Clinical decision-making in cardiac nursing: a review of the literature

Abstract

Clinical decision-making is an integral part of the professional nurse's role. This literature review aims to determine the present evidence available on clinical decision-making in cardiac nursing and to determine implications for practice and future research in this field.

Headnote

Summary

Clinical decision-making is an integral part of the professional nurse's role. This literature review aims to determine the present evidence available on clinical decision-making in cardiac nursing and to determine implications for practice and future research in this field.

Keywords

Cardiac nursing; Clinical decision-making; Literature review

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

NURSES ARE the only occupational group in the NHS to provide 24-hour bedside care and thus have great opportunity to apply their knowledge to meet patients' needs (Hurst 1993). In addition, nurses are usually the first to observe any rapid deterioration in a patient's physical state and it is the nurse's interpretation of events that determines subsequent action. This, combined with the increased responsibility associated with technology and specialisation, demands that nurses be effective clinical decision-makers (Boney and Baker 1997). In cardiac nursing, the decisions the nurse will face can range from routine to life or death. Patient conditions change quickly and thus nurses assume a decision-making role in an emergency situation. Consequently, clinical decision-making is an integral component of the role of the professional nurse.

Literature search strategy

The body of research on decision-making is large and complex. A thorough search was conducted of the relevant published English literature on clinical decision-making in cardiac nursing. Searches of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline, the National Library of Medicine's service, were conducted via CD-ROM. Primary search words used were 'clinical decision-making'. Secondary search words used included'cardiac nursing practice', and 'cardiac nursing education'. The search strategy covered the period from 1985 to 2004 and identified 687 articles.

Original research reports and literature reviews were considered relevant for inclusion in this review. Two specific questions asked of each literature review cited were: was it comprehensive, and was it a critical evaluation of the available literature?

Five specific questions asked of each published study cited were: Was the study clear, concise and relevant? Were the objectives and methods of the study clearly stated? Was the research design described? Were the results comprehensively reported? Were the recommendations made in the conclusion clear and concise, and did they relate to the study's stated objectives?

Of the articles, many were excluded for failing to meet the quality criteria or failing to offer new findings. This left 68 articles of which 11 were randomly selected for this discussion (Table 1).

Decision-making

Decision-making is an essential part of the nurse's role (Rhodes 1985, Caputo and Mior 1998, Palmier 1998). Decision-making is a process nurses use to manage a range of information from diverse sources to make professional clinical judgement (Clark 1996). Case (1994) states that nursing judgement involves selecting and organising data to support conclusions. In the decision-making process, judgement is one of the phases-deliberation and choice are the other two - that nurses consider (Moore 1996). Despite the extensive measurement of decision-making, most authors have defined the decision-making process rather than stating what a decision is. The Oxford Complete Wordfinder (Reader's Digest 1993) uses words such as 'judgement' and 'settlement', reporting that a decision is made with deliberation and consideration.

Effect on health

Nurse administrators must determine the best courses of action for managing staff members, budgets and supplies (Malloch 1999). The application of decision-making theories may assist in the allocation of resources.

Nurse education in the UK has been integrated into higher education and the academic status has been raised to a minimum of diploma level to quality as a registered nurse. Various social and political forces have under pinned current demands for higher education to demonstrate the effectiveness and quality of educational programmes. The quality of decision-making and the intellectual maturity that it confers is a qualitative indicator of higher education (Glen 1995).

Furthermore, medicine has the professional lead in most areas of diagnosis and treatment and therefore, many nurses seek more autonomy (McCoppin and Gardner 1994), and arguments for extended roles are made based on increasing patient choice, accessibility and continuity. Bandman and Bandman (1988) stress the need for decision-making in nursing that 'is of practical assistance and acts as a liberating force in thoughtful activity pertaining to nursing'. Decision-making implies power and the authority to function without the approval of others, Without the power that originates from the right to make independent decisions, no one can function as a true professional. Consequently, autonomous clinical decision-making is essential to the future of professional nursing practice (Scott et al 2003a). Nursing has been affected by changes in health care that have led to innovations, including the development of nurse-led clinics and nurse consultants. These changes are affecting inter-professional relationships, autonomy and the nature of decision-making.

Theoretical perspectives

The study of clinical decision-making can be divided into prescriptive and descriptive approaches (Marriner-Tomey 1942). Prescriptive (or normative) approaches are concerned with how decisions ought to be made and focus on the outcomes and results of the process, while descriptive models are concerned with describing how the decisions are actually made and focus on the processes that allow nurses to make decisions (Shin 1998). From a stated common purpose to explain and predict the processes that govern decisions, these approaches make various assumptions about the nature of knowledge and the generation of information.

Studies measuring decision-making have used different research approaches and examined different aspects (Kikuchi and Simmons 1999). Stevens (1985) asserts that clinical decision-making strategies can be divided into quantitative approaches that examine the outcome of the decisions using mathematical (statistical) techniques and qualitative approaches that concentrate on how decisions are made and the process of decision-making. In addition, studies have also examined the factors that influence decision-making (Erlen and Sereika 1997, Luker et al 1998) and the role of intuition (Benner and Tanner 1987).

A variety of different methods have been used to investigate clinical decision-making depending on what is being examined. If the outcome of a decision-making process is the aim of investigation, observation, interviews and surveys are appropriate techniques (Fonteyn et al 1993). Hurst (1993) revealed that nurses did not follow the stage model sequentially when making clinical decisions. The stage model includes (Marriner-Tomey 1992): problem identification, seeking alternatives, selecting an alternative, implementing a decision and evaluation.

In decision analysis an attempt is made to assign a probability to possible outcomes (Raiffa 1968). This analysis is often presented in a pictorial form called a decision tree. A decision tree leads the nurse from general to specific assessments and ultimately to a decision choice. Letourneau and Jensen (1998) found that the accuracy of decision-making with use of a chronic wound management decision tree improved over time, as did accuracy of decision-making after initial contact with the decision tree. The authors concluded that a decision tree can assist decision-making by guiding the nurse through assessments ami treatment options.

However, Moore (1996) states that using such analysis is questionable when addressing symptom management and the importance of patients' action and feedback in the decision-making process. Furthermore, Benner and Tanner (1987) assert that decision trees only apply to relatively structured problems. Hicks (1997) also reports that critical care nurses found difficulty in specifying probability and utility values in decision trees.

Fonteyn et al (1993) state that what people say they do and how they behave can be very different. This can be a problem in interviews as well as in questionnaires. Therefore, a method called 'think aloud' is often used in conjunction with simulations to examine the thought processes used (Holzemer et al 1986). Corcoran (1986a) used a think aloud method to describe the initial and overall approaches to planning, used by expert and novice nurses for three patient cases of varying complexity. He found that novices used narrow initial approaches more often than broad ones, while experts could develop a broad overview of the patient.

Factors that influence decision-making

Six influential factors have been identified in the literature: knowledge, experience, evidence-based practice, psychological stress, nurse-physician relationship and role. Where authors give practical examples the cardiac care situations are used.

Knowledge Several researchers found that knowledge and clinical experience were the most important factors influencing clinical decision-making (Bucknall and Thomas 1997, Caputo and Mior 1998). The knowledge a nurse brings to the diagnostic task plays a critical role in determining how the problem will be interpreted (Corcoran 1986b, Pelletier et al 1998). The knowledge that nurses store in their memories in the form of concepts, schema and scripts is retrieved when needed. The person with a broad knowledge base will produce many more perspectives when refraining problems and generating solutions (Drummond 1996). Thus, the deeper and broader the nurse's conceptual knowledge base, the wider the range of cues he or she will discover and use during the decision-making process (Moore 1996).

However, Bucknall and Thomas (1997) investigating clinical decision-making by 230 critical care nurses, found that 95 percent had difficulty making clinical decisions due to lack of knowledge. For example, only 20 percent were competent to identity basic types of arrhythmias, tor example, tachycardia and bradycardia. In a study of 53 qualified German nurses (Sefrin and Paulus 1994), none of the nurses were able to perform basic life support adequately, and 60 per cent were judged to be ineffective. In addition, Benner (1984) reported that, although community nurses believed their work required a scientific basis, their practice was founded on practice-based knowledge.

These findings raise two important issues. First, the relationship between knowledge and clinical decision-making is ambiguous, and the type of knowledge (research-based or practice-based) that nurses use when making decisions is not known. Research-based knowledge is scientific knowledge provided by written procedures, textbooks and research papers while practice-based knowledge concerns knowledge gained through clinical experience (Kitson 1997). Second, the aim of pre-registration education is to ensure that the right quantity and quality of practitioners are prepared appropriately to meet changing healthcare needs (Department of Health (DH) 1996).

Health education should aim to enable students to nutation, examine and reflect on ideas and values (Fox 2003a). Therefore, pre-registration education has a crucial role to play in clinical decision-making. Moule; and Knight (1997) state that there must be a sound and broad knowledge base to underpin effective clinical decision-making. In other words, nurses must he knowledgeable to make effective decisions.

However, scrutiny of the life and death decisions to initiate cardiopulmonary resuscitation (CPR), for example, shows that many nurses do not have the knowledge or skills to follow the decision to its logical conclusion (Gruden 1991, Couch and Graham 1993, Greig and Elliot 1996). Patient survival in cardiac care depends on competent and immediate initiation of CPR following cardiac arrest (Jowett and Thompson 1988). Therefore, it is essential that all nurses should have the skills and knowledge to perform CPR when necessary (Advanced Life Support Group 1993).

Smith and Hatchett (1992) surveyed 50 qualified nurses about their perceptions of their competence in resuscitation and cardiology-related skills. The authors reported that 20 per cent of the nurses felt competent in identifying all seven basic arrhythmias, 66 per cent believed that they were competent in handing the anaesthetist the correct equipment for intubation, and 44 per cent stated competence in providing the correct equipment required for central cannulation. Moule and Knight (1997) examined 24 nursing students and found that 43 per cent achieved competency levels in CPR skills, while 67 per cent needed further training and retesting to become competent.

Undergraduate and postgraduate programmes need to address the knowledge and skills necessary for nurses to he competent in their professional practice (Gordon and Grundy 1997). However, it is difficult for academics to educate nurses when the profession is constantly being redefined. Changes may include developing critical thinking, management, leadership and research skills, increasing use of technology and developing clinical decision-making approaches based on the ethical and legal aspects of health care.

Experience Clinical experience is identified as being essential for effective clinical decision-making (Benner and Tanner 1987). Benner (1984) showed that the experience level of the nurse has a profound effect on the decision-making process. In their experimental study examining differences in the way that novices and experts make decisions, Holden and Klingner (1988) showed that the experts often used less information in making a more accurate diagnosis.

Similarly, Corcoran (1986a) found that experts generated more alternative actions, were more specific in evaluating alternative actions and developed better nursing plans than novices, Furthermore, Clark (1996) investigated novice nurses and found that clinical decision-making was the foundation of thar daily work, and that it was a difficult process for them to apply theory to clinical practice. It seems that experts make better clinical decisions. Therefore, it is important that inexperienced nurses work with experiaieud or expert nurses to help them develop this skill either directly or indirectly through the mentorship process.

The contribution of intuition in clinical decision-making is subject to debate. Benner and Tanner (1987) state that experts see and use patterns as a whole rather than analysing a situation in discrete elements that may lead to sensitivity being lost and tlie basis tor decision-making being weakened. In emergency situations experts can focus on the problem accurately without wasteful searching for alternatives (Moore 1996).

Although the nature and characteristics of expert practice have been described in the literature, the description is incomplete (Adams et al 1997). How expertise is gained is not fully understood and definitions of expert competencies have yet to be developed. This is difficult to achieve because competency is a philosophical concept and can only be useful if role specific. In addition, previous experience of similar situations is valuable but does not override the need for flexibility and the ability to recognise that each new situation may require a different decision. Because expertise is gained in the context of practice, expertise cannot be achieved out of context or taught as an academic exercise (Harbison 1941, Adams et al 1997).

Evidence-based practice Studies have identified the need to base clinical decision-making on evidence-based practice (Alexander 1997, Davies 1997). Clinical guidelines, protocols and care pathways are approaches that encourage evidence-based practice if founded on the best available research evidence and kept up to date.

It is generally accepted that healthcare staff work towards providing the best possible outcomes of care and treatment (Fry 1998). Consequently, every decision that nurses make should take account of the evidence available and their ability to appraise and interpret this evidence. According to Marnner-Tomey (1992) clinical guidelines and protocols serve as a basis for decisions and actions, help co-ordinate plans, control performance, increase consistency of action and delegate authority. Davies (1997) implemented a protocol for nurse-led extubation for patients following cardiac surgery. The protocol had been used for three years without any adverse effects or failed extubations. Robertson (1996), after implementing a critical pathway in cardiac, orthopaedic and medical wards at Memorial Hospital, New York, reported that critical pathways improved the qualify of patient care outcomes, speeding up and enhancing the patient's recovery time and helping to manage costs.

Tingle (1997) argued that practitioners are better protected it they can show their decisions are based on care pathways or clinical guidelines, because this indicates that care is provided in a controlled environment that supports reflective clinical practice. However, the DH (1996) states that: '...the onus of responsibility remains firmly on individual clinicians. Clinical guidelines cannot be used to mandate, authorise or outlaw treatment options'.

However, the use of guidelines is not universally accepted. Gibson and Heart Held (1996) suggest that clinical guidelines in their current form may be seen as harmful to the discipline of nursing. They question whether it is realistic to suggest that guidelines can reflect the values of each healthcare discipline. However, Smith (1997) states that the development and implementation of clinical guidelines may place nursing at the vanguard of developments. Hunt (1997) identifies that nurses do not use research findings because: they do not know about them, they do not understand them, they do not believe them, they do not know how to apply them and they are not allowed to use them.

Psychological stress Psychological stress occurs during the decision-making process (Bucknall and Thomas 1997). Stress occurs when nurses try to reconcile their ideals of patient care with the reality of nursing (Walsh and Shaw 2000). Cardiac areas are described as stressful environments because of the complexity of patient health problems and the increasing use of high technology (Duff et al 1996). Cardiac nurses make many decisions m a short period or time and often with little information. These decisions may have a profound effect on the patient's survival and, therefore, nurses are aware of the serious consequences of mistakes. Although human errors are common in clinical practice, very little is known of the types, antecedents and consequences of errors in nursing practice (Meurier 2000). This limits the potential to learn from errors and to make improvements in the quality and safety of nursing care.

Baumann and Bourbonnais (1986) identified stress as an important factor in rapid clinical decision-making. They found that the quality of decision-making decreased due to stress as measured by the rate of error. Boumans and Landeweerd (1994) have described issues related to death and dying as particularly stressful, while Spoth and Konewko (1987) revealed that clinical decision-making and death and dying were the most important concerns of intensive care nurses.

Wichowski and Kubsch (1995) found that nurses reported the need to be competent in using technological equipment as a factor that produced stress. Technological changes are contributing to the increasing complexity of care and the tendency for hospital stays to become shorter (Gordon 1992). Technology is regarded as an essential aspect of patient care (Hawthorne and Yurkovich 1995) and needs to he skilfully managed and incorporated mm the nursing role (Mann 1991). Therefore, appropriate education and training are needed on the principles and uses of medical technology.

Nurse-physician relationship The mutually supportive nurse-physician relationship in cardiac care is paramount to the nurse's clinical decision-making (Baggs et al 1997). In this study nurses and physicians reported similarly moderate amounts of collaboration, but nurses reported less satisfaction with clinical decision-making than physicians. Knaus et al (1986) found that the interaction and joint decision-making that occurs between nurses and physicians in critical care units was more effective in mortality and morbidity issues. Nevertheless, Schumacher (1993) found that consulting with nurse colleagues when in doubt was perceived as essential in the clinical decision-making process of nurses.

Role The literature indicated that the role of the cardiac nurses has a profound effect on clinical decision-making (Bucknall and Thomas 1995). Nurses have a multidimensional role to fulfil. Cardiac areas are not quiet, calm environments but places with highly technological equipment, frequent alarms and emergency situations. Cardiac nurses must have an advanced knowledge-specifically of pathophysiology and pharmacology. They need to he highly skilled in the use of the equipment and develop characteristics, such as alertness, sensitivity and a full understanding of body haemodynamics to he able to interpret the patient's needs and take the necessary actions. Defibrillation, emergency intravenous drug therapy and the recording and interpretation of electrocardiograms have become normal nursing practice in many cardiac units (Smith 1999).

Care for the critical patient should not only focus on physical problems hut also on the patient's psychosocial state (Burton 2000). Cardiac nurses also have a teaching, counselling and supporting role to fulfil. An acute onset of myocardial infarction frequently causes anxiety and depression for the patient (Conduit 1997). In addition, family needs and concerns require honest communication and understandable information on a daily basis and questions should be answered directly (Fox 2003b). Consequently, cardiac nurses need to be active in cardiac rehabilitation and meet the educational needs of patients and families (Gibbon et al 2002).

Cardiac nurses are con fronted with patients experiencing rapidly changing health and may be called on to act in a crisis situation if medical staff are initially absent. Bowler and Mallik (1998) found that senior critical care nurses identified themselves as independent, autonomous practitioners involved in clinical decision-making.

It appears that, although cardiac nurses have a considerable amount of autonomy, they lack a clear clinical decision-making role. There is contusion about what nurses perceive as autonomy and what actually occurs in practice. When nurses make clinical decisions they are accountable for them. According to Vaughan (1989) nurses are held accountable when they have personal and structural autonomy. Personal autonomy is the expertise, knowledge and skills related to a defined area of work. In contrast, structural autonomy is freedom and authority given by the organisation to an individual to act (Vaughan 1989).

When nurses consider they have a high level of autonomy they perceive personal autonomy as the base on which clinical decisions are being made. However, what actually takes place is the structural autonomy or authority, which is usually bureaucratic (Scott et al 2003b), with medical staff having a traditional dominant role over nurses. Thus, personal and structural autonomy have contradictory effects (Vaughan 1989). While personal autonomy is about loyalty to the profession, maintenance of high standards and responsibility to patients, structural autonomy is about loyalty to the institution and following its rules and regulations.

Discussion

In day-to-day practice, nurses are constantly making decisions. One of the major roles of professionals is to make or to participate in clinical decision-making in conditions of uncertainty, especially m situations that have major life consequences, such as cardiac units,

To make cardiac nursing practice safe and professional, nurses need to develop the necessary skills, knowledge and confidence to be effective decision-makers. To gain confidence and practise safely, cardiac nurses should know what their roles are, what their limitations are and how best they can use research knowledge in practice. The demand to quantify outcomes and increase individual accountability will become the catalyst for nursing research to identity effective and safe clinical interventions (Castledine 1997). Nurses are more accountable to the profession in terms of roles and authority and therefore, clinical nurses are responsible for understanding and applying research and professional information to practice.

Registration to practice is conferred by the Nursing and Midwifery Council and part three of Assuring Fitness for Practice (NMC 2002) reports that the council shall establish the standards of proficiency necessary to be admitted to the profession. This raises the question of how nursing competency is judged. In other words, how do registered nurses know with confidence that they have the necessary and adequate knowledge and skills needed to perform their duties and responsibilities? In addition, the NMC ensures that universities follow the standards and requirements to be met for professional registration. It will be a challenge to nurse educators to ensure that competencies are identified and broken down into appropriate skill elements for learning and assessment.

Fey and Miltner (2000) suggest that course content should be determined by the individual student's professional needs and that rhe curriculum design should be flexible. It can be concluded that nurse education is supported by a policy that places responsibility on practitioners to define and assess their own standards of competency. Ultimately, practitioners have the final responsibility to recognise if they are competent for a particular task or not. The public has the right to expect nursing care that is delivered by competent and safe practitioners.

Conclusion

The literature in this field is growing steadily, with more systematic and rigorous studies emerging. Six main factors that influence clinical decision-making were identified with knowledge and clinical experience being the most important influence on clinical decisions. Although most studies examine how decisions are made and the numerous factors that influence decisions, there is a paucity of research on what clinical decisions cardiac nurses make in practice and the outcome of these decisions on the recovery of patients. However, the outcome of clinical decision-making is difficult to research because of the extraneous variables that influence patient care.

To make cardiac nursing practice safe and professional, nurses need to develop the necessary skills, knowledge and confidence to be effective decision-makers. Newly qualified nurses need to be supported by senior staff nurses to develop their skills in clinical decision-making. Since prior knowledge has an important influence on the proficiency of the decision-making that takes place, undergraduate and postgraduate courses need to provide the knowledge and skills for nurses to develop decision-making approaches

Sidebar

Bakalis N (2006) Clinical decision-making in cardiac nursing: a review of the literature. Nursing Standard. 21, 12, 39-46. Date of acceptance: January 25 2006.

References

References

Adams A, Pelletier D, Duffield C et al (1997) Determining and discerning expert practice: a review of the literature. Clinical Nurse Specialist. 11, 5, 217-222.

Advanced Life Support Group (1993) Advanced Cardiac Life Support. Chapman and Hall, London.

Alexander C (1997) Influencing decision-making. Nursing Standard. 11, 38, 39-42.

Baggs J, Schmitt M, Muslilin A et al (1997) Nurse-physician collaboration and satisfaction with the decision making process in three critical care units. American Journal of Critical Care. 6, 5, 393-399.

Bandman E, Bandman B (1988) Critical Thinking in Nursing Appleton and Lange, Norwalk CT.

Baumann A, Bourbonnais F (1986) A crisis decision making in coronary care. Nursing Papers. 17, 4, 4-18.

Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, California CA.

Benner P, Tanner C (1987) Clinical judgment: how expert nurses use intuition American Journal of Nursing. 87, 1, 23-31.

Boney J, Baker D (1997) Strategies for teaching clinical decision-making. Nurse Education Today 17, 1, 16-21

Boumans N, Landeweerd J (1994) Working in an intensive or non-intensive care unit: does it make a difference? Heart and Lung. 23, 1, 71-79.

Bowler S, Mallik M (1998) Role extension or expansion, a qualitative investigation of the perceptions of senior medical and nursing staff in an adult intensive care unit. Intensive and Critical Care Nursing. 14, 1, 11-20

Bucknall T, Thomas S (1995) Clinical decision making in critical care. Australian Journal of Advanced Nursing. 13, 2, 10-17

Bucknall T, Thomas S (1997) Nurses' reflections on problems associated with decision making in critical care settings. Journal of Advanced Nursing. 25, 2, 229-237

Burton C (2000) A description of the nursing role in stroke rehabilitation. Journal of Advanced Nursing. 32, 1, 174-181.

Caputo L, Mior S (1998) The role of clinical experience and knowledge in clinical decision-making. Topics in Clinical Chiropractic. 5, 2, 10-18.

Case B (1994) Walking around the elephant: a critical thinking strategy for decision-making. Journal of Continuing Education in Nursing. 25, 3, 101-109.

Castledine G (1997) Framework for a clinical career structure in nursing. British Journal of Nursing. 6, 5, 264-269.

Clark R (1996) Clinical decision-making by beginning nurses. Unpublished PhD dissertation. Virginia University, Charlottesville VA.

Conduit E (1997) Self-worth in the heart attack survivor British Journal of Therapy and Rehabilitation. 4, 6, 323-328.

Corcoran S (1986a) Planning by expert and novice nurses in cases of varying complexity. Research in Nursing and Health. 9, 155-162.

Corcoran S (1986b) Task complexity and nursing expertise as factors in decision-making. Nursing Research. 35, 2, 107-112

Crouch R, Graham L (1993) Resuscitation. Nurses' skills in basic life support: a survey. Nursing Standard. 7, 20, 28-31

Davies N (1997) Nurse-initiated extubation following cardiac surgery. Intensive and Critical Care Nursing. 13, 2, 77-79.

Department of Health (1996) Clinical Guidelines; Using Clinical Guidelines to Improve Patient Care Within the NHS. HMSO, London.

Drummond H (1996) Effective Decision-making. Second edition. Kogan Page, London.

Duff L, Kitson A, Seers K, Humphris D (1996) Clinical guidelines an introduction to their development and implementation. Journal of Advanced Nursing. 23, 5, 887-895.

Erlen J, Sereika S (1997) Critical care nurse's ethical decision-making and stress. Journal of Advanced Nursing. 26, 5, 953-961.

Fey M, Miltner R (2000) A competency-based orientation program for new graduate nurses. Journal of Nursing Administration. 30, 3, 126-132.

Fonteyn M, Kulpers B, Grobe S (1993) A description of think aloud method and protocol analysis. Quarterly Health Research. 3, 4, 430-441.

Fox J (2003a) Consumerism 2: pre-registration nursing and midwifery curricula. British Journal of Nursing. 12, 6, 378-386.

Fox J (2003b) Consumerism 1: the different perspectives within health care. British Journal of Nursing. 12, 5, 321-326.

Fry S (1998) Guidelines for making enct-of-life decisions. International Nursing Review. 45, 5, 143-144.

Gibbon B, Watkins C, Barer D et al (2002) Can staff attitudes to team working in stroke care be improved? Journal of Advanced Nursing. 40, 1, 105-111.

Gibson T, Heartfield M (1996) Critical pathways: a critical analysis. International Journal of Nursing Practice. 2, 4, 189-193.

Glen S (1995) Developing critical thinking in higher education. Nurse Education Today. 15, 3, 170-176.

Gordon S (1992) The importance of being nurses. Technology Review. October, 49-51.

Gordon F, Grundy M (1997) From apprenticeship to academia: an adult branch programme. Nurse Education Today. 17, 2, 162-167.

Greig M, Elliot D (1996) Basic life support skill acquisition and retention in student nurses undertaking a pre-registration diploma in higher education/nursing course. Nurse Education Today. 16, 1, 28-31.

Grobe S, Drew J, Fonteyn M (1991) A descriptive analysis of experienced nurses' clinical reasoning during a planning task. Research in Nursing and Health. 14, 4, 305-314.

Gruden E (1991) An investigation into why qualified nurses inappropriately describe their own CPR skills. Journal of Advanced Nursing. 16, 5, 597-605.

References

Harbison J (1991) Clinical decision making in nursing. Journal of Advanced Nursing. 16, 4, 404-407

Hawthorne D, Yurkovtah S (1995) Science, technology, caring and the professions: are they compatible? Journal of Advanced Nursing. 21, 6, 1087-1091

Hicks F (1997) Critical thinking abilities and clinical decision making consistency among critical care nurses. Unpublished PhD dissertation. University of Illinois, Chicago IL.

Holden C, Klingner A (1988) Learning from experience. Journal of Nursing Education. 37, 1, 23-29

Holzemer W, Resnik B, Slichter M (1986) Criterion-related validity of a clinical simulation. Journal of Nursing Education. 25, 7, 286-290.

Hunt J (1997) Towards evidence based practice. Nursing Management. 4, 2, 14-17

Hurst K (1993) Problem Solving in Nursing Practice. Scutari Press, London.

Jowett N, Thompson D (1988) Comprehensive Coronary Care. Scutari Press, London.

Kikuchi J, Simmons H (1999) Practical nursing judgement: a moderate realist conception. Scholarly Inquiry for Nursing Practice 13, 1, 43-55.

Kitson A (1997) Using evidence: to demonstrate the value of nursing. Nursing Standard. 11, 28, 34-39.

Knaus W, Draper E, Wagner D, Zimmerman J (1986) An evaluation of outcome from intensive care in major medical centres. Annals of Internal Medicine. 104, 3, 410-418.

Letourneau S, Jensen L (1998) Impact of a election tree on chronic wound care. Journal of Wound Chronic Care. 25, 5, 240-247.

Luker K, Hogg C, Austin L, Ferguson B, Smith K (1998) Decision-making the context of nurse prescribing. Journal of Advanced Nursing. 27, 3, 657-665.

Malloch K (1999) The performance measurement matrix: a framework to optimise decision making. Journal of Nursing Care Quality. 13, 3, 1-12.

Mann R (1991) Preserving humanity in an age of technology. Intensive and Critical Care Nursing. 8, 1, 54-59

Marriner-Tomey A (1992) Guide to Nursing Management and Leadership, Fifth edition. Mosby, St Louis MO.

McCoppin B, Gardner H (1994) Tradition and Reality. Churchill Livingstone, Melbourne.

Meurier C (2000) Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event Journal of Advanced Nursing. 32, 1, 202-207.

Moore P (1996) Decision making in professional practice. British Journal of Nursing. 5, 10, 635-640.

Moule P, Knight C (1997) Emergency, cardiac arrest! Can we teach the skills? Nurse Education Today. 17, 2, 99-105.

Nursing and Midwifery Council (2002) Assuring Fitness for Practice. NMC, London.

Palmier D (1998) How can the bedside nurse take a leadership role to affect change for the future? Concern. 27, 1, 16-17.

Pelletier D, Duffield C, Mitten-Lewis S, Nagy S, Crisp J (1998) Australian nurses and device use; the ideal and the real in clinical practice. Australian Critical Care. 11, 1, 10-14.

Raiffa H (1968) Decision Analysis. Addison-Wesley, Reading MA.

Reader's Digest (1993) Oxford Complete Wordfinder. Clarendon Press, Oxford

Rhodes B (1985) Occupational ideology and clinical decision making in British nursing. International Journal of Nursing Studies. 22, 3, 241-247

Robertson C (1996) Critical paths: a tool to improve skiing on the slopes of managed care. Tennessee Nurse. 59, 1, 19-22.

Schumacher L (1993) Decision-making in nursing. Unpublished PhD dissertation, University of Maastricht, Maastricht.

Scott P, Vallmaki M, Leino-Kilpi H et al (2003a) Autonomy, privacy and informed consent 4 surgical perspective. British Journal of Nursing. 12, 5, 311-320

Scott P, Valimaki M, Leino-Kilpi H et al (2003b) Autonomy, privacy and informed consent 1: concepts and definitions. British Journal of Nursing. 12, 1, 43-47

Sefrin P, Paiilus T (1994) Resuscitation skills of hospital nursing staff. Anaesthetist. 43, 2, 107-114.

Shin K (1998) Critical thinking ability and clinical decision nuking skills among senior nursing students in associate and baccalaureate programmes in Korea. Journal of Advanced Nursing. 27, 2, 414-418.

Smith C (1997) Evidence based nursing. Nursing Management. 3, 10, 22-23.

Smith M (1999) Rehabilitation in Adult Nursing Practice. Churchill Livingstone, Edinburgh.

Smith S, Hatchett R (1992) Perceived competence in cardiopulmonary resuscitation, knowledge and skills, amongst 50 qualified nurses. Intensive and Critical Care Nursing. 8, 2, 76-81.

Spoth R, Konewko P (1987) Intensive care staff stressors and life event changes across multiple settings and work units. Heart and Lung. 16, 3, 278-283.

Stevens B (1985) The Nurse as Executive. Third edition. Rockville Press, Aspen CO.

Tingle J (1997) Clinical guidelines and the law. In Wilson J (Ed) Integrated Care Management: The Path to Success? Butterworth Heinemann, Oxford, 70-71.

Vaughan B (1989) Autonomy and accountability. Nursing Times. 85, 3, 54-55.

Walsh D, Shaw D (2000) The design ot written information for cardiac patients; a review of the literature. Journal of Clinical Nursing. 9, 5, 658-667

Wichowski H, Kubsch S (1995) How nurses react to and cope with the uncertainty of unfamiliar technology: validation for continuing education. Journal of Continuing Education in Nursing. 26, 4, 174-178.