Nursing Process and Clinical Decision Making in Practice

Defining Clinical Decision Making

Clinical decision making is defined in the work of Higuchi and Donald (2002), "Thinking Processes Used by Nurses in Clinical Decision Making," as "a problem-solving activity that focuses on defining patient problems and selecting appropriate treatment interventions" (p. 145). Clinical decision making is further described as that which "forms the basis of expert clinical practice" (Higuchi & Donald, 2002, p. 145). The nurse works in clinical practice settings as a member of a healthcare team, which requires communicating decisions to other team members "to ensure the continuity and coordination of patient care" (Higuchi & Donald, 2002, p. 145). The nurse is also required to document clinical decisions in the patient's charts and plans for care.

Clinical decision making, according to Higuchi and Donald, has been studied using the theoretical perspectives of decision theory and information processing. They identify five major thinking processes:

(1) Description — the delineation or definition of a situation or the form of a thing;
(2) Representation — depiction or portrayal through enactive, iconic, or symbolic means;
(3) Inference — the act or process of drawing conclusions from premises or evidence;
(4) Synthesis — composition of parts or elements into a complex whole;
(5) Verification — confirmation of accuracy, coherence, consistency, or correspondence. (Higuchi & Donald, 2002)

Benner's Five Stages of Clinical Competence

Benner's stages of clinical competence describe a developmental continuum through which nurses progress as they gain experience and expertise. The five stages are as follows:

(1) Novice — This is the beginner stage, in which the nurse has no previous experience with the situations in which they are expected to perform. Context-free rules are learned for universal application, but these rules are unable to inform the novice which tasks are appropriate for each situation; therefore, the nurse is limited in applying these rules to the clinical setting (Saver, 2009, p. 1).

(2) Advanced Beginner — In this stage, the nurse has enough experience to acknowledge "recurring, meaningful components of a situation" (Saver, 2009, p. 1). During this stage the nurse begins to "formulate guidelines that dictate actions…they have knowledge, skills, and know-how, but don't have many in-depth encounters with a similar patient population" (Saver, 2009, p. 1).

(3) Competent — The nurse begins to view their actions in relation to long-term goals or plans. While competent, the nurse lacks both the speed and flexibility of the proficient nurse but is developing a feeling of mastery and is able to rely on advanced planning and organizational skills. "An increasing sense of saliency helps them recognize what is important. They begin to recognize patterns and the nature of a clinical situation more quickly and accurately. They need to examine fewer options to make decisions" (Saver, 2009, p. 1).

(4) Proficient — The proficient nurse "views situations as 'wholes' rather than parts, and maxims, reflecting nuances of a situation, guide performance. The proficient nurse learns from experience what events typically occur and how to modify plans in response to different events. The nurse sees goals and salient facts, but still must consciously make decisions" (Saver, 2009, p. 1).

(5) Expert — The expert nurse understands what needs to be accomplished due to a "well-developed ability to recognize demands and resources in situations and attain goals. They no longer rely solely on a rule, guideline, or maxim to connect understanding of a situation to the appropriate action. They have an intuitive grasp of each situation based on their deep knowledge and experience. They focus on the most relevant problems, not irrelevant alternative options. They use analytical tools only when they have no experience with an event or when events and behaviors don't occur as expected. The expert often 'just knows' a particular situation without internal analysis" (Saver, 2009, p. 1).

How the Nursing Process Supports Effective Clinical Decision Making

The nurse is responsible for contributing to a work environment that is both positive and healthy, and nurse managers must integrate nursing skills assessment into staffing planning to enable nurses to develop their expertise. The capacity of the nurse to collaborate effectively with physicians depends upon the expertise of the individual nurse combined with factors such as self-confidence and communication skills (Saver, 2009).

The components of critical thinking in nursing are identified as follows:

(1) Asking questions to determine why certain developments have occurred;
(2) Gathering relevant information;
(3) Validating information;
(4) Analyzing information;
(5) Drawing on past clinical experience and knowledge;
(6) Maintaining a flexible attitude that allows facts to guide thinking;
(7) Considering various options and their advantages or disadvantages;
(8) Formulating decisions that reflect independent decision making. (Critical Thinking, Ethical Decision Making and the Nursing Process, n.d.)

Conclusion

As the novice nurse becomes the advanced beginner and moves on into competency, proficiency, and then finally into the role of expert nurse, they gain the experience and knowledge necessary to assist the physician in clinical decision making. This advancement in the nurse's role is one that is enabled experientially and then supported by the educational knowledge gained and applied in the clinical setting by the expert nurse, who has become confident in their own ability.