians in cultural competency may improve patient engagement. Defined as “a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations,” cultural competency may be one way clinicians can improve communication with patients and better facilitate patient engagement in care processes [ 17 ]. In 2012, the Association of American Medical Colleges and the Association of Schools of Public Health released a joint report suggesting core competencies in cultural competency for health professional students. Such curricular elements may include (1) improvement in culturally appropriate communication behavior, (2) situational awareness, (3) adaptability and (4) knowledge of core cultural issues [ 84 ].

In terms of community, joint efforts by clinicians and health systems to be involved in the communities that patients live may help facilitate better patient engagement. Through such efforts, community resources can be leveraged that may reduce social barriers that patients may face to accessing health care in a timely and appropriate fashion. Interian suggests that joint efforts by community organizations and health care organizations may help better educate patients, improve the way that structural barriers such as problems with transportation, finances and housing are addressed, and improve communication between patients and clinicians [ 33 ].

Organizational efforts may also help with patient engagement. Kauffman calls for more research is needed to address health disparities and studies need to include “hard to reach patients [ 37 ].” When including patients in outreach such as developing patient advisory councils or seeking community input, health care organizations may benefit from intentionally recruiting and including their more disenfranchised patients. From a long-term perspective, the work that health professional training schools are doing to increase minority enrolment and recruit culturally and economically diverse students may also help with future efforts to better engage patients.

While much work still needs to be done to eliminate the disparities in patient engagement, recent efforts have at least drawn attention to this issue. Attention has helped develop frameworks to understand disparities and create curricula for health professional students to learn about and start proactively addressing such disparities.

7. Patients health information seeking behaviors

Information is central to a patient being engaged in their decisions, care, and self-management. With the advent of the internet, mobile technologies, and increasingly powerful search engines, patients can now instantaneously access all kinds of information anywhere they like to help guide their health with the touch of a button. Some patients still rely solely on the receipt of health information from clinicians, yet many more use a combination of approaches. Receiving information from a trusted clinician can be good – it can prevent a patient from being misled by inaccurate or commercially biased information. However, not actively seeking health information can be a missed opportunity. Many local and national organizations are working to raise awareness on the power of health information by promoting the need to get informed, directing patients to health information, and even creating information, ranging from educational material about health to reports on the quality of care from hospitals and clinicians to interactive and personalized tools to manage daily activities.

There are several models that explain how, why, and where patients seek health information. One model advanced in by Longo ( Fig. 3 ) [ 49 , 51 , 52 ], identifies two axes of information seeking behaviors: active-passive and aware-unaware. Not only do patients fall into a spectrum of preferring to be active or passive seekers of health information, but patients fall into a spectrum of knowing that they need health information or knowing that health information is available. Further, there is a range of settings and sources that patients use information. Even patients involved in active searches for information are informed by passive information that they come across during usual activities of living. These passive sources include newspaper articles, television talk shows, billboards, and magazines. Passive sources can be useful or potentially misleading, particularly if commercially biased. Naturally, information needs and activities vary over time based on a multitude of patient and contextual factors. Some of these factors are modifiable and can be improved, resulting in increased health information seeking and improved health literacy. Although further research is clearly needed to identify best strategies for engaging patients in information seeking.

A Model to Describe Patient’s Health Information Seeking Behaviors (Reproduced with permission from Health Information Seeking, Receipt, and Use in Diabetes Self-Management, July/August, 2010, Vol 8, No 4, issue of Annals of Family Medicine Copyright©2010 American Academy of Family Physicians. All Rights Reserved.)

The information that patients can access has been continually and rapidly evolving, including the format of information, content and focus of information, and even where information is accessed. In the 1980s, a wealth of consumer information provided by professional organizations and advocacy groups emerged. Patients could access this information in lay press articles, brochures from their clinician, directly from the producer, and in community settings. This same information quickly moved to the internet and new innovative information sources emerged such as patient provided information. With the internet, individuals can reach wide audiences to share their experiences, create virtual support groups, and learn from others experiencing similar conditions; this is exemplified by tools such as patients likeme [ 65 ].

Now mobile devices, wearables, and the hyperconnectivity of personal health information is creating a new era of mobile health. Clinicians and health care systems are designing patient portals that can be accessed on the web or any mobile device [ 40 , 66 , 74 ]. Through integration of clinical information and patient reported information, these systems can anticipate patient needs and decisions, personalize educational content to better speak to the patient, reach out to patients outside of clinical encounters, and transform care from being reactive to proactive [ 43 , 95 ]. Asynchronous communication with clinicians and virtual visits can further facilitate information exchange between patients and clinicians. However, the impact of these clinician-provided information sources have on health outcomes is largely unknown and much research is needed about how these new approaches can better engage and activate patients in their care [ 29 ].

Similarly, smart devices have become nearly ubiquitous, with an estimated 3.5 devices per every human on earth in 2015 [ 85 ]. These devices have resulted in an explosion of applications (“apps”) that can receive, collect, tailor, and transmit health information, allowing patients to self-digitize for health – often referred to now as Mobile Health or mHealth. mHealth has the potential to scale the delivery of highly personalized information directly to users and share the information with the user’s clinician to better support care [ 80 ]. To date the development and dissemination of these resources has largely been driven by industry and consumer demand. There are few active, completed, or published studies that rigorously test mHealth interventions in randomized controlled trials to evaluate the impact on health outcomes [ 83 ], and there is less information focusing on how mHealth impacts patient engagement or understanding of health information [ 5 ]. In a recent systematic review, Free and colleagues only identified 42 well designed trials in North American, Europe, Asia, and Australia that showed improvements in patient self-management of diseases, clinician communication, and appointment attendance [ 24 ]. Given the potential uses of mHealth , much more research is needed.

Despite the proliferation of health information there is a paucity of data about the type of health information vulnerable and less health literate consumers want, particularly as it relates to newer technologies. Several studies have engaged disadvantaged populations to identify what health information would most help them with their care for a range of health topics [ 50 , 70 ]. Generally, two sets of desired information are commonly identified – a need for information to assist them in selecting clinicians and basic health information to assist them in self-management. Regardless of race and ethnicity, patients express a greater need for self-management information than other forms of information. Most importantly patients expressed a need for basic, straightforward information. There is some evidence for higher uptake of mobile internet technology by minorities and disadvantaged populations [ 30 , 54 , 91 ]. Accordingly, some disparities experts posit that mHealth tools have the potential to narrow disparities [ 87 ]. Yet for the most part, clinicians at safety-net practices report minimal use of even basic mobile technology in their practices [ 10 ].

Efforts are needed to both encourage and motivate patients to seek health information as well as to create high quality, patient-centered health information that is written at a basic reading level, free of jargon, culturally sensitive, non-biased, and available in multiple languages. Yet it is also important to understand where patients are with their information needs [ 53 ]. Some patients will have basic information needs, such as information about a condition, test, or treatment. Others may have more advanced needs such as information about nuanced differences between options or where to receive treatment. Some may just want information to understand and feel comfortable with care recommended by their clinician. Providing patients information mismatched to their needs is unlikely to be useful. A holistic approach is needed to providing patients information that takes into account the patient’s diverse needs, desired sources, and various situations.

8. Future directions

There is clear evidence that working to respectfully encourage patient engagement improves health outcomes and wellbeing for patients. As discussed in this chapter, engagement is critical across the lifespan and across the disease spectrum, from prevention to chronic disease control. Recent decades have seen great advances in patient engagement for clinical decision-making, promoting healthy behaviors, and self-management of chronic conditions. Understanding and addressing health literacy is a central underpinning to all of these activities.

Despite clear advances in our understanding of the value of patient engagement and effective strategies to engage patients in health, much more is needed. There are clear evidence gaps that deserve further work. Further research is needed to understand how to better inform and engage patients in decisions and self-management. Needs range from improving timely access to information for patients, ensuring that information is clear and understandable, ensuring that patients understand the importance of the information, and designing information to be actionable. As information becomes increasingly accessible from a host of venues, helping patients to navigate the morass of information and better integrating diverse sources of information could reduce patient confusion about what they need. A massive challenge will be to learn how to better redesign the healthcare delivery system to make evidence-based patient engagement part of routine care. This is especially challenging given how many decisions and health behaviors benefit from patient engagement. The health care system will also need to learn how to receive and interpret a growing expanse of patient reported information from wearables and other devices. This information may not only be able to help clinicians with decisions, but also be a mechanism in of itself to engage patients. Clinicians will also need to build and study partnerships with community resources that can extend engagement outside the clinical setting and better support patients in their daily lives. Given the diversity of patients and their needs, a host of solutions will be needed to engage patients and understanding how to match these solutions with individual patients will be critical. This challenge may be particularly important for more disadvantaged individuals and those with lower health literacy.

The future of patient engagement will need to continue to advance these activities, but also move beyond, to authentically engage patients not only in their health care, but in designing and implementing care delivery systems, developing local and national health policies, and directing health research [ 95 ]. Patient insights and lived experiences can ensure that healthcare systems and programs align with their priorities, address their needs, and are delivered in an accessible manner. Patients can help set healthcare systems’ organizational priorities, participate in governance decisions, and define organizational strategies and activities. Similarly, patients can ensure that legislative, regulatory, and funding priorities reflect their needs. Patient engagement for research can help to frame research questions, select outcomes, develop study protocols, support recruitment, interpret results, translate research findings into lay language, disseminate results, and even sustain interventions.

Efforts will be needed to help patients realistically participate in these activities. Patient engagement will need to become the cultural norm. Patients will need training and support to meaningfully participate. Yet collectively, these higher levels of patient engagement can improve our very systems for promoting health.