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Decision-making in clinical practice: how do expert nurses, midwives and health visitors make decisions?
Nurse Edwalron Todq (1993) 13, 27W27fi 0 Longman GroupUK Ltd 1993
Decision-making in clinical practice: how do expert nurses, midwives and health visitors make decisions? Laila Orme and Christopher Maggs
Decision-making is an essential and integral aspect of clinical practice. Preparation for clinical decision-making is haphazard and unplanned, in part because the process of making clinical decisions is not fully understood. This is one study of how expert nurses, midwives and health visitors make clinical decisions. The project involved a literature review and a series of workshops with expert practitioners to uncover the decision-making process in clinical practice. The study found that decision-making is an essential attribute of the expert practitioner, must be based on sound knowledge, may involve risk-taking and can only flourish in a supportive environment. Most importantly, clinical decision-making must take place within the context of a philosophy of care. Without such a philosophy, decisions will be arbitrary, uninformed and probably unsafe.
Professional
INTRODUCTION
others,
In 1989, the English National Board for Nursing, Midwifery and Health Visiting (the Board) instigated a review of the organisation and provision of continuing professional education for nurses, midwives and health visitors (CPE). Part of that review involved a small scale research project to better understand how expert and experienced nurses, midwives and health visitors made clinical decisions. The outcomes of the research project were used to inform the Board’s
Framework
for Continuing
Laila Orme SRN RNT and Christopher Maggs PhD MA BA(Hons) SRN, Research Officer and Project Director, English National Board for Nursing, Midwifery and Health Visiting, UK (Requysts for offprints to LO) Manuscript accepted 9 March 1993
270
Education.
Benner
has drawn attention
(1984)
among
to the processes
by
which nurses make clinical decisions, emphasising the importance
of expertise
within as well as
between levels of clinical practice, novice to expert.
ranging from
Developments in service delivery, including quality assurance, clinical directorates and the reforms of the Health Service at provider unit level, demand that practitioners are more able to demonstrate accountability and better prepared for complex decision-making in the processes of care
delivery
resources.
and
the
allocation
of
If we are to devise continuing
clinical edu-
cation programmes and strategies to meet these challenges, we need to be better informed about the decision-making process. At the conceptual level, we need to explain these processes, including what intuition.
we
may
mean
by
expertise
and
NURSE EDUCATION
A group of practitioners, regarded by their peers and managers as experts and experienced in their clinical areas, came together to explore these issues and to reach some general and specific conclusions about decision-making in clinical practice.
BACKGROUND Nursing, midwifery and health visiting lay claim to a professional ideology. Models of practice are essentially decision-making models and are thus synonymous with accepted definitions of professional activity (Rhodes 1985). Jenkins (1985) states that clinical decisions come about as a result of a unique process which begins with a problem or state of discrepancy requiring resolution. Other authors differentiate between problem-solving - ‘the search for a correct solution to a problem’ - and decision-making ‘situations in which a choice is made among a number of possible alternatives, often involving trade-off among the values given to different outcomes’ (Baumann & Dauber 1989, p 69). The latter definition is taken, for the purposes of this study, as being more useful in understanding nursing practice. (For the sake of brevity, nurse and nursing include midwife and midwifery, health visitor and health visiting.) Much of the literature about decision-making in clinical practice comes from experiences in North America. Decision-making is regarded as an essential component of the nursing role (Joseph et al 1984; Jenkins 1985; Rhodes 1985). According to Itano (1989), experienced nurses are better able to pick up more cues on which to base decisions than inexperienced nurses. There is general agreement that the quality of the decision made will be enhanced by appropriate and relevant experience (Benner 1984). There is also a consensus that a broad knowledge base must underpin effective decision-making. Sims & Fought (1989) have, for example, noted discrepancies between nursing practice and knowledge and nursing interventions. Attempts by practitioners to uncover and
TODAY
27 1
understand the decision-making process can itself affect proficiency in decision-making. Henry et al (1989) argue that verbalisation of the cognitive processes of decision-making does not significantly affect proficiency or efficiency scores. Benner (1984) and Dreyfus & Dreyfus (1986) have suggested that the expert’s skill level might actually fall if asked to verbalise whilst performing the skill. On the other hand, Corcoran & Narayan (1988) argue that thinking aloud is a useful strategy to improve clinical decisionmaking, a view shared by Temple (1991) in a study of reflection and the charge nurse. A number of factors have been identified as contributing to the development of skilled decision-making, including the quality of the environment in which practice takes place. Joseph et al (1988) suggest that collaborative relationships and attitudes towards decisionmaking are important factors contributing to the development of the skill in USA staff nurses. Whilst Joseph et al (1988) argue that the decision-making process is the same no matter where the clinician is working, Prescott, Dennis & Jacox (1987) argue that nurses working in specialised and critical care units indicated more satisfaction with their decision-making than those in other clinical areas. The respondents in that study suggested that improved doctor/nurse relationships in specialist and critical care areas meant the nurses felt they had more freedom to make decisions and thus derived more satisfaction from those decisions. Risk-taking is a feature of the decision-making process highlighted in a number of studies. Joseph et al (1988) observed that nurses are ‘comfortable’ with being accountable for the decisions they make provided they are supported by ‘reasonable’ policies which allow for flexibility and encourage safe practice and provided they have received appropriate education to enable them to make decisions and to take risks. In acknowledging the risks involved, in some decisions, authors such as Arostar (1986) argue for a link between ethical and clinical aspects of decision-making. Arostar (1986) suggests that ethical reasoning requires time and space for reflection with others, in which perspectives may
272
NURSE EDIKATION
TODAY
be shared, validated and questioned leading to ethically sensitive decisions. Such an approach might rule out the selection of the most comfortable decision by clinical practitioners. Whilst a number of studies have attempted to determine objective criteria for decision-making (see, for example, Aspinall 1975), other authors argue for a more complex and comprehensive approach. Pyles & Stern (1983) constructed a ‘nursing gestalt’ to explain the cognitive processes of experienced critical care nurses. The nursing gestalt was described as a matrix, in which nurses were able to link past experiences, identified cues presented by patients and sensory clues - including what nurses described as ‘gut feelings’ - to make decisions. Such an approach, taking in the ‘whole picture’, bringing in patient experiences as well as the practitioner’s, is reiterated in Benner’s work where the expert demonstrates the ability to immediately access the total situation (Benner 1984). This process has been described as ‘intuitive’ or based on intuition. Rew (1988) gives three defining characteristics of intuition: intuition means knowing a fact or truth as a whole; having immediate possession of that knowledge; and having knowledge which is independent of linear reasoning process. Johnson (1980) questions the value of intuition in nursing decisionmaking and argues that nursing assessments should be neither haphazard nor intuitive. On the other hand, Rew (1988) argues that intuition is an essential cognitive skill to be developed in nurses. Intuition as a part of decision-making, it is claimed, should be valued, listened to and developed as a skill in others (Schrader & Fischer 1986). Young (1987) found that, whilst nurses may experience difficulty in finding adequate language to describe their intuitive experiences, intuition is accepted by practitioners for its contribution to decision-making. Practitioners suggest that intuition pervades the judgement process in a variety of clinical activities and settings. The literature reveals a close relationship between experience and intuition. Young (1987) claims that intuition is grounded in both knowledge and experience and is used in making
nursing judgements. Benner & Wrubal (1982) argue that, in contrast to theoretical knowledge, skilled knowledge relies on the development of perceptual awareness which singles out relevant from irrelevant information and which grasps the whole situation rather than distinguishing a series of sub-tasks. Despite general agreement about the need to develop skills in decision-making, attempts to transfer experiences in other disciplines to decision-making in nursing have been questioned by Baumann & Deber (1989). They suggest that decision analysis, for example, too closely mirrors a medical and scientific model, whereas nursing tends towards a process orientated approach to care. On the other hand, decision analysis, according to Webzell (1986), may be more relevant to improving workforce and resource allocation and may have an important part to play in enhancing the nurse’s management role. In recognising that decision-making is an accepted and important component of professional deveiopment, it is the case that developing clinical decision-making skills in others requires support and mentorship (Pyles & Stern 1983). On the other hand, even where knowledge of the decision-making process has been learned, a number of authors have found that the skills are not necessarily implemented in the clinical setting. Consequently, Lane et al (1983), for example, have produced a series of flow charts to aid decision analysis. More recently, computer based learning programmes have been devised to help practitioners through the stages of decision-making (Hirsch & Chang 1989).
PROCESS OF DISCOVERY A small group of 12 expert clinicians were brought together over a weekend to look at the decision-making process. The practitioners reflected the professional spectrum and were drawn from a wide geographical spread. Members of the group work in the National Health Service, in hospitals, the community and in the private health care sectors. All had been
NURSE EDUCATION
registered
for approximately
undertaken
varying
professional
education.
The
specific clinical decisions, processes common
5 years and had
levels of post-registration group
explored
sought to identify
at work and tried
the
to illuminate
the
and specific factors which make up the
decision-making The workshop
processes. included
group discussion
and
debate, and small group working and plenary sessions to explore and integrate findings. The analysis
and interpretation
researchers literature
were made
and set in the context
by the
of a critical
Fig 1 Factors enhancing the decision-making
Participants
said that effective
decision-making
is an integral part of the clinical role of the practitioner - ‘We are doing it all the time’. They
Process
support
Philosophy of nursinglmidwifery
Patient/client safety
Opportunity reflect
Resolution of ethical dilemmas
Involves professional judgement
Critical evaluation
Awareness of accountability
Requires in-depth professional knowledge
Supportive environment
Understanding of others’ roles
Confidence arising from reflective practice
Peer Group discussion
Good decisionmaking understood
Ability to resolve conflicts
Code of professional conduct
Identify potential to become an effective decision-maker
Acknowledgement of intuition as pat-t of the process
Permission to take risks
admitted that risk taking is often involved but acknowledged their professional accountability
likely to occur
within
the outcome
the parameters
Professional
Conduct
of the UKCC (UKCC
1984,
Code
of
1991).
following
The environment place affects Supportive
the clinical specialty but this was found not to be
encouragement,
so. Whilst the process of making
development
was
rapid decisions
was not thought
It had been expected, given the composition of the group, that the process would vary with a decision
the
within which practice
permission
to
of practitioner’s
take
risks,
confidence,
peers
involved
in the
willing
process and opportunity
for reflection
positive making.
to
deci-
sion-making
is a clearly
care
which
within
defined
practice
philosophy
takes
place.
of The
philosophy should take account of ethical, moral, legal and resource issues which the practitioner is likely to meet. More significance was credited to having an explicit philosophy in ‘crisis’ or life-threatening sions, of necessity, aneously.
situations
where deci-
must be made almost instant-
to discuss
or become
contribution
During
effective
the decision-making
stage, expert distinguish
takes
of decision-making. positive management, peer
even
to effective
and if
quality
the decision
within the same clinical area. A major factor contributing
to
to be ‘favourable’.
said to be similar in all settings, the pace at which had to be made was variable,
process
Preparation
review.
KEY FINDINGS
273
TODAY
and experienced
all make a decision-
data collection nurses are able to
relevant cues. Previous experience
of
similar situations is valuable but this does not override the need for flexibility and the ability to recognise different
that each new situation may require a decision. Factors which enhance the
decision-making 1.
process are illustrated
in Figure
Expert decision-making is dependent on an in-depth knowledge and experience of research and care provision for the group of patients/
The group discussed ‘expert decision-maker’
clients with whom the practitioner Whilst reflecting on decision-making
quently taken into account. The group endorsed the importance of intuition - both of the nurse and of the patient-when collecting information
is working. may be an
essential part of the process, in practice it is frequently the outcome rather than the process which is reflected on and evaluated. This is more
needing
information,
prior to reaching conclusion,
the characteristics of an (Fig. 2). In addition to ‘gut feelings’
a decision.
were
In coming
the group attempted
fre-
to this
to define what
274
NURSE EDUCATION
TODAY
deepen
Fig 2 Characteristics of the expert decision-maker Appreciative process
of the complexity
in the decision-making
the knowledge
base in order to support
these feelings and to link intuition
to an analysis
and synthesis of information. All decisions,
Able to resolve dilemmas Aware of when to seek help
safety
of
Able to make decisions at the right time
Tensions
the
it was argued,
are taken with the
patient/client
and conflicts
as
process may arise, in particular
Confident in decision-making
osophy of the practitioner
Uses breadth and depth of knowledge to identify relevant cues
titioner’s
where the phil-
differs
the patient/client or relatives. policies sometimes conflict
Cognizant of the normal situation
paramount.
in the decision-making from that of
Local employers’ with the prac-
chosen course of action.
Making
deci-
Owns the risks involved
sions can lead to a sense of satisfaction
Paces the decision accurately, whilst recognising that some decisions may be taken more slowly allowing time for reflection
based on a ‘feeling’ of having made the ‘right’ decision, irrespective of outcome in terms of
Incorporates ethical and moral issues sensitively
action. The
Demonstrates knowledge of resources and applies weight to demand for appropriate additional resources Flexible in all situations acknowledging may require individual approaches
that decisions
expert
group
identified
which is
a number
in the decision-making
extent
that they were able to devise a map or
pathway of exploration ing. However,
process,
of
stages
to the
in clinical decision-mak-
in urgent
or emergency
situa-
tions, these stages may not be immediately recognised. In such circumstances, reflection on
Resolves the tension between the care they wish to deliver and local policies and practices
the decision-making
process
and the decision
takes place later. Allowing for these particulars, was
meant
members’
by
intuition.
understanding,
According intuition
a state of heightened
to
the
is:
perceptual
awareness
which emanates from sub-conscious thought. It influences behaviour and therefore influences the decision-making
process.
The group argued that it is impossible
to analyse
or quantify what the intuitive decision or process might be because to do so would make intuitive behaviour longer
conscious
intuitive.
thought
However,
and therefore
before
intuition
practice,
7 broad stages in decision-making
nurses are sometimes criticised for voicing gut feelings. The potential for intuition may sometimes be stifled but students and newly qualified practitioners
must be positively
verbalise these intuitive feelings,
encouraged to broaden
to and
were
Figure 3 lists those stages.
Fig 3 Stages in decision-making provides the framework decisions can be made
within which
Stage 2
Determine whether the decision is necessary and can I (as opposed to someone else) make it?
Stage 3
Assess the whole situation
Stage 4
Explore and examine all possible courses of action, including client and practitioner intuitive feelings, ethical, moral and legal issues, available resources, knowledge and research findings, conflicts of interest, code of professional conduct, views of nursing and multi-disciplinary teams and past experience of similar situations
Stage 5
Select course of action and inform ‘concerned others’ of the rationale behind the decision
Stage 6
Implement action and monitor implementation
Stage 7
Reflect on both the outcome and the decision-making process
others. There was strong support for the view that the potential to become a ‘good decisionand junior
areas of clinical
Stage 1 Establish a philosophy of care which
of information.
Student
many specialist
agreed as common.
Practitioners, the group contended, do recognise ‘good decision-making’ in themselves and in
maker’ is also recognisable.
the group was made up of prac-
from
no can
be of value, there must be a pre-existing knowledge base which fosters the appropriate and relevant interpretation
and although titioners
NURSE EDUCATION
CONCLUDING REMARKS: IMPLICATIONS FOR CONTINUING PROFESSIONAL EDUCATION Decision-making is an essential and integral aspect of clinical practice. Preparation for clinical decision-making, in particular as an expert practitioner, is haphazard and unplanned. However, understanding how expert and experienced clinicians actually make decisions can inform the provision of professional development for registration and beyond. A number of supporting factors are essential for effective decision-making at expert level. In particular, there must be a sound and developed knowledge base, informed by evaluated research. The environment within which expert practitioners work can enhance or detract from the decision-making process. This implies a managerial and a professional commitment to developing the decision-making role and creating an environment which facilitates risk-taking within clear safety and professional boundaries. Peer support and approval is vital to the creation of such a supportive environment. Practitioners need to reflect not only on specific decisions but on the process by which decisions are made. To do so requires effective mentorship (a term not associated here with its use by the Board in pre- and post-registration education) by other practitioners as well as some mechanism - such as critical incident review or personal portfolio which enables such reflection to take place. Central to the whole process and to safeguarding the rights of clients and patients is the development and application of a philosophy of care. Without such a philosophy, decisions will be arbitrary, uninformed and perhaps unsafe. This paper has identified notjust a perspective on clinical decision-making derived from an English perspective and in comparison with the literature, for example of Benner (1989). The paper and the research which it records also argues for a particular research methodology. The paper records the success in using an expert group - outwith the conventional delphimethod - for establishing the principles of a
TODAY
275
philosophy of care underpinning what is expected of expert practice in nursing and midwifery. The research method - essentially but not exclusively expert group focused - permits a critique of the critical incident methodology for identifying the components of ‘best practice’ which leads into a critique of effective clinical decision-making. Given the resources tied in with and dependent upon effective clinical decision-making, any discussion which is derived from empirical analysis and which furthers nurses’ understanding of the phenomena of decision-making is to be welcomed and replicated.
References Aroskar M A 1986 Using ethical reasoningto guide clinical decision-making.PerioperativeNursing Quarterly (2): 20-26 AspinalM 1 1978 Nursingdiagnosis- The weak link.
Nursing-Outlook 24 (7): 433-437 Baumann A, Deber R 1989 Decision-making and problem-solving in nursing- An overvie; and analysis of relevant literature. Literature Review Monograph, University of Toronto, Toronto Baumann A, Deber R 1989 The limits of decision analysis for rapid decision-making in ICU nursing. Image Journal of Nursing Scholarship 2 I (2): 69-7 1 Benner P, Wrubal J 1982 Skilled clinical knowledge: The value of perceptual awareness. Nurse Educator May-June: 11-17 Benner P 1984 From Novice to Expert. Addison Wesley, London Corcoran R N, Narayan H 1988 Care Evaluation: ‘Thinking Aloud as a strategy to improve clinical decision-making. Heart & Lung: The Journal of Critical Care 15: 56-62 Dreyfus H L, Dreyfus S E 1988 Mind over machine: the power of human intuition and expertise in the era of the computer. New York Free Press, New York Fowler M D M 1989 Ethical decision-making in clinical practice. Nursing Clinics of North America 24 (4): 955-965 Henry S B, LeBreck, D B Holzener W L 1989 The effect of verbalization of cognitive processes on clinical decision-making. Research in Nursing & Health 12 (3): 187-193 Hirsch M, Chang B L 1989 A computer programme to support patient assessment and clinical decisionmaking in nursing education. Computers in Nursing 15’7-160 Itano J K 1989 A comparison of the clinical judgement process in experienced registered nurses and student nurses. Journal of Nursing Education 28 (3): 120-128 Jenkins H M 1965 Improving clinical decision-making in nursing. Journal of Nursing Education. 24 (6). Johnson D 1980 The behavioural system model for nursing. In: Riehl J P, Roy C eds. Conceptual models for nursing practice. Appleton Century Crofts, New York
276
NIJRSEEDUCATIONTODAY
Joseph S H, Maltronne J, Osborne E 1988 Actual decision-making factors that determine practices in clinical settings. Canadian Journal of Nursing Research 20 (2): 19-30 Lane G H, Cronin K M, Pierce A G 1983 FLOW charts Clinical decision-making in nursing. Lipincott, Philadelphia Prescott P A, Dennis K E, Jacox A K 1987 Clinical decision-making of staff nurses. Image: The Journal of Nursing Scholarship 19 (2): 56-62 Pyles S H, Stern P N 1983 Discovery of nursing gestalt in critical care nursing: The importance of the gray gorilla syndrome. Image: TheJournal of Nursing Scholarship XV (2): 5 l-57 Rew L 1986 Intuition: Concept analysis of a group phenomenon. Advances in Nursing Science 8 (2): 21-28 Rhodes B A 1985 Occupational ideology and clinical
decision-making in British nursing. International Journal of Nursing Studies 22 (3): 241-247 Schraeder B D, Fischer D K 1988 Using intuitive knowledge to make clinical decisions. American Journal of Maternal/Child Nursing 11 (3): 161-163 Sims K A, Fought S G 1989 Clinical decision-making in critical care. Critical Care Nursing Quarterly 12 (3): 79-83 Temple A 1991 Reflection and the charge nurse. Nursing Standard 5 (26): 32-34 United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC) 1984 Code of professional conduct for nurses, midwives and health visitors. UKCC, London Webzell B 1986 Taking decisions. Senior Nurse 4 (2): 26-27 Young C E 1987 Intuition and the nursing process. Holistic Nursing Practice 3: 52-62.
Decision-making in clinical practice: how do expert nurses, midwives and health visitors make decisions? Laila Orme and Christopher Maggs
Decision-making is an essential and integral aspect of clinical practice. Preparation for clinical decision-making is haphazard and unplanned, in part because the process of making clinical decisions is not fully understood. This is one study of how expert nurses, midwives and health visitors make clinical decisions. The project involved a literature review and a series of workshops with expert practitioners to uncover the decision-making process in clinical practice. The study found that decision-making is an essential attribute of the expert practitioner, must be based on sound knowledge, may involve risk-taking and can only flourish in a supportive environment. Most importantly, clinical decision-making must take place within the context of a philosophy of care. Without such a philosophy, decisions will be arbitrary, uninformed and probably unsafe.
Professional
INTRODUCTION
others,
In 1989, the English National Board for Nursing, Midwifery and Health Visiting (the Board) instigated a review of the organisation and provision of continuing professional education for nurses, midwives and health visitors (CPE). Part of that review involved a small scale research project to better understand how expert and experienced nurses, midwives and health visitors made clinical decisions. The outcomes of the research project were used to inform the Board’s
Framework
for Continuing
Laila Orme SRN RNT and Christopher Maggs PhD MA BA(Hons) SRN, Research Officer and Project Director, English National Board for Nursing, Midwifery and Health Visiting, UK (Requysts for offprints to LO) Manuscript accepted 9 March 1993
270
Education.
Benner
has drawn attention
(1984)
among
to the processes
by
which nurses make clinical decisions, emphasising the importance
of expertise
within as well as
between levels of clinical practice, novice to expert.
ranging from
Developments in service delivery, including quality assurance, clinical directorates and the reforms of the Health Service at provider unit level, demand that practitioners are more able to demonstrate accountability and better prepared for complex decision-making in the processes of care
delivery
resources.
and
the
allocation
of
If we are to devise continuing
clinical edu-
cation programmes and strategies to meet these challenges, we need to be better informed about the decision-making process. At the conceptual level, we need to explain these processes, including what intuition.
we
may
mean
by
expertise
and
NURSE EDUCATION
A group of practitioners, regarded by their peers and managers as experts and experienced in their clinical areas, came together to explore these issues and to reach some general and specific conclusions about decision-making in clinical practice.
BACKGROUND Nursing, midwifery and health visiting lay claim to a professional ideology. Models of practice are essentially decision-making models and are thus synonymous with accepted definitions of professional activity (Rhodes 1985). Jenkins (1985) states that clinical decisions come about as a result of a unique process which begins with a problem or state of discrepancy requiring resolution. Other authors differentiate between problem-solving - ‘the search for a correct solution to a problem’ - and decision-making ‘situations in which a choice is made among a number of possible alternatives, often involving trade-off among the values given to different outcomes’ (Baumann & Dauber 1989, p 69). The latter definition is taken, for the purposes of this study, as being more useful in understanding nursing practice. (For the sake of brevity, nurse and nursing include midwife and midwifery, health visitor and health visiting.) Much of the literature about decision-making in clinical practice comes from experiences in North America. Decision-making is regarded as an essential component of the nursing role (Joseph et al 1984; Jenkins 1985; Rhodes 1985). According to Itano (1989), experienced nurses are better able to pick up more cues on which to base decisions than inexperienced nurses. There is general agreement that the quality of the decision made will be enhanced by appropriate and relevant experience (Benner 1984). There is also a consensus that a broad knowledge base must underpin effective decision-making. Sims & Fought (1989) have, for example, noted discrepancies between nursing practice and knowledge and nursing interventions. Attempts by practitioners to uncover and
TODAY
27 1
understand the decision-making process can itself affect proficiency in decision-making. Henry et al (1989) argue that verbalisation of the cognitive processes of decision-making does not significantly affect proficiency or efficiency scores. Benner (1984) and Dreyfus & Dreyfus (1986) have suggested that the expert’s skill level might actually fall if asked to verbalise whilst performing the skill. On the other hand, Corcoran & Narayan (1988) argue that thinking aloud is a useful strategy to improve clinical decisionmaking, a view shared by Temple (1991) in a study of reflection and the charge nurse. A number of factors have been identified as contributing to the development of skilled decision-making, including the quality of the environment in which practice takes place. Joseph et al (1988) suggest that collaborative relationships and attitudes towards decisionmaking are important factors contributing to the development of the skill in USA staff nurses. Whilst Joseph et al (1988) argue that the decision-making process is the same no matter where the clinician is working, Prescott, Dennis & Jacox (1987) argue that nurses working in specialised and critical care units indicated more satisfaction with their decision-making than those in other clinical areas. The respondents in that study suggested that improved doctor/nurse relationships in specialist and critical care areas meant the nurses felt they had more freedom to make decisions and thus derived more satisfaction from those decisions. Risk-taking is a feature of the decision-making process highlighted in a number of studies. Joseph et al (1988) observed that nurses are ‘comfortable’ with being accountable for the decisions they make provided they are supported by ‘reasonable’ policies which allow for flexibility and encourage safe practice and provided they have received appropriate education to enable them to make decisions and to take risks. In acknowledging the risks involved, in some decisions, authors such as Arostar (1986) argue for a link between ethical and clinical aspects of decision-making. Arostar (1986) suggests that ethical reasoning requires time and space for reflection with others, in which perspectives may
272
NURSE EDIKATION
TODAY
be shared, validated and questioned leading to ethically sensitive decisions. Such an approach might rule out the selection of the most comfortable decision by clinical practitioners. Whilst a number of studies have attempted to determine objective criteria for decision-making (see, for example, Aspinall 1975), other authors argue for a more complex and comprehensive approach. Pyles & Stern (1983) constructed a ‘nursing gestalt’ to explain the cognitive processes of experienced critical care nurses. The nursing gestalt was described as a matrix, in which nurses were able to link past experiences, identified cues presented by patients and sensory clues - including what nurses described as ‘gut feelings’ - to make decisions. Such an approach, taking in the ‘whole picture’, bringing in patient experiences as well as the practitioner’s, is reiterated in Benner’s work where the expert demonstrates the ability to immediately access the total situation (Benner 1984). This process has been described as ‘intuitive’ or based on intuition. Rew (1988) gives three defining characteristics of intuition: intuition means knowing a fact or truth as a whole; having immediate possession of that knowledge; and having knowledge which is independent of linear reasoning process. Johnson (1980) questions the value of intuition in nursing decisionmaking and argues that nursing assessments should be neither haphazard nor intuitive. On the other hand, Rew (1988) argues that intuition is an essential cognitive skill to be developed in nurses. Intuition as a part of decision-making, it is claimed, should be valued, listened to and developed as a skill in others (Schrader & Fischer 1986). Young (1987) found that, whilst nurses may experience difficulty in finding adequate language to describe their intuitive experiences, intuition is accepted by practitioners for its contribution to decision-making. Practitioners suggest that intuition pervades the judgement process in a variety of clinical activities and settings. The literature reveals a close relationship between experience and intuition. Young (1987) claims that intuition is grounded in both knowledge and experience and is used in making
nursing judgements. Benner & Wrubal (1982) argue that, in contrast to theoretical knowledge, skilled knowledge relies on the development of perceptual awareness which singles out relevant from irrelevant information and which grasps the whole situation rather than distinguishing a series of sub-tasks. Despite general agreement about the need to develop skills in decision-making, attempts to transfer experiences in other disciplines to decision-making in nursing have been questioned by Baumann & Deber (1989). They suggest that decision analysis, for example, too closely mirrors a medical and scientific model, whereas nursing tends towards a process orientated approach to care. On the other hand, decision analysis, according to Webzell (1986), may be more relevant to improving workforce and resource allocation and may have an important part to play in enhancing the nurse’s management role. In recognising that decision-making is an accepted and important component of professional deveiopment, it is the case that developing clinical decision-making skills in others requires support and mentorship (Pyles & Stern 1983). On the other hand, even where knowledge of the decision-making process has been learned, a number of authors have found that the skills are not necessarily implemented in the clinical setting. Consequently, Lane et al (1983), for example, have produced a series of flow charts to aid decision analysis. More recently, computer based learning programmes have been devised to help practitioners through the stages of decision-making (Hirsch & Chang 1989).
PROCESS OF DISCOVERY A small group of 12 expert clinicians were brought together over a weekend to look at the decision-making process. The practitioners reflected the professional spectrum and were drawn from a wide geographical spread. Members of the group work in the National Health Service, in hospitals, the community and in the private health care sectors. All had been
NURSE EDUCATION
registered
for approximately
undertaken
varying
professional
education.
The
specific clinical decisions, processes common
5 years and had
levels of post-registration group
explored
sought to identify
at work and tried
the
to illuminate
the
and specific factors which make up the
decision-making The workshop
processes. included
group discussion
and
debate, and small group working and plenary sessions to explore and integrate findings. The analysis
and interpretation
researchers literature
were made
and set in the context
by the
of a critical
Fig 1 Factors enhancing the decision-making
Participants
said that effective
decision-making
is an integral part of the clinical role of the practitioner - ‘We are doing it all the time’. They
Process
support
Philosophy of nursinglmidwifery
Patient/client safety
Opportunity reflect
Resolution of ethical dilemmas
Involves professional judgement
Critical evaluation
Awareness of accountability
Requires in-depth professional knowledge
Supportive environment
Understanding of others’ roles
Confidence arising from reflective practice
Peer Group discussion
Good decisionmaking understood
Ability to resolve conflicts
Code of professional conduct
Identify potential to become an effective decision-maker
Acknowledgement of intuition as pat-t of the process
Permission to take risks
admitted that risk taking is often involved but acknowledged their professional accountability
likely to occur
within
the outcome
the parameters
Professional
Conduct
of the UKCC (UKCC
1984,
Code
of
1991).
following
The environment place affects Supportive
the clinical specialty but this was found not to be
encouragement,
so. Whilst the process of making
development
was
rapid decisions
was not thought
It had been expected, given the composition of the group, that the process would vary with a decision
the
within which practice
permission
to
of practitioner’s
take
risks,
confidence,
peers
involved
in the
willing
process and opportunity
for reflection
positive making.
to
deci-
sion-making
is a clearly
care
which
within
defined
practice
philosophy
takes
place.
of The
philosophy should take account of ethical, moral, legal and resource issues which the practitioner is likely to meet. More significance was credited to having an explicit philosophy in ‘crisis’ or life-threatening sions, of necessity, aneously.
situations
where deci-
must be made almost instant-
to discuss
or become
contribution
During
effective
the decision-making
stage, expert distinguish
takes
of decision-making. positive management, peer
even
to effective
and if
quality
the decision
within the same clinical area. A major factor contributing
to
to be ‘favourable’.
said to be similar in all settings, the pace at which had to be made was variable,
process
Preparation
review.
KEY FINDINGS
273
TODAY
and experienced
all make a decision-
data collection nurses are able to
relevant cues. Previous experience
of
similar situations is valuable but this does not override the need for flexibility and the ability to recognise different
that each new situation may require a decision. Factors which enhance the
decision-making 1.
process are illustrated
in Figure
Expert decision-making is dependent on an in-depth knowledge and experience of research and care provision for the group of patients/
The group discussed ‘expert decision-maker’
clients with whom the practitioner Whilst reflecting on decision-making
quently taken into account. The group endorsed the importance of intuition - both of the nurse and of the patient-when collecting information
is working. may be an
essential part of the process, in practice it is frequently the outcome rather than the process which is reflected on and evaluated. This is more
needing
information,
prior to reaching conclusion,
the characteristics of an (Fig. 2). In addition to ‘gut feelings’
a decision.
were
In coming
the group attempted
fre-
to this
to define what
274
NURSE EDUCATION
TODAY
deepen
Fig 2 Characteristics of the expert decision-maker Appreciative process
of the complexity
in the decision-making
the knowledge
base in order to support
these feelings and to link intuition
to an analysis
and synthesis of information. All decisions,
Able to resolve dilemmas Aware of when to seek help
safety
of
Able to make decisions at the right time
Tensions
the
it was argued,
are taken with the
patient/client
and conflicts
as
process may arise, in particular
Confident in decision-making
osophy of the practitioner
Uses breadth and depth of knowledge to identify relevant cues
titioner’s
where the phil-
differs
the patient/client or relatives. policies sometimes conflict
Cognizant of the normal situation
paramount.
in the decision-making from that of
Local employers’ with the prac-
chosen course of action.
Making
deci-
Owns the risks involved
sions can lead to a sense of satisfaction
Paces the decision accurately, whilst recognising that some decisions may be taken more slowly allowing time for reflection
based on a ‘feeling’ of having made the ‘right’ decision, irrespective of outcome in terms of
Incorporates ethical and moral issues sensitively
action. The
Demonstrates knowledge of resources and applies weight to demand for appropriate additional resources Flexible in all situations acknowledging may require individual approaches
that decisions
expert
group
identified
which is
a number
in the decision-making
extent
that they were able to devise a map or
pathway of exploration ing. However,
process,
of
stages
to the
in clinical decision-mak-
in urgent
or emergency
situa-
tions, these stages may not be immediately recognised. In such circumstances, reflection on
Resolves the tension between the care they wish to deliver and local policies and practices
the decision-making
process
and the decision
takes place later. Allowing for these particulars, was
meant
members’
by
intuition.
understanding,
According intuition
a state of heightened
to
the
is:
perceptual
awareness
which emanates from sub-conscious thought. It influences behaviour and therefore influences the decision-making
process.
The group argued that it is impossible
to analyse
or quantify what the intuitive decision or process might be because to do so would make intuitive behaviour longer
conscious
intuitive.
thought
However,
and therefore
before
intuition
practice,
7 broad stages in decision-making
nurses are sometimes criticised for voicing gut feelings. The potential for intuition may sometimes be stifled but students and newly qualified practitioners
must be positively
verbalise these intuitive feelings,
encouraged to broaden
to and
were
Figure 3 lists those stages.
Fig 3 Stages in decision-making provides the framework decisions can be made
within which
Stage 2
Determine whether the decision is necessary and can I (as opposed to someone else) make it?
Stage 3
Assess the whole situation
Stage 4
Explore and examine all possible courses of action, including client and practitioner intuitive feelings, ethical, moral and legal issues, available resources, knowledge and research findings, conflicts of interest, code of professional conduct, views of nursing and multi-disciplinary teams and past experience of similar situations
Stage 5
Select course of action and inform ‘concerned others’ of the rationale behind the decision
Stage 6
Implement action and monitor implementation
Stage 7
Reflect on both the outcome and the decision-making process
others. There was strong support for the view that the potential to become a ‘good decisionand junior
areas of clinical
Stage 1 Establish a philosophy of care which
of information.
Student
many specialist
agreed as common.
Practitioners, the group contended, do recognise ‘good decision-making’ in themselves and in
maker’ is also recognisable.
the group was made up of prac-
from
no can
be of value, there must be a pre-existing knowledge base which fosters the appropriate and relevant interpretation
and although titioners
NURSE EDUCATION
CONCLUDING REMARKS: IMPLICATIONS FOR CONTINUING PROFESSIONAL EDUCATION Decision-making is an essential and integral aspect of clinical practice. Preparation for clinical decision-making, in particular as an expert practitioner, is haphazard and unplanned. However, understanding how expert and experienced clinicians actually make decisions can inform the provision of professional development for registration and beyond. A number of supporting factors are essential for effective decision-making at expert level. In particular, there must be a sound and developed knowledge base, informed by evaluated research. The environment within which expert practitioners work can enhance or detract from the decision-making process. This implies a managerial and a professional commitment to developing the decision-making role and creating an environment which facilitates risk-taking within clear safety and professional boundaries. Peer support and approval is vital to the creation of such a supportive environment. Practitioners need to reflect not only on specific decisions but on the process by which decisions are made. To do so requires effective mentorship (a term not associated here with its use by the Board in pre- and post-registration education) by other practitioners as well as some mechanism - such as critical incident review or personal portfolio which enables such reflection to take place. Central to the whole process and to safeguarding the rights of clients and patients is the development and application of a philosophy of care. Without such a philosophy, decisions will be arbitrary, uninformed and perhaps unsafe. This paper has identified notjust a perspective on clinical decision-making derived from an English perspective and in comparison with the literature, for example of Benner (1989). The paper and the research which it records also argues for a particular research methodology. The paper records the success in using an expert group - outwith the conventional delphimethod - for establishing the principles of a
TODAY
275
philosophy of care underpinning what is expected of expert practice in nursing and midwifery. The research method - essentially but not exclusively expert group focused - permits a critique of the critical incident methodology for identifying the components of ‘best practice’ which leads into a critique of effective clinical decision-making. Given the resources tied in with and dependent upon effective clinical decision-making, any discussion which is derived from empirical analysis and which furthers nurses’ understanding of the phenomena of decision-making is to be welcomed and replicated.
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