Clinical judgment in nurse-midwifery

CLINICAL JUDGMENT IN NURSE-MIDWIFERY A Review of the Research with Implications for Education

Deborah Greener, CNM, MS

ABSTRACT The purpose of this paper is to provide a review of the literature in medicine and nursing that may be helpful for understanding and teaching clinical judgment and decision-making in nurse-midwifey. An overview of the major theoretical perspectives is presented, and research related to the discovery of processes and progression of expertise in clinical judgment are discussed from each framework. Studies on teaching methods in the area of clinical judgment are analyzed, and the implications for nursemidwifery teaching and evaluation are discussed.

The abilitiy to make complex decisions under conditions of uncertainty is a critical component of nurse-midwifery practice. In fact, cognitive and/or psychomotor competencies are essentially useless, and potentially dangerous, if they are not integrated with the ability to make appropriate management decisions. But where and when do students learn to make competent, independent clinical judgments? How can nurse-midwifery educators and preceptors foster and evaluate the processes involved in learning clinical judgment? And finally, how can problem-solving deficiencies be identified and remediated? The purposes of this paper are to provide a selected overview of research on the development of clinical judgment and to discuss the implications for nurse-midwifery education. In this context, “clinical judgment” is defined as decision-

Address correspondence to: Deborah Greener, University of Utah College of Nursing, 25 South Medical Drive, Salt Lake City, UT 84112. Journal of Nurse-Midwifery

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making by the nurse-midwife garding

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1) the type of observations

to be made in the client situation (data collection), 2) the evaluation of the data observed and derivation of meaning (identification of relevant problems and needs, or diagnosis) , and 31 the identification of appropriate actions that should be taken with or on behalf of the client (nursemidwifery management plan). For this discussion, the terms clinical judgment, clinical decisionmaking, and clinical problem-solving will be used interchangeably. According to many investigators, the development of appropriate instructional methods for teaching clinical judgment and decision-making must be based on a thorough understanding of the processes underlying decision-making, and the differences between expert and novice decisionmakers. l-* Process studies of clinical decision-making attempt to gain an understanding of how competent individuals proceed in determining

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what observations to make, in identifying health problems within those observations, and in deciding on appropriate actions. The second aspect of interest is the examination of the progression of competence in clinical problem-solving. This growth or progression of judgment ranges from the level of the beginning student, through the novice practitioner, to the expert clinician. A number of theories have been used to provide a framework for the investigation of one or both of these two major aspects of clinical judgment among nurses and physicians; most notable are concept attainment theory, statistical decision theory, and information processing theory. In addition to these three major deductive perspectives, several inductive approaches have also been used to study process and expert/novice differences. Each of these perspectives will be discussed briefly; a more detailed review can be found in the work of Tanner.7 Because no research or theoretical literature examining either the processes or progression of clinical problem-solving in nursemidwifery was found, theory and re261 0091~2182/88/$03.50

search from the related fields of nursing and medicine will be reviewed. THEORETICAL PERSPECTIVES AND RELATED RESEARCH

Concept attainment theory describes the cognitive strategies that people use to form categories, patterns or groups of concepts when confronted with a set of incoming data.g According to the theoy, people attend selectively to information, formulating hypotheses about possible ways to categorize the input, and then selecting strategies to test the hypotheses for “proper fit.” The perspective of concept attainment theoy was first applied to the study of clinical judgment in nursing during the 1960s. In these studies, clinical problem-solving was defined as the process of identifying the unobservable “state of the patient” from observable data. Contrary to the theoy which predicted that patterns of categorization would be detectable in the ways that nurses used data to infer patient states, and that patterns would vary as a function of complexity, no such patterns of inference were found. These findings suggest that concept attainment theory did not adequately explain the processes of clinical decision-making in nursing. 4,5,10-15 Another theoretical approach to the study of clinical judgment in nursing and medicine is through a rational decision-making approach. This approach consists of interdependent and sequential management steps. Examples include An-

Debomh Greener is an Assistant Professor at the Uniuersity of Utah College of Nursing where her prima y teaching responsibilities are in the nurse-midwifery program. A gmduate of the Utah nurse-midwifey progmm in 1982, she is now a doctoral candidate in Educational Psychology where her study has focused on instruction and evaluation in the health professions.

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drew’s16 description of medical problem-solving as the six steps of problem-sensing, hypothesizing, searching and defining, identifying, resolving, and verifying; and Vamey’s17 nurse-midwifery management process that identifies the seven steps of the management process as data collection, identification of problems/diagnoses, anticipation of potential problems, identification of priorities, development of a comprehensive plan of care, implementation of care, and evaluation. Another rational decision analysis approach is utility theory. Utility theory describes a process for problem formulation in decisionmaking that involves the construction of a matrix or decision tree. This decision matrix displays the conditions, the cues or data, the alternative decisions, and the outcomes or effects. Each outcome is assigned a probability and a value. The values are usually derived in consultation with the client (for example, the value of a cesarean delivery with a 95% chance of a healthy baby, versus the value for a normal spontaneous delivery with a 50% chance of a healthy newborn). Using this theory, the utility (or value) associated with each outcome can be computed. To solve the problem, a clinician must decide which alternative gives the maximal expected utility. Each of these statistical models has been demonstrated and utilized in numerous studies of physician decision-making, 18,1gbut rarely in examining nursing clinical judgment. Grierzo used the utility theoy to describe the selection of nursing actions based on subjective assignments of value to certain outcomes and the probability of the occurrence of those outcomes given certain nursing actions. It was found that nurses’ intuitive judgments agreed with the actions prescribed by the model in the majority of cases. However, this study did not adequately support the use of this approach in the modeling of nursing judgment processes. NevJournal of Nurse-Midwifery

ertheless, this perspective may have some value in the instruction of clinical problem-solving and will be discussed later. A third theoretical framework used in the study of clinical judgment is information processing theory.21p22 From this perspective, the human mind is likened to a computer. Problem-solving is described as an interaction between an information processing system (the problem solver), and the demands of the task environment. The major assumption underlying the theory is that there are limits to human information processing capacity. Effective problemsolving, including diagnostic reasoning, rests on an individual’s ability to adapt to these limitations and to reduce the cognitive strain imposed by the task.23 According to information processing theory, the major types of limitations are factors that determine the amount of information to which the human can attend, and internal factors that determine the clarity and accessibility of information to the problem-solver. These limitations are imposed by the structure and capacity of the two main human memory systems: short-term memory (STM) and longterm memory (LTM). One example of an internal factor is the ability to remember clearly the meaning of clinical data; another is the limited capacity of STM, which is thought to be able to handle only between five and nine simple concepts at one time. Because clinical problemsolving situations are characterized by a huge amount of data, these data must be organized in some fashion upon entering STM or the information would quickly be forgotten. Information processing theory predicts that one way clinicians adapt to such complexity is by categorization (“chunking”) of incoming data so that the capacity of STM can be dramatically increased, conserving memory resources. These categories for classifying information are then stored and organized in semantic memory, a part of

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the LTM system. The semantic LTM is comprised of a vast network of categorized concepts or data; current evidence suggests clinical knowledge is stored in semantic LTM in a hierarchical manner, that allows abstract concepts to be linked with more concrete examples of the concepts.23 These concepts and associated examples are then more easily retrieved by the problem-solver. For example, a more abstract diagnosis is clustered with specific clinical cases and concrete examples. A rich network of association between and among such concepts is predicted to lead to more efficient retrieval and thus better judgment and problemsolving. One of the specific strategies predicted by information processing theory is early hypothesis activation. With this strategy, hypotheses are advanced very early in the data collection process, allowing further data collection to focus on the confirmation or elimination of the hypotheses. This strategy has been found to characterize physician and medical student problem-solving in a variety of studies,24 and is thought to be important in the description of process differences between expert and novice problem-solvers. In short, novices are more likely to collect extensive data and delay hypothesis generation, while experts tend to generate hypotheses very early and collect fewer data. Strategies of activating diagnostic hypotheses have also been described in several studies of nursing students and/or practicing nurses; however, the reported differences between novice and expert hypothesis activation were not statistically significant. 8,25,26 Additionally, Corcoran3,27 found that inexperienced and experienced nurses seemed to differ in their approaches to planning care and in their ability to modify their approach based on the complexity of the task, although the differences were again not statistically significant. The failure to detect statistically significant differences in Journal

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these studies may have been due to the very small sample sizes or to insensitive measures; these studies do not represent an adequate test of the applicability of information processing theory to studies of the processes and progression of clinical judgment. Studies using inductive approaches have also been applied to the study of clinical judgment in nursing. 6,28-30 Benner29 has described seven domains of skilled performance in nursing; among those directly related to clinical judgment are the helping role, the teachingcoaching function, the diagnostic and patient-monitoring function, and effective management of rapidly changing conditions. Of particular interest for nurse-midwifery is what Benner and Wrube130 described as the clinician’s “grasp of the whole situation” which is a qualitative or perceptual assessment based on a combination of input from the senses and an interpretation of the patient’s physical, verbal, and behavioral expressions. This description is similar to what Pyles and Stern6 identified as the formation of a “gestalt,” or the achievement of an insight about a patient situation. The investigators using this intuitive approach studied both expert and novice performance, and identified this intuitive grasp of the situation or gestalt as characteristic of expert performance. Additionally, from comparisons between new graduates and experienced nurses, Benner also reported development of expertise and skills along three dimensions: progression from use of abstract principles as a basis for judgment to the use of past concrete experiences, change in the subject’s perception of the patient situation as a compilation of equally relevant pieces of information to a perception of a complete whole, in which only selected bits are relevant, and finally, movement from detachment as an observer to full involvement in the situation. Certainly more research is needed to understand the full contributions of the inductive ap-

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preach to the study of clinical decision-making in nurse-midwifery. RESEARCH ON TEACHING CLINICAL JUDGMENT

Educators and researchers in the health professions have assigned considerable importance to the task of teaching clinical judgment, as evidenced by a recent Delphi survey of research priorities in nursing education, where strategies for teaching clinical problem-solving were identified as the second highest priority topic of 63 listed.32 At a 1987 meeting of a task force to examine the development of a Division of Research in the American College of Nurse-Midwives, research on clinical decision-making was identified as a critical need for future study. However, while numerous articles and studies on the topics of clinical judgment and problem-solving have been published in journals relating to nursing and medical education, there are extensive problems in drawing conclusions about the results due to the range of findings, methodological problems, and the lack of uniform definitions and measurement of clinical problem-solving. Because of these problems, only a brief summay of selected studies will be presented. The literature on teaching about clinical problem-solving generally can be classified into three categories. These include

1) studies on the use of a problembased approach to teach a specific content area, such as antepar-turn management; 2) studies that focus on teaching generally useful skills, such as decision theory, or statistical approaches and algorithms; and 3) studies that emphasize teaching specific skills, such as the seven step nurse-midwifery management process. The major proponents of the use of a problem-based approach to teaching medicine are Barrows and 263

Tamblyn,3s who believe that it is appropriate for teaching content as well as skills, because it allows information, concepts, and skills to be put into memory in association with a problem. Then, information can be recalled more easily when the student or practitioner faces another problem for which the information is relevant. In this approach, basic science information (such as reproductive anatomy or physiology) is taught through clinical problems, cases studies, or situations. While extensive literature exists, no specific research studies examining this approach were found. Numerous investigators in medicine and nursing have attempted to derive and evaluate both general and specific strategies for teaching clinical decision-making.4p24*3-37 Although there are numerous anecdotal descriptions of successful approaches to teaching clinical judgment in nursing, only a few studies were identified that included systematic evaluation of such strategies 25.38-41 AspinaP used the perspective of utility theory and tested the effectiveness of using decision trees to improve nursing diagnostic accuracy. Significant differences were found between nurses provided with decision trees and a control group. Hambdi and Hutelmyefl examined the effectiveness of using a structured assessment guide in improving the ability of nurses to identify pertinent problems. While there were no significant differences between experimental and control groups on the number of problems identified, the experimental group was able to provide a greater number of reasons for selecting problems. According to Tanner,7 the only conclusion possible from these two investigations is that when these nurses were told what to look for and how to interpret the data, they were able to make relevant observations and interpretations. Two additional nursing studies examined the effectiveness of theoreti264

tally based teaching methods on improving clinical judgment in undergraduate nursing students. Both the teaching methods used and the outcomes measured were quite diverse. DeTornyay3g designed an experimental teaching strategy to assist students in the discovery of concepts and principles, with performance measured through a written simulation. No significant main effects were found for the experimental teaching strategy. Tanner25 designed an experimental teaching method that differed from the traditional approach in two respects: first, the content was organized in a way thought to facilitate activation of diagnostic hypotheses, which was presumed to be a critical activity in clinical decisionmaking; and second, practice was provided in generating and testing hypotheses through written exercises. Scores on diagnostic ability were derived from verbal reports to five videotaped simulations. No significant main effects were found to be due to the experimental treatment. As previously stated, it is difficult to draw conclusions about the effectiveness or ineffectiveness of either specific or general instructional interventions for increasing clinical judgment. Numerous methodological problems exist, primarily small sample sizes, short interventions, and the scarcity of valid measures of clinical judgment. Although the use of small convenience samples drawn from a few institutions may be appropriate for exploratory research, generaliiations made to populations are inappropriate. Intervention problems arise because the treatment probably must be lengthy in order to modify performance in such a complex area as clinical judgment. Measurement problems are primarily related to the heavy reliance of investigators on written simulation as a means of assessing performance in clinical judgment. Unfortunately, the tasks in written simulations may not be representative of actual clinical judgment tasks, and the responses Journal of Nurse-Midwifery

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elicited may not be like those that would occur in actual practice. Much research has been reported on the subject of the measurement of clinical problem-solving; reviews by other authors provide more detailed information on this complex topic. 7,19,42-45 Although the results of these studies on teaching methods are discouraging, it is premature to abandon hope that effective approaches to teaching clinical judgment can be discovered. Further study is needed in appropriate teaching strategies, including the value of instruction for clinicians in formal decision theory, the value of strategies such as hypothesis generation and testing, and how to facilitate students’ learning to attend to important aspects or cues. RECOMMENDATIONS FOR NURSE-MIDWIFERY EDUCATION & EVALUATION

In the process of becoming a nursemidwife, the learner must gain competence in several important areas, which may be considered facets of clinical judgment. First, the beginner must learn what the salient problems are in nurse-midwifery (e.g., common discomforts of pregnancy, anemia, postpartum hemorrhage, vaginitis, etc.), and then the relevant dimensions (signs and symptoms) on which these problems are evaluated. Then the student must learn specific data collection techniques, the relative importance of the various dimensions, and the appropriate rules for identifying the problem or problems (differential diagnosis). The new nurse-midwife must also learn the relevant categories of intervention (e.g., pharmacological, nonpharmacological, teaching, counseling), and the appropriate modalities for specific problems. Add to these facets the context in which problem-solving occurs, including the characteristics of the problemsolvers (client and care provider), their values, cultural differences, ed33, No. 6, November/December

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ucational backgrounds, financial and social supports and the environmental/political climate in which care occurs, and the resultant system becomes very complex. The clinician’s task is to develop the acumen to combine these facets in order to make optimal decisions; it is clear that good clinical judgment requires an integration of both a sound, foundational knowledge base in nursemidwifery and decision-making skills. Substantial learning is certainly required in all of these areas, and such learning does not occur overnight. One issue regarding clinical judgment that usually arises early in the nurse-midwifery student’s career is the need to develop an increasing tolerance for uncertainty. In the health care field there is frequently no definitive solution; no one right answer; and often, no certain result. Indeed, some authors have referred to the “art” of clinical judgment as the blending of a large body of knowledge with the scientific method and a willingness to back hunches or intuition.& The problem for educators is how to encourage students to tolerate uncertainty and to solve heterogeneous problems. In order to learn this process, beginning midwives must be confronted with multiple “possibly right” ways to approach a problem, must be offered numerous opportunities to make their own decisions in a “safe environment,” and must be encouraged to begin to cement such concrete clinical examples to more abstract concepts stored in long-term memory. Problem-based learning offers some avenues for meeting these objectives during the didactic portion of a nurse-midwife’s education; one way is to use written case studies and/or computer-based simulations to guide the student’s reading and self-study, as well as to generate management discussions on specific topics in the classroom. Such simulations seem most valid for teaching purposes, but are also commonly Journal of Nurse-Midwifery

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used for evaluation on the credentialing examinations for health professionals. The modified essay format of the American College of Nurse-Midwives Certification Examination is a type of written simulation exercise. Role-play situations can also be effectively used to teach and evaluate clinical problem-solving, and allow the learner to actively engage in the learning process and begin to associate concrete examples with abstract concepts. Simulated patients (people who are given a script to follow so that appropriate history can be gathered and assessment techniques evaluated) are used extensively in medicine and could be applied to midwifery education as well. Use of multiple classroom and clinical instructors, and management discussions led by teams of experienced nurse-midwives also allow students to hear multiple perspectives and be exposed to more clinical examples. Another way of approaching this issue is to categorize the types of problems that a nurse-midwife might face, and then examine ways students might learn to solve such problematic situations. Getzels47 has suggested a way of categorizing social science problems that may be adapted to nurse-midwifery, and Shanteau and Phelps* have discussed mechanisms by which students learn to make expert judgments, including through feedback, by rules or algorithms, and through role-modeling by an expert. Three main types of nurse-midwifery instructional problems will be discussed, and specific suggestions will be offered. First, there are problems in which both the problem and the appropriate solution are known to the problem-solver. Such problems may be considered “pattern recognition tasks,” where there is a fairly standard solution that can be met with the use of a rule or management protocol. One example is monilia vaginitis. Analogies can be used to aid the process of pattern recogni-

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tion: “the discharge sometimes smells like yeast, or baking bread.” Research on the use of analogies, metaphors, and mnemonics supports their general usefulness in increasing retention. Students can memorize signs and symptoms, apply appropriate learned skills, and follow a management protocol. Feedback can be given at the time by the instructor, and students can make a straightforward decision, and observe what happens. Feedback from good and bad decisions eventually leads to better outcomes through some trial and error, but the problems are generally readily solved and learning takes place quickly. Evaluation of student progress on this type of problem can utilize any format, including well-constructed multiple choice questions, written simulations, and directly observed clinical encounters. A second, and larger class of problems are those in which the solution is clear once the problem is identified. Many nurse-midwifery problems would fall into this category, and are frequently defined in written standards and protocols (e.g., anemia in pregnancy, urinary tract infection, etc.) Feedback is again important in this type of problemsolving, as is the use of logical strategies, rules, and algorithms. Whereas exhaustive data collection before hypothesis generation is probably important only for the beginner, strategies such as the seven step nursenurse-midwifery management process are often helpful for both beginners and novices. Such teaching aids serve to organize thought processes, focus data collection, and aid development of a comprehensive management plan; they also provide a rule to follow in each clinical situation. However, such heuristics should closely approximate the ways in which clinical decision-making and management occur in the real world (e.g., collect some data, hypothesize, collect some more data, confirm or reject, develop new hypothesis, collect more data, etc.). 265

Such use of the heuristic also fosters efficient management early in the nurse-midwife’s career, so that the student would be less likely to spend two and one-half hours conducting a new prenatal visit if she or he were less concerned about collecting an absolutely perfect, complete data base. For many years, it has not been thought legitimate to admit that we really don’t need to collect a “complete data base” before proceeding to problem identification; educators need to move beyond this traditional, ritualistic approach. Certainly, the question of premature closure (a belief that the hypothesis has been confirmed before the true problem is identified) remains. Nonetheless, students should be questioned about data collection, and asked to justify strategies and interpret the uses of the data. For example, “Why do you want to ask about that? How will it change your thinking? Why do you need to obtain that laboratory specimen? What will the result tell you? Will it change your management either way?’ are questions that would provide opportunities for the evaluation of clinical judgment and decision-making in the clinical area. This process can also effectively involve the client in the diagnostic decisionmaking process if done during the visit, or clinical encounters can be tape-recorded and reviewed at a later time without the client present. Because this type of problem only differs from the first type in the diagnosis stage, appropriate management strategies can be applied and evaluated using methods noted in the previous section. The preceding two types of nursemidwifery problems are relatively easy to learn about, teach, and evaluate, primarily because memorized facts, processes such as hypothesis activation and testing, and management protocols can be used to good advantage. Another type of problem may present more difficult instructional dilemmas. This type includes situations where the diagnoses are 266

known but there is no readily agreed-upon solution, such as management of rupture of membranes before labor, history of herpes in pregnancy, when to use episiotomy, or management of prolonged second stage. Alternate strategies each have their associated risks and benefits, or the client may have multiple problems for which the management strategies are incompatible. Additionally, midwives, physician colleagues and clients may attach different values to various solution alternatives. These problems are well suited to instructional strategies that allow beginners to actively make decisions with feedback and support within a safe preclinical environment, using case discussion, written patient management problems, computer simulations, and role-plays. Structured decision analysis, utility analysis, and other rational approaches may also be taught. Guided design and structured concept attainment strategies may help the student identify salient data, categorize such data, become familiar with examples, and apply decision rules if available. This author has developed a self-study module for teaching episiotomy decision-making that guides the nursemidwifery student through positive and negative examples (written clinical scenarios) in which salient cues are organized into four main categories (maternal factors, fetal factors, client preferences, and practitioner preferences) that may influence nurse-midwifery decision-making about episiotomy. The student is then pushed to recognize, classify, and distinguish relevant and irrelevant cues, and apply the decision algorithm in simulated exercises. Development of such instructional packages is time-consuming, but difficult concepts may be learned more effectively using such a method. Once in the actual clinical situation, students must be allowed to “think-aloud” their managment strategies, and to have the opportunity to listen to an expert do the same. In many cases, these situaJournal of Nurse-Midwifery

tions involve consultations between physicians and midwives, and beginners must be able to “see” the judgment processes the experts used. It is helpful to role-model “thinking aloud’ to identify and display important aspects of the problem-solving situation for the beginner. The expert must identify the salient cues for the student, and attempt to make visible what seems to be an almost magical or mystical intuitive process. We must learn to take a step back and recognize our extensive nurse-midwifery knowledge base and make explicit our skilled judgments within our areas of expertise. One problem with this suggestion is that it often seems difficult and unnatural for the teacher, who is usually an expert clinician and is focusing on the gestalt of the problem rather than the specifics. A situation that may be complicated and difficult for the beginner may be a simple pattern recognition task for the expert, and not easily accessible to conscious “thinking aloud.” An appropriate analogy used by some authors is that of driving a car; most of us do not consciously think about what we are doing with our feet, hands, and eyes as we drive down the road. The rules and skills of driving have become habitual, and are not easily accessible to the expert driver. This is also true about many of the rules, skills, strategies, and decisions that are used by nurse-midwives in clinical management situations. Evaluation of this type of clinical problem is also difficult. Many experts in medical education and evaluation have struggled to derive valid measures of clinical problem-solving. For educational purposes, written or computerized simulations that use either open-ended or branching multiple choice responses seem most satisfactory. However, these types of instruments are very difficult and time-consuming to construct, and the lack of a “true right answer” makes scoring complex and difficult. Direct observation and evaluation of

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“think aloud” processes are also often used. Because most of the solutions to this type of problem are extremely context-dependent (on the location of the practice/birth site, on the nurse-midwife, on the client, and on the consulting physician), performance seems to be appropriately evaluated through direct observation, on a highly individualized basis within the clinical setting. These types of problems are rarely found on examinations, particularly licensure and certification tests, because the solutions are so difficult to key and validate. CONCLUSIONS

A wide range of theoretical perspectives have been used as the basis for relatively few studies on clinical judgment, and even fewer studies on the applicability of different instructional strategies to teach or improve decision-making. Additionally, there are a number of methodological and conceptual problems in the research. The most common methodological problems are in the areas of measurement and sampling, and there are numerous studies on clinical decision-making not mentioned in this paper that are atheoretical or conceptually weak. Consequently, in over 20 years of research, no single theory has been investigated sufficiently to conclude that the theory can be supported or refuted, or that it is in need of revision. Additionally, some authors are suggesting that there may not be a single underlying process for clinical decision-making, and no method to teach or measure a single process. Therefore, the goal of describing the processes of clinical judgment as a prerequisite to the development of instructional strategies has not yet been achieved. Despite these problems, some instructional strategies and methods of evaluation have been studied or recommended. The problem of which instructional strategy or mode of evaluation to use in a given clinical judgment situation seems to fall into Journal of Nurse-Midwifery

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Getzels’ third category: a problem for which there is no agreed-upon method of solution. The best advice that can be offered to the educator may be to develop a large repertoire of strategies and heuristics, and to use “good judgment.” REFERENCES

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33, No. 6, November/December 1988