Helping Novice Nurses Make Effective Clinical Decisions: The Situated Clinical Decision-Making Framework

Article excerpt

ABSTRACT The nature of novice nurses' clinical decision-making has been well documented as linear, based on limited knowledge and experience in the profession, and frequently focused on single tasks or problems. Theorists suggest that, with sufficient experience in the clinical setting, novice nurses will move from reliance on abstract principles to the application of concrete experience and to view a clinical situation within its context and as a whole. In the current health care environment, novice nurses frequently work with few clinical supports and mentors while facing complex patient situations that demand skilled decision-making. The Situated Clinical Decision-Making Framework is presented for use by educators and novice nurses to support development of clinical decision-making. It provides novice nurses with a tool that a) assists them in making decisions; b) can be used to guide retrospective reflection on decision-making processes and outcomes; c) socializes them to an understanding of the nature of decision-making in nursing; and d) fosters the development of their knowledge, skill, and confidence as nurses. This article provides an overview of the framework, including its theoretical foundations and a schematic representation of its components. A case exemplar illustrates one application of the framework in assisting novice nurses in developing their decision-making skills. Future directions regarding the use and study of this framework in nursing education are considered.

Key Words Clinical Decision-Making--Clinical Judgment--Clinical Nursing Practice--Nursing Education--Novice Nurses

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There is well-documented concern in the nursing literature that decision-making among novice nurses tends to be linear, based on limited knowledge and experience in the profession, and focused on single tasks or problems. Novice nurses, new graduates or nurses with limited experience in the care settings in which they work, tend to view decision-making as responding to patient complaints and following protocols or documented care plans (Chase, 1995; Itano, 1989; Radwin, 1998). As they make decisions, their focus leans toward doing, rather than on thinking and reflecting (Benner, 1984; Benner, Tanner, & Chesla, 1992). Novice nurses often do not recognize or appreciate the relevance of deviations from the textbook picture of a clinical situation (Benner, Tanner, & Chesla, 1996; Haffner & Raingruber, 1998; Tabak, Bar-Tal, & Cohen-Mansfield, 1996).

When confronted with complex or unfamiliar clinical situations, novice nurses frequently respond by drawing on theoretical knowledge and psychomotor skills, rather than enacting decision-making that addresses the complex and multidimensional nature of the situation. Further, when novices lack confidence in the clinical setting, they may rely excessively on more experienced nurses and avoid situations that require them to make decisions. Experiencing role dissatisfaction, some novice nurses will leave the profession (Messmer, Gracia Jones, & Taylor, 2005).

The full significance of this phenomenon becomes evident when placed at the intersection of two current trends in health care. First, a significant percentage of the nursing workforce is expected to retire within the next decade (Yancey, 2005). Second, complexity and acuity of patients is increasing in every sector of health care (Ebright, Patterson, Chalko, & Render, 2003). It is anticipated that the inexperienced nurse will carry increasing responsibility for clinical decision-making about the care of increasingly complex patient situations.

It has been suggested that nurses become expert in their practice when they have sufficient experience in the clinical setting to move from reliance on abstract principles to the application of concrete experience, viewing clinical situations within context and as a whole (Benner et al., 1996; Decker, 2006). …