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CDM Workbook Clinical Decision-making Workbook? (British Columbia College of Nurses & Midwives)

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Clinical Decision
Making
BCCNM LEARNING MODULE — WORKBOOK
Within the Standards of Nursing Practice
Describing clinical decision-making
In this activity you will describe a
clinical decision-making scenario
from your practice. Please take the
time to complete this description
as this scenario will be the focus of
many of the subsequent learning
activities in the workbook.
Begin by considering your clinical
decision-making in your nursing
practice during the last few days at
work. Select one decision that you
made in the course of providing
care for clients. The decision
does not need to be ‘difficult’ or
‘complex’, but it is important that
you can recall it clearly. Mentally
review the situation (what was
happening) and the process you
went through (what were your
thoughts and actions) in making
those decisions. Now write down
that information in any format
that works for you. You may wish
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to write a description, list steps,
or perhaps even draw a picture or
two! Be sure to provide a reasonable
degree of detail – this will be helpful
in completing learning activities
later in the module.
When you have completed this
activity, please continue with
Workbook Activity #2 before
returning to the module.
Common elements in clinical
decision-making
This activity will help you discover
the common elements or themes in
your own clinical decision-making.
Begin by reading your clinical
decision-making scenario and, if
you wish, reflect on your clinical
decision-making in general. From
this basis, note the common
elements that make up your clinical
decision-making.
Your response does not need to be
complex or detailed. The goal is to
develop a sense of how you would
describe clinical decision-making.
When you have completed this,
compare your ‘common elements’
with the themes you identified in
the nurses’ descriptions of clinical
decision-making provided in the
module.
Here are some strategies that you
might find helpful in completing
this activity:
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• Imagine you were describing ‘the
basics’ of clinical decision-making
to someone who was unfamiliar
with nursing practice.
• Complete the sentence: “When I
make clinical decisions I ...”
• If you have nursing colleagues that
are also completing this module,
have a discussion and possibly
compare your conclusions with
theirs.
Clinical decision-making frameworks
In this activity you will consider the
various elements or steps in your
clinical decision-making process
and how they relate to one another.
Begin by reviewing the description
you completed in Workbook
Activity #1 and the themes or
common elements in your clinical
decision-making that you identified
in Workbook activity #2. Using
this information, and your creative
talent, create a ‘map’ or a framework
that depicts your clinical decision-
making process. We will return to
this framework later in the module.
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If you would like more information
in how to go about developing a
map or framework, please see the
example included in Appendix 1 at
the end of this workbook.
Contextual factors in clinical
decision-making
1. Return to the clinical scenario
from Workbook Activity #1 and
consider each of the levels of
context influencing your clinical
decision.
• Identify contextual factors that
influenced the way the decision(s)
unfolded. Try and locate at least
one factor at the micro, meso and
macro-levels.
• Consider the influence these
factors had on your clinical
decision-making: To what extent
did they help or hinder your
decision-making process?
• What, if any, modifications to
context would you see as helpful
in similar situations in your future
practice? i.e. if you could change
these contextual factors, what
would you do?
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2. Now take a few moments to
reflect on the section of the module
and the associated Workbook
Activity that you have just
completed. What have you learned
about clinical decision-making in
your nursing practice? Perhaps this
discussion and workbook activity
has affirmed some aspects of your
clinical decision-making? Or maybe
you have experienced an ‘ah-ha’
moment regarding a challenge
you experience in making clinical
decisions?
Record your conclusions on the
“Affirmations and Insights” page in
this Workbook. At the completion
of the module, you will have an
opportunity to use the insights
and affirmations gained in various
learning activities, as part of your
planning for future professional
growth and development.
Foundational knowledge in clinical
decision-making
1. Using the clinical scenario from
Workbook Activity # 1, consider
the dimensions of foundational
knowledge you used in this clinical
decision: Can you see evidence of
the five dimensions of knowledge
described in the module in your
situation?
• For dimensions that are evident,
in what ways did they contribute
to your decision-making process?
• For dimensions that are not
apparent, what difference did this
make to your decision-making
process? In a future occurrence
of a similar situation, would it be
helpful to access other dimensions
of knowledge in making your
decision?
• Consider your use of the various
dimensions of knowledge in your
decision-making in general. Are
there dimensions of knowledge
that you favor/ feel unsure
about in your decision-making
processes? What influence does
this have on your clinical decision-
making?
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2. Now take a few moments to
reflect on the section of module and
the associated Workbook Activity
that you have just completed.
What have you learned about
clinical decision-making in your
nursing practice? Perhaps this
discussion and workbook activity
has affirmed some aspects of your
clinical decision-making? Or maybe
you have experienced an ‘ah-ha’
moment regarding a challenge
you experience in making clinical
decisions?
Record your conclusions on the
“Affirmations and Insights” page in
this Workbook.
KNOWING THE PATIENT
KNOWING THE PERSON
KNOWING THE CASE
KNOWING THE PROFESSION
KNOWING THE SELF
Cues, judgments, decisions
and evaluation in clinical
decision-making
1. Return to the clinical decision-
making scenario described in
Workbook Activity # 1. Using your
understanding of the phases of the
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Cues
• Using the various sources of cues identified in the Situated Clinical Decision-Making framework as a prompt,
evaluate the effectiveness of your cue collection in this situation.
• In what ways did your knowledge, skills and abilities support and hinder your cue collection?
Judgment(s)
• Consider the process of moving between cue collection and forming a judgment in your situation. Did your
process support formation of a sound judgment? If so, why? If not, why not, and how will this understanding
influence your practice in the future?
• To what extent were you open to revising the judgment after you had formed your ‘best conclusion’?
• Did you involve or consult other health care professionals in the process of forming a judgment? If not, why not?
If you did, was this process effective and why?
• Consider the process of assigning a priority to the judgment(s). What was the basis for the priority you assigned?
What contextual factors, in any, influenced the prioritization?
clinical decision-making process
within this decision and within your
nursing practice generally, answer
the following questions.
CUE(S) JUDGMENT(S) DECISION(S) EVALUATION
Cues, judgments, decisions
and evaluation in clinical
decision-making (continued)
Decision(s)
• Consider the process you used to determine a course of action in
this situation. What decision did you make? Was the decision made
independently or did you work collaboratively in some way in this process?
To what extent did the course of action move the client toward the overall
goals in their care?
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Evaluation
• What process did you use to evaluate the effectiveness of the decision? On reflection, were there additional steps
that you could have used to enhance the effectiveness of our evaluation process?
2. Now take a few moments to
reflect on the section of module and
the associated Workbook Activity
that you have just completed.
What have you learned about
clinical decision-making in your
nursing practice? Perhaps this
discussion and workbook activity
has affirmed some aspects of your
clinical decision-making? Or maybe
you have experienced an ‘ah-ha’
moment regarding a challenge
you experience in making clinical
decisions?
Record your conclusions on the
“Affirmations and Insights” page in
this Workbook.
CUE(S) JUDGMENT(S) DECISION(S) EVALUATION
Thinking processes in clinical
decision-making
1. Review the clinical decision-making scenario described in Workbook
Activity #1
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• Identify the types of thinking processes that you used in this decision-making scenario.
• Using insights gained from the reflection points in the module, consider the contribution of critical, systematic,
creative, and anticipatory thinking in your clinical decision-making in general. What dimensions of your
thinking processes do you see as strengths in your clinical decision-making and which thinking processes would
you like to develop further?
2. Now take a few moments to
reflect on the section of module and
the associated Workbook Activity
that you have just completed.
What have you learned about
clinical decision-making in your
nursing practice? Perhaps this
discussion and workbook activity
has affirmed some aspects of your
clinical decision-making? Or maybe
you have experienced an ‘ah-ha’
moment regarding a challenge
you experience in making clinical
decisions?
Record your conclusions on the
“Affirmations and Insights” page in
this Workbook.
Revisiting your clinical decision-making
framework
1. In Workbook Activity #3,
you created a framework that
represented your clinical decision-
making in nursing practice. Return
to that framework now and review
it in light of what you have learned
about your clinical decision-making
as you have worked through
this module. Is there anything
you would like to add to your
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Now that your framework is
‘completed’, consider the possibility
of using this framework as a guide
in your clinical decision-making
in practice. Perhaps you will find
it helpful to carry a copy of it with
you to prompt you when you are
challenged in your clinical decision-
making. Or alternatively, you may
wish to select another framework
(from this module or otherwise) for
the same purpose.
framework that is not there? Make
any additions or alterations that you
need to at this time.
Clinical decision-making:
Planning for professional growth
This final learning activity will guide
you in developing a plan for future
growth in clinical decision-making.
A sample plan outline is included in
this Workbook.
1. Begin by reviewing “Affirmations
and Insights” insights page in this
Workbook. This page includes
some of the conclusions you have
formed about your clinical decision-
making in your nursing practice
as you have worked through this
module. It is, in other words, a
comprehensive self-assessment of all
the components that are part
of, or influence, your clinical
decision-making. Now its time to
put that to use!
Take some time to read through
these conclusions: First, notice
and acknowledge your strengths.
Now pay attention to the areas that
you have identified as areas for
development and growth. As you
read these, notice which ones seem
to resonate with you or feel
most important to you. Use these
conclusions to determine the goals
that will support ongoing growth of
your clinical decision-making.
2. Create three goals that reflect
your focus for development in your
clinical decision-making. Write
these in the appropriate place in
“My Plan for growth in clinical
decision-making”. (located on p. 13
of the Workbook)
3. The next step is to develop an
action plan that will help you meet
those goals. Begin by identifying
resources that you could use to
assist you in meeting your goals.
If you are not aware of specific
resources, then begin by listing the
sources you will explore in order to
learn what you can do to support
your growth toward your goals.
4. Once you are familiar with the
learning opportunities that are
available to you, create an action
plan that outlines specific strategies
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you will use, what resources you
need in order to implement these
strategies (e.g. who do you need to
talk to, learning materials you want to
acquire, learning experiences you
need to arrange etc) and, importantly,
a target date for completion.
Not sure how to do identify goals and
create an action plan? The planning
for growth page has provided a
brief example of this process is
included in Appendix 3. As well, it
is recommended that you use the
BCCNM Quality Assurance resources
to assist you in this process. You may
wish to review these now.
5. Finally: Add your plan to your
Quality Assurance file, workbook or
portfolio. And remember to update it
once you have completed the actions!
Notes from Reflection Points
page 11clinical decision making within the standards of nursing practice
My clinical decision-making:
Affirmations and Insights
page 12clinical decision making within the standards of nursing practice
My plan for growth in clinical
decision-making
Goals
1.
2.
3.
page 13clinical decision making within the standards of nursing practice
Action plan
Places or people that I can explore for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assuirance Portfolio.
A P P E N D I X 1
Developing a concept map or framework:
example
page 14clinical decision making within the standards of nursing practice
Some of you will be familiar with
the process of linking steps or ideas
related to a process into a ‘concept
map’. For others, this will be a new
activity. If you are not sure how to
get started, here are some thoughts
to help you. Remember – there is no
‘right or wrong’ in this - These are
your ideas and you can depict them
any way that makes sense to you!
1. Begin by identifying the key
components of your decision-
making process. You will likely
find these are the ‘steps’ in the
scenario you described and/or the
key elements that you identified in
Workbook Activity #1 Part 2. You
might think of them as
the key ‘chunks’ that together make
up the whole process of clinical
decision-making.
2. Choose a key word or two to
represent these steps, elements or
component. Write these on a page
(in a circle or a box if you want
to) in an order or positioning that
makes sense to you.
3. Now link these key words up so
that the interconnecting lines make
the relationships between these key
components evident. You can use
arrows to indicate the direction of
influence between components..
4. And voila! Your very own clinical
decision-making framework!
As an example, here is the beginning
of a concept map based on the
decision scenario that was included
in the previous Workbook activity.
As you ‘read’ the map, following
the direction of the arrows, we can
see my clinical decision-making
process in this situation. At the
top, labeled # 1, I noticed a change
in the client. This resulted in me
(2) assessing (3) several factors
(asked the client questions, did
an assessment, considered client
history). I used (4) knowledge to
guide my assessment. The example
map stops at this point, but if I
had continued it would highlight
and link the relationships between
remaining steps or components of
my decision-making process in that
situation.
(1) Client short
of breath –
new finding
(2) Assess
(3) Ask client how he
is feeling; how long he
has been SOB?
(3) Did respiratory
assessment (inspect,
ausculate chest)
(3) Considered client
history
A P P E N D I X 2
Clinical decision-making process
page 15clinical decision making within the standards of nursing practice
Cues
• Observations
• Statements from patients or others
• Assessment and laboratory data
• Atypical responses/behavior/data
• Intuition
Judgments
• What could be happening?
• What data/evidence supports this?
• Do I need more information? From whom?
• Who should I involve or consult?
• What priority is it?
Decision(s)
• Should I wait and watch?
• Should I try something?
• Should I inform someone?
• Should I involve or consult someone else?
• How will I know if I made the best decision?
Evaluation of outcomes
• Did the decisions achieve what I wanted to happen?
• Should I make another decision?
• Should I collect more information?
• Who should I involve or consult?
Source: Gillespie. M & Paterson, B. (in press).
A P P E N D I X 3
My plan for growth in clinical
decision-making: example
Goals
1.
2.
3.
page 16clinical decision making within the standards of nursing practice
Action plan
Places or people that I can explore for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assurance Portfolio.
To become familiar with best practices related to preventing falls with elderly clients
Talk to Clinical Nurse Educator and/or Nurse Leader in geriatric care unit for suggestions about learning resources
Example: detailed plan
1. Review resources available in
my nursing unit
2. Review RNAO Best Practices
web site and Joanna Briggs
Institute Best Practices web site
for specic documents
1. None – just look on
the shelves!
2. Use work computer
to do this. Web site
URLs in Learning
resource section of
CDM module
1. During my next set
of scheduled shifts
2. By end of this
month
3. By end of next
month.
Ask the nurse educator at work
– maybe she can help me with
this?
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CDM Workbook Clinical Decision-making Workbook (British Columbia College of Nurses & Midwives)

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Completed 27 February 2021

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