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Nurse Education in Practice 10 (2010) 333e340

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Using the Situated Clinical Decision-Making framework to guide analysisof nurses’ clinical decision-making

Mary GillespieBritish Columbia Institute of Technology, Speciality Nursing, 3700 Willingdon Ave, Burnaby, BC, Canada V5G 3H2

a r t i c l e i n f o

Article history:Accepted 7 February 2010

Keywords:Clinical decision-makingClinical judgmentClinical nursing educationAssessment

E-mail address: mary_gillespie@shaw.ca1 The term clinical educator refers to a registered n

assist nurses and nursing students to develop compractice and encompasses roles such as clinical teachelearning facilitator, etc.

1471-5953/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.nepr.2010.02.003

s u m m a r y

Nurses’ clinical decision-making is a complex process that holds potential to influence the quality of careprovided and patient outcomes. The evolution of nurses’ decision-making that occurs with experiencehas been well documented. In addition, literature includes numerous strategies and approachespurported to support development of nurses’ clinical decision-making. There has been, however,significantly less attention given to the process of assessing nurses’ clinical decision-making and noviceclinical educators are often challenged with knowing how to best support nurses and nursing students indeveloping their clinical decision-making capacity. The Situated Clinical Decision-Making framework ispresented for use by clinical educators: it provides a structured approach to analyzing nursing students’and novice nurses’ decision-making in clinical nursing practice, assists educators in identifying specificissues within nurses’ clinical decision-making, and guides selection of relevant strategies to supportdevelopment of clinical decision-making. A series of questions is offered as a guide for clinical educatorswhen assessing nurses’ clinical decision-making. The discussion presents key considerations related toanalysis of various decision-making components, including common sources of challenge and errors thatmay occur within nurses’ clinical decision-making. An exemplar illustrates use of the framework andguiding questions. Implications of this approach for selection of strategies that support development ofclinical decision-making are highlighted.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Nurses’ clinical decision-making is a complex process withpotential to influence the quality of care provided and, subse-quently, patient outcomes (Benner et al., 1999; Minick and Harvey,2003; Tanner, 2006). Effective clinical decision-making processesdevelop over time as nurses acquire necessary knowledge, thinkingprocesses and clinical experience (Benner et al., 1996). Whiletheorists’ descriptions of nurses’ clinical decision-making at variouslevel of skill performance provide vision for professional growth(Benner, 1984; Benner et al., 1996), the process of supporting novicenurses and nursing students in building decision-making skillstoward expertise often challenges novice clinical educators.1

There has been a longstanding interest in assisting nurses andnursing students to develop clinical judgment and decision-makingprocesses. Research and descriptive literature presents programs,

urse whose primary role is topetence in clinical nursingr, preceptor, mentor, practice

All rights reserved.

pedagogical approaches and specific strategies intended to developnurses’ clinical decision-making and reasoning. There has been,however, significantly less attention given to the process ofassessing nurses’ clinical decision-making processes. Literatureincludes descriptions of a specifically designed Clinical Decision-Making Assessment tool (CDMA) (Grossman et al., 1996) and theObjective Structured Clinical Assessment tool (Boney and Baker,1997). More recently, rubrics that incorporate dimensions of clin-ical judgment have been used to assess nurses’ clinical judgmentduring simulated clinical experiences (Dillard et al., 2009; Lasater,2007). In addition, research studies examining the relationshipbetween critical thinking and clinical decision-making or judgmenthave used the WatsoneGlaser Critical Thinking Appraisal tool(Tanner, 2006).

Novice clinical educators often struggle with knowing how toeffectively support nursing students and novice nurses in devel-oping their clinical decision-making capacity. This challenge isreflected in observations related to new graduate nurses in theUnited States: Del Bueno notes that “only 35% of new registerednurse graduates, regardless of educational preparation andcredentials, meet entry expectations for clinical judgment” (2005,p. 278). In considering this phenomenon against existing literature,

Foundational knowledge: Definitions

Knowing the profession Knowledge of standards of practice, competencies, skills and roles of nurses.

Knowing the self Knowledge of individual strengths, limitations, skills, experience, assumptions, preconceptions, learning and other needs.

Knowing the case Knowledge of pathophysiology, patterns that exist in typical cases, predicted trajectory and patient responses.

Knowing the patient/client Knowledge of a patient’s or client’s baseline data, patterns that exist in laboratory or other data, or patterns in physiological responses to pathology and treatment.

Knowing the person Knowledge of a patient’s or client’s past experience in relation to health and illness, patterns in relation to personal response to pathology and treatment, preferences, supports and resources.

Fig. 1. The Situated Clinical Decision-Making framework (Gillespie and Paterson,2009). Reproduced with the permission of the National League for Nursing.

M. Gillespie / Nurse Education in Practice 10 (2010) 333e340334

two points of interest emerge. First, nurses’ clinical decision-making is well recognized as a complex, multidimensional process(Benner, 1984; Benner et al., 1996; Tanner, 2006): Nurses’ clinicaldecisions occur within the dynamic context of clinical practice, areinformed by multiple sources of knowledge, influenced by all thatthe nurse brings to the situation, and supported by a range ofthinking processes (Gillespie and Paterson, 2009; Tanner, 2006). Assuch, the effectiveness of clinical decision-making can be influ-enced by any of its component parts. In contrast, the majority ofstrategies described in literature focus on improving clinical deci-sion-making as a whole, with limited consideration of specificcomponents of the larger process. This blanket approach to inter-vention offers little direction for educators in determining whichstrategies will best support the development of specific clinicaldecision-making components. Second, the discussion of strategiesassumes that educators are able to effectively analyze a situationand identify the components of a nurse’s clinical decision-makingprocess that require development. This assumption obscuresa critical challenge for educators: Typically, when nurses or nursingstudents lack capacity in some aspect(s) of clinical decision-making, issues tend to present as general concerns about theirpractice e.g., ‘poor clinical judgment’, ‘ineffective patient care’, or‘inappropriate decisions’. Identification of the specific source(s) ofissues underlying the broader concern regarding a nurse’s clinicaldecision-making capacity is an essential prerequisite to selectingstrategies that offer relevant and meaningful support fordevelopment.

In this article, the Situated Clinical Decision-Making frameworkis presented as a tool that provides clinical educators with a struc-tured approach to analyzing nursing students’ and novice nurses’decision-making in clinical nursing practice, and assists them inidentifying specific issues within nurses’ clinical decision-making.By supporting identification of specific issues, the framework alsoguides educators in selecting relevant strategies to support devel-opment of clinical decision-making. Following the structure of theframework, the discussion highlights key considerations related toanalysis, including common issues and errors that may occurwithin nurses’ clinical decision-making. An exemplar illustrates useof the framework. Finally, implications of this approach for selec-tion of strategies that support development of clinical decision-making are highlighted.

The Situated Clinical Decision-Making framework

The Situated Clinical Decision-Making framework incorporatescontext, foundational knowledge, decision-making processes, andthinking processes (Fig. 1). The framework and its theoreticalfoundations have been described in detail in a previous publication(Gillespie and Paterson, 2009). This article introduces a series ofquestions that will prompt for educators in the process of analyzingnurses’ clinical decision-making (Fig. 2).

Context

Nurses make clinical decisions within a multi-layered contextthat includes micro- (nurse and patient in relationship), meso-(nursing unit and health care agency) and macro-levels (profession,society and government). Each level potentially includes social,cultural, political, ideological, economic, historical, temporal, andphysical factors that may influence clinical decision-making. Thereare aspects of each contextual level that require educators’ consid-eration when analyzing nurses’ clinical decision-making (see Fig. 2).

At the macro-level, the scope of nurses’ clinical decision-makingis defined by the boundaries of professional nursing practice andinfluenced by the characteristics of the health care system. The

meso-level of context incorporates the relational matrix withinwhich nurses make their decisions and, in turn, emphasizes theimportance of effective communication and the possibility ofcollaboration within clinical decision-making. Collaborative possi-bilities are strongly influenced by social aspects of the nursing unitsuch as unit culture, organizational structure, nursing workload,and the availability of appropriate persons with which to collabo-rate (Bucknall, 2003; Chase, 1995). Although often a source ofsupport for clinical decision-making, the relational matrix may alsoembody challenges for nurses. The influence of interruptions andthe need for nurses to refocus their thinking, have been noted toinfluence the quality of clinical decisions (Ebright et al., 2003;Hedberg and Larsson, 2004; McCarthy, 2003; Potter et al., 2005).Other meso-contextual factors reported as influencing decision-making include physical layout of the unit, time of day, and fiscalrestraint (Bucknall, 2003).

The inclusion of the nurse and patient within the micro-levelcontext highlights the relational nature of nursing practice andthe ethical dimension inherent in all clinical decisions. In thisregard, educators are prompted to consider moral issues asa source of difficulty within nurses’ clinical decision-making(Doane, 2002; Hartrick, 1997). In particular, as junior staff withinthe health care hierarchy, novice nurses may be uniquely chal-lenged in maintaining moral agency within their decisions(Beckett et al., 2007). Theorists’ descriptions of the influence of

Fig. 2. Analyzing nurses’ clinical decision-making: guiding questions for educators.

M. Gillespie / Nurse Education in Practice 10 (2010) 333e340 335

nurses’ experience on their clinical decision-making (Benner,1984; Benner et al., 1996; Tanner, 2006) provide a benchmarkfor educators’ expectations regarding nurses’ clinical decision-making at various levels of practice. For example, novice nurses’decision-making characteristically tends toward rule-basedthinking, with a focus on task completion or responding todiscrete patient issues while, in contrast, more experienced nursesare more likely to view patient situations as a whole and withincontext (Benner et al., 1996; Decker, 2006). Educators can also usethese ‘benchmarks’ to consider the implications of the ‘fit’

between a nurse’s level of experience and patients’ acuity andcomplexity for nurses’ decision-making. Finally, the limitinginfluence of a lack of confidence on novice nurses’ clinicalreasoning and decision-making should be considered (Etheridge,2007; Haffer and Raingruber, 1998).

Overall, acknowledging that nurses’ clinical decision-makingoccurs within the larger context emphasizes the need for educatorsto differentiate contextual factors from nurse-related factors asa source of challenge for nurses’ clinical decision-making. Whenissues reside in the context (e.g., limited opportunities to

Fig. 2. (continued).

M. Gillespie / Nurse Education in Practice 10 (2010) 333e340336

collaborate) then effective support will entail altering the context,rather than focusing remedial action with the nurse.

Foundational knowledge

Nurses’ clinical decision-making is informed by foundationalknowledge that arises from multiple dimensions: the nursingprofession, self, and general and specific aspects of the patientsituation (Fig. 1). The use of knowing rather than knowledge innaming the various dimensions reflects the need for nurses tomovebeyond ‘having’ knowledge: Effective decision-making entailsactive acquisition of new knowledge pertinent to the specificpatient and situation, along with thoughtful use of existingknowledge. The defining attributes of each knowledge dimensionprovide direction for educators when analyzing nurses’ use ofknowledge within their clinical decision-making (Fig. 2).

Nurses’ capacity for knowing the profession is made evident inclinical decision-making that reflects the scope and standards ofnursing practice, and specific nursing unit roles, competencies andskills. Knowing the self highlights the importance of nurses’ aware-ness of all that they bring to a decision-making situation and, assuch, offers a critical contribution to patient safety. Nurses’ capacityto reflect on their clinical judgment and their self-awareness areessential components in developing clinical decision-makingcapacity (Etheridge, 2007; Tanner, 2006). When considering thisdimension of foundational knowledge, educators may explorenurses’ awareness of their strengths, limitations, skills, experience,and learning needs as they relate to the situation and their will-ingness to seek oroffer help as appropriate. In addition, effective andethically sound clinical decision-makingwill be grounded in nurses’awareness of the potential for their beliefs, values, assumptions andpreconceptions to influence their clinical decisions.

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Case, patient or client and person dimensions (Liaschenko,1997)encompass patient-related knowledge used in clinical decision-making (Fig. 1). In assessing knowing the case, educators will focuson nurses’ understanding of the theoretical concepts related togeneral patient populations and, critically, their capacity to applythis knowledge in making clinical decisions. For novice practi-tioners, case knowledge will be drawn primarily from text books;with experience this base is expanded through the acquisition ofexperiential knowledge (Benner et al., 1996). Knowing the client orpatient occurs when nurses use case knowledge to build anunderstanding of an individual’s clinical state, focusing on baselineinformation, patterns and trends in physiologic and diagnostic data.Knowing the person incorporates a patient’s past and currentexperience of health and illness, as well as their preferences,supports and resources. Knowing the patient and person arefoundational to the provision of individualized nursing care andsupports nurses’ anticipatory thinking (Ebright et al., 2003).

There are several issues that may influence nurses’ capacity tobuild knowledge that supports individualized clinical decision-making and nursing care. First, because case knowledge providesdirection for knowing the patient and person, deficits in caseknowledge will limit the nurses’ ability to build individualizedknowledge. Second, nurses’may have adequate case knowledge but,due to underdeveloped thinking processes, have difficulty using thisknowledge to build patient and person knowledge, guide accurateproblem identification, and to inform decision-making (del Bueno,2005). Third, nurses’ experience will influence their capacity tobuild individualized knowledge. For example, novice nurses mayexperience difficulty building an understanding of patients as indi-viduals when clinical situations are complex. With increasingexperience, nurses begin to view situations more holistically andattend to patients as individuals (Benner et al., 1996).

The clinical decision-making process

In this framework, the phases that comprise the clinical deci-sion-making process (i.e., cues, judgments, decisions, and evalua-tions of outcomes) are non-linear, inform and may be informed byone another. Questions provided in Fig. 2 guide analysis of each ofthese phases.

CuesNurses’ clinical decision-making processes are initiated when

they recognize a cue from the patient; this may be either a partic-ular patient response or the absence of something expected. Fromthis beginning point, nurses collect additional cues from multiplesources in order to understand the situation.

There are several aspects of nurses’ cue collection that warrantconsideration by educators. First, because assessment andcommunication are central to the process of cue collection, nurses’competence in these areas will influence the quality of cue collec-tion. Secondly, novice nurses’ reliance on rule bound thinking andlack of experiential knowledge challenges them completingappropriate cue collection (Benner et al., 1996). With limited abilityto recognize salient aspects of a patient situation, novice nursesmay collect a wide range of cues in a relatively non-discerningmanner, and then struggle with making sense of the accumulatedinformation. Alternatively, either because of lack of knowledge, orin response to a real or perceived sense of urgency to ‘solve theproblem,’ novice nurses may fail to collect adequate cues andsubsequently form a judgment that is based in limited information(Taylor, 2002). Nurses’ lack of ‘a total picture’ of a patient situationemerged as a theme surrounding novice nurses’ near-miss andadverse-event situations (Ebright et al., 2004). Accordingly, analysisof this phase of nurses’ clinical decision-making process should

consider the sources, scope and relevancy of cues collected as wellas nurses’ recognition of patterns within cues and their capacity toassign meaning to cues.

JudgmentJudgment is defined as the best conclusion a nurse can reach at

a point in time, given the information available (Gillespie andPaterson, 2009). This definition reflects the clinical reality inwhich nurses engage in a dynamic process, moving betweenpossible judgments and cue collection. Ongoing cue collectioninforms, and is informed by, a nurse’s evolving understanding ofthe situation and continues toward a best conclusion. Analysis ofthis phase is guided by questions in Fig. 2.

There are several potential sources of error in the process ofmoving between cues and possible judgments to form a bestconclusion. First, novice nurses’ limited knowledge base may resultin them failing to consider and explore a full range of explanationsfor patients’ presenting cues, resulting in formation of an incorrectjudgment (Chase, 1995; Taylor, 2002). Second, errors can occurwhen nurses fail to consider cues that do not fit their favoredjudgment: this may arise from a nurse’s sense of urgency to ‘makea decision,’ or from bias arising from misplaced confidence or lackof understanding. When a judgment is favored, nurses may collectcues to ‘rule in’ that judgment, and consequently narrow theirscope of consideration. In contrast, when cue collection is struc-tured to build evidence related to a variety of possible judgmentsand ultimately ‘rule out’ less likely explanations, the probability ofan accurate judgment is increased (Evans, 2005). Similarly, errorsmay occur if, after forming an initial judgment, nurses fail to remainopen to revising the judgment as new information emerges (Chase,1995; Harbison, 1991). Finally, the time spent in collecting cues toconfirm judgments must always be weighed against the patient’sclinical state. In more acutely ill patients, delay in forming a judg-ment may result in deterioration in patient condition. Safe practiceis supported by nurses’ awareness of their progress toward forminga judgment (knowing self) and their willingness to seek assistancefrom other health care professionals.

Once a judgment is formed, the nurse assigns priority by rankingthe judgment within concerns related to the individual patient aswell as within an assigned group of patients. Appropriate prioritiesare congruent with patient care goals and reflect patient safety.Nurses’ ability to assign appropriate priority to judgments isinfluenced by their knowledge base and thinking processes. Aswell, nurses’ experience influences their vision of priorities in care,with novice nurses often placing emphasis on completion ofassigned tasks, while more experienced nurses focus on care ofpatients and families more broadly (Benner et al., 1996). Finally,prioritization is influenced by various contextual factors includingthe nurseepatient relationship, resource availability, predominantpatient-care philosophy, unit culture, and time-related factors(Bowers et al., 2001; Bucknall, 2003; Chase, 1995; Hendry andWalker, 2004).

Decision(s)Having reached a ‘best conclusion’, the nurse must determine

a course of action, a phase that requires consideration of both whatshould be done and how that should occur (Boblin-Cummings et al.,1999). The Situated Clinical Decision-Making framework acknowl-edges that nurses may enact decisions in various ways including‘waiting and watching’ and ‘trying something’ (Gillespie andPaterson, 2009). When assessing this phase of nurses’ clinical deci-sion-making, educators must differentiate between the outwardlysimilar states of choosing to ‘wait andwatch’ and a delay in decision-making that arises from uncertainty. Inaction arising from uncer-tainty holds significant implications for patient safety, and highlights

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the importance of nurses recognizing when they need to seekassistance. The decision option of ‘trying something’ recognizesa quality of testing that is inherent in many nursing decisions. In thisdecision variant, nurses choose to proceed with a tentative course ofaction but remain open to revising the actions as new informationbecomes available to them. Patient safety, and a focus for educatorassessment, rests on the nurses’ ability to differentiate betweenconsciously choosing to test a course of action versus trying some-thing because they lack other alternatives, as well as the nurses’capacity to revise actions based on patient responses. Finally, novicenurses’ concern about making a right decision can be a stalling pointin this phase of their clinical decision-making process. The SituatedClinical Decision-Making framework frames the goal of the decisionphase as a best decision, highlighting two relevant points foreducators to consider. First, there may be more than one course ofaction that constitutes safe, appropriate, and ethical care. Second, thebest decision will consider the uniqueness of the patient and thesurrounding context.

Evaluation of outcomesIn the final phase of clinical decision-making, nurses consider

the effectiveness of the decision, a process that requires effectiveassessment processes and adequate cue collection. In response totheir conclusion regarding outcomes, nurses may return fromevaluation to any point in the decision-making process, or mayrecognize the need for assistance and choose to involve anotherhealth care professional. These various possibilities guide educatorsin considering the effectiveness of the evaluative phase of nurses’decision-making.

Thinking

The Situated Clinical Decision-Making frameworkmakes explicitthe critical contribution of critical, systematic, creative, and antici-patory thinking to clinical decision-making. This multidimensionalperspective of thinking mirrors Tanner’s (2006) assertion thatnurses use a variety of reasoning processes in making clinicaldecisions and offers guidance for educators in assessing nursesdecision-making (see Fig. 2 for guiding questions).

Critical thinking underpins nurses’ inquiry and generativethinking and has been linked to effective clinical decision-making(Boney and Baker, 1997; Cruz et al., 2009; del Bueno, 2005). Criticalthinking becomes evident in nurses’ ability to identify and chal-lenge assumptions, values, and beliefs that they bring to a situation;consider the influence of context; generate possible explanations,judgments and decisions; and maintain reflective skepticism(Brookfield, 1987). Critical thinking ability may be inhibited bya variety of contextual factors including workload, time pressures,and a narrow focus on a patient issue (Ebright et al., 2004; Potteret al., 2005). Systematic thinking is reflected in nurses’ ability tocollect, analyze and organize information in a methodical mannerthat supports pattern recognition, formation of sound judgments,selection of actions, and evaluation. Creative thinking is integral toand made evident in nurses’ responses to everyday challenges inthe clinical environment that arise from patients’ individuality,increasing acuity and complexity of patients, and limitations inresources. Finally, anticipatory thinking or ‘thinking ahead’ isessential to prevention and early detection of potential patientproblems, timely intervention when problems occur, alignment ofspecific decisions with broader patient care goals and, conse-quently, favorable outcomes for patients (Benner et al., 1999;Minick and Harvey, 2003). Anticipatory thinking also supportsprioritization and workload planning (Ebright et al., 2003). Novicenurses’ predominant orientation toward present time and taskcompletion, often limits their ability to think ahead. With

experience, capacity for anticipatory thinking evolves, becomingevident at competent level of practice (Benner et al., 1996).

The inclusion of thinking in the framework is highly relevant toanalysis of nurses’ clinical decision-making. First, by differentiatingthinking from foundational knowledge, educators are prompted toconsider both areas as possible sources of challenge: that is, todetermine if nurses’ clinical decision-making issues arise frominadequate knowledge or from an inability to use various thinkingprocesses to utilize existing knowledge to a specific patient situa-tion. This differentiation is critical as many novice nurses experi-ence challenges related to thinkingwithin clinical decision-making.In a recent study, new graduates reported feeling unprepared andoverwhelmed by the thinking required in the provision of patientcare (Etheridge, 2007), while surveys of new graduates’ criticalthinking and clinical judgment reveal poor performance in thinkingprocesses (del Bueno, 2005).

Using the framework

Clinical nurse educator roles are enacted in various ways acrossthe global nurse education community and, accordingly, afforddifferent opportunities for assessment of nurses’ clinical decision-making. While the inherent complexity of the framework may beperceived as a constraint, its structure offers flexibility in itsapplication. The framework can be used to guide an in-depthexamination of a nurse’s clinical decision-making or a focusedexploration of specific components of the larger decision-makingprocess. The order of assessment is contextually dependent, withexploration potentially beginning at any component of decision-making and expanding to other aspects as appropriate. In all situ-ations, the guiding questions (Fig. 2) streamline the assessmentprocess by drawing an educator’s attention to relevant points forconsideration. The questions are intended to guide inquiry: infor-mation related to these questions may be obtained throughobservation of clinical practice and through conversation withlearners. Educators are cautioned against rigidly using the guidingquestions as an ‘interview tool’. Instead, inviting the nurse to ‘talkthrough’ a clinical decision-making situation will provide insightnot only into various phases of nurses’ clinical decision-making, butalso their thinking processes and knowledge. The followingexample illustrates the use of Situated Clinical Decision-Makingframework and questions as an analysis tool.

Exemplar

A clinical nurse educator (Jill) was working with a group ofsenior undergraduate nursing students. She was concerned aboutone student’s (Sue) ability to set appropriate priorities in providingcare for acutely ill medical patients. To understand the influence ofcontext on Sue’s clinical decision-making, Jill began by reviewingthe meso-context of the situation. From the question “whatopportunities exist for Sue to collaborate and consult?” Jill inves-tigated the adequacy of unit staffing, influence of physical layoutand unit culture on consultation, and workload (for Sue and her‘buddy RN’). She looked for evidence of correlation between Sue’scapacity to prioritise and her workload and patient assignments. Atthe micro-context level, Jill considered Sue’s level of confidence,her communication ability, and the fit between her level of expe-rience and the acuity of assigned patients.

Next, aware that adequate cue collection and judgment formationnecessarily precede appropriate prioritization, Jill explored thesephases of Sue’s decision-making process. To augment her previousobservations of Sue’s decision-making, Jill arranged a time andlocation to talk with Sue. After outlining the purpose of theirconversation, Jill focused Sue on a recent patient care situation. She

M. Gillespie / Nurse Education in Practice 10 (2010) 333e340 339

asked Sue to describe her actions, and to articulate her thinkingrelated to those actions, including considerations about the patient’scondition. As Sue shared her ‘story’, Jill listened for informationrelevant to the cues and judgments questions, as well as evidence ofSue’s thinking processes and use of relevant knowledge. As theconversation continued, Jill’s evolving understanding directed herongoing exploration. For example, Jill noted that Sue’s ‘story’reflected limited cue collection and was unsure if this was a result ofinadequate knowledge, thinking or contextual influences. Conse-quently, Jill explored Sue’s case knowledge relevant to the situation,as well as her capacity to generate and use patient and personknowledge in decision-making processes. Jill concluded that work-load and staffing patterns were significantly impacting Sue’sopportunity to consult with her buddy RN. Further, it was evidentthat while Sue’s knowledge in this situation was reasonable, hercapacity to ‘think ahead,’ and consider the implications of plannedactions, was not well developed. Ultimately, Jill identified two focalareas to support Sue in developing her clinical decision-making:First, to strengthen opportunities for consultation and collaborationand second, to build her capacity for anticipatory thinking. Her nextstep would be to select and implement relevant strategies.

Selection of strategies

Clear identification of the origin of issues within a nurse’s clinicaldecision-making sets the stage for selection of strategies that arealigned with developing the capacities needed for effective clinicaldecision-making.With a clear focus for development, educatorsmaymake meaningful selections from the numerous strategies andapproaches for developing clinical decision-making that have beendescribed in literature. Additionally, the Situated Clinical Decision-Making framework is designed to guide novice nurses in makingclinical decisions in simulated and clinical practice. Previous publi-cation includes questions that guide nurses in the phases of clinicaldecision-making, while the multidimensional knowledge baseprompts nurses’ use of various kinds of knowledge (Gillespie andPaterson, 2009). Educators can also use the framework as the basisfor a rubric that describes levels of performance in clinical decision-making that in turn, can guide development (Lasater, 2007). Finally,the framework provides educators and nurses with a sharedlanguage for feedback regarding nurses’ clinical decision-making(Gillespie and Paterson, 2009; Tanner, 2006).

Implications for education and research

The Situated Clinical Decision-Making framework has been usedwithin specialty nursing education to support development ofregistered nurses’ clinical decision-making in classroom, distanceand clinical learning environments (Gillespie and Paterson, 2009).The ready comprehension of this framework by registered nursesfurther suggests that clinical educators could easily be familiarisedwith the framework and the guiding questions, supporting its usewithin clinical nursing education. Anecdotal reports from clinicaleducators within specialty nursing programs indicate that theframework alone provides useful direction in assessing nurses’clinical decision-making. More recently, the guiding questions havebeen added to enhance its utilization by novice clinical educators.Finally, while this anecdotal evidence is encouraging, the use of theSituated Clinical Decision-Making framework as a tool to assessnurses’ clinical decision-making requires empirical testing.

Conclusion

The multidimensional nature of the Situated Clinical Decision-Making framework assists educators in ‘unpacking’ the complexity

of nurses’ clinical decision-making and identifying the source ofissues than impair decision-making processes. By drawing atten-tion to the many contextual factors that influence clinical decision-making, it prompts educators to make critical distinctions betweenissues arising from the context and nurse-related factors thatinfluence nurses’ decision-making. The various dimensions offoundational knowledge prompts consideration of nurses’ selfknowledge within their decision-making process, and highlightscritical differences between understanding general theoreticalconcepts and using that information to build knowledge of indi-vidual patients. There are many variables that can disrupt theeffectiveness of the process: By identifying the various phases ofthe clinical decision-making process, the framework guideseducators in exploring a nurse’s effectiveness in each of the phases.Finally, the inclusion of various thinking processes promptseducators to differentiate between clinical decision-making issuesthat arise from inadequate knowledge and concerns that have theirorigins in poorly developed thinking processes. By assistingeducators to clearly identify sources of issues that contribute toa nurse’s ineffective clinical decision-making, the possibility ofeffective support is enhanced. With a clearly identified issue, theeducator is then able to work with the nurse to select meaningfuland relevant strategies that will help develop clinical decision-making capacity.

Acknowledgment

The author acknowledges Dr. Barbara Paterson for her work indeveloping the original version of the Situated Clinical Decision-Making Framework.

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