decision making and multi disciplinary practice week two

7/31/2019 Decision Making and Multi Disciplinary Practice Week Two

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NUR 479 Principles and Practice of Adult Nursing

Dr Bernie Reid


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By the end of this section you will be able to: Identify and define types of decision-making Discuss characteristics of decision-making Discuss factors that influence decision-making

Understand theories of decision-making Discuss ethical factors in clinical decision-making Understand and discuss teams Describe the multidisciplinary team Demonstrate an understanding of what

professional boundaries are Describe the purpose and process of referring Describe the utility of networking They will be able to operate as a team member


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There are several theories of decisionmaking to take into account. They fall intothree main categories and have beenlabelled as normative, descriptive orprescriptive.

Each of the theories makes assumptionsabout people and the way things are. This

then forms the basis of their thinking abouthow and why people make decisions in aparticular way.


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Assume that everyone is (or has the capacityto be) a rational, logical thinker.

Therefore, normative theories are centredupon the processes involved in making anideal decision.


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Describes how individuals arrive at decisionsand are concerned with analysing each of thesteps in a decision-making process and howone gets from one to the other.


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Assume that people's decision-makingprocesses are flawed.

Therefore, prescriptive theories attempt toprescribe ways of improving the process witha view to making better decisions.


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Traditional Problem solving process The managerial decision making process The nursing process Intuitive decision making model

Regardless of the process used, it isalways important to be critical of theaccuracy and quality of the decisions youmake given the consequences that may beinvolved.


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You will come across many terms used todescribe decision making such as clinicaldecision-making, clinical judgement, clinicalinference, clinical reasoning etc.

It is however important to distinguish fromthe outset the difference between judgementand decision-making.


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Judgement has been described as, theassessment of alternatives whereasdecision-making is, choosing betweenalternatives (Dowse 1993).

Therefore, you can see that judgement (or

in this case, clinical judgement) is a keycharacteristic of decision-making. Consequently, decision-making may be

defined as a process by which information(or evidence) is assimilated and judged and

from this, a course of action or outcome isarrived at. This is then communicated as a decision


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You must remember, however, that as thisprocess relies on your judgement you mustalways be mindful of the Code of Conductand make sure that you are practicing within

its guidance.


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Fundamentally, the tools offered thus far fordecision making are a way of thinking' and enableyou to calmly and methodically work through aproblem, gathering evidence, weighing upalternatives and coming to a reasoned logical

conclusion that is workable. The goal here then is that when presented with aproblem in placement, you will be able to call uponthis knowledge and blend it with your practice toguide the care you deliver. The learning contractsthat you will be completing on placement aredecision-making tools also and will help in thisprocess when they enable you to see how modulelearning outcomes are translated into practice.


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It should be noted however that decisionmaking is a part of the problem solvingprocess and the terms should not be usedinterchangeably. It is possible to make a

decision without engaging in the processoutlined above


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There are two main types of decision thatcan be made.

There are :

decisions that go for what is possible asopposed to what you would like to do.

On the other hand, there are; decisions that choose the

best option from the alternatives that meetthe needs of the person or solve theproblem in hand.


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Experience and knowledge: Education

Self-concept

Environmental stressors Creative thinking ability


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Making a decision does, of course, haveconsequences (as highlighted previously). Inpractice, the consequences of yourdecisions will have ethical implications. Byethical implications, we mean the extent to

which the decision would be interrogatedalong the lines of,

Ethical principles have been addressed in

other modules so now would be a goodtime to review the ethical principles thatpractice is founded upon.


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The first team that you will work within is thenursing team. Nursing teams are slightly differentfrom other teams in that they are always changing.

The way in which shift patterns are designed tocover the ward results in different people being on

at different times and this means that the team onduty every day will nearly always be different. It could therefore be argued that this influences

how the members of the team function and howquickly the team settles down to becomeeffective.

Underpinning this are group formation processesand to function as a manager you need tounderstand what these processes are.


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In this context we should point out that theterm group does not just refer to anumber of people who happen to work inthe same location but rather a number ofpeople who believe themselves to be insome way linked either by purpose oridentity.

It could be argued that this underpins theuse of the term team as opposed togroup because team implies belonging.


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Groups have both organisational purposesand individual purposes.

The organisational purpose of a group wouldbe to solve a problem or carry out a particularfunction.

The individual purpose of a group is to derivepleasure from being a member of the group,

the provision of security.


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Bass & Ritterband, (1979), identified four distinctstages in the development of groups and thesemay be listed as:

The development of mutual acceptance andmembership. This is characterised by initial

mistrust and inadequacies felt by members. Themembers of the group may appear defensive andmay limit behaviour through conformity and ritual.

The promotion of communication and decision-making. This is possible once acceptance occursand feelings are expressed. At this point norms of

procedure develop and members develop liking orcaring for one another. More constructive problem-solving and decision making strategies develop.


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Rising motivation and productivity. Thismay be manifested by members co-operating instead of competing and at thisstage motivation by intrinsic reward toachieve productivity becomes apparent.

Control and organisation. Work is allocatedby agreement according to abilities.

Members work independently and the groupis flexible and adapts to new challenges.


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Forming; the group comes together or meets andconsideration is given (either overtly or in a less obviousfashion) to the hierarchical structure of the group,patterns of leadership, individual roles, codes ofconduct, etc. This is an anxious stage as the members

are creating an impression and testing each other toestablish themselves and boundaries.

Storming; at this stage the members have become morefamiliar with each other. Disagreement may occur asviews are expressed more forcefully. This may lead to

hostility within the group. There is important reformingor refocusing of working arrangements if this stage issuccessfully completed.


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Norming; at this point conflict and hostilitywane. Standards and guidelines areestablished, as members need to co-operatein order to plan and fulfil the purpose of the

group Performing, at this stage the group structures

are established, the group is cohesive andfunctions effectively


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Group membership has benefits for the individualbut there is also a price to be paid in the form ofbehaviour modification to conform to establishednorms. This is known as social influence.

Sherif (1936), argued that people will adjust theirperception to conform to social or group norms

and that the effect of this social influence is covertand extremely strong. Knowledge of social influence can enable a

manager to influence outcomes and manipulate theworkforce to produce the results that he/shedesires.

The purpose of this is to ensure that theorganisational goals are met and in this case, itwould be the delivery of good quality nursing care.


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Each of the professions noted in the diagramprovide a unique service to the patient.

In practice, it would be good practice to speakto each of the professions when you see them

on the ward and ask them what their specificrole is. Sometimes its easy to misinterpret what others

do. With a detailed knowledge of their functionit will make the process of referral easier foryou and will reduce the number of timesrequests for services are rebuffed as beinginappropriate.


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Clinical practice is constantly changing and theboundaries that define where one profession stopsand another begins are constantly shifting.

This is especially clear in the realm of specialistpractice but can be just as confusing for the staffnurse on the ward.

From the point of view of the Code of Conduct weare constantly reminded of our personalaccountability and how this may be in part bedefined by having an awareness of where your ownpersonal boundaries lie.

This will be based in part upon your awareness of

your competency but will be complemented byknowledge of local policy determining where adefinitive boundary may lie.


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Referring may take two forms: In the first instance, it may be viewed as a process by

which you refer something onto a senior or moreexperienced colleague when you feel that you havereached the limits of your knowledge and experience.

Secondly, a more traditional view of referring would bea process by which you refer a patient onto anotherservice for a specialist opinion, or to arrange a service.

This is usually accompanied by a discussion of thepatients needs with medical colleagues and will involve

administrative processes so that the process may beappropriately logged and recorded in the patientsnotes.


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We have looked at:

Making informed decisions Definition and characteristics of decision-making Theories of decision-making

Applying theory to practice The skills involved in clinical decision-making Ethical factors in clinical decision-making Groups and group processes Multidisciplinary working Roles Professional boundaries Referring

decision making and multi disciplinary practice week two

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