Clinical Decision Making 59 

Nursing and medical literature that addresses clinical decision making tends to classify decision making into two broad models (Luker, Hogg, Austin, Ferguson, & Smith, 1998). The first is a scientific, analytical approach which involves logical analysis, where probabilities for outcomes are assigned a numerical value relating to importance. It is understood in this model that not all knowledge may be available at the time the decision has to be made and so there are elements of risk where a practitioner has to decide if benefits of a decision will outweigh the risks. The other model of decision making relies on intuitive knowledge gained by

past experience rather than objective sources of knowledge. There are always elements of uncertainty in the clinical decision-making process and it could be argued that nurses take fewer risks with their decision-making than medical doctors do. With the expectation that nurses will become more independent practitioners and autonomous decision-makers this will increase the risk associated with decisions, and the knowledge that a nurse would be required to draw upon.

Lim, Honey and Kilpatrick (2007) advocate that the education of nurses to become nurse practitioners (a recognised postgraduate, post-registered nursing professional who may gain prescribing rights and can practice in a certain area of speciality) also requires them to develop skills in clinical reasoning and clinical based decision-making. They propose a framework that is based on three tiers - the first tier being knowledge, the second tier being application of the knowledge and the top tier being decision-making. This implies that a current, experienced registered nurse may not have the decision-making capability required for higher level practice, yet according to the registered nurses’ scope of practice, it is registered nurses who have responsibility for decision-making and so it could be assumed, that this should already be part of the professional skill set of a registered nurse, irrespective of any ambition to become a nurse practitioner. Dreyfus and Dreyfus (1986) proposed a five stage model of skill acquisition as professionals move from novices to experts. Benner (1982) aligned these five stages of skill acquisition to nursing practice and suggested that the novice tends to have no or limited experience to draw upon, so many of their decisions are based on procedures or guidelines. The second stage of skill acquisition, ‘advanced beginners’ tend to see the individual becoming more reflective than the new novice, and beginning to recognise what is important, and what is not, as they move towards competence (stage three). When competent, the practitioner tends to feel more responsible for their actions than an advanced beginner. Proficient practitioners (stage four) tend to use intuition and know-how but also are more analytical in their judgements and more able to identify the important actions to take. The expert has the ability to alter their practice due to their knowledge of the

individual situation, with the decision-making being intuitive and often unconscious (Pritchard, 2007).

An expert nurse has experience to draw upon and their decision making is often intuitive (Benner, 1982), however this intuitive decision-making and experiential practice basis is not necessarily based on scientific information, but is more grounded in social-context of repeating actions that have worked before, or have been observed to work when other experts do it. There is no guarantee that the expert nurse’s decision-making process results in favourable patient outcomes. Hamm (1988) utilised the same stages of transition as Benner but related them to medicine instead of nursing decision-making, suggesting that the novice thinks analytically by working through guiding principles, whilst the expert clinician can make decisions intuitively. Hence, he linked the two theories of decision making into the one process, making the analytical, scientific model a process utilised by the novice practitioner and the intuitive model utilised by the expert. Decision- making will ultimately consist of analytical and intuitive aspects. Hamm suggests that the more information and time that is available, the more analytical the decision making process will be. The use of guidelines and practice protocols in nursing removes the analytical decision making process from the novice nurse to some extent, possibly providing some quality assurance and removal of some risk. Botermans (1996) examined the training requirements of psychotherapists, whose training traditionally consisted of didactic methods of instruction, case supervision and personal therapy. He suggested that most established professions such as medicine and law study curricula starting from basic knowledge to operating concepts, moving into technical and practical skills that the profession operates under a defined context. He found that ‘micro’ training and the use of treatment manuals (guidelines) provided a method to control the integrity of treatment delivery and he indicated that these could also form the basis of training to provide continuous control over performance, until the novice psychotherapist gained more experience, developed their confidence, and moved from a novice towards an expert practitioner.

Successful nurses are considered to have attributes that include high levels of technical expertise, cognitive capabilities and emotional intelligence. This often includes the ability to recognise patterns in complex situations and to adjust accordingly (Scott, 2003). There is also a suggestion that the decision-making process of the nurse is influenced by how well the nurse knows the patient. Radwin (1995) suggests four stages of decision-making, from ‘empathy’ when the nurse is not familiar with the patient, to an ability to balance preferences with difficulties where a nurse can individualise the interventions due to familiarity of the patient. The development of evidence-based practice in nursing should minimise the risk associated with clinical decisions as the policies and guidelines that nurses follow should be based on research - but this has implications for the nurses’ knowledge base to interpret and analyse literature and research. Some authors suggest that nursing practice is still experiential, rather than research- based (Camiah, 1998; Fulbrook, Rolfe, Albarran & Boxall, 2000). The intuitive nature of expert nursing practice appears to be based on the ability to detect changes in the patient’s condition and this is enhanced by experience. Radwin (1998) suggests that knowing the patient is core in such decision-making processes and that the confidence of the nurse increases with experience. The experienced nurse tends to ask more relevant questions, be able to listen and intuitively observe changes in condition. Experiential knowledge of patients in similar situations had relevance to interventions chosen by previous experience (Radwin, 1998) however, in situations where the nurse has limited experience; their knowledge of bioscience information should support their decision-making ability. This would be so, if not directly in terms of recall, then in terms of being able to source, read, critique, understand and apply information and evidence.