Summary Clinical Judgement and Decision-Making

Perceptions of clinical decision-making: a matrix model Mooi Standing Overview This chapter defines and discusses clinical decision-making in relation to cul- tural influences, professional identity, decision theory and a matrix model that cross-references nurses’ perceptions of clinical decision-making with their conceptual understanding of nursing. Although most of the discus- sion and examples relate to nursing, the issues are relevant to other health professionals. The requirement for all health professionals to be publicly ac- countable in demonstrating sound clinical judgement and decision-making sets the context against which these skills, together with critical thinking and problem solving, are discussed. Normative, prescriptive and descrip- tive decision-making models are related to contrasting scientific and ex- periential processes (and sources of evidence) to support clinical decisions. Benner’s ‘novice to expert’ model of clinical expertise is critiqued and a matrix model, derived from a longitudinal phenomenological study of nurses’ de- velopmental journey, acquiring and applying clinical decision-making skills, is presented. Reflective activities invite readers to relate the matrix model to their experience and perceptions of clinical decision-making. The matrix model is then critiqued with reference to decision theory. Objectives  Appreciate how clinical decision-making defines the nature of healthcare professions  Describe problem solving, critical thinking, clinical judgement, and clin- ical decision-making  Distinguish between normative, prescriptive and descriptive decision- making models  Compare and contrast a ‘novice to expert’ model of skill acquisition with the matrix model  Identify different types and sources of evidence, and ways of processing clinical decisions  Consider common errors in clinical judgement/decision-making and how to prevent themDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 2 Clinical judgement and decision-making  Reflect on development needs regarding clinical judgement and decision- making skills Background The importance of developing and using effective clinical decision-making skills was reinforced by a National Health Service (NHS) reform that intro- duced a system of clinical governance to facilitate quality-assured healthcare and greater public accountability of health professionals (DH 1998). This was supported by calls for evidence-based decisions to raise standards of care, ac- companied by performance-related pay to encourage health professionals to review and adapt their practice in line with organizational and managerial changes (NHS Executive 1999; DH 1999). The NHS Plan identified targets to increase public access to high quality healthcare, established criteria to mon- itor achievement of targets via NHS Service Frameworks, and advocated a flexible multidisciplinary workforce to improve the coordination, efficiency, and effectiveness of health services (DH 2000). The concept of ‘working to- gether, learning together’ through lifelong learning acknowledged the ongo- ing education and training implications of developing health professionals’ core skills in communication, information processing, teamwork, and clin- ical competence. Partnerships between Workforce Development Confedera- tions and higher education institutions were established to tailor education to health service providers’ requirements in matching skills to local clinical demands (DH 2001). Background summary  In the United Kingdom a policy of healthcare for all, freely available at the point of delivery, is achieved via the NHS, the largest employer in the country, publicly funded by taxation.  Government-led NHS reform aims to improve its efficiency, quality, and cost effectiveness on behalf of the public who elected them and whose taxes indirectly pay for services.  Organizational changes such as setting health targets and clinical govern- ance mean that the actions of health professionals are subject to greater managerial and public scrutiny.  Health professions continue to self-regulate standards of practice but, as NHS employees, practitioners are also assessed through quality audit and individual performance appraisal.  The increased public accountability of health professionals means that clinical judgements, decisions and interventions must be explained, justi- fied, and defended when challenged.  Changes in health professionals’ education complement NHS reform by linking theory to evidence-based practice, developing skills, and encour- aging interprofessional learning. The above factors have implications for reviewing the role and function of health professionals (Chapter 2), adapting the organization and managementDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Perceptions of clinical decision-making 3 of NHS services (Chapter 3), and, continuing interprofessional development in clinical judgement and decision-making (Chapter 4). The impact of cultural change and NHS reform also poses a challenge to the professional identity and autonomy of healthcare workers in accommodating government health targets, principles of evidence-based practice, and pub- lic accountability for their clinical judgements and decisions. This chapter explores these issues in relation to nursing, the largest professional group in the NHS, but the points raised are also relevant to other health professionals. Nursing, clinical decision-making and professional identity For many years the following definition was thought to convey the essential nature and professional identity of nursing: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, or its recov- ery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. (Henderson 1966: 15) Thirty-three years later the (then) regulating body for nursing stated that this ‘definition of nursing has not been bettered’ (UKCC 1999: 15). Indeed, Henderson’s patient-centred, needs-focused, collaborative, and goal-directed emphasis appears as relevant now as it was then but the cognitive skills nec- essary to determine and demonstrate how best to ‘assist the individual’ were not made explicit. More recently the Royal College of Nursing has redefined nursing as: The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health to cope with health problems, and to achieve the best possible quality of life whatever their disease or disability, until death. (RCN 2003: 3) Both definitions support the view that nursing, ‘as a human science focuses on life and health as humanly experienced’ (Pilkington 2005: 98). However, the emphasis upon ‘use of clinical judgement’ distinguishes the RCN defi- nition from earlier versions and shows how nursing is continually adapting to cultural change, including NHS reform, in order to meet new challenges and role requirements that enhance the quality of care and accountability for clinical decision-making. The subtle shift in focus from what nurses do, to how they think about what they need to do, places clinical judgement and decision-making skills at the forefront of nurses’ professional identity. This is also true for other professions since comparing judgements and decisions made by different healthcare professionals enables the identification of their distinctive contri- bution to patient care. The implications for nurse education led to reform of pre-registration programmes through the introduction of practice-orientatedDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 4 Clinical judgement and decision-making curricula designed to equip nurses with relevant clinical skills so they are ‘fit for practice and purpose’ (UKCC 2001). In other words theoretical know- ledge is of limited value unless it helps to inform and guide high standards of patient care that is responsive and adjusted to individual needs and cir- cumstances. This capacity to integrate theory and practice underpins the notion of the nurse as a ‘knowledgeable-doer’ (Benner 1984) and it is also needed ‘to justify, explain and defend judgements and decisions’ (Dowding and Thompson 2002: 190). Hence, the Nursing and Midwifery Council (the current regulating body) require pre-registration nursing programmes to prepare nurses who can ‘demonstrate sound clinical decision-making’ (NMC 2004: 33) and these skills are internationally acknowledged as core competences in nurse edu- cation (Gonzalez and Wagenaar 2005). All registered nurses and midwives in the United Kingdom are bound by a code of conduct which states ‘As a pro- fessional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’ and, ‘You must de- liver care based on the best available evidence or best practice’ (NMC 2008: 1). Other health professions’ regulatory bodies stipulate similar requirements for their practitioners. Clarifying what is meant by the terms clinical judgement and decision-making is, therefore, needed in healthcare. Problem solving, critical thinking, clinical judgement, and clinical decision-making Healthcare involves addressing health problems and the nursing process is a well-established problem solving approach to systematically assess, diagnose, plan, implement and evaluate individualized care using intellectual, interper- sonal and technical skills (Yura and Walsh 1973). Each stage of the nursing process requires the use of judgement and decision-making and this is more effective when critical thinking skills are applied. Indeed, criticisms of the nursing process focus mainly on its uncritical application: Parse (1981) argued it was too mechanistic; Hurst et al. (1991) reported that the more cognitively demanding planning and evaluation stages were neglected; Corcoran-Perry and Narayan (1995: 70) asserted that it ‘delineated neither the underlying thinking processes nor the specific knowledge involved’; and Benner et al. (1996) claimed it led to the routine use of standardized care plans that militated against individualized care planning. The development of clini- cal judgement and decision-making skills can, therefore, complement the nursing process by encouraging the application of critical thinking from as- sessment to evaluation. A panel of experts put together a consensus statement in defining critical thinking as follows: We understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as wellDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Perceptions of clinical decision-making 5 as explanation of the evidential, conceptual, methodological, criteriologi- cal, or contextual considerations upon which that judgment is based. (American Philosophical Association (APA) 1990) Problem solving is goal-directed and involves evaluating the outcome of interventions so, like critical thinking, it is purposeful and involves self- regulatory judgement. For example, the nursing process and judgement are linked together in a new international classification of nursing practice (ICN 2005). The above features of critical thinking can be linked with problem solving, as follows: Six steps to effective thinking and problem-solving (Facione 2007: 23) Ideals Five Whats and a Why Identify the problem What’s the real question we’re facing here? Define the context What are the facts and circumstances that frame this problem? Enumerate choices What are our most plausible three or four options? Analyse options What is our best course of action, all things considered? List reasons explicitly Let’s be clear: Why are we making this particular choice? Self-correct Okay, let’s look at it again. What did we miss? Identifying the problem and context correctly is vital, as anyone who is misdiagnosed understands, so it requires careful consideration of available evidence using appropriate assessment criteria or tools, and conceptual knowledge and understanding to make sense of (interpretation) and draw reasonable conclusions (inferences) from the information gathered. Enumer- ating choices and analysing options in planning actions are enhanced by reflecting on experience in dealing with such issues, awareness of pertinent policies or procedures, and critical application of relevant research evidence that is methodologically sound. This is an important stage in being able to satisfy the requirement for ‘care based on the best available evidence or best practice’ (NMC 2008: 7). Listing reasons to implement the chosen interven- tion challenges practitioners to be very clear about their rationale for using this approach and it also enables them to explain and justify decisions to oth- ers. Self-correction is the hallmark of an autonomous practitioner who is able to evaluate the strengths and weaknesses of adopted strategies in achieving desired outcomes, and, can then reassess the problem and/or consider alter- native options that might be more effective in addressing it. Effective problem solving in healthcare employs critical thinking skills, clin- ical judgement and decision-making in all stages of the process. Clinical judgement is defined as ‘the application of information based on actual obser- vation of a patient combined with subjective and objective data that lead to aDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 6 Clinical judgement and decision-making conclusion’ (Mosby 2008). It, therefore, represents a practitioner’s informed opinion based on both qualitative (subjective) interpretations and quanti- tative (objective) analysis of observations and other relevant information sources that guide clinical decision-making. Hence, clinical judgement and decision-making are closely inter-related; the former involves assessment of alternative options whereas the latter involves choosing between alternative options (Dowie 1993). Defining clinical decision-making Defining clinical decision-making is important because, in doing so, the na- ture of healthcare itself is revealed. A valid definition of clinical decision- making in nursing must, therefore, reflect the realities of practice that nurses experience. ‘Decision-making is a case of choosing between different alter- natives’ (Bloomsbury 2002: 408) is a simple definition highlighting a key component of decisions in committing to one course of action as opposed to others, as observed by Dowie. However, this definition is not specific to nursing and does not convey the knowledge required to determine what the available choices are, or how to review and select the most effective strategy. Advocates of evidence-based healthcare argue that the most trustworthy source of knowledge is achieved from the results of scientific research and rigorous tests of its validity and reliability: Without knowledge which flows from a comprehensive and sound research and development programme, the first building block in evidence-based clinical decision-making will be missing. When such knowledge is gener- ated it must be converted into information which is tailored to the needs of health professionals taking clinical decisions. This means focusing on the means by which evidence is made accessible and equipping staff with the skills to know how to evaluate and apply it in individual situations. (NHS Executive 1999: 8) The promotion of research evidence-based clinical decisions to improve the quality of care is one of the aims of current NHS reforms. The National Insti- tute for Health and Clinical Excellence (NICE) was established to conduct ex- tensive healthcare research and produce evidence-based guidelines to inform practice. This enables local practice to benefit from a far greater accumulation of relevant information from national databases than individual practition- ers’ clinical experience can provide. For example, NICE guidelines for assess- ment and management of head injuries advise replacing skull X-rays with CT (computerized tomography) cranial scans which are far more accurate in detecting intra-cranial pathology (Hassan et al. 2005). However, it can be dif- ficult to implement such guidelines where they depend on round-the-clock availability of specialist practitioners. In one study, of 88 patients who should have had a cranial CT scan under NICE guidelines, only ten patients did as most attended at evenings or weekends when radiologists were not at workDownloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Perceptions of clinical decision-making 7 (Harris et al. 2006). One of the critical incidents discussed later may have had a less tragic outcome if NICE guidelines for the assessment/management of head injuries had been applied. It is, therefore, important for nurses and other health professionals to apply relevant research in evidence-based clinical decisions but it is not always possible without additional resources. Furthermore, while it may be desirable, it is not realistic to develop research-based guidelines for every conceivable decision that nurses make. They also need to be able to process and respond to a much wider range of evidence (e.g. observations of patients, feedback, reflective practice) in addition to that provided by formal scientific research methods (Rycroft-Malone et al. 2004). A broader and more practical understanding of clinical decision-making is conveyed in the following definition developed for nursing (but could apply to other health professions): Clinical decision-making is a complex process whereby practitioners deter- mine the type of information they collect, recognize problems according to the cues identified during information collection, and decide upon ap- propriate interventions to address those problems. (Tanner et al. 1987) This definition acknowledges that nurses may be able to think and act sys- tematically to identify and address problems even when research evidence is not available to inform decisions. However, it does not convey the critical thinking skills needed or professional accountability for the decisions. The following, more comprehensive, definition was developed in a longi- tudinal phenomenological study of nurses’ perceptions of clinical decision- making (which is discussed later): Clinical decision-making is a complex process involving observation, in- formation processing, critical thinking, evaluating evidence, applying rel- evant knowledge, problem solving skills, reflection and clinical judgement to select the best course of action which optimizes a patient’s health and minimizes any potential harm. The role of the clinical decision-maker in nursing is, therefore, to be professionally accountable for accurately assess- ing patients’ needs using appropriate sources of information, and planning nursing interventions that address problems and which they are competent to perform. (Standing 2005: 34) This definition of clinical decision-making accommodates problem solving, critical thinking, judgement, scientific evidence-based practice, experiential reflective practice, ethical values and professional accountability (it could also be adapted by other health professions). It suggests that qualitative research can be valuable in portraying practitioners’ perceptions of everyday reality of practice in which professional knowledge, clinical judgement and decision- making are embedded.Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 8 Clinical judgement and decision-making Normative, prescriptive, and descriptive decision-making models