NUR 479 Principles and Practice of Adult Nursing Dr Bernie Reid

By the end of this section you will be able to: Identify and define types of decision-making Discuss characteristics of decision-making Discuss factors that influence decision-making Understand theories of decision-making Discuss ethical factors in clinical decision-making Understand and discuss teams Describe the multidisciplinary team Demonstrate an understanding of what professional boundaries are Describe the purpose and process of referring Describe the utility of networking They will be able to operate as a team member

There are several theories of decision making to take into account. They fall into three main categories and have been labelled as normative, descriptive or prescriptive. Each of the theories makes assumptions about people and the way things are. This then forms the basis of their thinking about how and why people make decisions in a particular way.

Assume that everyone is (or has the capacity to be) a rational, logical thinker. Therefore, normative theories are centred upon the processes involved in making an ideal decision.

Describes how individuals arrive at decisions and are concerned with analysing each of the steps in a decision-making process and how one gets from one to the other.

Assume that people's decision-making processes are flawed. Therefore, prescriptive theories attempt to prescribe ways of improving the process with a view to making better decisions.

Traditional Problem solving process The managerial decision making process The nursing process Intuitive decision making model Regardless of the process used, it is always important to be critical of the accuracy and quality of the decisions you make given the consequences that may be involved.

You will come across many terms used to describe decision making such as clinical decision-making, clinical judgement, clinical inference, clinical reasoning etc. It is however important to distinguish from the outset the difference between judgement and decision-making.

Judgement has been described as, the assessment of alternatives whereas decision-making is, choosing between alternatives (Dowse 1993). Therefore, you can see that judgement (or in this case, clinical judgement) is a key characteristic of decision-making. Consequently, decision-making may be defined as a process by which information (or evidence) is assimilated and judged and from this, a course of action or outcome is arrived at. This is then communicated as a decision

You must remember, however, that as this process relies on your judgement you must always be mindful of the Code of Conduct and make sure that you are practicing within its guidance.

Fundamentally, the tools offered thus far for decision making are a way of thinking' and enable you to calmly and methodically work through a problem, gathering evidence, weighing up alternatives and coming to a reasoned logical conclusion that is workable. The goal here then is that when presented with a problem in placement, you will be able to call upon this knowledge and blend it with your practice to guide the care you deliver. The learning contracts that you will be completing on placement are decision-making tools also and will help in this process when they enable you to see how module learning outcomes are translated into practice.

It should be noted however that decision making is a part of the problem solving process and the terms should not be used interchangeably. It is possible to make a decision without engaging in the process outlined above

There are two main types of decision that can be made. There are decisions that are satisficing: decisions that go for what is possible as opposed to what you would like to do. On the other hand, there are decisions that are optimising; decisions that choose the best option from the alternatives that meet the needs of the person or solve the problem in hand.

Experience and knowledge: Education Self-concept Environmental stressors Creative thinking ability

Making a decision does, of course, have consequences (as highlighted previously). In practice, the consequences of your decisions will have ethical implications. By ethical implications, we mean the extent to which the decision would be interrogated along the lines of, was it the right thing to do given the circumstances? Ethical principles have been addressed in other modules so now would be a good time to review the ethical principles that practice is founded upon.

The first team that you will work within is the nursing team. Nursing teams are slightly different from other teams in that they are always changing. The way in which shift patterns are designed to cover the ward results in different people being on at different times and this means that the team on duty every day will nearly always be different. It could therefore be argued that this influences how the members of the team function and how quickly the team settles down to become effective. Underpinning this are group formation processes and to function as a manager you need to understand what these processes are.

In this context we should point out that the term group does not just refer to a number of people who happen to work in the same location but rather a number of people who believe themselves to be in some way linked either by purpose or identity. It could be argued that this underpins the use of the term team as opposed to group because team implies belonging.

Groups have both organisational purposes and individual purposes. The organisational purpose of a group would be to solve a problem or carry out a particular function. The individual purpose of a group is to derive pleasure from being a member of the group, the provision of security.

Bass & Ritterband, (1979), identified four distinct stages in the development of groups and these may be listed as:
The development of mutual acceptance and membership. This is characterised by initial mistrust and inadequacies felt by members. The members of the group may appear defensive and may limit behaviour through conformity and ritual. The promotion of communication and decisionmaking. This is possible once acceptance occurs and feelings are expressed. At this point norms of procedure develop and members develop liking or caring for one another. More constructive problemsolving and decision making strategies develop.

Rising motivation and productivity. This may be manifested by members cooperating instead of competing and at this stage motivation by intrinsic reward to achieve productivity becomes apparent. Control and organisation. Work is allocated by agreement according to abilities. Members work independently and the group is flexible and adapts to new challenges.

Forming; the group comes together or meets and consideration is given (either overtly or in a less obvious fashion) to the hierarchical structure of the group, patterns of leadership, individual roles, codes of conduct, etc. This is an anxious stage as the members are creating an impression and testing each other to establish themselves and boundaries. Storming; at this stage the members have become more familiar with each other. Disagreement may occur as views are expressed more forcefully. This may lead to hostility within the group. There is important reforming or refocusing of working arrangements if this stage is successfully completed.

Norming; at this point conflict and hostility wane. Standards and guidelines are established, as members need to co-operate in order to plan and fulfil the purpose of the group Performing, at this stage the group structures are established, the group is cohesive and functions effectively

Group membership has benefits for the individual but there is also a price to be paid in the form of behaviour modification to conform to established norms. This is known as social influence. Sherif (1936), argued that people will adjust their perception to conform to social or group norms and that the effect of this social influence is covert and extremely strong. Knowledge of social influence can enable a manager to influence outcomes and manipulate the workforce to produce the results that he/she desires. The purpose of this is to ensure that the organisational goals are met and in this case, it would be the delivery of good quality nursing care.

Each of the professions noted in the diagram provide a unique service to the patient. In practice, it would be good practice to speak to each of the professions when you see them on the ward and ask them what their specific role is. Sometimes its easy to misinterpret what others do. With a detailed knowledge of their function it will make the process of referral easier for you and will reduce the number of times requests for services are rebuffed as being inappropriate.

Clinical practice is constantly changing and the boundaries that define where one profession stops and another begins are constantly shifting. This is especially clear in the realm of specialist practice but can be just as confusing for the staff nurse on the ward. From the point of view of the Code of Conduct we are constantly reminded of our personal accountability and how this may be in part be defined by having an awareness of where your own personal boundaries lie. This will be based in part upon your awareness of your competency but will be complemented by knowledge of local policy determining where a definitive boundary may lie.

Referring may take two forms: In the first instance, it may be viewed as a process by which you refer something onto a senior or more experienced colleague when you feel that you have reached the limits of your knowledge and experience. Secondly, a more traditional view of referring would be a process by which you refer a patient onto another service for a specialist opinion, or to arrange a service. This is usually accompanied by a discussion of the patients needs with medical colleagues and will involve administrative processes so that the process may be appropriately logged and recorded in the patients notes.

We have looked at:

Making informed decisions Definition and characteristics of decision-making Theories of decision-making Applying theory to practice The skills involved in clinical decision-making Ethical factors in clinical decision-making Groups and group processes Multidisciplinary working Roles Professional boundaries Referring