p47-52w36 5/14/04 11:23 AM Page 47

C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T

By reading this article and writing a practice profile, you can gain Clinical decision-making:
theory and practice
a certificate of learning. You have up to a year to send in your pages 47-52

practice profile. Guidelines on how to write and submit a Multiple choice questions and
submission instructions
profile are featured at the end of this article. page 54

Practice profile
assessment guide
page 55

Clinical decision-making: A reader’s practice profile

page 26

theory and practice

NS242 Muir N (2004) Clinical decision-making: theory and practice. Nursing Standard. In brief
18, 36, 47-52. Date of acceptance: January 9 2004.
Author
aware of how they make these decisions. The Nursing Nita Muir RGN, RNT, DN,
Aim and intended learning outcomes PgCSHCE, MSc, BSc(Hons), is
and Midwifery Council clearly identifies this pro-
senior lecturer, Institute of
The aim of this article is to provide an introduction fessional responsibility in the Code of Professional
Nursing and Midwifery,
to the theory of clinical decision-making in the context Conduct (NMC 2002) and the Department of Health’s
University of Brighton.
of everyday nursing practice. This introduction will emphasis on clinical governance and quality in clin- Email: n.muir@bton.ac.uk
consider the frequency and type of decisions nurses ical decision-making underpins this further (DoH
make in practice. It will also discuss how decisions 1997, Harbison 2001). Summary
are made and the ways in which some of these deci- There is increasing emphasis on evidence-based Nurses have to make
sions can be improved will be considered. practice in health care, defined by Sackett et al important clinical decisions in
Exemplars from practice are used to illustrate some (1996) as: ‘The conscientious, explicit and judicious their everyday practice. This
of the theory. Reading this article and completing use of current best evidence in making decisions article provides an
the associated Time Out activities will assist you to about the care of individual patients.’ This defini- introduction to the theory of
reflect on your own practice, to determine how tion makes clear that nurses use a conscious process clinical decision-making,
describes the type of
you make decisions and how you use information of decision-making both in deciding which evidence
decisions that nurses make
to approach decision-making in your nursing arena. to use and with which patients.
and outlines the different
After reading this article you should be able to: By gaining insight into the processes by which approaches that can be used
■ Discuss the relevance of clinical decision-making nurses make decisions, this process can then become to make a decision.
theory in nursing practice. visible to other members of the healthcare team
■ Outline the type of decisions that you regularly and the profession. This transparency is beneficial Key words
make. when team decisions are required and can improve ■ Decision-making process
■ Describe how some of your decisions are made. communication, patient care and interprofessional ■ Models and theories
■ Identify what information or knowledge may be relationships (Cook et al 2001). ■ Professional development
used in decision-making.
■ Through reflection, become more aware of how TIME OUT 1 These key words are based
Review how knowledge of decision- on subject headings from the
your decision-making skills can develop.
making might enhance your clinical British Nursing Index. This
practice. Identify specific areas, for article has been subject to
Introduction example – understanding how you made double-blind review.
a decision to start the patient on oxygen
Nurses make important clinical decisions every day
therapy, and then how you rehearsed this
and these decisions have an effect on the patient’s aloud with a student nurse who was
health care and the actions of the healthcare pro- observing so that she might understand Online archive
fessional. As care provision is becoming increas- the associated rationale for making the
ingly complex, nurses have to rely on sound decision. For related articles visit our
decision-making skills to maintain up-to-date care online archive at:
and positive outcomes. Nurses are accountable for www.nursing-standard.co.uk
Decisions: types and frequency and search using the key
their decisions at a professional and organisational
words above.
level, and therefore it is imperative that they are Often decision-making is such a common activity

may
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal 19/vol18/no36/2004
use nursing
only. No other uses without standard 47
permission.
Copyright © 2017 RCN Publishing Company Ltd
p47-52w36 5/14/04 11:23 AM Page 48

Models and theories

that any thought is rarely devoted to discovering

TIME OUT 2
what a decision is. The word decision relates to the
Reflect on a one-hour duty period and
activity ‘to decide’ (Matterson and Hawkins 1990).
write down the type of decisions you
The New Oxford Dictionary of English (2001) defines made during it. Compare your list with
a decision as being a conclusion or resolution reached those presented in Table 1. Identify areas
after consideration. Other components of a decision that may be similar or different.
are that it (Matterson and Hawkins 1990):
■ Ends doubt or debate.
■ Is based on indications or evidence. Theories of decision-making
■ Involves deliberate mental choice.
■ Includes two or more options. When attempting to describe decisions, the start-
The actual decision made is the final point of the ing point should be some form of conceptual frame-
decision-making process which involves complex work or model (McGrew and Wilson 1982). There
processes of problem solving (McGrew and Wilson are numerous models used to interpret and explain
1982). This all occurs in an environment of uncer- the process of clinical reasoning and the diversity
tainty which is an inescapable fact of decision-mak- of explanation has often masked common themes
ing in modern health care (Thompson and Dowding between them. There is also debate about how
2001). If there is no uncertainty and the relation- best to achieve a compromise or ‘middle ground’
ship between the problem and outcome were cer- between the various theories that are espoused
tain, then no decisions would be required, rather (Buckingham and Adams 2000a, Harbison 2001,
the best solution to the problem could be calcu- Thompson 1999).
lated. Therefore a distinguishing characteristic of Two key opposing conceptual frameworks under-
decision-making is that it only occurs where there pin the decision-making process – the analytical frame-
is uncertainty about the choices to be made. work and the intuitive framework (Hamm 1988).
By understanding the type of decisions that you
make you will be better equipped to identify what The analytical framework
sort of knowledge you need to use during this
process. If researchers are to develop evidence to When using an analytical approach to decision-
supplement and guide decision-making in nursing making the decision-maker relates the presenting
then they need to know what type of decisions situation to a set of guiding principles or follows
nurses make – consequently, there has been some some rules. There have been various proponents
research interest in this area (McCaughan 2002). of this stance and the suggested rules and guid-
Bucknall (2000) undertook an observational study ance are often expressed in information-processing
in Australia on the decisions of nurses (n=18) in an terms (Fonteyn and Ritter 2000).
acute care setting. She identified that nurses made Information-processing model These principles
a patient care decision every 30 seconds and that are based on information-processing theory (Fonteyn
there were three main areas where nurses made and Ritter 2000). A key assumption of this theory
the majority of their decisions: is that the decision-maker stores relevant informa-
■ Intervention decisions – where the decision made tion in his or her memory and that effective deci-
had the aim of modifying the patient situation. sion-making or problem solving occurs when the
■ Communication decisions – where the aim of problem solver retrieves information from both
the decision was to give or receive information. short- and long-term memory.
■ Evaluation decisions – where the aim of the Fonteyn and Ritter (2000) discuss how information
decision was to review or evaluate patient data gained from education and experience is stored
so that the current health status of the patient throughout life in long-term memory and, while this
could be determined. can take longer to access than short-term memory,
In the UK, Watson (1994) observed nurses (n=11) there is more storage capacity. They also suggest that
over a two-hour period on a medical ward and clinical experts use information stored in their short-
identified that they made 18 decisions during this term memory to stimulate retrieval of long-term
time, which is approximately three decisions every memory information. For example, an expert nurse
20 minutes. who is diagnosing a leg ulcer will use his or her short-
More recently, in a larger NHS research and devel- term memory of the knowledge of the patient and
opment study where nurses (n=108) were inter- his or her signs and symptoms, to retrieve informa-
viewed and observed in practice, six key decision tion stored in his or her long-term memory such as
types were identified (Thompson et al 2000). This the signs and symptoms of venous leg ulceration.
study identified that during observational periods This theory underpins the following decision-
on acute hospital wards, a grade E staff nurse making models. The first is suggested by Carnevali
would make on average one decision every ten and Thomas (1993). The model describes a seven-
minutes (Thompson et al 2000). Different types stage process of ‘diagnostic reasoning’ or clinical
of decisions and associated clinical questions are decision-making:
listed in Table 1. 1. Exposure to pre-encounter data.

48 nursing standard
Downloaded may
from 19/vol18/no36/2004
RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
p47-52w36 5/14/04 11:23 AM Page 49

Models and theories

2. Entry to the data search field and shaping the The word hypothesis is used in this model; this is not
direction of data gathering. defined in the true scientific sense but rather as a
3. Coalescing of cues into clusters or ‘chunks’. potential explanation for the situation that uses the
4. Activating possible diagnostic explanations information gathered. A hypothesis is thus generated
(hypotheses). and this then guides the nurse into either gaining
5. Hypothesis and data-directed search of the data more information or interpreting the cues gathered
field. to either confirm or refute the hypothesis that is made.
6. Testing for the correct diagnostic hypothesis. The hypothesis evaluation is a key component in the
7. Diagnosis. decision-making processes of nursing practitioners
In other words, the nurse meets the patient and gath- (Offredy 2002). From the careful consideration of
ers cues or information; this could be signs and symp- these cues and evaluation of hypotheses, a correct
toms, the patient’s history and so on. Either during diagnosis of the situation can be made. Consider the
or following the interaction, the nurse begins to iden- example outlined in Box 1.
tify the key cues or important aspects of the data. In these approaches, reasoning is considered to
The nurse may then begin to make inferences from be conscious, speculative and evaluative where the
this information and this is when the short-term and practitioner is solving problems. However, nurses
long-term memory are used as the nurse begins to generally manage this process with varying degrees
cluster the cues together and begins to identify patterns. of attention where, if the process occurs frequently,

Table 1. Decision types and associated clinical questions

Decision type Exemplar decision Exemplar question

Intervention/effectiveness
This type of decision involves choosing between Choosing a mattress for a frail older In older and inactive patients who
interventions man who was admitted with an may require surgical intervention,
acute bowel obstruction which is the most suitable pressure-
relieving mattress to prevent pressure
ulcers?

Targeting
This is strictly speaking, a subcategory of the Deciding which patient should get Is there a risk assessment tool available
intervention/effectiveness decisions outlined above. antiembolism stockings that will accurately predict which group
These decisions are of the form ‘Choosing which of patients will benefit from antiembolism
patient will benefit most from the intervention’ stockings?

Timing
This is also a subcategory of intervention/effectiveness Choosing a time to commence asthma When to commence asthma education
decisions. These commonly take the form of education for patients with newly for patients with newly diagnosed
choosing the best time to deploy the intervention diagnosed asthma asthma?

Communication
This type of decision commonly focuses on choices Choosing how to approach cardiac Would I be better to explain rehabilitation
relating to ways of delivering information to and rehabilitation following acute myocardial when the patient’s family is present so
receiving information from patients, families or infarction in an older patient who lives that a clear understanding is obtained
colleagues. Sometimes these decisions are alone before the patient is discharged home?
specifically related to the communication of risks
and benefits of different interventions or
prognostic categories

Service organisation, delivery and

management
This type of decision concerns the configuration Choosing how to organise handover so How should I organise handover so that
or processes of service delivery that communication is most effective the information is communicated in the
most effective way?

Experiential, understanding or hermeneutic

This relates to the interpretation of cues in the Choosing how to reassure a patient who How best do you reassure a patient who
process of care is worrying about a cardiac arrest after has witnessed someone having a cardiac
having witnessed another patient arresting arrest?

Adapted from Thompson et al (2000) with permission from Elsevier

mayuse19/vol18/no36/2004
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal nursing
only. No other uses without standard 49
permission.
Copyright © 2017 RCN Publishing Company Ltd
p47-52w36 5/14/04 11:24 AM Page 50

Models and theories

then less attention is paid to the process. If there The intuitive framework
are new problems with different circumstances and
larger risk, nurses may undertake more detailed The roots for understanding intuition in nursing
conscious and consultative reasoning. were initially identified by Carper (1978), and intu-
Carroll and Johnson (1990) suggest an alterna- ition is regarded as an alternative explanation for
tive information-processing model that outlines how nurses make decisions. Intuition is defined as:
seven temporal stages of decision-making, which ‘Understanding without rationale’ (Benner and
REFERENCES
do not follow a linear pattern but can be repeated Tanner 1987). It is often described in abstract ways
Benner P (1984) From Novice to Expert:
Excellence and Power in Clinical or returned to as necessary: such as gut feeling, insight, instinct or a hunch.
Nursing. Menlo Park CA, 1. Recognition of the situation. Pyles and Stern (1983) were among the first
Addison-Wesley.
2. Formulation of explanation. researchers to consider that when identifying car-
Benner P, Tanner C (1987) Clinical
judgement: how expert nurses use 3. Alternative generation of other explanations. diogenic shock, critical care nurses used ‘gut feel-
intuition. American Journal of Nursing. 4. Information search to clarify choices and available ings’ in addition to the presenting patient cues.
87, 1, 23-31.
evidence. The motivational approach of the decision-maker
Bryans A, McIntosh J (1996) Decision
making in community nursing: an 5. Judgement or choice. differs between these two stances. The prime
analysis of the stages of decision 6. Action. motivators in the analytical stance are related to
making as they relate to community
7. Feedback. the task such as the number of cues and task com-
nursing assessment practice. Journal of
Advanced Nursing. 24, 1, 24-30. This model is more flexible and focuses directly plexity. However, when individuals use intuition in
Buckingham C, Adams A (2000a) on decision-making. The purpose differs slightly in decision-making then they themselves are the pri-
Classifying clinical decision making: a
that the aim of the decision is action and feedback mary force (Thompson 1999).
unifying approach. Journal of
Advanced Nursing. 32, 4, 981-989. rather than diagnosis as described by Carnevali and Benner’s (1984) well-known work argues that
Buckingham C, Adams A (2000b) Thomas (1993). Bryans and McIntosh (1996) and intuition is an essential part of clinical judgement
Classifying clinical decision making:
Kennedy (2002) considered that this framework and is linked clearly to the nurse’s expertise. Benner
interpreting nursing intuition,
heuristics and medical diagnosis. was more applicable for flexible decision-making found that the judgements of expert nurses were
Journal of Advanced Nursing. 32, 4, used in community nursing. different from those of nurses with less expertise.
990-998.
Pattern recognition is used in both models; pattern Novice nurses rely on analytical principles to under-
Bucknall T (2000) Critical care nurses’
decision-making activities in the recognition is the process of making a judgement stand the current situation and to guide their actions,
natural setting. Journal of Clinical on the basis of a few critical pieces of information. whereas the expert nurse no longer relies on an
Nursing. 9, 1, 25-36.
The primary feature of pattern recognition suggests analytical principle to connect with the situation
Carnevali D, Thomas M (1993) Diagnostic
Reasoning and Treatment: Decision that each new case is compared with previous cases but uses intuition instead.
Making in Nursing. Philadelphia PA, that are stored in an individual’s memory and categorised An alternative approach to understanding intuition
Lippincott.
according to similarity. Offredy (1998) suggests that is offered by Buckingham and Adams (2000b) and
Carper B (1978) Fundamental patterns of
knowing in nursing. Advances in it can be viewed from two levels: analytically where Cioffi (1997), who offer the term ‘heuristics’ to
Nursing Science. 1, 1, 13-23. the whole situation is grasped (as in the example in explain intuition. Heuristics are often referred to as
Carroll J, Johnson E (1990) Decision
Box 1) and intuitively where pattern matching is ‘rules of thumb’ and are strategies used by the
Research: A Field Guide. California,
Sage. linked with intuition and ‘gut feeling’. problem solver to deal with large amounts of infor-
Cioffi J (2001) A study of the past mation, where shortcuts are created so that only
experiences in clinical decision making
in emergency situations. International
TIME OUT 3 certain cues are identified among huge amounts
Journal of Nursing Studies. 38, 5, Identify a decision that you made recently of information (Cioffi 1997). Cioffi (2001) suggests
591-599. where you may have used information- that these shortcuts are based on past experiences,
Cioffi J (1997) Heuristics, servants to processing theory and consider if you for example, nurses may recall the usual pattern or
intuition, in clinical decision-making.
Journal of Advanced Nursing. 26, 1,
used any of the models suggested. Can presentation of patients with a particular condition
203-208. you identify the cues in the presenting and compare this against the presenting patient’s
Cook G et al (2001) Decision-making in situation and the possible hypotheses
progression. Buckingham and Adams (2000b) fur-
teams: issues arising from two UK that were generated? How did this guide
evaluations. Journal of ther argue that intuition is rather a function of expe-
your decision-making?
Interprofessional Care. 15, 2, 141-151. rience and pattern recognition and may occur at
an unconscious level, while more analytical rea-
Box 1. Example of clinical decision-making soning may occur at a conscious level.

The nurse identifies key cues when dealing with a patient who has just returned to TIME OUT 4
the ward after abdominal surgery and is looking pale and feeling clammy (these cues Can you identify any decisions that you
have been clustered together and interpreted as being meaningful). The nurse begins made recently where you may not have
to create a tentative hypothesis or explanation that the patient may be experiencing been aware of why you made the
postoperative internal bleeding and the nurse then wants to either refute this or decision? Reflect on why you made this
accept it. The nurse will then seek and interpret other key cues of the patient’s clinical decision and what influenced you.
status – this may include the patient’s blood pressure, pulse, temperature, pain
assessment, colour, wound assessment and patient’s position – before any diagnosis
or decision is made. The hypothesis is then evaluated and if the patient is medically The middle ground
stable with no signs and symptoms of bleeding then the hypothesis is rejected. The
nurse may then generate another hypothesis that the patient may be in pain and so How nurses make decisions has incited much debate,
the information is gathered to try to test another hypothesis. and many authors suggest that nurses tend to use
a combination of analytical and intuitive strategies

50 nursing standard
Downloaded may
from 19/vol18/no36/2004
RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
p47-52w36 5/14/04 11:24 AM Page 51

Models and theories

when making a decision. This means that neither context of their work they do not make structured Department of Health (1997) The New
the analytical nor the intuitive framework offers an analytical decisions as represented by the scientific NHS: Modern, Dependable. London,
The Stationery Office.
exclusive explanation for how decisions are made experimental to quasi-experimental modes. Flemming K, Fenton M (2002) Making
in nursing practice (Harbison 2001, Kennedy 2002, Depending on the situation nurses’ cognitive sense of research evidence to inform
Thompson 2001). practices may occur between mode 4 – a system- decision making. In Thompson C,
Dowding D (Eds) Clinical Decision
The cognitive continuum (adapted from Hamm aided judgement, mode 5 – peer-aided judgement Making and Judgement in Nursing.
1988) is offered as an alternative explanation to and mode 6 – intuitive judgement. A system-aided Edinburgh, Churchill Livingstone.
consider decision-making in nursing, and acknow- judgement may occur if the nurse refers to a deci- Fonteyn M, Ritter B (2000) Clinical
reasoning in nursing. In Higgs J, Jones
ledges the differences between analysis and intu- sion framework (where all statistical probabilities M (Eds) Clinical Reasoning in the
ition (Figure 1). The key features of this continuum and outcomes have been considered) when mak- Health Professions. Oxford,
are that the mode of cognition used by the clini- ing his or her decision. However, Harbison (2001) Butterworth Heinemann.
Hamm R (1988) Clinical intuition and
cian is determined by the structure of the task he argues that this is unlikely as this mode of prac- clinical analysis: expertise and the
or she is undertaking, the time available and the tice is neglected in nursing. A peer-aided judge- cognitive continuum. In Dowie J,
number of information cues. ment may occur if the nurse decided on a treatment Elstein A (Eds) Professional Judgment:
A Reader in Clinical Decision Making.
Cognition is viewed along a continuum with plan through discussion with peers and a review Cambridge, Cambridge University
analytical thinking opposed to intuition. This is of the literature pertaining to the treatment. An Press.
divided into six modes of cognitive practice. For intuitive judgement may occur if the nurse relies Harbison J (2001) Clinical decision making
in nursing: theoretical perspectives and
example, when the task is structured as in experi- on intuition to guide his or her judgement. Hamm their relevance to practice. Journal of
mental situations, where fewer cues are available (1988) suggests that most clinicians make deci- Advanced Nursing. 35, 1, 126-133.
and there is more time, the cognitive practice modes sions around the cognitive modes 5 and 6. Kennedy C (2002) The decision-making
process in a district nursing
used are more analytical and will lead the decision- assessment. British Journal of
maker to an analytical judgement (action). The oppo- TIME OUT 5 Community Nursing. 7, 10, 505-512.
site end of the continuum occurs when the task is Lauri S et al (2001) An exploratory study
Review the cognitive continuum shown of clinical decision-making in five
unstructured, there is little time available and with in Figure 1 and consider in which countries. Journal of Nursing
the potential of lots of cues then the intuitive mode cognitive practice modes you make the Scholarship. 33, 1, First Quarter: 83-90.
of cognition is used and leads the decision-maker Luker K, Kenrick M (1992) An exploratory
majority of your decisions. You may need
study of the sources of influences on
to an intuitive judgement (action). to consider the structure of the tasks, the clinical decisions of community
Nurses often work under time constraints with time available and the amount of cues nurses. Journal of Advanced Nursing.
decisions being made from every 30 seconds to available to do this. 17, 4, 457-466.
Matterson P, Hawkins J (1990) Concept
every ten minutes, and the tasks they undertake analysis of decision making. Nursing
are often unstructured with numerous cues. Therefore, Information and influences Forum. 25, 2, 4-10.
using the cognitive continuum in Figure 1, it is clear McCaughan D (2002) What decisions do
nurses make? In Thompson C,
that nurses do not always make judgements in Nurses use a range of information to inform their Dowding D (Eds) Clinical Decision
modes 1, 2 or 3. In other words because of the decision-making in clinical practice. The effects of Making and Judgement in Nursing.

Figure 1. Hamm’s cognitive continuum

Well structured 1 Scientific

High
experiment

2 Controlled
trial

3 Quasi-
experiment Possibility of
Task manipulation;
structure 4 System-aided visibility of
judgement process; time

5 Peer-aided
judgement

6 Intuitive
judgement
Poorly structured Low
Intuition Analysis
COGNITIVE MODE
Adapted from Hamm (1988) with permission
from Cambridge University Press

mayuse19/vol18/no36/2004
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal nursing
only. No other uses without standard 51
permission.
Copyright © 2017 RCN Publishing Company Ltd
p47-52w36 5/14/04 11:24 AM Page 52

Models and theories

Edinburgh, Churchill Livingstone. knowledge and experience have been identified as ■ Faulty perception of cues due to poor skills or
McGrew A, Wilson M (1982) Decision significant influences in decision-making (Flemming interruption during cognitive processes.
Making. Approaches and Analysis.
Manchester, Manchester University and Fenton 2002). Benner (1984) introduced the ■ An incomplete knowledge base.
Press. notion that two broad categories of knowledge ■ Misapplication of known facts to a specific
New Oxford Dictionary of English (2001) guide decision-making: theoretical and practical. problem.
New Oxford Dictionary of English.
New York NY, Oxford University Press. Theoretical knowledge is formalised as general, These can be avoided if nurses reflect on their
Nursing and Midwifery Council (2002) abstract rules and principles and practical knowl- practice and identify how they use knowledge in
Code of Professional Conduct. London, edge is gained from experience. Practical knowl- their everyday practice. By considering errors that
NMC.
Offredy M (2002) Decision making in edge tends to be used more, as demonstrated by occur in the decision-making process, nurses can
primary care: outcomes from a study Luker and Kenrick (1992). Luker and Kenrick (1992) gain insight into the complexities of this cognitive
using patient scenarios. Journal of suggest that nursing knowledge is operationalised process in clinical practice.
Advanced Nursing. 40, 5, 532-541.
Offredy M (1998) The application of through clinical decision-making, but although
decision making concepts by nurse nurses demonstrate high levels of skill, their work TIME OUT 6
practitioners in general practice. is often unsubstantiated by rationale. Their research Review some of the decisions that you
Journal of Advanced Nursing. 28, 5,
988-1000. identified that community nurses’ clinical decisions have already identified and answer the
Pyles S, Stern P (1983) Discovery of were informed by: following:
nursing gestalt in critical care nursing: ■ Knowledge based on research and tested theories. ■ Did research-based information
the importance of Gray Gorilla influence your decision?
Syndrome. Image: The Journal of ■ Knowledge based on practice and arising out of
Nursing Scholarship. 15, 2, 51-57. nursing experience: clinical experience and situ- ■ Did past experience influence your
Sackett D et al (1996) Evidence based ational variables. decision?
medicine: what it is and what it isn’t. ■ Were you aware of the potential for
British Medical Journal. 312, 7023, ■ Knowledge that is common sense and current.
error in any of the decisions you made,
71-72. The majority of nurses in the study identified that
if so, why was this?
Scott I (2000) Teaching clinical reasoning: clinical experience (82 per cent, n=39) and situ-
a case-based approach. In Higgs J,
Jones M (Eds) Clinical Reasoning in the ational variables (76 per cent, n=36) were the
Health Professions. Oxford, major influences on their decisions. While this Conclusion
Butterworth Heinemann. research is more than ten years old, the findings
Thompson C (2002a) The value of
research in clinical decision-making. are evident in recent research (Kennedy 2002, This article has provided an introduction to the com-
Nursing Times. 98, 42, 30-34. Lauri et al 2001, Watson 1994). The relationship plex theory of clinical decision-making in nursing.
Thompson C (2002b) Human error, bias, between experience and the ability to make com- The following points summarise the key elements:
decision making and judgement in
nursing: the need for a systematic plex decisions in nursing practice is a valuable ■ Nurses make a range of decisions in their every-
approach. In Thompson C, Dowding D contributor to clinical decision-making (Benner day practice, often in time constraints.
(Eds) Clinical Decision Making and and Tanner 1987, Cioffi 2001). This affects the ■ There are different stances or perspectives to
Judgement in Nursing. Edinburgh,
Churchill Livingstone. speed at which nurses can make decisions and explain decision-making. These differ in their
Thompson C (2001) Clinical decision the approach they use. account of influencing factors and the extent to
making in nursing: theoretical As well as professional experience or ‘know-how’ which decision-making is analytical or intuitive.
perspectives and their relevance to
practice – a response to Jean Harbison. knowledge, successful decision-making from an Heuristics is offered as an alternative to intuition.
Journal of Advanced Nursing. 35, 1, evidence-based perspective incorporates three addi- ■ A case can be made for the middle ground, that
134-137. tional elements to support the successful decision nurses use different approaches at different times
Thompson C (1999) A conceptual
treadmill: the need for ‘middle ground’ (Thompson 2002a): depending on the context of the clinical situation.
in clinical decision making theory in ■ The available resources. ■ Decision-making involves many different types
nursing. Journal of Advanced Nursing. ■ Patient’s informed values. of knowledge, which are used in varying degrees.
30, 5, 1222-1229.
Thompson C, Dowding D (2001) ■ The research knowledge (‘know-what’ knowledge). Some forms of knowledge are more authorita-
Responding to uncertainty in nursing However, Thompson et al (2001a, 2001b) found tive than others, for example, considered research.
practice. International Journal of that few sources of information accessed by nurses Clinical decision-making is an integral aspect of the
Nursing Studies. 38, 5, 609-615.
Thompson C et al (2001a) The were research-based. The strongest piece of evi- nurse’s role. When nurses make reasoned judge-
accessibility of research-based dence-based practice that influenced nurses’ deci- ments in times of uncertainty, then the decisions
knowledge for nursing in United sion-making were human sources such as the clinical that are made generally lead to positive patient out-
Kingdom acute care settings.
Journal of Advanced Nursing. 36, specialist and link nurses associated with the spe- comes. Understanding the basic theory behind the
1, 11-22. cialism under investigation. decisions nurses make will help to enhance this
Thompson C et al (2001b) Research It is suggested that nurses can make mistakes that process thereby improving patient outcomes. By
Information in nurses’ clinical decision
making: what is useful? Journal of affect patient outcomes if they rely purely on this being able to identify the different types of deci-
Advanced Nursing. 36, 3, 376-388. potentially flawed source of information (Flemming sions being made in everyday practice, you can
Thompson C et al (2000) Nurses’ Use of and Fenton 2002, Thompson 2002b). Further errors begin to identify any knowledge or skills deficits
Research Information in Clinical
Decision Making: A Descriptive and can occur throughout the process of decision-mak- and devise strategies to overcome these
Analytical Study. Final Report. London, ing and if the knowledge that nurses use to under-
National Co-ordinating Centre for NHS pin this process relies either on their own experience TIME OUT 7
Service Delivery Orºganisation.
Watson S (1994) An exploratory study or the experience of others, then they are open to Now that you have completed the article,
into a methodology for the human error and bias in their judgement. Other you might like to write a practice profile.
examination of decision making by key causes of errors identified in decision-making Guidelines to help you are on page 55.
nurses in the clinical area. Journal of
Advanced Nursing. 20, 2, 351-360. are (Scott 2000, Thompson 2002a):

52 nursing standard
Downloaded may
from 19/vol18/no36/2004
RCNi.com by ${individualUser.displayName} on Aug 10, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd