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“Mooi Standing’s book provides an excellent application of the principal
concepts of Cognitive Continuum Theory; her presentation is clear, accurate
and her inferences show that she has a first rate grasp of the implications of
the theory, and what it means for the care of patients. Her work should stand
as a monument to the application of psychological theory to nursing care.”
PROFESSOR EMERITUS KENNETH R. HAMMOND, University of Colorado, USA
Sound clinical judgement and decision-making are vital to delivery of high quality,
patient-centred, nursing and interprofessional healthcare. This book integrates the
theory and practice of decision-making to guide and enhance practitioners’
understanding and clinical expertise.
Mooi Standing presents relevant, contemporary theory and research that relates
decision-making to:
● Professional identity
● Organization of healthcare
● Developing knowledge and skills
● Selecting and applying the most appropriate interventions
Real case studies written by various advanced practitioners demonstrate how to apply
theory to practice in reviewing, explaining and continually developing clinical
judgement and decision-making skills. A patient’s account of care received for a serious
illness provides a valuable patient-centred insight.
The author’s new ‘reflexive-pragmatism’
model summarizes the key knowledge,
skills, values and processes of clinical
judgement and decision-making, for readers
to apply in reviewing and enhancing their
own clinical practice. Extensive reflective
activities and self assessment tools are
included throughout the book.
www.openup.co.uk
MOOI STANDING
Cover design Hybert Design • www.hybertdesign.com
Contributors: Kate Dewar, Carolyn
Jackson, Peter Ellis, Antonio Sama,
Roger Goldsmith, Michael Standing,
Elizabeth Duck, Douglas MacInnes,
Susan Plummer, Hesham Hassan
Edited by
Clinical Judgement and Decision-Making is
essential reading for qualified nurses,
midwives and allied health professionals,
especially those undertaking CPD modules
in judgement and decision-making,
evidence-based practice and reflective
practice or studying to be advanced
practitioners.
Dr Mooi Standing is Principal
Lecturer in the Department of
Nursing and Applied Clinical Studies,
at Canterbury Christ Church
University, UK. Her PhD researched
nurses’ perceptions of clinical
decision-making and she has
published and presented various
related papers internationally.
Clinical Judgement and Decision-Making
in Nursing and Interprofessional Healthcare
Clinical Judgement
and Decision-Making
in Nursing and
Interprofessional
Healthcare
Edited by MOOI STANDING
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Clinical Judgement and Decision-Making
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in Nursing and interprofessional
healthcare
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Clinical judgement
and decision-making
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In loving memory of Lau Wai Cheng, my father, whose energy, vision,
self sacrifice, sense of duty and practical wisdom ensured that my nine
brothers and sisters and I all benefited from and valued education as a
means of developing character and transforming our lives.
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in Nursing and interprofessional
healthcare
Edited by
Mooi Standing
Open University Press
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Clinical judgement
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email: enquiries@openup.co.uk
world wide web: www.openup.co.uk
and
Two Penn Plaza, New York, NY 10121-2289, USA
First published 2010
C Mooi Standing 2010
Copyright
All rights reserved. Except for the quotation of short passages for the
purposes of criticism and review, no part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise,
without the prior written permission of the publisher or a licence from the
Copyright Licensing Agency Limited. Details of such licences (for
reprographic reproduction) may be obtained from the Copyright Licensing
Agency Ltd of Saffron House, 6-10 Kirby Street, London, EC1N 8TS.
A catalogue record of this book is available from the British Library
ISBN13: 978-0-33-523626-8 (pb) 978-0-33-523625-1 (hb)
ISBN10: 0-33-523626-X (pb) 0-33-523625-1 (hb)
Library of Congress Cataloging-in-Publication Data
CIP data has been applied for
Typeset by Aptara Inc., India
Printed in the UK by Bell and Bain, Glasgow
Fictitous names of companies, products, people, characters and/or data that
may be used herein (in case studies or in examples) are not intended to
represent any real individual, company, product or event.
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Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL
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List of figures
List of tables
About the editor
Contributors
Introduction
vii
ix
xi
xiii
xvii
1
Perceptions of clinical decision-making: a matrix model
Mooi Standing
1
2
Advanced practitioners and advanced practice
Kate Dewar
28
3
Creative thinking for whole systems working
Carolyn Jackson and Peter Ellis
54
4
Lifelong learning in judgement and decision-making
Mooi Standing and Antonio Sama
80
5
Cognitive continuum theory – nine modes of practice
Mooi Standing
100
6
Prioritizing decisions during the patient journey
Roger Goldsmith and Michael Standing
129
7
Accountability within interprofessional healthcare
Elizabeth Duck
153
8
Short- and long-term risk assessment and management
Douglas MacInnes
167
9
Reflecting on judgement and decisions in clinical supervision
Susan Plummer and Hesham Hassan
191
10
Reflexive-pragmatism: logic, practicality, rigour and relevance
Mooi Standing and Michael Standing
205
Conclusion
Glossary
Index
223
227
231
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Contents
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1.1 Matrix 1: Perceptions of clinical decision-making/conceptions of
nursing after 3–5 months as nursing students (n = 20) (Standing 2005,
2007)
1.2 Matrix 4: Perceptions of clinical decision-making/conceptions of
nursing after 6–12 months as registered nurses (n = 10) (Standing
2005, 2007)
3.1 Plsek’s (1997) Directed Creativity Cycle
4.1 Supportive/Challenging and Reflective/Competency Education
(SCaRCE) mentoring model (Standing 1998)
5.1 Lens model: intuitive judgement/decision-making in a healthcare
situation
5.2 Clinical intuition and clinical analysis: expertise and the cognitive
continuum – the six modes of inquiry (Hamm 1988: 87)
5.3 Cognitive continuum of clinical judgement/decision-making – nine
modes of practice (Standing 2007, 2008)
10.1 Reflexive-pragmatism: Logic, practicality, rigour and relevance in
patient-centred, interprofessional clinical judgement and
decision-making (Standing and Standing 2010)
16
18
70
89
103
114
117
215
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List of figures
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2.1 Personal characteristics of advanced practitioners
2.2 Career framework for health
2.3 Types of competence
2.4 Career framework for health (extract)
3.1 Characteristics of a whole system compared to a conventional
healthcare system
3.2 Core characteristics of complex adaptive systems
3.3 Examples of dispositions considered necessary for critical and
creative thinking
3.4 Examples of skills used in critical and creative thinking
3.5 Adapted from: Rossman’s Creativity Model
(1931 cited in Plsek 1996)
3.6 Osborn’s Seven-Step Model for Creative Thinking
(cited in Plsek 1996)
3.7 de Bono’s (1986) Six Thinking Hats
5.1 Intuitive/experiential versus analytic/rational decision theory
5.2 Bayes’ theorem: analytic/rational judgement/decision-making
in healthcare
6.1 Stages of the ‘patient journey’ and priorities in a
minor injury unit (MIU)
6.2 Linking advanced practitioners’ personal characteristics and
perceptions of clinical decision-making to case study of
ENP practice within nurse-led MIU
6.3 Network of agencies with whom ENP in a nurse-led minor
injury unit (MIU) communicates and collaborates to deliver
safe and effective care
6.4 Patient journey stages/priorities and cognitive continuum – nine
modes of practice
8.1 Violence at presentation as a guide to security needed at the time of
admission (Kennedy 2002: 438)
8.2 Dangerousness as a guide to security needed on admission
(Kennedy 2002)
8.3 Matrix of decisions made in relation to Case study 1
8.4 Matrix of decisions made in relation to Case study 2
10.1 Comparison of Case study 1 and Case study 2
30
40
41
42
60
62
66
68
69
69
73
101
107
131
136
140
147
168
169
180
186
207
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List of tables
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List of tables
10.2 GP(1) correspondence and coherence competence –
Case study 1
10.3 Relating individual learning styles to clinical decision-making
10.4 Reflexive-pragmatism: logic, practicality, rigour and relevance –
a checklist
208
217
219
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Mooi Standing, BSc, MA, PhD, RGN, RMN, CPN, RNT is a Principal
Lecturer and Quality head in nursing and applied clinical studies at Canterbury Christ Church University. Mooi practised mental health and general
nursing in various hospital and community settings before becoming a lecturer, and has been involved in nurse education for over 20 years. Mooi is
actively involved in the development of overseas collaborative nursing programmes at undergraduate and post-qualifying levels. She is the designated
Programme Director and Academic Link Manager for the collaborative BSc
(Hons) Nursing Studies, Malaysia.
In addition, she teaches and supervises nursing students from undergraduate
to PhD level studies including designing and facilitating experiental judgement and decision-making workshops on the MSc Interprofessional Health
and Social Care. Mooi has established her professional and academic standing through her PhD research on the perception by nursing students and
the development of clinical decision-making skills of nursing students. She
has since developed and published a new critical framework for applying
hermeneutic phenomenology, nine modes of practice on a cognitive continuum of decision-making, and a matrix model on the perception of nursing
and decision-making skills.
Mooi is also an accredited Nursing and Midwifery Council (NMC) reviewer
who applies her expertise and experience in approving, monitoring, and assuring the quality of nursing programmes throughout the United Kingdom.
Mooi also provides external consultancy in curriculum development assessment and quality enhancement both nationally and internationally.
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About the editor
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Kate Dewar RGN, RNT, MSc (Nursing) is an independent higher education lecturer, teaching in both interprofessional and unidisciplinary Masters
level programmes. She has particular interest in all issues associated with advanced practice including the critical thinking skills that underpin it. When
previously working as a Senior Lecturer at Canterbury Christ Church University, she developed programmes and courses which supported advanced
level nursing practice, and undertook various research projects related to
these developments. Kate’s current doctoral research concerns the theory
and knowledge associated with advanced level practice.
Elizabeth Duck is an Advanced Practitioner/Therapy Radiographer and
Clinical Lead for breast cancer patients attending the radiotherapy department. She is responsible for imaging and treatment field planning. Elizabeth
has taken part in the Society of Radiographers’ pilot study for accreditation of
advanced practitioners. She is currently undertaking research on oncologists’
decision-making processes within the field of breast radiotherapy as part of
a higher degree dissertation.
Peter Ellis is a Senior Lecturer at Canterbury Christ Church University. His
main teaching interests are evidence-based practice and research methods,
epidemiology and public health medicine, nephrology nursing, ethics and
care management. He is widely published in renal nursing and epidemiology
of renal disease, healthcare ethics and health service management. He also
teaches, monitors, and examines on Managing Care for the Open University.
Peter was Senior Nurse Renal Outpatients and Research Projects Manager in
the Renal Unit at King’s College Hospital, London, and is a visiting lecturer
at various universities in London.
Roger Goldsmith is a Senior Lecturer at Canterbury Christ Church University. His clinical expertise lies in Accident and Emergency Nursing which
he continues to practise. Roger teaches on the pre-registration interprofessional learning programme, focusing on clinical science and care of acute
and critically ill patients. He also teaches advanced practice in minor injury
and minor illness management.
Hesham Hassan is a Consultant Psychiatrist with a vast experience of psychiatry in various health settings. He is employed by the Kent and Medway
Partnership Trust. He practises in a town and rural community mental health
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Contributors
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Clinical judgement and decision-making
team developing and applying new frames of working to care for adults with
severe and enduring mental illness.
Carolyn Jackson is Head of Department for Nursing and Applied Clinical
Studies at Canterbury Christ Church University. With a career spanning almost three decades in nursing in the UK, the Mediterranean and Australasia,
Carolyn’s main concerns are to advance nursing practice through education,
scholarship and practice development initiatives. Her main interests are in
management and leadership, education, advanced practice, health policy and
interprofessional practice.
Douglas MacInnes, Reader in Mental Health, is a mental health nurse
whose main expertise concerns working with mentally disordered offenders.
He undertook a PhD at Guy’s Kings and St Thomas’ School of Medicine, King’s
College, University of London. The dissertation examined the views and experiences of the caregivers of people with schizophrenia. Subsequently, he
also completed an MSc in Cognitive Behaviour Therapy. Douglas is involved
in the teaching of research skills (from diploma to PhD students) as well as
undertaking and supervising research projects. He is also seconded by the local health trust to work in clinical practice as a cognitive therapist for one day
a week. Douglas’s recent research has centred on the themes of cognitive therapy, family work, illness beliefs, working with mentally disordered offenders,
and examining the stigma faced by those with mental health problems. His
research has been supported and funded locally by Health and Social Care
Trusts and Nationally by the Department of Health.
Susan Plummer is a Principal Lecturer in mental health at Canterbury
Christ Church University. Susan was awarded a Medical Research Council
Special Training Fellowship in the Health of the Public and Health Services
Research in 2001. She has participated in many research projects in mental
health at the Institute of Psychiatry, London and co-authored a number of
related journal articles/book chapters. She has presented at conferences in
the United States, Australia and Europe. She continues practice in primary
mental health nursing two days a month.
Antonio Sama is a Senior Lecturer at Canterbury Christ Church University. He currently lectures on the MSc Interprofessional Health and Social
Care including: judgement and decision-making; psychodynamics of interprofessional practice/organizational dynamics; and advanced collaborative
practice models. Antonio’s interests include: organizational changes in social care; evaluating innovations in social policy and social services; comparative research and education in European social work; and the history of
professional organizational consultancy.
Michael Standing obtained a PGCEA, Six Category Intervention Analysis
Trainers Certificate, and an MSc in Social Research (quantitative and qualitative methods) at the University of Surrey (Education, Human Potential
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Research Project, and Sociology departments). He combined and applied
these influences to lead the development and facilitation of an innovative
community mental health nursing programme for a consortium of six Kent
health authorities. He also led an applied psychosocial sciences team at City
University (School of Nursing and Midwifery) in integrating social sciences,
research methods, interpersonal, management, leadership and learning/
teaching skills throughout the curriculum. More recently Michael has been
adapting to a disability but continues to offer others support and mentoring,
from home, in their scholarly endeavours.
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Contributors
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The main audience for this book will be the nursing profession including advanced practitioners, registered nurses engaging in professional development, clinical nurse managers, specialist nurses, midwives, community
nurses, and nurse educators. Its focus on the theory and practice of clinical
judgement and decision-making will also interest other healthcare professionals given the interprofessional nature of many decisions. Most authors
are experienced nurses but there are contributions by a radiographer (Chapter 7) and a psychiatrist (Chapter 9), and whole systems theory (Chapter 3)
emphasizes collaborative, integrated healthcare. Chapter 10 applies decision
theory to evaluate a general practitioner’s diagnostic skills, and then offers
a new interprofessional healthcare model. There is, therefore, an interprofessional thread throughout the book, and much of the theory presented is
applicable to a wide range of health professionals.
The book is intended as essential reading to support higher education nursing/interprofessional continuing professional development programmes, including postgraduate decision-making, research, evidence-based, and reflective practice modules. It will also appeal to practitioners with inquiring minds
and a commitment to their professional development, who wish to supplement informal work-based learning with new ways of exploring, understanding and applying clinical judgement and decision-making skills. It aims to
engage the interest of any reader who is prepared to question and reflect on
clinical practice with a view to developing their understanding and expertise,
which can enhance the quality of patient-centred care. Elements of the book
may also be suitable as recommended reading for students on pre-registration
programmes, for example, Chapter 1 refers to a study of nursing students’
development in decision-making.
Nursing is a practice-orientated profession in using clinical skills to promote
health, supplement individuals’, families’ and local communities’ self-caring
abilities, and relieve pain and suffering where necessary throughout the human lifecycle. Sound clinical judgement and decision-making skills are vital
to perform this complex role effectively in a wide range of challenging healthcare contexts. They require the ongoing development and synthesis of relevant theoretical and research knowledge, self-awareness, interpersonal, and
practical skills (Higgs and Titchen 2001). The structure and organization of
the book are intended to enhance the reader’s personal understanding, application and integration of theoretical and practical considerations in this
respect.
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Introduction
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Clinical judgement and decision-making
The first five chapters present relevant, contemporary theory, and recent research findings in clinical judgement and decision-making. The second half
of the book presents advanced nurse practitioners’ accounts, reflections and
analysis (e.g. mapping interventions against decision theory) of their clinical judgements and decision-making in a variety of hospital and community
healthcare settings. A patient’s account of care received for a serious illness is
also included to provide a patient-centred perspective, and reflecting on this
experience culminates in the creation of a new ‘reflexive-pragmatism’ model
of interprofessional healthcare. It also illustrates that clinical practice is not
simply a place to apply the findings of existing theory and research; it is also
a place where new insights and experiences can be described which help to
generate new models of understanding. In this way, theory and practice are
mutually energizing influences in the book.
Chapter 1 presents the findings of a longitudinal phenomenological study
from which a matrix model is derived combining nurses’ personal, theoretical conceptions of nursing with their practical experience and perceptions
of developing clinical decision-making skills. The findings support a synthesis of reflective and evidence-based practice within ethical and professional
patient-centred care. Chapter 2 includes an extensive literature review of the
intellectual and personality attributes of advanced practitioners needed for
a wide range of clinical competences and role functions. Chapter 3 looks beyond practitioners’ perceptions to the organizational contexts in which they
work and advocates the understanding and application of whole systems
theory using creative thinking skills and interprofessional collaboration for
effective care delivery. Chapter 4 explores the importance of lifelong learning in clinical judgement and decision-making skills and ways of enhancing
informal work-based learning opportunities. A case is also made for creating
a participative interprofessional community of learning in formal continuing professional development programmes to integrate theory and practice.
Chapter 5 explores the development of cognitive continuum theory in combining intuitive/experiential and analytic/rational decision approaches. A
new revised cognitive continuum is developed for nurses and other health
professionals, relating nine modes of practice to patient-centred tasks, and
correspondence (practical) and coherence (logical) competence are applied
to evaluate judgement and decision-making. Each of the above theoretical
and research perspectives encourages in-depth understanding of applying
critical thinking skills, in patient-centred judgement and decision-making in
healthcare contexts.
Chapters 6 to 10 present real case study situations that are analysed using the
theory and research referred to in Chapters 1 to 5. Chapter 6 focuses on prioritizing skills for a patient in a nurse-led minor injury unit who has fallen and
fractured a bone in her hand. Chapter 7 focuses on interprofessional accountability when a radiotherapist discovers a procedure requested by an oncologist is not supported by the patient’s pathology. Chapter 8 explores shortand long-term risk assessment and management strategies within forensic
mental health care. Chapter 9 presents a reflection of clinical supervision
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regarding the supervisee’s judgements, decisions and interventions in assessing a patient with suicidal intentions. Chapter 10 describes experiences of
receiving urgent medical care over a ten-year period, and the concepts of correspondence and coherence competence (from cognitive continuum theory)
are applied to evaluate decision-making. In reflecting on ways to enhance
the development and application of decision-making skills, a new reflexivepragmatism model is created for interprofessional healthcare. The discussion
of the case studies will highlight decision-making themes that are relevant
to other areas of healthcare, and readers will be encouraged to relate the
contents to their own particular area of clinical practice.
The most important emphasis of the book is to challenge and enable readers
to reflect on and enhance their clinical practice by presenting theory and
research which they can understand and relate to, and to present extensive
examples of how to integrate the theory and practice of clinical judgement
and decision-making via practitioners’ review of real clinical scenarios. Currently, there is no other book so strongly practice-orientated with extensive
input from a wide range of advanced practitioners, sharing their experiences,
helping bridge a theory–practice gap, and providing unique insights into
their clinical judgement and decision-making processes. Reflective activities
are included throughout the book to encourage active participation in the
learning process and test out the feasibility of the ideas presented. The book
also contains models, diagrams and self-assessment tools which readers can
apply to enhance clinical practice, and provides useful reference sources for
formal studies and their continuing professional development.
Reference
Higgs, J. and Titchen, A. (2001) Practice Knowledge and Expertise. Oxford: Butterworth
Heinemann.
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Introduction
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Mooi Standing
Overview
This chapter defines and discusses clinical decision-making in relation to cultural 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 discussion and examples relate to nursing, the issues are relevant to other health
professionals. The requirement for all health professionals to be publicly accountable 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 descriptive decision-making models are related to contrasting scientific and experiential 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’ developmental 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
r Appreciate how clinical decision-making defines the nature of healthcare
professions
r Describe problem solving, critic
