臨床決策之概念分析：以護理角度出發

A Conceptual Analysis of Clinical Decision-Making From a Nursing Perspective

10.6142/VGHN.202109_38(3).0006

顏旻萱(Min-Syuan Yen)；楊鎮宇(Cheng-Yu Yang)；施倩鈴(Chien-Ling Shih)；蔡慧于(Hui-Yu Tsai)；謝菁怡(Ching-Yi Hseh)；奉秀盈(Shion-Ying Fong)；蕭乃嘉(Nai-Chia Hsiao)；吳麗敏(Li-Min Wu)

臨床決策 ； 判斷 ； 推理 ； 護理 ； 概念分析 ； clinical decision-making ； judgement ； reasoning ； nursing ； concept analysis

榮總護理

38卷3期（2021 / 09 / 01）

269 - 278

繁體中文

護理人員面對臨床各種情境，必須透過評估、分析後做出決定，此過程稱為「臨床決策」且此為動態過程。臨床決策是護理人員必須具備的能力，但隨著多元社會和全球化，臨床決策變得更複雜亦需要注入更多考量。故本文依Walker與Avant（2011）的步驟進行概念分析，結果確認此概念之定義性特徵為：一、過去的知識和實務經驗；二、透過資料或證據了解病人的需求，並辨別出病情變化；三、依據病人最佳利益，確定事件的優先順序；四、綜整後得出最佳行動方案的結論，並對事件做出回應；五、預期達成一個或多個特定的目標。藉由典型、邊緣及相反案例的列舉，更清楚分析此概念及確認臨床決策發生之前置因素與後果，透過實證工具的應用將此抽象的概念具體化，讓臨床護理受用。故本文希望透過概念分析後，護理人員在進行臨床決策時除了透過過往經驗外，更能經由思考、實證依據及與病人或家屬溝通後進行決策，達到護病雙贏的結果。

Nurses must assess and analyze various clinical situations to make decisions. This dynamic process is called clinical decision-making. Due to globalization and the increasingly pluralization of societies, clinical decision-making has become more complicated and requires greater consideration. This conceptual analysis is guided by Walker and Avant (2011). The attributes of clinical decision-making are 1. drawing on knowledge and experience; 2. recognizing the patient's needs and their disease conditions using data or evidence; 3. prioritizing an event based on what is in the patients' best interests; 4. coming to a conclusion on the best course of action and responding to the event; 5. expecting to accomplish a specific goal or goals. Exemplars of model, borderline, and contrary cases are presented to clearly illustrate clinical decision-making and better understand the antecedents and consequences. Empirical referents are used to render the abstract concept measurable and thus beneficial to nursing practice. Therefore, this article hopes to encourage nurses to make clinical decisions based not only on experience but also on critical thinking, empirical evidence, and communication with patients or patients' family members to achieve a win-win outcome.

1. 許維邦、張瑞月、呂美君、周明智、蕭培靜 (2015)．共同決策於臨床醫學之應用．澄清醫護管理雜誌，11(2)，24-29。
   連結：
2. Adamson, K. A., Gubrud, P., Sideras, S., & Lasater, K. (2012). Assessing the reliability, validity, and use of the Lasater Clinical Judgment Rubric: three approaches. The Journal of Nursing Education, 51(2), 66-73.
   連結：
3. Bjørk, I. T., & Hamilton, G. A. (2011). Clinical decision making of nurses working in hospital settings. Nursing Research and Practice, 2011, 1-8.
   連結：
4. Brunt, B. A. (2005). Critical thinking in nursing: An integrated review. The Journal of Continuing Education in Nursing, 36(2), 60-67.
   連結：
5. Canova, C., Brogiato, G., Roveron, G., & Zanotti, R. (2016). Changes in decision-making among Italian nurses and nursing students over the last 15 years. Journal of Clinical Nursing, 25(5-6), 811-818.
   連結：
6. Dowding, D., & Thompson, C. (2003). Measuring the quality of judgement and decision‐making in nursing. Journal of Advanced Nursing, 44(1), 49-57.
   連結：
7. Edeer, A. D. & Sarıkaya, A. (2015). Adaptation of clinical decision making in nursing scale to undergraduate students of nursing: The study of reliability and validity. International Journal of Psychology and Educational Studies, 2(3), 1-9.
   連結：
8. Farčić, N., Barać, I., Lovrić, R., Pačarić, S., Gvozdanović, Z., & Ilakovac, V. (2020). The influence of self-concept on clinical decision-making in nurses and nursing students: a cross-sectional study. International Journal of Environmental Research and Public Health, 17(9).
   連結：
9. Hart, P. L., Spiva, L., & Mareno, N. (2014). Psychometric properties of the clinical decision-making self-confidence scale. Journal of Nursing Measurement, 22(2), 312-322.
   連結：
10. Hoffman, K., Donoghue, J., & Duffield, C. (2004). Decision‐making in clinical nursing: Investigating contributing factors. Journal of Advanced Nursing, 45(1), 53-62.
    連結：
11. Johansen, M. L., & O'Brien, J. L. (2016). Decision making in nursing practice: A concept analysis. Nursing Forum, 51(1), 40-48.
    連結：
12. Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503.
    連結：
13. Liou, S. R., Liu, H. C., Tsai, H. M., Tsai, Y. H., Lin, Y. C., Chang, C. H., & Cheng, C. Y. (2016). The development and psychometric testing of a theory-based instrument to evaluate nurses' perception of clinical reasoning competence. Journal of Advanced Nursing, 72(3), 707-717.
    連結：
14. Manetti W. (2019). Sound clinical judgment in nursing: A concept analysis. Nursing Forum, 54(1), 102-110.
    連結：
15. Nibbelink, C. W., & Brewer, B. B. (2018). Decision-making in nursing practice: An integrative literature review. Journal of Clinical Nursing, 27(5-6), 917-928.
    連結：
16. Noone J. (2002). Concept analysis of decision making. Nursing Forum, 37(3), 21-32.
    連結：
17. Simmons, B., Lanuza, D., Fonteyn, M., Hicks, F., & Holm, K. (2003). Clinical reasoning in experienced nurses. Western Journal of Nursing Research, 25(6), 701-719.
    連結：
18. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.
    連結：
19. 中華民國教育部 (2015，11月)．教育部重編國語辭典修訂本。http://dict.revised.moe.edu.tw/cbdic/search.htm
20. 歐乃嘉、陳淑貞、張瓈方、張寶琪、尹玓 (2018)．二年期護理師（護士）訓練計畫執行成效相關研究．中華職業醫學雜誌，25(1)，31-42。
21. Hicks, F., Coke, L., & Li, S. (2009). The effect of high-fidelity simulation on nursing students’ knowledge and performance: A pilot study. National Council of State Boards of Nursing: Research Brief, 40. 1-35.
22. Jenkins, H. M. (1983). Perceptions of decision making among baccalaureate nursing students as measured by the clinical decision making in nursing scale [Doctoral dissertation]. University of Maryland.
23. Jenkins, H. M. (2001). Clinical decision making in nursing scale. In: Waltz, C.F., Jenkins, L.S. (Eds.). Measurement of Nursing Outcomes Volume 1: Measuring Nursing Performance in Practice, Education and Research (2nd ed., 33-37). Springer Publishing Company.
24. Oxford University Press. (n.d.) (2020). Oxford Learner's Dictionaries. https://www.oxfordlearnersdictionaries.com
25. Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Prentice Hall.