Clinical judgement and decision-making in nursing and interprofessional healthcare Author: Mooi Standing Open University Press, Glasgow, 2010; 238 pages; AUS$68/NZ$75/[pounds]65; ISBN: 9780335236268
Clinical judgement and decision-making - these are key attributes of professional practice, and feature highly in most models for evidence-based practice as well as in much of the guidance available on clinical leadership, quality improvement and organisational change. In short, Clinical judgement is central to the safe and effective functioning of health services. Not only is it central to safe, effective care, it is also the most difficult element of professional practice to define, and to implement in terms of how it relates to organisational needs and priorities and in how such an individualised concept can contribute, particularly in practice-based professions such as nursing and to some extent allied health which are often characterised by regulation and standardisation of structures and processes.
This book aims to present theory and research findings (although the emphasis is on the theory rather than research findings) that inform models and method for applied clinical judgement and decision-making. The approach taken includes a series of reflective activities that are intended to facilitate the readers' deeper consideration of the theories presented. It is clearly a text targeted at the academic reader and will be of interest to students undertaking studies that specifically require a comprehensive understanding of the theories and models associated with clinical reasoning.
The opening chapter defines and discusses clinical decision-making from a cultural context, professional identity, decision theory and a matrix that brings together perceptions with conceptual understandings of nursing. The linkage with professional standards and expectations is clearly articulated. A matrix for applied clinical decision- making is combined with a series of recommended activities that illustrate how to use the matrix. The matrix includes capacity for practitioners of varied expertise levels to participate in their selfevaluation, and is based on qualitative research which informed its development.
Subsequent chapters focus on the advanced practice nurse, the wider health system and lifelong learning. Kate Dwer identifies the significant elements of decision-making from an advanced practice perspective, including the working environment and individual attributes of the practitioner. This chapter very much focuses on what it is to be an advanced practitioner and how fulfilling this role impacts on clinical decision-making.
At a wider, health system level, the role of decision-making advocated should be multidisciplinary, and integrated. Within this context, the skills of the advanced practitioner are used to enhance client-centred care and communication, facilitation of continuous learning and interprofessional work that again maintains the client at the centre. This chapter brings a range of theories together into one integrated structure, with an emphasis on how it could function within the British National Health Service. Quite usefully, the chapter brings together an overview of models of creative thinking - drawing out the commonalities with practical tips on how to implement them in a complex work environment.
Models of lifelong learning are described as being grounded in different ways of knowing and these are clearly defined and explored. The linkage between models and continuing professional development is explored, with an emphasis on applied principals.
Chapter 5, perhaps the strongest chapter in this book brings these opening chapters together by linking the concepts raised via cognitive continuum theory and models. The forms of knowledge described and their sources and attributes will resonate with nurses in particular who often grapple with questions about how they use intuitive knowledge to make decisions. It is a type of knowledge particularly valued in nursing, and this chapter describes models which explain its structures and give insight into how tacit knowledge is filtered and facilitates decision-making. The chapter also explores analytic or rationale forms of knowledge, and their origins and impact on decision-making. Many nurses would be familiar with the dichotomy of ways of knowing; however, this chapter emphasises that nurses need to use both methods to enhance our ability to make good decisions where intuition is informed by more explicit forms of knowledge. The remainder of the chapter explores contexts and methods by which the cognitive continuum can be applied, and concludes with an observation that fits well with the current focus on evidence-based practice. That is that evidence alone is not all the necessary information; clinical judgement is also required. This chapter articulates that clinical judgement can be established and brought into decision-making whether one is operating from an evidence-based perspective or another model.
Chapters 6 to10 use case study formats to illustrate how different aspects of clinical judgement and decision-making can be applied. In this way, the reader is reflectively engaged in issues around prioritising decisions during the patient journey, accountability in multiprofessional care, risk assessment and risk management, reflection and reflexive pragmatism. Each of these chapters also includes structured points for reflection and consideration in terms of how clinical judgement and decision-making is integral to those elements of care or service delivery. As with preceding chapters, the emphasis is on theory and application rather than evidence or research findings. However, this does not detract from this excellent book; it is a journey in praxis.
The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia