CLINICAL DECISION

MAKING PROCESS
Ye b o a Ky e r e m a a N a o m i
Dept. Maternal and Child Health
School of Nursing and Midwifery
University of Cape Coast
Introduction
Decision making in midwifery is a complex process that shapes
and underpins clinical practice and determines, to a large
extent, the quality of care.

Clinical decision making is a balance of experience, awareness,

knowledge and information gathering, using appropriate
assessment tools, and evidence-based practice to guide safe
care.

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Introduction
The process of utilizing evaluative data, patients individual
needs and clinical judgement to formulate the most
appropriate strategies to achieve desire outcome is termed as
decision making.

Decision making can range from fast, intuitive, or heuristic

decisions through to well reasoned, analytical, evidence-based
decisions that drive patient and client care.

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Core Skills of Clinical Decision Making
•Pattern recognition: learning from experience.

•Critical Thinking: removing emotion from our reasoning with

the ability to clarify goals, examine assumptions, be open-
minded, recognise personal attitudes and bias, able to evaluate
evidence.

•Evidence-based approaches: using available evidence and

best practice guidelines as part of the decision making process.
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Core Skills of Clinical Decision Making

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Core Skills of Clinical Decision Making
Communication Skills: Effective communication skills
involves active listening.

Midwives must have the ability to listen to the patient, what

they say, non verbal cues, their story, their experiences and
their wishes.

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Core Skills of Clinical Decision Making
Active listening enables a patient centred approach that
embraces self-management and comprehensive information
provision that allows patients/clients and their family to be
involved in the decision making process.

Sharing: your learning and getting feedback from colleagues

on your decision making.

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Core Skills of Clinical Decision Making
Team work: using the gathered
evidence to enlist help, support and
advice from colleagues and the wider
multi-disciplinary team.
It's important to liaise with colleagues,
listen and be respectful, whilst also
being persistent when you need support
so that you can plan as a team when
necessary.

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Core Skills of Clinical Decision Making
Reflection: using feedback from
others, and the outcomes of the
decisions to reflect on the decisions
that were taken in order to enhance
practice delivery in the future.

It's also important to reflect on your

whole decision making strategies to
ensure that you improve your decision
making skills and learn from
experience.

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Factors Affecting Decision Making
Evidence from research findings provides basis for current
practice and affect knowledge and health outcomes when
combined with experience.

Self Awareness: Being aware of your behaviour,

competencies, attitudes, emotions, values and those of
patients/clients and colleagues. It is important to know
boundaries and limitations.

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Factors Affecting Decision Making
Recognition of patient and person: Knowing the patient's
preferences, their experiences of illness and their current
situation or care needs and what is normal for that patient in
terms of observation, mobility and level of function might
change your care strategies.

Environment and team dynamics: Awareness and

recognition of the approach to decision making and the wider
team dynamics within the clinical setting affect decision on
care.
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 The Decision Making Process
•The decision making process refers to case base reasoning, the
methods and steps involved in the making of critical judgement.

•The steps in clinical decision making also integrates the nursing

process approach to provide interventions.

•Analysis is a key component to find evidence to support occurrences,

assessing who should be consulted, using intuition to make
judgments and prioritise care based on situation and the
environment.
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The Decision Making Process

•Making decisions is deciding what to do and how to do it,

deciding who might need to be informed and consulted.

•This can include colleagues, and the patient/client involved in

the centre of decision making.

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Clinical Decision Making Steps
Appropriate clinical decision making considers the need to
make a precise diagnosis in midwifery practice.

Clinical decision making has five steps which integrates the

nursing process into the decision making.

The steps are assessment, diagnosis, planning, implementation,

and evaluation.

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Clinical Decision Making Steps
Assessment
•Assessment is the first step and involves critical thinking skills
and data collection; subjective and objective.

•Subjective data involves verbal statements from the patient or

caregiver. Objective data is measurable, tangible data such as
vital signs, intake and output, and height and weight.

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Clinical Decision Making Steps
Assessment
•Data may come from the client directly or from primary
caregivers who may or may not be direct relation family
members as well as friends can play a role in data collection.

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Clinical Decision Making Steps
•Electronic health records may populate data and assist in
assessment.

•Critical thinking skills are essential to assessment, thus the

need for concept-based curriculum changes.

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Clinical Decision Making Steps
Diagnosis
•The formulation of a nursing/midwifery diagnosis by employing
clinical judgment assists in the planning and implementation of
patient care.

•The North American Nursing Diagnosis Association (NANDA)

provides nurses and midwives with an up-to-date list of
nursing diagnoses.

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Clinical Decision Making Steps
A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health
problems on the part of the patient, family, or community.

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Clinical Decision Making Steps
Diagnosis
•The diagnosis or problem statement can be done after
assessment is completed to have enough data to diagnose the
patient.

•The problem statement, or the diagnostic label, describes

the client’s health problem or response to which nursing
therapy is given concisely.

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Clinical Decision Making Steps
Diagnosis
•A diagnostic label usually has two parts: qualifier and focus of
the diagnosis.

•Qualifiers (also called modifiers) are words that have been

added to some diagnostic labels to give additional meaning,
limit, or specify the diagnostic statement.

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Clinical Decision Making Steps

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Clinical Decision Making Steps
The four types of NANDA-I nursing diagnosis are:
•Actual (Problem-Focused)
•Risk
• Health Promotion
•Syndrome

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Clinical Decision Making Steps

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Clinical Decision Making Steps
•Problem-focused diagnosis also known as actual
diagnosis are the client problems present at the time of the
nursing/midwifery assessment.

•Actual diagnoses are based on the presence of associated

signs and symptoms. Actual nursing diagnosis should not be
viewed as more important than risk diagnoses but priority is
key.

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Clinical Decision Making Steps
•There are many instances where a risk diagnosis can be the
diagnosis with the highest priority for a patient.

•Problem-focused nursing diagnoses have three components:

Nursing diagnosis
Related factors
Defining characteristics

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Clinical Decision Making Steps
Examples of three part nursing/midwifery diagnosis
•Ineffective breathing pattern related to pain as evidenced by
pursed-lip breathing, reports of pain during inhalation, use of
accessory muscles to breathe.

•Anxiety related to stress as evidenced by increased tension,

apprehension, and expression of concern regarding upcoming
surgery.

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Clinical Decision Making Steps
Examples of three part nursing/midwifery diagnosis
•Acute pain related to decreased myocardial flow as evidenced
by grimacing, expression of pain, guarding behavior.

•Impaired skin integrity related to pressure over bony

prominence as evidenced by pain, bleeding, redness, wound
drainage.

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Clinical Decision Making Steps
Examples of three part nursing/midwifery diagnosis
•Delayed surgical recovery related to increased blood glucose
level and obesity as evidenced by poor wound healing, fatigue,
and excessive time.

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Clinical Decision Making Steps
•The second type of nursing diagnosis is called risk nursing
diagnosis.

•The risk nursing diagnosis are clinical judgments that the

problems does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses
intervene.

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Clinical Decision Making Steps
•Risk diagnosis is based on the patient’s current health status,
past health history, and other risk factors that may increase
the patient’s likelihood of experiencing a health problem.

•The risk diagnosis are integral part of nursing/midwifery care

because they help to identify potential problems early on and
allows the nurse to take steps to prevent or mitigate the risk.

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Clinical Decision Making Steps
•There are no etiological factors (related factors) for risk
diagnoses.

•The individual (or group) is more susceptible to developing the

problem than others in the same or a similar situation because
of risk factors.

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Clinical Decision Making Steps
•Components of a risk nursing diagnosis include risk diagnostic
label, and risk factors.

Example of two part diagnosis

•An elderly client with diabetes and vertigo who has difficulty
walking refuses to ask for assistance during ambulation may be
appropriately diagnosed with risk for injury or risk for adult
falls related to difficulty walking.

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Clinical Decision Making Steps
Example of two part diagnosis:

•Risk for Falls as evidenced by muscle weakness

•Risk for Injury as evidenced by altered mobility

•Risk for Infection as evidenced by immunosuppression

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Clinical Decision Making Steps
•Health promotion diagnosis also known as wellness
diagnosis is a clinical judgment about motivation and desire
to increase well-being.

•It is a statement that identifies the patient’s readiness for

engaging in activities that promote health and well-being.

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Clinical Decision Making Steps
•For example, if a first-time mother shows interest on how to
properly breastfeed her baby, a nurse make a health promotion
diagnosis of “Readiness for enhanced breastfeeding.”

•This nursing/midwifery diagnosis will be then used to guide

nursing/midwifery interventions aimed at supporting the
patient in learning about proper breastfeeding.

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Clinical Decision Making Steps
•Health promotion diagnosis is concerned with the individual,
family, or community transition from a specific level of wellness
to a higher level of wellness.

•Components of a health promotion diagnosis generally include

only the diagnostic label or a one-part statement.

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Clinical Decision Making Steps
Examples of one part statement
•Readiness for enhanced spiritual well being.

•Readiness for enhanced family coping.

•Readiness for enhanced parenting.

•Readiness for enhanced health literacy.

•Readiness for enhanced exercise management.

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Clinical Decision Making Steps
•Syndrome diagnosis is a clinical judgment concerning a
cluster of problem or risk nursing diagnoses that are predicted
to present because of a certain situation or event.

•Syndrome diagnosis are written as a one-part statement

requiring only the diagnostic label or problem statement.

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Clinical Decision Making Steps
Example of syndrome diagnosis
Chronic Pain Syndrome
Post-trauma Syndrome
Frail Elderly Syndrome
Relocation Stress Syndrome
Neonatal Abstinence Syndrome

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Clinical Decision Making Steps
•Possible nursing/midwifery diagnosis is not a type of
diagnosis as are actual, risk, health promotion, and syndrome.

•Possible nursing/midwifery diagnoses are statements

describing a suspected problem for which additional data are
needed to confirm or rule out the suspected problem.

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Clinical Decision Making Steps
Possible nursing diagnosis provides the nurse with the ability
to communicate with other nurses that a diagnosis may be
present but additional data collection is indicated to rule out or
confirm the diagnosis.

Examples include:
Possible chronic low self-esteem.
Possible social isolation.

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Clinical Decision Making Steps
Planning
•The planning stage is where goals and outcomes are
formulated that directly impact patient care based on evidence
based planning guidelines.

•These patient-specific goals and the attainment of such assist

in ensuring a positive outcome. Nursing care plans are
essential in this phase of goal setting.

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Clinical Decision Making Steps
•Care plans provide a course of direction for personalized care
tailored to an individual's unique needs.

•Overall condition and comorbid conditions play a role in the

construction of a care plan.

•Care plans enhance communication, documentation,

reimbursement, and continuity of care across the healthcare
continuum.
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Clinical Decision Making Steps
Planning
•Initial planning is done by the nurse who conducts the
admission assessment.

•Usually, the same nurse would be the one to create the initial
comprehensive plan of care.

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Clinical Decision Making Steps
Planning
•Ongoing planning is done by all the nurses who work with the
client.

•As a nurse obtain new information and evaluate the client’s

responses to care, they can individualize the initial care plan
further.

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 Clinical Decision Making Steps
Planning
•An ongoing care plan also occurs at the beginning of a shift.

•Ongoing planning allows the nurse to:

◦ determine if the client’s health status has changed.
◦ set priorities for the client during the shift.
◦ decide which problem to focus on during the shift.
◦ coordinate with nurses to ensure that more than one problem
can be addressed at each client contact.
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Clinical Decision Making Steps
Planning
•Discharge planning is the process of anticipating and planning
for needs after discharge and to provide continuity of care,
nurses/midwives need to accomplish the following:

•Start discharge planning for all clients when they are admitted
to any health care setting and involve the client and the client’s
family in the planning process.

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Clinical Decision Making Steps
Planning
•Collaborate with other health care professionals as needed to
ensure that biopsychosocial, cultural, and spiritual needs are
met.

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Discussion
Discuss the specific component to include in the discharge
planning.

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Clinical Decision Making Steps
Planning
Goals should be:
•Specific
•Measurable or Meaningful
•Attainable or Action-Oriented
•Realistic or Results-Oriented
•Timely or Time-Oriented

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Clinical Decision Making Steps
Implementation
•Implementation is the step that involves action or doing and
the actual carrying out of nursing/midwifery interventions
outlined in the plan of care.

•This phase requires nursing/midwifery interventions such as

applying a cardiac monitor or oxygen or cardiotocography
medication administration, standard treatment protocols, and
evidence base practice standards.

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Clinical Decision Making Steps
Evaluation
•This final step of the nursing process is vital to a positive
patient outcome and whenever a healthcare provider
intervenes or implements care, they must reassess or evaluate
to ensure the desired outcome has been met.

•Reassessment may frequently be needed depending upon

overall patient condition and the plan of care may be adapted
based on new assessment data.

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Discussion

What the sources of patient information and how is missing

information replaced

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Summary
•Clinical decision making is a complex dynamic process that involves
critical thinking and evidenced based practice to make meaningful
health outcomes.

•The decision making process comprises gathering data, analysing ,

making decision and evaluating to produce a comprehensive care
for the patient/client.

•The decision making process is cyclical and interventions are not

producing expected outcomes, there is the need to implement
other options to provide quality care for patients.

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 Reference
Casanova R. et al (2019). Beckmann & Ling’s Obstetrics &
Gynecology Eighth Edition. Wolters Kluwer. E-book. Chapter 6.
Topic 9, page 142.

Daemers, D.O.A. et al (2017). Factors influencing the clinical

decision-making of midwives: a qualitative study. BMC Pregnancy
Childbirth 17, 345.https://doi.org/10.1186/s12884-017-1511-5

Sakala B. K. (2009).“Factors Influencing Midwifery Clinical

Decision-making”, Int. Ann. Sci., vol. 7, no. 1, pp. 28–32.

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