Nurses Clinical Decision Making

Nurses' Clinical
Decision Making
Russell Gurbutt
Senior Lecturer Health Informatics
Lancashire School of Health and Post Graduate Medicine
University of Central Lancashire
Foreword by
Carl Thompson
Radclie Publishing
Oxford Seattle
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# 2006 Russell Gurbutt
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While every eort has been made to ensure the accuracy of the information
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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
ISBN-10 1 84619 037 1

ISBN-13 978 1 84619 037 7
Typeset by Anne Joshua & Associates, Oxford

Printed and bound by TJ International Ltd, Padstow, Cornwall
Contents
Foreword iv
Preface vi
About the author vii
Acknowledgements viii
A guide to using this book ix
1 Setting the scene: the clinical landscape of decision making 1
2 Making clinical decisions: a model of nurses' decision making 18
3 The narratives that nurses generate: ways of knowing the patient 39
4 Demonstrating narratives: dierences between verbal and written

narratives 51
5 The games nurses play: making narratives known to doctors 66
6 Narratives and expert decision makers: creating and using

narratives 78
7 Nurses as decision makers: where next? 90
Appendix: Suggested lesson plans 102
Index 127
Foreword
The clinical decisions of nurses and the quality of the judgements that inform
them are at the heart of modern health services. Since Florence Nightingale,
nurses have engaged in the selection of choices for and with patients. Often this
contribution has been downplayed or classed as ùnocial' or ìnformal'. This
situation is changing. Nurses have begun to take on decision-making roles and to
embrace the opportunities for improved patient care that these roles oer.
Moreover, the delivery and organisation of services themselves have begun to
be shaped by the recognition that, at least for some patients, nurses provide as
good, and in some cases better, care than their medical colleagues. Areas such as
tissue viability, diabetes care, stroke rehabilitation and heart failure management
have all seen signi®cant bene®ts accrue when nurses are freed up to lead, exercise
their judgement and make decisions. In the UK, the vision of the modern nurse as
someone who can bridge outmoded and outdated distinctions between `caring'
and `curing' is fast becoming a reality. Initiatives such as nurse prescribing, the
ordering (and just as importantly, the interpretation) of diagnostic tests and
spread of nurse-led `®rst contact' care all mean that seamless provision of services
is at least on the policy agenda.
Of course, with these roles and opportunities for professional development
come great responsibilities. Approximately one in ten patients coming into
contact with acute healthcare endure some form of adverse event, of which
around half are due to errors and have an avoidable component to them. Nurses,
as a central part of the healthcare team, are implicated in these statistics. Areas
such as responding to deteriorating physical observations (60% of cardiac arrests
have documented abnormal observations), diagnosing risks and communicating
those risks to patients and medical colleagues, as well as assessing the preferences
of patients for the choices they face are all areas in which nursing can improve
(and thankfully is improving).
Russell Gurbutt's contribution to this improvement is to explore, describe and
highlight the hidden and the discrete in nurses' decision making. This is an
important contribution, for if we are to start really improving the choices that
healthcare professionals make then the ®rst step on this journey is to know
something about the reality of the types of decisions and judgements that are
involved, the contexts in which they are made, the points of departure from the
rational or what we know about how people should make decisions, and the ways
in which groups of decision makers interact. Only when we have this information
is it possible to adapt normative models of decision making to clinical practice. An
analogy to wine making is possible here: producing great wine depends in part on
knowledge of the terroir (or terrain, micro culture, local climates and soil
composition) in an area. What Russell has produced in this text is a map of
nursing's decision making `terroir'. Like any journey in which progress is mapped
there are some uncomfortable moments: the negative impact of workload and
limited time on choices; the doctor-nurse `game' (still so prevalent after being ®rst
Foreword v
revealed in the 1960s); and the often woeful inadequacies and ineciencies of
information systems (including nurses' own records) all stand out. However,
what this text manages to reveal is that despite this discomfort, there is a richness
and depth to the ways in which nurses describe, and are seen to enact, their
decisions and judgements.
This book provides a ®ne start point for all those interested in enhancing the
decision making capacity of nurses and improving their contribution to patient
care. I have no hesitation in commending this book to all those who want to
improve their knowledge of the realities of decision making from a nurse's
perspective.
Dr Carl Thompson D. Phil (Social Policy) BA (Hons) RN
Senior Lecturer Health Sciences
University of York
Editor Evidence Based Nursing
July 2006
Preface
Clinical work is complex and takes place in a complex environment that centres
around individuals who themselves are physically, socially and spiritually com-
plex. Clinical work also involves multiple participants (nurses, doctors, patients,
physiotherapists, occupational therapists and pharmacists, to name just a few)
who in the course of a day's work can make scores of decisions. Some of these are
deliberatively thought out whilst others are seemingly made at a subconscious
level, often described as intuitive decisions. How then can we make sense of the
complex real world of clinical practice to the extent that we can recognise how
decisions are made and know whether or not these decisions satisfy a range of
evaluation measures?
This book oers a way of ®nding answers to these questions. Its origins lie in
having to examine complaints made about practitioners' decisions in the real
world of clinical practice. In it I draw upon and use the ®ndings of a research
study of nurses' clinical decision making as a framework to guide your examina-
tion of how you, the reader, make decisions, evaluate decisions, learn about
decision making, and understand notions of developing experience and expertise
in decision making. I do not claim that this is a universal account of how all
nurses make decisions, but I do oer this particular account as a means of drawing
attention to the centrality of nurses' clinical decision making in their work.
Decision making is not fully understood, and there is still much to study
about how dierent groups of practitioners make decisions, and about multi-
disciplinary decision making and the interplay between the participants and the
organisational setting in decision making. Having acknowledged this, we still
need to take a proactive approach to understanding clinical decision making in
the complex real world of healthcare service delivery. This book is a step on the
trajectory of a work in progress that takes up the baton of decision enquiry that
has been reported to date, and will no doubt be handed on to a new generation of
enquiring practitioners.
My decision to write the book is grounded in experience of clinical decision
making and research into nurses' decision making alongside the education of
nurses, doctors, social workers and therapists. This has speci®cally included
teaching decision making, health informatics and risk management modules as
well as being course leader for adult nurse training. The latter role highlighted the
need to recognise decision making as part of the nurse's role and to seek ways to
prepare trainees to be competent decision makers and then continue to develop
their expertise after registration. I hope, therefore, that you enjoy reading the
book and that it provokes you to examine how decisions are made in your
workplace, their context, the participants and your role in this process. Above all I
hope that it stimulates re¯ection on how you know patients and act in response
to such knowledge.
Russell Gurbutt
July 2006
About the author
Russell Gurbutt has been a registered nurse for almost 20 years and has clinical
experience in the public and private sectors, including management of a number
of NHS hospital ward teams in surgery and medicine. He currently works at the
University of Central Lancashire as part of the health informatics team in the
School of Health and Postgraduate Medicine. His research interests are in
management and clinical decision making.
Acknowledgements
I wish to thank Steve Willcocks, Martin Johnson and Alan Gillies for advice
received while undertaking the decision-making study that is referred to in this
book. I am also grateful to Gillian Nineham for advice and encouragement to
publish the book. Last but not least, thanks to Dawne, Jessica and Thomas
Gurbutt, who have lived with this study and the subsequent drafting of the
manuscript.
A guide to using this book
This book has been written with particular audiences in mind. These are
practitioners who make decisions, those learning to make clinical decisions as
part of gaining professional registration, those who monitor decisions, and those
involved in pre- and post-registration education of decision makers. The chapters
build up a description of how patients are known and how this knowledge is used
by nurses to make decisions. A range of questions might be raised as you read
through the book and consider the complexity of nurses' clinical decision making.
I have included some questions at the end of each chapter in the `Stop and think'
section to facilitate the making of links with your own practice.
Each chapter has the following format:
. introduction
. main text of chapter
. chapter summary box
. `Stop and think' section.
Chapter 1 Setting the scene: the clinical landscape of

decision making
In this chapter I set the scene with regard to clinical decision making and examine
developments in the role of nurses as decision makers, and the process, outcomes
and context of decision making.
Chapter 2 Making clinical decisions: a model of nurses'

decision making
In this chapter I introduce a model of decision making that is used as a framework
to guide examination of a range of dierent features of the process. This model
represents how nurses seek and interpret information to generate a narrative
about a patient. This is used to identify their needs and choose interventions. The
transition from an individual- to a group-owned narrative and way of shaping
consensus on how a patient is known is examined.
Chapter 3 The narratives that nurses generate: ways of

knowing the patient
In this chapter I focus on how patients can be known in dierent ways and I
explore the implications that this has for the decisions that nurses make.
x A guide to using this book
Chapter 4 Demonstrating narratives: dierences between

verbal and written narratives
In this chapter I examine the invisibility of much of what nurses know about
patients by comparing verbal narratives with their written counterparts in nurses'
records.
Chapter 5 The games nurses play: making narratives

known to doctors
In this chapter I examine the invisibility of nurses' decision making and how they
make their narratives known in order to in¯uence doctors' decisions.
Chapter 6 Narratives and expert decision makers:

creating and using narratives
In this chapter I examine how dierent nurses can be described as inexperienced,
experienced and expert, according to the extent to which they can create and use
narratives.
Chapter 7 Nurses as decision makers: where next?

This summary draws on the preceding chapters to consider the challenges and
opportunities that nurses face in placing knowing the patient at the heart of
clinical practice.
Chapter 1
Setting the scene: the clinical landscape

of decision making
Introduction . Raising questions . Origins and developments . Knowledge

and decision making . Rules and decision making . Assistants in medical
decision making . Breakout: developing nurse decision making . Nursing
models and decision making . Decision-making enquiry about dierent
types of nurse . Decision-making enquiry about dierent types of decision .
Decision-making enquiry about process . Decision-making enquiry and the
use of dierent terminology . Decision making and problem solving .
Decision-making outcomes . Decision-making process . Theoretical explan-
ations . Decision-making context . The clinical landscape . Conclusion .
Stop and think
Introduction
If nurses are decision makers, how can their role and practice be explained? Can
decision making be taught and are there dierent levels of decision-making skill?
If so, how can expert decision makers be recognised? These are just some of the
pertinent questions that need to be asked if we are to recognise and understand
the centrality of clinical decision making in nursing practice.
This chapter introduces nurses' decision making. At the outset it considers two
clinical incidents which highlight a range of questions that real-world practice
raises about decision making. Then selected developments in nurses' decision-
making practice are introduced to highlight how the role has developed and
subsequently moved away from its medically dominated origins. The contribution
of nursing models to the construction of professional identity is used to mark a
shift in focus towards nursing decisions. Dierent types of nurse and nursing
decision are explored along with the processes that they use and the descriptive
terminology employed. Links between decision making and problem solving are
discussed along with explanations of decision outcomes. Dierent theoretical
explanations of the whole process are identi®ed before returning to contem-
porary accounts of the context of nurses' decision making and its in¯uence on the
process.
Throughout the chapter the intention is to show that nurses have a decision-
making role and that their practice includes a range of elements (e.g. information
seeking, processing, knowledge, outcome). Although theoretical accounts draw
2 Nurses' clinical decision making
these elements together, a unifying theory of decision making does not exist.
Figure 1.1 shows how key areas of decision making can be drawn together as a
reference to consider where decision-making enquiry has been and can be
directed. It incorporates the decision maker(s), decision process, decision outcome
and decision-making context. Now let us turn our attention to questions about
decision making that can be generated through real-world practice.
Figure 1.1 A model showing key areas of decision making. The model consists of a
decision maker, a decision process, a decision outcome and a decision-making context.
Raising questions
Think about what it is like to go into hospital as a patient, to be drawn into the
daily business of a complex service provided by numerous people. These include
nurses, therapists, chaplains, doctors, porters, laboratory technicians, chefs,
cleaning sta, administrators and managers, to name just a few. As a patient,
you have expectations about the service that you think you need, an under-
standing of the extent of your participation in decision making, and a degree of
trust in the decisions that healthcare sta make about your care and treatment.
Incidents occur that raise concerns ± perhaps a missed medication, overlooked
requests or sta seeming to be too busy to stop and chat. A catalogue of small
events can lead to a perception that decisions are being made about you but not
with you. Some might actually contribute to harm rather than good. Why would
this be and how can it be explained? Who is making decisions and, perhaps more
importantly, are some decisions being overlooked? Clinical incidents occur in
health service delivery. The two scenarios that follow raise interesting questions.1
During an evening shift on an understaed 36-bed stroke rehabilitation ward
the nurse in charge was commencing a drug round. She had two care assistants
on duty who were busy attending to patients as they worked their way down the
ward. The sta nurse glanced down the ward and saw a patient trying to roll over
in his bed. She called to him to stop as she anticipated (correctly) that he would
fall on to the ¯oor. There was not time to get to his bed, and as he fell out of bed
on to the ¯oor, there was an audible crack. His femur had fractured. Three days
later he died.
This incident raised many questions. Who had assessed the patient's needs and
planned his care? Had a care plan been devised that addressed the need to
maintain a safe environment? Should rehabilitating patients be expected to take
risks (as people in normal health do) and should it be accepted that falls can
happen during the process of regaining independence? Had a decision not been
made that ultimately contributed to the patient's death? Sometimes examining
practice generates far more questions than answers. Fortunately, not all clinical
incidents are as serious as this one. The next story is about a complaint which
Setting the scene: the clinical landscape of decision making 3
implied that nurses were omitting to provide adequate care for a patient. At best it
was an organisational or resource management problem and at worst an
allegation of negligence.
A stroke patient had been convalescing for several weeks on a busy 28-bed
rehabilitation ward. The ward was short staed and the three or four sta on duty
on each shift (registered nurses and care assistants) were involved in physically
demanding work. The most that they could achieve with each patient during a
shift was to attend to their daily needs (such as washing, dressing, feeding and
toileting) and help with some physical therapy. A complaint was made by the
patient's relative in which it was claimed that the rehabilitation process was too
slow. This was attributed to de®cits in the nursing care provided. A local enquiry
took place to investigate the complaint and provide a written response.
The investigation included discussions with the ward team about their care
decisions and examination of their records. Neither of these sources of enquiry
provided a satisfactory answer about what was planned and provided, nor did
they explain how and why decisions had been made or, as was alleged, over-
looked. However, this investigation did generate interest in proposing a study of
how registered nurses made clinical decisions. The ®ndings of that study (of
nurses in four NHS general medical wards) are used to explain dierent features
of decision making, decision makers and their practice in the chapters of this
book. The aftermath of the response to the complaint generated several questions
about nurses' decision making. For example, could nurses recognise the range
and volume of decisions made in the course of their practice? Could they
recognise and explain their decision making? Furthermore, if this could be
explained, why did their care records not clearly demonstrate this? Both scenarios
require questioning to go beyond asking what happened and who made
decisions. The decision-making processes, context, participants and their re-
sources are just some of the factors that need to be considered when seeking to
®nd out why and how decisions are made.
Back in the ward a learning opportunity was lost. The pace of work gave little
respite to seriously examine practice that at times was on a merry-go-round of
trying to match limited resources with ever-increasing demand. There is a saying
that ìf we do what we have always done then we will get what we have always
got'. How apt ± but we need to ®nd a way of stepping aside for a while to examine
what it is that nurses do and to learn about their clinical decision making. Why is
this? It is so that nurses can know how central decision making is to their role and
are able to articulate what it is that they do.
Given that there are often more questions than answers, any simple explan-
ations of decision making seem inadequate. Indeed, as was intimated earlier,
hospitals are complex organisations involving many people, many interactions,
and dierent processes and information sources. It is not surprising that real-
world clinical decision making should be regarded as complex. Some scene setting
follows about the development of nurses as decision makers and their decision-
making practice.
Origins and developments

There are dierent claims about the origin of nurse decision-making enquiry.
These have included the game theory,2 which dealt with decision making under
uncertain conditions and has been linked to applications in economics and

military planning.3 In contrast, others4 have favoured an organisational basis in
models taken from the ®eld of academic administration to explain management
and patient care decisions. These dierences re¯ect a preference for a methodo-
logical approach and point of enquiry ± for instance, a psychology discipline
perspective.5 The work of Florence Nightingale6 can be taken as a convenient
origin point. In her era the foundations of decision making in contemporary
British adult nursing practice were laid. Decision making is implicit within her
1859 text, Notes on Nursing, in which she described the nurse's role and linked it to
a distinction (made in response to criticism from medical sta) between nursing
care and medical cure roles. This had implications with regard to the legitimate
scope of nurses' decisions, their knowledge base and decision-making informa-
tion processing. Although other groups, such as religious orders (especially in
Germany), pre-dated Nightingale's response, it was her work that described the
role of the nurse in Britain.7 Nursing care roles were grounded in Nightingale's
belief that health was subject to laws of nature which required nurses to `put the
patient in the best condition for nature to act upon him.' Consequently they had a sick-
room management role and observed a patient's health change. In contrast,
medical sta were concerned with curative interventions to assist the natural
processes of healing. Political legitimacy had been given to medical diagnostic
decision making through the 1858 Medical Registration Act, which excluded
from medicine the amateur `physicking' of ùnauthorised practitioners' who were
described as `wise women, healers, chemists and druggists'.8 This rendered diagnostic
decision making by nurses illegal, whilst decision-making authority resided with
doctors. It was not until the latter part of the twentieth century that economic
expediency, policy shifts and professionalisation agendas reshaped the scope of
nursing work as far as clinical decision making was concerned.
From Nightingale's day nurses' decisions addressed their duty of being ìn charge
of the personal health of another',6 which implied an individual focus (on a patient),
acting vicariously (in charge of another's health) and having decision authority
(taking charge). As sick-room managers, nurses controlled the physical environ-
ment (noise, heat, light, ventilation) and regulated patient activity (mobility, diet,
hygiene, toileting) and social issues (access of others and recreation). These
translate into contemporary practice as management of the patient in the ward
environment, and include clinical governance, risk management and resource
management. It is often the nurse who òwns' the ward, orders equipment,
checks stock levels, and ensures that maintenance is periodically undertaken and
that sucient sta are rostered to provide care. All other sta visit the ward, but
nurses have a 24-hour presence. Today, as in the 1800s, nurses own the ward and
the patients within it. This has not unnaturally led to them wanting to do more
than merely observe health change and carry out the instructions of medical sta.
They also wanted to diagnose problems, and to do that they needed to develop
their knowledge base. Two directions could have been taken. The ®rst was to
make medical diagnoses, and the second was to develop a nursing knowledge
base and make nursing diagnoses. Both directions have been taken, although at
dierent times, and this has resulted in recent developments in the scope of
nurses' work ± for example, nurse practitioners and consultant nurses.
Knowledge and decision making

Resistance to nursing development came swiftly when attempts were made to
second guess medical diagnoses and threatened medical control.9 Servitude
characterised nursing work, which as far back as 1885 was based on carrying
out the doctor's instructions.10 Whilst upholding a notion of obedience to medical
sta, some doctors recognised the value of independent cognitive action, stating
that the nurse must demonstrate `constant obedience and loyalty in ful®lling her
prescribed duties, but also . . . much more intelligent co-operation in the treatment of
disease'.11
Assumptions about the ability of women to utilise information limited the
progress that could be made towards independent decision making. Far from not
knowing anything about the laws of health in Nightingale's era, nurses sought to
acquire clinical knowledge. This was sucient for a doctor in 1925 to acknow-
ledge a problem of `preventing nurses from attempting to acquire knowledge' and to
recommend that doctors use òur in¯uence to prevent the illegitimate use of such
knowledge'.9 Nurses' desire for knowledge could not be stemmed, and opinion was
divided about what to do, from regulating its use to espousing a thorough
understanding of `scienti®c detail'.10 Medical sta and the dominant medical
model ± which viewed the person in terms of physical systems, disease processes
and treatment regimes ± shaped nursing curricula. For some, nursing knowledge
was a selection of facts and practice as tasks to be learned.12 For others, it
extended to include health and the patient's context, as in a 1923 syllabus that
included medical knowledge (disease and treatment), concepts of health (the
general rules of health) and institutional culture (patterns of ward work).11 This
developed to re¯ect a broadening in the scope of the knowledge that nurses
needed. In 1959, for example, nurses' knowledge included `hygiene, anatomy,
physiology, chemistry, physics, pharmacy and psychotherapy'.13 A dominant medical
view persisted well into the 1980s, with some nursing texts14 continuing to
espouse a physician-centric view of nursing practice.
Nurses' work was limited to their de®ned scope of practice (sick-room manage-
ment or its later equivalent), and they were not to encroach on medical decision
making or ùsurp the role of the medical man' 9 by attempting to diagnose, prescribe
or give an opinion on a case.11 They were `not expected to take on any responsibility
outside their own sphere of work'15 or to àct on her (sic) own responsibility except in an
emergency'.
Rules and decision making

The organisational context in those early days also established some patterns that
persisted well into the later decades of the twentieth century. Each hospital had a
series of local rules (known as hospital etiquette)9 that nurses observed. Within
this culture, nurses developed additional rules (`compelled by experience') to secure
decision outcomes of `proper care for patients'. This was seen as the mark of a good
nurse, and rule-driven practice demonstrated compliance with the medical and
organisational context. Obedience to hospital rules also lent support to the
positional power of doctors in service delivery. Conformity was the rule of the
day as nurses `work(ed) under the doctor' and ward sisters policed this by being
`responsible for the proper carrying out of all the duties and for the observance of order and
discipline'.9 The potency of such socialisation into non-questioning obedience to

doctors was commented on as a `common experience that the more highly quali®ed is
the nurse the less likelihood is there of her attempting to usurp the role of the medical
man'.9 Some nurses colluded with these extrinsic views of their role16 which
depicted them as àn aid in managing the sick', and went so far as to claim that any
challenge brought `discredit' on themselves and their profession. Successful
nursing practice was demonstrated by those `who had learnt not to challenge
doctors'. This has been retrospectively likened to a family metaphor of domestic
role divisions.8 Where did it leave decision making? Nurses tended towards being
medical assistants, provided information for doctors' decision making and
followed rules as far as the legitimate scope of their decision making was
concerned. How then could nurses' participation in decision making be described
within a hierarchical and patriarchal care system?
Assistants in medical decision making

Nurses' work included information seeking and processing ± observation, judge-
ment, reporting and recording. Doctors regarded patient observation as the `key
function' and `the most helpful role that a nurse performed'.17 Observation had long
been valued by doctors on account of nurses being with patients for longer than
doctors. Even in the 1930s, observations were categorised as `proper' and
included appearance, behaviour, bodily systems and communication.16 Current
professional guidance still includes similar remarks about `relevant' information.
Observations were made to identify change, implying information processing,
which was reported to the doctor so that `he may be enabled to make his diagnosis and
orders regarding treatment'.18 Information processing also included descriptions of
the type of change (e.g. `sudden or insidious') but had to report not òpinion but the
facts observed by her [the nurse] during her period of duty'. 18 Other doctors diered
from this and wanted nurses to use àn intelligent mind trained to observe and deduce'
and to avoid `thinking on routine lines.'19
Nurses were originally expected to report their observations to doctors verbally
from memory, so that they could ànswer any questions about the conduct or
appearance of her patient',18 but increasingly used supplementary notes which
were considered to be `more handy and reliable than many memories'. A formal
nursing record was used as a communication book between doctors and nurses,
and this contained medical orders, nurses' observations and nurses' notes of
treatment given.11,18
Deciding what to report to a doctor represented one type of nurse decision, and
implied learning what and when to report. Knowing how to do this was
commonly described as àn issue that required time and experience'.10 Some know-
ledge could be acquired in the classroom, but it would seem that its application in
making decisions was learned in practice.
Breakout: developing nurse decision making

The scope of nurses has altered in the last 25 years, due to the combined eect of
intrinsic and extrinsic factors. Nurses have sought to develop a nursing know-
ledge base and nursing diagnoses related to nursing therapy rather than medical
treatment. In the 1950s and 1960s, nursing was rooted in a medically orientated
èmphasis upon fact, objectivity and reductionism', and the adoption of positivist
approaches emulated the dominance of medical science and a medical model.
Non-positivist methods were used to challenge existing patriarchal and `class-based
expositions of nursing'.20 Descriptions of nursing practice as an art and a science
encompassed these dierences.13,21 Nurses' former practices of apprenticeship
alongside an experienced nurse (learning the art of nursing) were challenged22 as
being insucient to satisfy the contemporary need for a clear theoretical base, as
this only perpetuated existing practices, whereas development of a theory base
would enable practitioners to `develop their own skills'. However, with regard to
learning the art of decision making there was limited evidence of teaching
strategies that `would be most bene®cial to the development of decision-making skills
in nursing'.23 The changing nature of nursing work has led some to conclude that
ìt may never be possible to de®ne the nursing contribution to patient care, due to the ever
changing nature of this work'.24 The art±science dualism at least highlighted the
need to acknowledge the use of dierent types of evidence in nurses' decision
making.
Nursing models and decision making

Nursing is also expressed through the way in which nurses conceptualise their
patients. The development of nursing models marked a departure from the
dominant medical model and challenged it. In contrast to the biomedical gaze
that focused on the body, cells and pathology, nurses in the 1960s and 1970s
began to study other disciplines, developed conceptual systems of nursing and
articulated grand theories.25 The use of these marked a move from a doctor-led,
task-orientated culture (with `nursing orders' which persisted into the 1980s)
towards a care-planning and problem-solving approach to care (also called the
nursing process). It also marked a subtle change in purpose from helping the
doctor to helping the patient.
A problem-solving approach to care had been sanctioned in 1977 by the
General Nursing Council (UK). It led to the introduction of nursing diagnosis
into UK practice that represented ìnitial eorts to identify the phenomena that are of
concern to nursing',26 involving a `clear nursing diagnosis and concept of the nursing
problem'.
An Activities of Daily Living (ADL) model of nursing was developed in 198021
and was claimed to be the ®rst attempt by UK nurses to develop a conceptual
model for nursing.20 It has since become widely accepted in practice. Baroness
McFarlane recorded the change that had been occurring in nursing from ritual-
ised and institutional approaches to those that are rationally planned and
individualised. She noted how Roper, Logan and Tierney21 had de®ned the
nurse in terms of elements of practice relating to the patient's functional ability.
The preface of Roper, Logan and Tierney's' book21 implied how a decision-
making process utilised a core of knowledge that was augmented by experience,
combined with specialised knowledge to develop a way of thinking about nursing
to achieve stated outcomes (èective and compassionate nursing') in a range of
contexts (`people of whatever age who have various problems who are in dierent
healthcare settings'). Although assessment and intervention are stages of a prob-
lem-solving process (assess, plan, implement and evaluate), this model did not
explain how intervention decisions were made. However, it was a valuable step in
crafting a de®nition of nursing practice, and it linked the art (experience) and
science (process) of nursing practice.
So far it can be seen that decision making involves individuals who within the
framework of a problem-solving approach make decisions by seeking and
processing information. This is in¯uenced by their method of conceptualising
the patient (nursing model), and is informed by dierent types of `knowledge from
nursing and a variety of other disciplines as a basis for making nursing practice
decisions'.27 Knowledge alone is insucient to make decisions; clinically derived
experience of using it is also necessary. A shift in practice has occurred that has
strengthened independent decision making by nurses, but has not fully achieved
autonomous decision-making status. The making of decisions requires skill, and
some see the need for `clinicians who are autonomous decision makers . . . [to] . . .
develop eective problem-solving and decision-making skills'.28 This brief description of
selected developments in describing nurses' decision making from sick-room
managers to semi-autonomous problem-solving practitioners involves a decision
maker, a decision process, a decision outcome and a decision context. The scope
of nurses' legitimate decision making can be understood as being de®ned by the
boundary established between the interplay of intrinsic and extrinsic factors (e.g.
nursing development, policy shifts, medical dominance, views of the role of
women as nurses).
Decision-making enquiry about dierent types of nurse

Nurses cannot be described as a homogenous group, but rather as several
subgroups within a wider community. The decision-making practice of many of
these subgroups has been examined. This has included coronary care nurses,29
emergency nurses,30 critical care nurses,31,32 obstetric nurses,33 neonatal
nurses,34 perioperative nurses,35 general practice nurses,2 advanced practice
nurses,36 expert nurses and midwives,37 health visitors,38 community nurses39
and general nurses.40
Decision-making enquiry about dierent types of decision

A range of dierent types of nursing decision has been examined. These have
included placing a person into residential care,41 deciding when to call for
emergency assistance,42 intensive care unit nurses' transfer decisions,43 triage
decisions44 and nurse prescribing.45 Others have categorised the types of decision
that nurses make ± for example, intervention, communication and evaluation,
and a further distinction between new and old decisions.31
Decision-making enquiry about process

The scope of nurse decision-making enquiry has included decision-maker
relationships,46 roles and identity as decision makers,47,48 accountability,49
decision outcomes50 and explanations of practice errors.51 An existing diculty
in nurse decision-making enquiry is the lack of consensus over a precise52 and
agreed use of terminology that has led to claims that decision-making studies `may
not even be reporting the same phenomenon'.53
Decision-making enquiry and the use of dierent

terminology
A range of terms has been used in reports on decision-making enquiry. These
have included a reasoning process,54 judgement,55 reasoning strategies,2 analyt-
ical and intuitive processes,22,56 critical thinking57 and discriminative thinking.57
Terms such as decision making, problem solving, critical thinking, diagnostic
reasoning and judgement are sometimes used interchangeably and their meaning
requires clari®cation. Steps have been taken to classify nursing terminology, with
several examples in use in the USA.58,59 These are the North American Nursing
Diagnosis Association (NANDA), the Nursing Interventions Classi®cation (NIC),
the Nursing Outcomes Classi®cation (NOC), the Omaha System, the Georgetown
University Home Healthcare Classi®cation (HHCC), the Ozboldt partnership with
the University Hospital Consortium (UHC) and the International Classi®cation for
Nursing Practice (ICNP).
Agreement in this area would oer a level of con®dence that researchers were
actually examining the same phenomenon across nursing subgroups. Its absence
has been thought to impede the development and validation of standards to
evaluate nursing practice, and is seen as an essential step in developing the role of
the professional nurse. Other advantages that can be gained through agreeing a
precise decision-making terminology include enhancing the visibility of nurses'
contributions to healthcare delivery, and avoiding this being subsumed under the
larger medical model.49 The terms `problem solving' and `decision making' have
been used synonymously,60 and will be considered next.
Decision making and problem solving

Problem solving as a process has widespread agreement among nurses61 and gives
decision making a solution- or product-orientated focus.62 However, problem-
solving terminology is ill de®ned as ùnique',37 `reasoning'63 and `dynamic'.64
Although it has been equated to the four-stage nursing process of assessment,
planning, implementation and evaluation,65 this has been challenged66 to make
the distinction that the nursing process was a tool used to plan care, whereas
problem solving was a life skill. Descriptions of problem-solving steps (several,67
three,68 ®ve31 and six2) share common features of problem information, identi-
®cation, interpretation and solution generation, and add clarity to approaches
designed to facilitate learning the skill.
Decision-making outcomes
Problem solving and decision making both point to outcomes. These have been
described in broad terms as to `promote, maintain or regain health'.69 A scope of
outcomes can be described, ranging from medical interests concerned with the
detection and treatment of health disorders70 to a health rather than illness
focus,71 or further towards a holistic stance, such as in¯uencing a patient's well-
being.72 Other types of outcome can be categorised as being right for the patient73
and appropriate.2,47 Appropriateness can also refer to the process used by the
nurse, such as `discriminative thinking that led to the choice of a particular course of
action'61 or `the right course of action'.54 To understand what the right course of
action may be and identify decision-making skills, it is useful to know how
decision making has been theoretically explained. Two perspectives dominate
decision-making explanations. These are prescriptive (also termed normative or
rational) and descriptive (also termed intuitive or phenomenological) explan-
ations.
Decision-making process: theoretical explanations

Descriptive and prescriptive explanations address dierent issues and use dier-
ent methodologies. Prescriptive explanations are concerned with how decisions
ought to be made and have an outcome focus.74 They assume that the individual
is a rational thinker and that human behaviour is logical and consistent. When
making decisions, rational thought precedes action and is able to be made explicit.
Decision trees and line-of-reasoning diagrams are typical ways of representing
prescriptive decision making. These representations incorporate probability cal-
culations and reduce the complexity of decision making to a series of variables
and probabilities of outcomes.
In contrast, descriptive approaches are based on the assumption that action
precedes rational thought, and correspond to a holistic view of nursing practice in
which the decision maker sees the whole situation rather than reducing it to
discrete elements. Descriptive explanations are concerned with how decisions are
made, and focus on the processes involved. A unifying theory of decision making
does not exist, although attempts have been made to develop one.74
The context of decision making: the clinical landscape

Nurses' decision making (in the UK) has developed since the 1800s from a
medical assistant role that initially majored on sick-room management within a
rule-driven and patriarchal context. It is accepted that nurses' roles include
decision-making responsibility,75 and that they make practice-orientated deci-
sions which largely fall within two domains, namely nursing and medicine.76 The
patient links these, although some argue that doctors' `traditional positional
dominance' remains.46 A decision-making context continues to exist that includes
the healthcare organisation and participants within a wider legal and social
interpretation of nurses' roles. The term `clinical landscape' has been used to
describe this context.77
The changing technological context has contributed to nurses caring for more
acutely ill patients using complex technology.78 This has contributed to organ-
isational change in eorts to make services more eective and ecient, and has
run the risk of undervaluing knowing the patient in favour of prioritising
òrganisational arrangements, economic restraints and eciency of healthcare systems'.79
Protocols and guidelines are a means of standardising approaches to decision
making. Guidelines are `systematically developed statements to assist practitioner and
patient decisions about appropriate health care for speci®c clinical circumstances', 80 and
comprise elements that describe dierent aspects of the patient's condition and
the care to be given. They can form benchmarks for best practice, so are useful to
healthcare organisations. A protocol is an explicit framework for the process of
care, and members of the care team can follow precise steps of practice. Claims
that these can aid nurses' decision making make assumptions about the nature of
the evidence used in decision making and the `correct' way of processing some
information (e.g. investigations and observations).
Healthcare policy also shapes the clinical landscape. For example, the `ruthless
standardisation'81 required in the implementation of the NHS Plan82 through the
use of information technology claims to support clinical decision making so that
`those who give and receive care have the right information, at the right time'.71
Computer decision-support systems make specialist (expert) knowledge more
widely available,76 support nursing diagnosis and so are claimed to be an
intelligent assistant and a valuable resource.
Human as well as non-human factors (e.g. patient situation, available resources
and interpersonal relationships) shape the clinical landscape.77 This landscape
includes the nurse's `duties, rights and social values'.83 Changes in the clinical
landscape have also included developments in information and knowledge
bases,78 and implicate nurses as active participants through ànalysis, cue interpret-
ation, [and] weighing evidence'.34 Descriptive decision-making processing terms,
such as a `gut feeling',42 suggest links between the nurse, their experience,
information and the generating of knowledge about a patient. Such individual
factors in the clinical landscape are dicult to quantify and have resulted in
claims that decision making was an ùnpredictable process' and subject to `changing
practical exigencies' of the context.34 Clearly, more research is needed into the way
in which these factors impact on decision making.77
The individual nurse as a factor in the clinical landscape gives rise to several
questions. Much of their decision-making work is cognitive, and there is a need to
make `public' their narratives to describe the knowledge that is embedded in their
practice and knowledge of patients. It has been argued that qualitative approaches
to enquiry are useful84 for making `non-objective and less quanti®able clinical
judgements visible and demonstrable' and for uncovering knowledge that is
embedded in practice.85 The way in which nurses think has been associated
with dierent types of decision maker. Novice decision makers have been
described as deliberative, whereas experts think intuitively.86 This raises the
question of whether or not it is possible to think like an expert and learn by
copying experts. It is questionable whether this can be achieved without identi-
fying the essential elements of expert practice (e.g. practice-based knowledge),
and in turn implies that the essential elements of a decision process can be known
and made amenable to manipulation. Furthermore, it implies that there is an
expert state of `correct thinking', and it has long been acknowledged that expert
decision making needs to be de®ned if these questions are to be answered.37
A bridge between novice and expert decision making was formed by applying
context-free rules to guide action to being able to make a response that was
intuitive or that came àpparently out of nowhere'. 87 This challenges other views
that intuitive thinking was just a faster unconscious performance of analytic
thinking processes, rather than a dierent form of thinking.4 However, uncover-
ing the nature of intuition as the de®ning factor in expertise is problematic,
especially as intuitive judgement has been described as ùnderstanding without a
rationale'.88 The types and processes of thinking, the participants, the context and
the outcomes are all a part of decision making, and are shaped by the context in
which the decision is made.
Conclusion
A nurse's role includes decision making that involves participants, process and
outcomes, and which occurs in a given context. The context is shaped by many
factors, human and non-human. It follows that decision making is contextually
shaped, as are the scope and practice of nurses as decision makers. The two
scenarios that were introduced at the beginning of this chapter can now be
revisited to consider what needs to be asked about the decisions that nurses make.
These questions must go beyond what happened (a particular intervention was
carried out) to how and why a point of action was reached. This must include
understanding how knowledge of the patient was constructed and shaped so that
their problems or needs could be identi®ed. The next chapter explores a decision-
making model that centres on constructing an account of the patient, called a
narrative. This model will be used to show how answers can be oered to
questions of decision-making role, context and expertise.
Chapter summary box

. Nurses' roles as clinical decision makers are shaped by intrinsic and
extrinsic factors.
. The clinical landscape describes the context of their decision making.
. Decision making includes a range of terms, some of which are used
interchangeably.
. A precise de®nition of decision making does not exist.
. A unifying theory of nurses' decision making does not exist.
. There are dierent types of nursing decision.
. There are dierent types of nurse decision maker.
. There are dierent views on the thinking processes that are used when
making decisions.
. The medical profession has dominated the development of nursing
practice and therefore the scope of nurses' decision making.
Stop and think

This chapter has set the scene for further examination of decision making. Use the
following questions as prompts for developing insights into decision-making
enquiry that are directly related to the type of nursing work that is involved in
your area of interest or work.
Origins
. If you had to describe the development of nurse decision making, which
origin point would you select and why is this signi®cant?
. Search out historical accounts of nursing practice. Sort them into time
periods and abstract the direct or indirect remarks made about nurses'
decision making.
. What points do they make about the process of decision making?

. What points do they make about the types and outcomes of decisions?
. What is the extent of nurses' decision authority?
. How have descriptions of nurses' decision making altered over the time
period chosen?
. If the descriptions of decision making have altered, what reasons can you
oer for this? Are these linked to policy, economics and social change?
Sub-area of nursing practice

. What aspects of practice have been examined in your chosen area of
clinical nursing?
. Has the focus of decision-making enquiry within this practice altered
over time?
. If so, are there any indications why the focus of enquiry has altered?
The elements of decision making

. Think about how you make decisions.
. Describe the process that you use.
. How would you explain your thinking to a trainee nurse as you make a
decision?
. What is the legitimate scope of your decision making?
. Who has the authority to veto your decisions?
The clinical landscape

. Examine the clinical landscape in your chosen area of practice. What do
you identify as the key features of the clinical landscape in the following
areas:
± organisational structures and practices
± dierent sta groups
± healthcare policies
± technological advances?
. How do these shape nurses' work?
. When a clinical incident occurs, how is it investigated?
. What types of question are asked?
. To what extent do these generate explanations of how and why decisions
are made?
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Chapter 2
Making clinical decisions: a model of

nurses' decision making
Introduction . An overview of narrative development . Stage 1: Pre-

admission and admission stages . Stage 2: Report . Stage 3: Caregiving .
Narrative development stage 1: Pre-admission accounts and admission
narratives . Narrative development stage 2: Report . Narrative development
stage 3: Caregiving . Conclusion . Stop and think
Introduction
A model of nurses' clinical decision making is described in this chapter and will be
referred to in subsequent chapters. The model represents how nurses construct
knowledge of their patients. I have labelled this as the development of a narrative
about a patient, which is the story or account that expresses how the patient is
known. Narrative development has a cyclic characteristic, but for clarity of
explanation I shall describe its dierent stages in a linear manner. In this way I
shall describe how a ¯eeting account about a patient is developed into a narrative
that is shared by a team of nurses and individually owned by each one of them.
Nurses use their narrative to identify the patient's needs and to select corres-
ponding interventions. A decision is made when an intervention (or more than
one) has been chosen. A brief overview of the narrative follows, before I move on
to examine its stages of development in more detail. Figure 2.1 illustrates the
stages of narrative development as part of nurses' clinical decision making.
An overview of narrative development

Narrative development commences with a pre-admission account about a patient
that is developed into an admission account following the patient's arrival on the
ward. Successive revisions through information seeking and processing at indi-
vidual and team levels support the transformation of the narrative from a story
about knowing the patient to one that is owned by the nurse who can claim to
`know' the patient. On the basis of knowing, the patient's needs are identi®ed and
interventions chosen. Clinical decision making therefore rests on how the patient
is known.
Making clinical decisions: a model of nurses' decision making 19
Figure 2.1 The stages of narrative development as part of nurses' decision making.
Stage 1: Pre-admission and admission stages

During the pre-admission and admission stages, information about the patient is
initially received and subsequently used to seek more information to construct an
account of them. This is shaped by the nurse's roles and how these direct enquiry
for particular types of information. This is chie¯y information in relation to
caring, care management and medical domains. The focus of the nurse's
information seeking can be described as using dierent lenses according to
their dierent roles. I have collectively termed these a conceptual lens.
Stage 2: Report
Next the admission account is informally communicated to other nurses on duty,
sometimes on a one-to-one basis. However, it is formally told, or `given', during
the next shift handover report to nurses commencing their shift. In report, nurses
`take' each narrative through listening and note taking. Note taking is part of a
process of committing the narrative to memory. Often, narrative giving follows a
sequence that includes references to the nursing record (called a Kardex) and also
to nurses' personal note sheets. This process of information giving and taking is
part of the development of a group consensus about how the patient is known. It
often involves discussion in which the narrative is challenged, corroborated or
revised by the team.
Written records were compiled contemporaneously, but the narratives con-
tained in these diered from their verbal counterparts. This dierence will be
examined in Chapter 4 together with the informal temporary notes written by
nurses.
Stage 3: Caregiving
After report, nurses proceeded to care for their patients, often without referring to
written care records until the end of the shift. This created opportunities to check
the existing narrative and add new information to it. In this way the individual
nurse developed their own version of the narrative which was subsequently
passed on to other nurses at the next report. A continuing cycle of narrative
giving and taking, team review, individual checking and adding new information
continued shift after shift, day after day. The construction of knowing the patient
is therefore dynamic.
These three stages of narrative development ± giving and taking, developing
and giving to the next group of nurses ± (see Figure 2.1) contribute to ongoing
narrative development along the patient's journey through their experience of
hospitalisation. I have called this journey their trajectory of care (see Figure 2.2), as a
chronological journey extending from pre-admission, through admission, con-
tinuing care and treatment to the point of the patient being discharged from
hospital. These narrative stages will now be examined further.
Figure 2.2 The trajectory of care.

Narrative development stage 1: Pre-admission accounts

and admission narratives
It's essentially looking for what is wrong with the patient and thinking ahead
as to what needs to be done.
The pre-admission account

The pre-admission stage marks the beginning of a patient's journey along the care
trajectory. It involves a ward nurse forming an initial impression about the
patient before actually meeting them. The substance of this impression is
drawn from secondary information sources, usually via a telephone conversation
with whoever is referring the patient to the ward. This includes general
practitioners, Accident and Emergency nurses or doctors and medical sta from
other wards who are authorising a transfer of a patient from elsewhere in the
hospital. Pre-admission information also includes excerpts from the patient's
medical and nursing records. The nurse uses it to anticipate the patient's needs
and prepare for their arrival on the ward.
In the following discussion, Julie, a sta nurse, explained how she developed
her account of John, a patient who was being transferred from the Accident and
Emergency department. She had been informed that `The SHO (senior house ocer)
had telephoned through that a 43-year-old patient was coming who has a two-day history
of coee-ground vomiting.' John's medical casenotes had already been delivered to
the ward, and Julie skim-read them: `He has had a number of previous admissions for
epigastric pain ± they (doctors) have been querying pancreatitis and that was followed up
by a gastroscopy and triple drug therapy treatment. He had then not been taking all of the
prescribed medication and also had defaulted from (hospital) appointments. He subse-
quently had an overdose, and had also not attended for a planned vasectomy.'
Julie's account included medical history information (à number of previous
admissions'), diagnosis (èpigastric pain . . . querying pancreatitis'), previous investi-
gation and treatment plans (a gastroscopy and triple drug therapy'), and John's
compliance with this. She depicted John as a medical `case' who was not
compliant with a prescribed medical treatment plan. Given that her account
lacked ®rst-hand information derived from her own observations and discussion
with John, I asked her how valid it was. She sounded a note of caution, stating
that it was àwful really, but you do form an impression'. The problem is whether or
not this impression is valid.
The validity of such accounts is strengthened when the nurse has previously
cared for the patient. This allows a comparative judgement to be made between a
previous and current admission to anticipate the patient's needs.
Sister Zoe, after taking a telephone referral from a GP, explained how previous
knowledge of a patient did in¯uence her pre-admission account. `He was started on
a drug which the GP prescribed, not the hospital, as it was quite expensive and a new drug.
It sounds like he is having problems of reactions to it and will need to come in.' Enquiring
further about the reason for the admission, she replied that it was `to wean him o
the drug and for him to be reassessed. The doctor will need to review him by the sound of it
. . . having said that, he might say the patient can be nursed at home! But I think that he
will admit him. We know the patient.'
As in the earlier account of John, this also included medical information

(`started on a drug') and the patient's response (ìt sounds like he is having problems
of reactions to it'), but was triangulated with previous knowledge of nursing him
(`we know the patient'). Sister Zoe processed this information to make a judgement
about the patient's need for admission (`will need to come in'), linking this to
medical needs (`to wean him o the drug' and `to be reassessed'), and anticipated the
doctor's decision (Ì think that he will admit him'). Prior knowledge of caring for this
patient supported the nurse's con®dence in her own pre-admission account and
anticipation of needs.
Both accounts amount to little more than an impression that the nurses used to
anticipate needs and make preparations for the patient's arrival on the ward.
However, many nurses regarded pre-admission accounts as unreliable, as they
were largely based on secondary information sources. These represented know-
ledge about the patient rather than of the patient. Tony, a charge nurse, explained
how relying on these accounts led to inaccurate anticipation of needs and the
making of inappropriate preparatory decisions. A contributing factor to the
unreliability of pre-admission accounts was attributed to the referring nurse's
lack of knowledge of a patient, and was summarised as `sta [who] are moving
patients on [from another department] who don't know them that well'.
He continued, `We get people sent up and they are said to be independent and don't
need much care, only to assess their state on arrival to the ward as dependent and in need of
nursing care. When they come they need about six sta to move them, or are moribund,
and they get allocated to perhaps an inappropriate part of the ward because of the report
given.'
In this case, the pre-admission account was triangulated with one generated
through direct observation, allowing a comparative judgement to be made about
the patient's health and subsequent reassessment of their needs. At this stage of
the process nurses did make decisions ± preparatory ones while they were
awaiting the patient's arrival on the ward.
Pre-admission account decisions

Decisions were made about the physical preparations needed to nurse the patient,
and also about what to ask about during the patient assessment interview.
Physical preparations included designating a particular bed, and preparing
equipment such as monitors and infusion pumps. A part of this was not dissimilar
to nurses' sick-room management of a previous era, in which they controlled the
environment in which the patient was placed. However, the preparation for the
assessment interview began to reveal how the nurse `saw' the patient in relation
to the pre-admission account, their role and understanding of the purpose of the
admission phase.
Nurses described variations in their approach to information seeking during the
admission, which included the use of a general questioning framework and a cue-
driven approach. Some nurses described the general framework as à set patter
which I ask ± it's a bit like the police do when it comes to telling them about their property
± but I tend to have the same sort of questions which I ask'. A cue-driven approach
picked up on statements in the pre-admission account. For example, a patient
with àlcohol problems' was going to be asked speci®cally about `the alcohol intake
and if he is still a heavy drinker, and about his medication at present.'
Although these decisions might seem cursory with regard to the actual care that
the patient subsequently received, and the pre-admission account did change,
their importance lies in the glimpse that it oers into nurses' thinking. These
decisions shaped how the narrative developed and became personally owned.
The admission account moved this process on.
The admission account

Once the patient arrived on the ward, the pre-admission account began to be
developed into an admission narrative. Information was gathered through
observation and interview. During these interviews the reliability of the pre-
admission account was checked and discrepancies identi®ed: `You ask patients if
they have any past medical history, they tell you ``no'', and then you ®nd that they have a
laparotomy scar or something like that.' Similarly, direct observation was sometimes
sucient to discount the reliability of a pre-admission account, as in the case of a
patient who was expected to arrive at the ward ìn a wheelchair with a vomit bowl'
but in fact walked in and was not nauseous.
Medical records were sometimes seen as being more useful during the
admission process than nursing records. A sta nurse explained how she favoured
medical model information to establish the reason for the patient being on the
ward and what their problems might be: Ì don't trust what another nurse tells me
when we get a new patient. I look at the medical case notes. Sometimes there is hardly
anything written on the nursing sheet when they come from the Medical Assessment Unit.
No diagnosis or anything like that. Take this, for example. It said he had back pain and
weight loss. I felt that he might have a malignancy because he is a heavy smoker. So I
looked in the medical notes and found that they are querying some malignancy and are
doing tests.'
Sometimes nurses augmented their admission narrative with information from
outside the ward ± for example, by telephoning community nurses who had cared
for the patient prior to the admission. Ìf the patient has been living in a rest home I
read the notes. I might ring the rest home to see what normal care for the patient was like.
They [rest home sta] will give a verbal report of the patient's mobility and wheelchair
use, etc., but their history doesn't get written in the rest home notes.'
Information seeking was used to make comparative judgements between
accounts of the patient's pre-admission and admission health status so that
needs could be identi®ed and a plan of care developed. Needs identi®cation
and planning revealed the nurse's purpose in the whole admission process, which
was described as èssentially looking for what is wrong with the patient and thinking
ahead as to what needs to be done'. A medical focus underpinned the meaning of
`what is wrong', and the nurse's role corresponded to understanding medical
interventions: `What's wrong ± where is the patient's treatment going?' The nurse's
roles in relation to information seeking will be examined shortly, but ®rst I shall
consider what shaped information seeking.
Shaping information seeking

The nursing record was a popular tool used to shape nurses' information seeking.
This record was divided into several sections corresponding to an Activities of
Daily Living model.1 Each section was used as a prompt for questioning the
patient:
I use the Roper model because I trained using that and have only worked here.
I have a question list in my mind relating to each section of the form and I tend
to go through the same questions with everyone. For example, with diet I ask if
they are diabetic or have a special diet, whether or not they drink alcohol, and
if so how much.
The extent of the admission interview was limited by competing workload
pressures, principally the care of other patients and associated clerical work.
Time ®gured prominently in this (`the time available and the other patients needing to
be seen'), and an admission interview varied from àbout 10 to 15 minutes, but was
longer if investigations such as ECG monitoring [electrocardiogram, a form of cardiac
monitoring] were required'. Administration, particularly record keeping, was cited
as doubling the total assessment workload to the extent that `with all the paper and
investigations it can take 45 minutes to an hour to complete'. The requirement to
compile contemporaneous records also meant that some nurses stayed beyond
the end of their shift to complete their records.
Time management was clearly a factor in patient assessment discussions, and
two strategies were used to manage this, namely short cuts and curtailing patient
discussion. A short cut was used when the patient had a record of a previous
admission to hospital. In these instances old information was copied from
previous case notes and used to focus questioning. Unfortunately, this action
led to a one-sided conversation in which the nurse aimed to `just . . . verify a lot of
previous details'. Despite this, nurses claimed that they valued the patient's
response as `you can never be sure unless you check with the patient', but a short cut
only modi®ed a previous account through marginal revisions. Furthermore, the
opportunity to explore other health issues that might have been of concern to the
patient was limited. In defence of short cuts, nurses claimed that the amount of
interaction taking place was down to the patient: ìt depends upon how much they
want to talk to you'. This was not necessarily the case, as some nurses curtailed a
patient's conversation if it was delaying their completion of the assessment: Ìt
[assessment] can take minutes, but others talk and talk and you have to focus it.'
Focusing involved taking control of the discussion: `He [the patient] talked and
talked and I had to actually say that we needed to get on with the assessment.'
It can be seen that information seeking was in¯uenced by time, the purpose of
the assessment and the approach taken by the nurse. Consequently, this
introduced a degree of selectivity which left other areas of information unex-
plored. Selectivity in information seeking is also linked to the dierent roles that
nurses adopted in the clinical setting. These directed the nurse's gaze in
information seeking. Figure 2.3 shows how this gaze is represented as a lens
that has three facets corresponding to the nurse's roles. Each facet is used to seek
a speci®c type of information.
Figure 2.3 The three facets of the conceptual lens used by nurses in information
seeking.
Role and information seeking: nurse as carer

The term `nurse' encompasses several roles and cannot be assumed to be a
homogenous single entity. These roles shaped their information seeking. A
common role that was described as a core feature of nurses' work, regardless of
grade ± whether referring to themselves as a standard nurse, manager or
advanced practitioner ± was `hands on' or `basic care.' This was characterised by
à good bedside manner' and seen as a `nursing priority' that emphasised `the
important role of the nurse', which was being patient focused, chie¯y `looking after
the sick.' Nurses claimed that a basic care role was compatible with a holistic view
of the patient that addressed his or her physical, social and psychological needs.
Ward managers took a broader role perspective than some junior nurses, which
emphasised management concerns linked to their `responsibility to know what is
going on in the whole ward.' They valued basic care as the `traditional' heritage of
practice, and required other nurses to take a `pride in ensuring that these tasks are
completed.' They also implied that threats to basic care delivery existed: `Before I
had a closer contact and would be thinking on how I would reduce the [patient's]
discomfort. There was less time constraint. Now it is so busy and things get forgotten . . . as
sister you have to keep more in your head and there is less time. It can be mentally
exhausting.'
These tasks of care had an enduring or traditional characteristic:
A traditional role, one where you give attention to detail, patients are fed and
washed, are wearing appropriate clothing. Other things are important but you
have to get the basics right ®rst and the other comes with it. There needs to be
pride in making sure that they're washed, clean and tidy, the medicines and
dressings are done and the observations are done.
These expressions of responses to needs identi®cation by implication demon-

strated that nurses were making numerous individualised decisions. The promo-
tion of the nurse's role as carer thus encouraged engagement with knowing the
patient and making care decisions: Ì try to instil that in everyone, it ``narks''
[annoys] me the most when the basics are not attended to.' Clinical decision making
included, but was not limited to, tasks representing the nurse as carer. Indeed
some junior nurses were described by experienced sta as having a limited
understanding of the patient, being described as `task focused'. This was corrobo-
rated by ward managers, who acknowledged that juniors were `good at tasks'.
Although tasks represented a limited role perspective, attention to them was
valuable, especially in relation to complaints, as these were often `the thing we get
the most complaints about'.
Engagement in care tasks was also an opportunity to seek more information
about them: `Basic care is about being sure that the patient is comfortable and clean in a
physical sense. It is also about ensuring that they are comfortable with where they are and
are able to talk [for example, asking], ''Sister, can I chat with you?'', so that they can
talk about their problems.'
Information seeking through basic caregiving allowed the nurse to check that
care was meeting a range of needs and to ®nd out the patient's views about their
illness and hospitalisation. This information was included in the developing
narrative about the patient. Nurses used their knowledge of the patient with
care needs to be an advocate for them. Advocacy was described as being a `go-
between ± between the patients and doctors' in which they acted as an ìnterpreter for
the patient' to doctors. This, they argued, was necessary because `doctors with the
elderly don't understand what they [patients] are saying and they need someone to
interpret across the culture'. It was mentioned earlier that nurses' pre-admission
accounts were closely linked with a medical view of the patient and, in being an
advocate, the nurse had to decide how to represent the patient to the doctor. This
process amounted to à matter of judgement' according `to the nurse as they stand by
the patient'. The interactions between nurses and doctors in making narratives
known will be examined further in Chapter 5, as games nurses play. These games
reveal how dierent ways of knowing the patient exist in the ward, and how the
nurses' way of knowing (the narrative) can be used to alter the medical treatment
plan. These interactions also made apparent the nurse's care management role.
Role and information seeking: nurse as care manager

Experienced nurses who discussed their care management role spoke of their
òwnership' of care beyond `more than just the work that sta nurses did'. They
recognised a need `to organise the management of patients' arising from their
`responsibility to know what is going on in the whole ward, somebody needs to see to
that'. Nurses' decisions as care managers encroached on the `territory of the junior
doctor' due to concerns over ineective medical case management. For example,
some `consultants did not know what their junior doctors had done regarding case
management'.
As care managers, sisters and experienced sta nurses saw themselves as a
`fulcrum' at the interface between managing and delivering patient care. They
regarded themselves in this role as an information hub, and nurses in general as
more likely to have a broad scope of information about patients due to their 24-
hour presence on the ward. Èveryone [non-nurses] who comes on to the ward is
prescriptive, they just come and go, but the nurse is at the centre of things. They are always
there, so they get it [information] from all directions.'
They were also a focus for less-experienced team members who sought peer
guidance via this information hierarchy. Sister Kath, a ward manager, explained:
The junior nurse is task focused. As far as the sta are concerned I am here as
`mother'. So I am a focus for them. They can go and ask the sister ± she will
probably know. I know who to go to to sort things out because I have worked
here for so long. I know a lot of sta on surgery, and have seen many of them
pass through as students. Usually I will know what to do, but if I don't I will
know someone who might. You should have a rapport with other wards,
especially if you want to transfer patients. The hospital has always been like
that.
Sister Kath retained an overview of patients' problems and acted as an informa-
tion resource for other nurses. This included processing information brought by
other nurses who approached her `to sort out things' as part of making or guiding
their decision making. The use of the term `mother' revealed a relational and
hierarchical information-seeking structure that extended beyond the ward.
Patients and their relatives also saw the ward sister as a reference point for
information, and would bypass sta nurses to ask her questions, even about
minor issues such as details of ward visiting times. Other nurses recognised this
and associated the symbolism of a sister's dark blue uniform with having a greater
level of knowledge, even if this was not necessarily true: `The patients perceive that a
dark blue uniform means that you know more than someone in a white uniform.' . . . À
sta nurse can tell them the same information but the dark uniform seems to instil
con®dence.'
A part of information seeking associated with the management of the patient
along the care trajectory included medical information. This gave rise to a third
role, namely the nurse as medical assistant. Care management involved coordi-
nating the contribution to the healthcare team, especially doctors, who were
frequently regarded as having a limited perspective of the patient beyond medical
concerns:
For example, consultants ± they are typically totally divorced from the reality of
planning a discharge of a patient who went home and died. The doctors don't
take into account the service arrangements involved. For example, on a Friday
there is no support available. Doctors get very blinkered and make decisions
without thinking of these things. All they think is that they have got a patient
with a surgical or medical problem and have a thing to ®x or make better, and
once done they don't see why they can't go home there and then. When they
decide they can't do any more for them they decide to discharge [the patient]
without making any mention of it until then.
Many but not all doctors were like this. Some `doctors are better ± they look at the
patient and ask selves if they can manage at home. They ask `Ìf we let you go home, will
you cope?''' A part of care management therefore involved nurses' resistance to
doctors' unilateral decision making about patients: `With junior doctors we tell them
not to tell the patient that they can go home until we have discussed all the issues we need to
deal with prior to discharge.'
Role and information seeking: nurse as medical assistant

The prominent role of doctors in medical wards in¯uenced nurses' work to the
extent that they actively sought some medical information so that they could
`know ± like the doctors' ± that is, have a medical perspective of the patient and their
treatment needs. Whereas the nursing model that was used was thought to be
holistic, it was recognised that `The doctors all use a medical model and that works for
them. The doctors need to know what is happening from their viewpoint and we obviously
have to work alongside that.'
Nurses who took on a medical assistant role were concerned with `getting work
done' in the belief that junior doctors were `too busy to do everything' and needed
help in `completing blood investigation forms' and `changing drips'. They sought
information that supported medical diagnostic decision making, and typically
described this work as follows: `Well, we admit them before the doctor sees them. I did
the admission paperwork, routine bloods, the ECG was already done, card for X-ray. Then
I went to inform the doctor who was on the unit about the ®ndings, the admission to date.
He will then go and see her and make a provisional diagnosis and decide what to prescribe
as current treatment.'
Such work could involve following routines, as acknowledged in `we take too
much blood', indicating that the rationale behind this was unclear. Nurses also
described medical knowledge as being useful so that they could `be sure of our
knowledge about practice', and at times supported an information-seeking focus that
was `more medically orientated than on other wards'. Indeed, medical knowledge was
favoured over that found in the nursing record. During the admission phase, for
example, a sta nurse commented that Ì don't trust what another nurse tells me,
when we get a new patient I look at the medical case notes.' Diagnostic information was
particularly sought: `Sometimes there is hardly anything written on the nursing sheet
when they come from the medical assessment unit. No diagnosis or anything like that. Take
this, for example [selecting a nursing record], it said he had back pain and weight loss. I
felt that he might have a malignancy because he is a heavy smoker. So I looked in the
medical notes and found that they [doctors] are querying some malignancy and are doing
tests.' Nurses' emphasis on a medical assistant role often rendered nursing care
and nursing care decisions invisible, these being addressed òn an as-required basis',
and by implication many were not recorded.
Role and information seeking: a summary

Nurses' roles in wards (nurse as carer, care manager and medical assistant) are
associated with three types of information seeking. These three roles help to
describe the meaning of the term medical ward nurse.* As mentioned previously,
information gathering can be explained as the nurse using a conceptual lens that
has three facets corresponding to their roles (see Figure 2.3). They `see' the patient
through this to generate three information categories. They then process the
latter to develop knowledge of the patient and use this to represent how the
patient is known. It follows that a preference for one lens facet over others shapes
* A ward nurse in this study can be de®ned as a registered person whose role is to provide patient-
centred care, managing the patient along a trajectory of care while coordinating the contributions of a
multi-disciplinary team.
the emphasis that is given to how the patient is known. Dierences in ways of
knowing the patient were discussed and reviewed during report, but before this
took place the admission narrative about a patient was recorded in the nursing
records.
Recording the admission account

The admission narrative superseded the pre-admission account and was written
in the nursing record. This was commonly referred to as the Kardex, and had an
implicit sequential problem-solving design. It consisted of a pre-printed assess-
ment sheet, a care plan and a free text continuation sheet. Additional patient
information was recorded on observation charts that were kept by the patient's
bed.
The assessment sheet had three sections ± a patient identi®cation section
(name, age and next of kin), a medical information section (previous medical
history, treatment, reason for admission and consultant) and a nursing assess-
ment section. The nursing section was divided under Activities of Daily Living
headings (e.g. mobility, dressing, hygiene) in which nurses recorded information,
patient's remarks and comments about identi®ed needs or problems.
Blank template care plans were available to produce a bespoke care plan. These
had headings of identi®ed needs, goals and corresponding action steps. Some pre-
printed care plans had been introduced in an attempt to reduce the written work
of the assessment, but these were not always adapted to the needs of the
individual patient. In written and pre-printed care plans the associated action
steps were not always recorded.
A free-text patient's progress report of care and treatment was written on a
continuation sheet. As a contemporaneous record, these notes were written at
least once per shift and sometimes more frequently, depending on what was
happening to the patient. Progress reports were typically brief, except when the
nurse thought that the patient was likely to complain. Dierences did exist in the
content of verbal and written narratives about the same patient (these will be
discussed in Chapter 4). Once the assessment was completed and records written,
the narrative was told to the next team of nurses commencing duty during the
shift handover report.
Narrative development stage 2: Report

I always ask in report . . . you need to know what is happening to the patient.
Shift handover report was the principal occasion when information about
patients was told to other nursing sta. This involved a cyclical process of
narrative giving, taking and discussion. It was then followed after report by
narrative development by each nurse as they worked with patients. This cycle
was repeated on every shift, every day and every week, and led to each nurse
personally owning a patient narrative to the extent that they could claim to `know
the patient'. Evening and morning reports had dierent lengths on account of the
shorter 15-minute shift overlap at the start and end of the shift (morning, 7.45±
8.00 a.m.; evening, 9.15±9.30 p.m.). A longer report, lasting up to an hour, took
place during the lunchtime shift overlap (1.30±2.30 p.m.). All reports had a
general format that was adapted according to how well those listening knew the
patients.
The process of report

Nurses giving report referred to the Kardex and their own personal note sheet
along with personal recollections of having cared for the patient. Nurses
habitually began report by reading details from the Kardex: Àt report I tend to
follow a set pattern from the Kardex.' These included patient identi®cation (`name,
age, date and reason for admission'), recent care, treatment and changes in
treatment. Each individual patient report ended with a verbal signal which
indicated that the nurse was moving on to talk about a dierent patient. This
was usually a rhetorical question, such as ÒK?' or àll right?'. The ®rst report
given about a patient was typically formulaic and focused on tasks requiring
completion and work in support of diagnosis or treatment.
The content of report

Nurses giving report were selective about the amount of narrative content that
they provided, according to their expectations of what others should know about
the patient. Nurses were asked if they knew the patients ± èyes down, were you all
on duty yesterday?' ± and if they replied `we know him', the content of report was
limited to patient identi®cation information and remarks about changes to the
patient's treatment or care: Ì always give name, age, diagnosis and then any changes
and tests done.' Nurses who claimed to `know' their patients tended to focus on
narrative change: Ì only tell what has changed after that.'
Sometimes the narrative content was deliberately limited because experienced
sta held the view that other nurses should make an eort to know each patient:
Ì try to keep it to a minimum because you should know your own patients.' This popular
comment placed the emphasis on each individual nurse taking the initiative to
check it and to seek information for themselves: À lot are like me and only give what
I give. I like to get a full history and go and look it up myself.'
The time available to give report also in¯uenced how much information was
given and how much discussion was permitted. The nurse giving report regulated
it to accommodate open discussion or manage interjections. Sometimes these
interjections were limited due to time pressure to `move the report forward', or
because the nurse was keen to get o duty on time: Ì've got to get o [duty].'
Occasionally interjections were simply ignored and the nurse continued to give
report.
Nurses listening to report also had views on the level of information required,
and report was the primary place where it was found. When returning after
several days o duty, a nurse explained Ì haven't got time to look at what happened
three weeks ago, so I ask at report. The information is important and I try to get as much as
I can. It might have happened on a previous shift but might be relevant in the future.' She
went on to add that Ì always ask in report ± they give a lot of irrelevant information,
like who has had a bath . . . but you need to know what is happening to the patient.' Later
on she checked `the notes for the results and tests and things like that'.
Even when time was limited nurses sought speci®c information such as Àll
observations, ¯uid balance, how they are doing medically, how they are feeling, e.g. low in
mood, how the physiotherapist got on with them, the occupational therapist's input, and
medical social worker referrals, the home circumstances, whether the family is involved and
if there is anything they want doing.' This highlights how the nurse collated a range
of information with regard to nursing, care management and medical categories
to develop their own narrative of the patient. Dierent reports had dierent
functions. Short reports focused on continuing care and treatment plans, whereas
long reports allowed more time for group discussion and narrative revision to take
place. These will be examined next.
Narrative giving: short reports

Short reports were brief, lasting little more than a minute, and were given on the
day-to-night and night-to-day shift handovers. They were pithy portrayals of how
the patient was known, and included three categories of information (nursing,
management and medical) and judgements representing information processing
within and across narrative categories. Two examples are given below.
Day-to-night shift report

Mr Jones, 51, Parkinson's disease. In for PD medication review, sti tremor on
left side plus at rest with freezing episodes, nice man, general bath given,
transferred plus two, diet and ¯uids taken OK. He was shattered post bath,
hourly position change, likes cream ± sacrum dry, transfers plus two, the
physiotherapist gave him a rollator, but he's not steady or safe with two, the
doctor said that he can be discharged when his wife is back. GP to start a drug
treatment and then to readmit him for assessment to see if there is any
improvement.
Night-to-day shift report

Mr Armand, 21, a Muslim, diagnosis, symptoms. [She questioned the
diagnosis and then con®rmed an original date of diagnosis in the
nursing record as being March 1999.] Dependent, past medical history, no
allergies [reading from the nursing record]. On haloperidol, got an m.s.u.
± nearly [laughs]. It is still needed. Was bad on Tuesday but OK last night.
A summary of the dierent elements of these reports is given in Table 2.1. The
narratives contain three information categories (nursing, management and
medical) implying the use of a conceptual lens. Individual judgements associated
with a particular category reveal how the patient is known as an individual as
seen by the nurse as carer (`shattered') and as an object of care by the nurse as care
manager (`dependent'). A global judgement made across all three categories (`nice
man') represents how he is known overall as a person in relation to the healthcare
team. References to investigations highlight information seeking in support of
medical diagnostic decision making.
Although brief, and focusing on continuing care rather than opening up
discussion for change, these reports did not refer to a written care plan or
prescribe nursing care tasks to those listening to them. This implied that nurses
were expected to `take' the narrative and use it to decide for themselves the
patient's care needs on that shift.
Table 2.1 A summary of the narrative information category content of short

reports
Shift Narrative judgements Narrative Narrative information
report categories
Day Patient known as: Nursing . General bath given, transferred plus two
to . Nice man . Diet and ¯uids taken OK
night . He was shattered post bath
. Hourly position change, likes cream ± sacrum
dry
. Transfers plus two
. The PT gave him a rollator but he's not steady
or safe with two
Medical . Diagnosis
. GP to start a drug treatment and then to
readmit him for assessment to see if there is any
improvement
Management . Name, age
. In for PD (Parkinson's disease) medication
review
. The doctor said that he can be discharged when
his wife is back
Night Patient known as: Nursing . Obtained an m.s.u.(urine specimen)
to . Was bad on
day Medical . Diagnosis, symptoms
Tuesday but OK . Past medical history
last night . No allergies
. Dependent . On haloperidol
Management . Name, 21, a Muslim
Narrative giving: long reports

Long reports were given at the lunchtime shift change and allowed time for
discussion and narrative revision through a process of challenge, corroboration
and validation. These contrasted with short reports, which often went unchal-
lenged (or had any challenges limited) and were passively corroborated. Some
long reports did pass without challenge, especially when the patient was `known'
by the nurses and the care and treatment plan had not altered. A typical sequence
of narrative giving for a long report follows, and is summarised in Table 2.2.
Mr Vincent, 60, came in with chest pain and an intralateral MI [heart
attack], TIAs [transient ischaemic attacks ± blackouts] for the last 6
months, he had streptokinase [an anti-blood-clotting treatment] in A and
E on the 21st. A quiet chappie, he spent the morning lying on his bed, not
saying a lot, barely got an answer. Taking diet and ¯uids well, quite
independent.
This report follows a sequence of the nurse giving patient identi®cation details
(read from the Kardex) and narrative category information. Nursing category
information included observations, the patient's mobility, communication and
nutritional needs. Medical category information included a previous medical
history (`TIAs for the last 6 months'), diagnosis (`MI, TIAs') and treatment (`had
streptokinase'). Two judgements summarise how the patient is known. One is a
global judgement about the patient's character in relation to the healthcare team
(à quiet chappie'), and the other is about his response to healthcare management
needs (`quite independent'). As with short reports there was an absence of
prescriptive instructions about the care to give, which again suggests that
nurses were expected to identify the patient's needs and make their own
decisions. The narrative being given was discussed during these reports.
Table 2.2 A summary of the sequence of a long report
Narrative-giving sequence Narrative data Narrative

categories
Patient Reading from a Name, 60, came in (date) with chest Management
identi®cation and nursing record pain and an intralateral MI (of care)
management
+
Nursing category Nursing practice He spent the morning lying on his bed, Nursing
focus not saying a lot, barely got an answer,
taking diet and ¯uids well
+
Medical category Medical TIAs for the last 6 months, he had Medicine
narrative; streptokinase in A and E on the 21st
treatment plans
+
How the patient Summary A quiet chappie, quite independent Management
is known judgement (of care)
Discussing the narrative during long reports

These discussions involved challenge, corroboration and validation. Challenges
were made to check information as it was given, as in the following conversation
between two sta nurses:
SN John (giving report): `Mr Davies, 64, TB, meningitis, revision of shunt,
no allergies, to contact physiotherapist and occupational therapist for
continuing care form. She needs to do it.' He veri®es this by referring
to the Kardex.
SN Alex: Discussed details of the occupational therapist's involvement.
SN John: Questioned whether the occupational therapist needed to be
involved and continued with the report: `full bed bath, 2-hourly care
given, rested 06.45F. Feed on at 10.45, nil aspirate.'
SN Alex: `Has he had feeds since 10.45?'
SN John: `Yes ± back on jevity plus [a liquid food]. He is awaiting private
hospital, catheter, obs satisfactory.'
SN Alex: Ìs he opening his eyes?'
SN John: `Yes, he is.'
Discussion allowed other nurses to add information to the narrative being given
and to corroborate or challenge what was heard. In Chapter 3, dierences in
narratives about patients are discussed to illustrate how report included chal-
lenge, corroboration and group validation. Discussion during long report giving
supported the development of a group consensus on how the patient was known
through contributions from dierent nurses.
During report, nurses also jotted down their own informal notes on scraps of
paper. These were occasionally referred to in subsequent reports and during
caregiving to check whether any outstanding tasks needed to be completed. The
purpose and role of note sheets are examined further in Chapter 4.
So far an explanation of the narrative development cycle has included a pre-
admission account, an admission narrative, record keeping and giving, and taking
the narrative during report. The ®nal part of the cycle is completed when nurses
go to care for their patients.
Narrative development stage 3: Caregiving

From report, I make some notes and then go and look at the patient.
After report nurses usually went directly to care for patients, generally without
referring to nursing records. Ì go down the ward, get them up for breakfast, make sure
they are comfy, get them washed, help with breakfast, get them ready for whatever they are
going to do. I don't read the notes ± I go and see the patients. I look at the patient and check
what I think. I check how well they are, are they blue or not, if they are ready to get up or
want to be left for a rest, or if they are wet they need seeing to straight away.' Their
interaction with patients provided an opportunity to check the narrative, add new
information and develop personal ownership of it as they developed knowledge
of the patient.
Several information sources could be drawn on to develop the narrative.
Various sta members could be consulted to ®nd out information, including
nurses, doctors, relatives, physiotherapists, occupational therapists, dietitians,
radiographers, porters and pharmacists: Ìf I'm working with another quali®ed
nurse I will discuss the care and what we need to do, it is a joint thing really, but if
I'm just with untrained I will chat with other team members.'
Information seeking also included narrative checking to detect change. For
example, a patient's level of pain was checked by `looking at the patient, his position
in the bed and how he twists his body and groans when moved', and judgement of
change was made in relation to the existing narrative. He was `seen to be in pain by
nursing sta, had spent an uncomfortable night and already had been given 10 mg stat of
diamorphine in the past 24 hours'. When adding to the narrative, some nurses saw
the patient as a subject of care, and valued talking with them in addition to
drawing upon other information sources: Ì talk to the patient, their family, do my
own observations of their appearance and general health, also look in the medical case
notes.'
The narrative development cycle was completed through this third step of
patient contact, information seeking and checking. New information was added
and processed so that the latest development of the narrative could be told to
nurses at the next report, as well as being used during the shift to identify the
patient's current needs as the precursor to deciding on appropriate interventions.
Conclusion
Nurses' decision making has at its heart the creation and development of a
narrative, which is an account of how the patient is known. The narrative
originated through processing referral information into a pre-admission account
or impression of the patient. This was subsequently revised following the patient's
arrival on the ward through the nurse's involvement in seeking information
directly from the patient. A nursing record includes an abstract of the narrative,
and is referred to when giving the admission account to other nurses during
report. The other nurses took report, listening to the narrative and often making
their own informal notes on scraps of paper. After report nurses typically
proceeded to care for their patients without reading the nursing record. As they
cared for patients they checked the existing narrative and added new informa-
tion, thus developing it. The nursing record was routinely updated towards the
end of the shift. The revised narrative was told to nurses at the next shift
handover report. The narrative development cycle continued from shift to shift
and from day to day as a contemporaneous account of how the patient was
known as they progressed along the trajectory of care. The whole purpose of the
narrative development cycle was to know the patient and use this knowledge to
identify the patient's needs and select interventions in relation to these. Knowing
the patient in terms of three narrative categories (nursing, management and
medical) was at the heart of decision making. Decision making is bound up with
how patients are known, and the following chapter will examine some dierent
ways of knowing patients.
Chapter summary box

. Narrative development and use are at the heart of real-world clinical
decision making by the ward team.
. A patient is known by nurses through a narrative which is their account
of them.
. A narrative has three categories of knowing, corresponding to the roles of
the nurse as carer, care manager and medical assistant.
. A narrative begins when referral information is processed to form an
impression of the patient. This is the pre-admission account.
. The admission narrative (account) is developed as the pre-admission
account is checked and revised through direct observation and an
interview discussion.
. The admission narrative is told to other nurses during report.
. During report, nurses listen to the narrative and make notes as part of the
process of remembering it.
. Following report, nurses care for their patients and check the narrative to
develop it by adding new information to produce a revised version.
. The revised narrative is told to nurses during the next report.
. A narrative development cycle involves giving and taking during report,
checking and development during direct caregiving, and giving the
developed narrative during the next shift report.
. The narrative is used in preference to the written record to identify the
patient's needs, and forms the basis of nurses' real-world decision

making.
. The narrative develops as the patient moves along the care trajectory,
which is the journey through the experience of healthcare.
Stop and think

This chapter has introduced the narrative of knowing the patient as being at the
heart of decision making. The following questions ask you to consider the extent
to which the narrative model helps to identify and explain aspects of your own
clinical decision-making practice. The way in which you make decisions might
dier, in which case the narrative model could be useful as a reference point from
which you identify local dierences and similarities.
Pre-admission
. How do you ®rst hear about a patient being sent to your clinical area?
. What information do you receive?
. How do you make sense of it to categorise the type of patient and their
needs?
Admission
. How is the admission process planned?
. Which documents are used and how does their use in¯uence the type of
questions and thus the information that you seek?
. To what extent do joint nurse±patient discussions constitute your
admission assessment?
. What are the implications of conducting a largely one-way information-
seeking interview with the patient?
Information sources
. Identify the range of information sources that you use during decision
making and group them into dierent categories (e.g. verbal, written).
. Examine these categories and consider the quality of the information and
its accessibility.
. What eect could restricted access to some information have on develop-
ing the narrative and subsequent decision making?
. Are there any information gatekeepers? If so, why do they have this role
and what would be the eect on narrative development if their
gatekeeper's role was to be removed?
. Could the information be made available in a dierent way (for example,

electronically)?
. If so, would it support narrative development?
Information processing
. How do you process information and add meaning to it?
. How does information processing contribute to the way in which you
develop knowledge of the patient?
. How does it direct your admission assessment interview?
Nursing roles
. What dierent nursing roles can you identify in your clinical setting?
. Do these add any additional lens facets to the conceptual lens outlined in
this chapter?
. How do these roles revise your explanation of the phrase `holistic
knowledge of the patient'?
Report
. How do nurses giving report decide what to tell those listening to it?
. How is report conducted? Where does it take place and what is its
content?
. How would altering the format and place of report shape narratives about
patients?
. What formal and informal rules govern report and how do they shape
narratives about patients?
. Analyse the information given in report and categorise it in relation to
the roles that you have identi®ed which nurses perform in your clinical
area. Which roles are prominent in information giving at report and how
does this shape how the patient is known?
. What assumptions are there about what every nurse should know about
the patients they care for?
. Could report be altered in any way to promote knowing patients? If so,
what would you recommend?
Recording narratives
. Do nurses compile their own personal informal note sheets during
report?
. If so, when do they use them and what role do they play in knowing
patients and organising nursing work?
. How are patients represented in the nursing record?
. How is nursing work represented in the nursing record?
(Records will be revisited in Chapter 4.)
Decisions
. What pre-admission decisions are made on the basis of the pre-admission
account?
. What types of decision are made following the assessment interview and
assessment narrative development?
. How are decisions represented in the patient's record?
. Which decisions, if any, are not written in the patient's record?
. Are there any factors that lead to decisions not being recorded?
. Could a change in practice alter what is recorded, and if so, what needs to
be done?
Reference
1 Roper N, Logan WL and Tierney AJ (1980) The Elements of Nursing. Churchill
Livingstone, Edinburgh.
Chapter 3
The narratives that nurses generate:

ways of knowing the patient
Introduction . Narrative scope and depth . Information processing .

Judgements within narrative categories . The ease of making judgements
. Judgements across narrative categories . Ownership judgements . Owner-
ship judgements and non-compliance with informal rules . Global judge-
ments and non-compliance . Global judgements and the contribution of the
healthcare team . Competing narratives . Conclusion . Stop and think
Introduction
Nurses know patients through the narratives that they construct about them. You
might ®nd that narratives about patients are a feature of your clinical practice and
consider why it is easy to recall knowledge of some patients while less so for
others. Part of the explanation for this lies in the scope and depth of a narrative.
The scope refers to the inclusion of information in relation to the nurse's dierent
roles, and the depth refers to the content of each narrative category. Nurses made
judgements as they processed information to develop knowledge of the patient
both within each narrative category and globally across all categories.
Narrative development included several nurses working in a complex clinical
setting, and the potential existed to generate dierent versions of knowing the
patient. This in turn led to questioning which narrative prevailed in clinical
decision making. Given that there can be so many factors in¯uencing real-world
decision making, there has to be an explanation of how consistency and
continuity of care is achieved. Two moderating in¯uences shaped information
processing and narrative development, namely the ward information hierarchy
(individual peer review by more experienced sta) and group peer review (by the
nursing team during report). There were times, for example, when dierent
nurses in the same ward team had competing narratives with regard to whether a
patient was lazy or ill. This had direct consequences for the decisions made about
the patient.
Narrative scope and depth

In the previous chapter I explained how the conceptual lens could be used to
describe how nurses' information seeking was shaped according to their roles
within the ward. The information gathered was developed into corresponding
narrative categories that the nurse interpreted to represent how the patient was
known. Role in¯uenced the scope of information seeking, while the extent of
information seeking within each category determined the depth of information
contained.
Narrative scope is a description of a nurse's use of one or more facets of the
conceptual lens to seek information from or about the patient. It includes
dierent combinations of the nursing, management and medical lenses. It follows
that a limited-scope narrative will represent knowing the patient dierently to a
narrative that has a full scope. For example, a nurse and management lens
combination supports knowing the patient as a person to be cared for coupled
with overseeing their progression through their hospital stay. Such narratives are
likely to include information and judgements about the patient's character, their
stated requirements, and how they are responding to their own care and health
problems. A medical and management lens combination, on the other hand,
supports knowing the patient as a case to be managed, and can depict the patient
as an object more than as an individual who might want to be an active
participant in what happens to them.
Junior nurses were described as having limited-scope narratives: `The junior will
say in a report ``®ne, eating and drinking'' and stay on a safe base. The experienced nurse
will talk about the family details and contacts and have a lot more at their ®ngertips.' This
had a direct eect on recognising the need to make a decision: `When results come
in we will have a look at them and act on it ± e.g. ring the doctor about a blood result and
see if he will come up and prescribe some treatment such as blood. A junior wouldn't.'
Narrative depth refers to the content of information generated in each narrative
category. As nurses spent more time with the patient and developed their
narratives, these categories contained a greater wealth of information. This
contributed to their ability to remember the narrative to the extent of describing
the patient as `known'.
When taken together, narrative scope and depth referred to the quality of the
narrative held in the mind of each nurse. It was revealed as nurses told their
narratives during report and recorded aspects of it in the nursing record.
Information loss in written records meant that the verbal narrative given in
report could have a greater scope and depth and so became a more valuable
source of ®nding out about the patient. This dierence is dealt with in Chapter 4.
Information was processed within and across the narrative categories and in-
volved making a series of judgements. It was intrinsically linked to each nurse's
knowledge and experience. This aspect will be revisited in Chapter 6 when
explaining a trajectory between inexperienced, experienced and expert nurse
decision makers.
Information processing
Information processing involved a series of judgements either within or across
narrative categories. Judgements within narrative categories generated summary
statements about the patient's health. Global judgements were made across
narrative categories and included ownership, compliance with ward rules, non-
compliance and judgements locating the patient in relation to the contribution of
the healthcare team.
The narratives that nurses generate: ways of knowing the patient 41
Judgements within narrative categories

Judgements made within narrative categories included comparisons between two
states, such as observations of, or comments by, the patient. These types of
judgement were statements of change or no change in relation to a particular
aspect of information. When referring to health status this could be change as
improvement, change as deterioration, or stability as a statement of no change.
In the following report, two judgements were made about the patient: `Mr
Jones, 59, acute sob [shortness of breath] exacerbation of COAD [chronic obstructive
airways disease], history of hypertension; 100% better; IV discontinued; absolutely ®ne ±
doing own thing.'
The ®rst judgement of improvement change is `100% better', in which the
baseline reference is èxacerbation' of a respiratory problem. The second judgement
implies an improvement, àbsolutely ®ne ± doing own thing', suggesting independ-
ent activity, but does not include the baseline of `not being ®ne' that was the
health status when the patient was admitted to the ward.
Judgements of health deterioration included statements of `he's going downhill'
and `he's worse than yesterday'. As with health improvement judgements, these
were comparative and included concepts of movement (along an imagined health
continuum), such as `going', `deteriorating' and òn a decline'.
Judgements of health stability indicated that there was no change between
reporting periods. Often during report a convalescing patient who was known by
the team would be brie¯y identi®ed along with a diagnostic label, and a
judgement statement would be made about no change in his health and
treatment or care programme (`Mr Stanley, you all know him; MS, no change').
The ease of making judgements

Prolonged involvement in patient care facilitated information processing through
accrual of knowledge about the patient: `You meet them and see them and gauge how
they are. You're able to just look and see how they are. You can soon know. You can judge
quite quickly if you have been having someone for a long time.' The process involved
thinking through: `You compare with your mental image to assess the change.' One
nurse gave the analogy of a mother±child relationship in which minor changes
were detected even if the speci®c details were not consciously identi®ed. There
was a state of just `knowing' that a change was occurring through comparison of
current observations of the patient with the existing narrative about them. One
part of knowing the patient included making global judgements across narrative
categories.
Judgements across narrative categories

Global judgements were made across narrative categories and represented the
patient both in relation to the healthcare team and in relation to the limits of the
contribution made by the healthcare team. Judgements about the patient's
relationship to the healthcare team included statements about ownership and
compliance.
Ownership judgements
I'm taking him home for a garden gnome.
During a lunchtime report a nurse commented Ì'm taking him home for a garden
gnome.' The remark caused smirks but was not challenged. This represented a
judgement about the patient as an object to be owned, which in turn implied an
owner (the nurse). Although a gnome might be an object of aection or humour,
this comment implied that an emotional distance existed between the patient and
the nurse. There could be a reason for this, as it facilitated taking prescriptive care
management decisions, such as where the nurse chose to place the patient in the
ward. A sta nurse implied in her explanation of managing patients' activity how
she had `sat them in a day room until it was time to return them to their bedrooms'.
Referring in this way to patients rather than to individuals supports a process of
objecti®cation where the locus of control for decision making can move further
into the nurses' domain. Information was interpreted to identify tasks to be
completed, such as giving medication and bed bathing, in which the individual
was cast as a passive object and as the focus of care tasks. Labelling the patient as
an object (a gnome) moved this on a step further, and although it might have
been intended in the context in which it was said as an expression of fondness for
the patient, it nonetheless revealed far more about nurses approving particular
characteristics of patients' behaviour. In this case one characteristic was com-
pliance which lent itself to the role of nurse as manager/caregiver and the patient
as object/recipient. Judgements that cast the patient as an object did in¯uence
practice to the extent of speaking at them or about them in their presence. For
example, two sta nurses were checking on elderly patients in a four-bed bay
early one morning. One nurse called to the other Ì need a bit of help getting him into
bed. I fed him and he's still slipping down in his chair.' Her colleague told the patient
`We'll put you in bed as the chair is not being any good for you' and then said over the
man's head to the other nurse, while holding him, `He drinks quite well from a cup.
I'll put him in a shirt ± use one of our own.' Throughout this episode the patient, an
elderly man, was not included in their discussion or in the decisions that were
being made about him.
Remarks about a patient's attempts to make autonomous choices also implied
challenges to nurses' assumptions of ownership. An experienced sta nurse who
reported `He will eat and drink but only when he wants to, you know what I mean?'
implied a plan to get the patient to take food and drink as the nurse thought
appropriate, which was countered by the patient's own choices.
Further challenges to ownership occurred in judgements linking the patient's
behaviour to their mental state. The judgements in the statement `He is barmy, a
sandwich short of a picnic, he is like a ferret, in and out of everything' liken the patient's
inquisitive behaviour (ìn and out of everything') to that of an animal (`like a ferret').
Certainly the transition from a person to a non-person is evident here, and the
supporting rationale is provided in a judgement of altered mental state (`barmy').
Ownership judgements also located the patient in relation to nurses, especially
when challenges to their decisions threatened their control over the decision
process.
Labelling patients as compliant or `good' referred to the lack of challenge made
by the patient to the nursing sta. This was evident in judgements about patients
who were àll right because they don't give us a lot of trouble'. Frustration with non-
compliant patients was aired during reports. A sta nurse explained to her
colleagues that ìn some way he is not an easy man to nurse ± I feel like I have been
banging my head against a brick wall'.
This frustration was also in¯uenced by the pressure that a nurse sensed if she
was to be blamed for not carrying out a doctor's instruction. In the previous
example the patient was expected to be a passive object in receipt of prescribed
treatment, but whose non-compliance created a dilemma for the nurse. It was not
the patient being proactive that was the threat, so much as the challenge to the
status quo of hierarchical power which signi®ed where the control of decision
making lay. In this case the comment `he [the patient] wants to have his say ± there
might be ®reworks when he sees the doctor' shows how the challenge rather than the
content of communication threatened the status quo in the doctor±nurse±patient
relationship. The nurse's anticipation of a reaction from the relatives also
indicated how non-compliant patients threatened their ownership and control
of decision making: `He refused to put them [pyjamas] on. I don't know what his
relatives will say.'
Information processing within the narrative generated judgements about the
patient that revealed a doctor±nurse±patient relationship and also how a nurse's
role as caregiver, care manager and medical assistant could promote a view of the
patient as a compliant object. The patient could be located in relation to nurses as
an object to be owned and controlled. Patients were classi®ed as ÒK' when this
relational hierarchy was preserved.
The informal rules of this relational hierarchy were often only recognised when
they had been broken. In the following incident the rule of being given
permission to leave the ward was `discovered' by a patient.
Ownership judgements and non-compliance with

informal rules
I've only gone for a fag.
Some patients were allowed, at a nurse's discretion, to leave the ward to go to the
hospital shop, but most of them remained within the ward. The expectation that
permission would be asked was not explicitly explained to patients or written on a
notice anywhere. Apart from reasons of physical incapacity and the need to be
regularly observed, patients remained on the ward for the convenience of medical
sta. Doctors could visit the ward at any time to review a patient's treatment, and
there was an expectation that the nurse would ensure that patients were available
to be examined or interviewed. Given that there were several consultants
attached to each ward, their teams of junior doctors did visit according to their
own workload needs in each ward. These visits tended to involve a minimum of
social chat with nurses and focused on completing medical tasks (reading test
results, reviewing medical treatments and responding to nurses' requests).
Patients who did not ask permission to leave the ward broke this informal rule
and often were only made aware of it after they had broken it.
As Samantha, a ward sister, entered the hospital on her way to commence duty
she noticed Shirley, one of her ward's patients, sitting in the entrance lobby. The
NHS trust had a no smoking policy, so it was customary for several patients to be
seen congregating around the hospital entrance to light their cigarettes. Shirley, a
young woman, was sitting on a commode chair smoking a cigarette.
During the lunchtime report Sister Samantha explained to the nurses how she
had asked Shirley what she was doing and was told Ì've only gone for a fag.'
Samantha recounted how Shirley was àsked not to go again on a commode chair', at
which the whole group of nurses listening erupted in laughter. The narrative
during report majored on the humorous aspect of Shirley having used a mobile
commode chair (as a seat) in public view. She had broken two informal rules, by
inappropriately using ward equipment and leaving the ward without permission.
The narrative about Shirley did not develop into one of problem patient and
persistent rule breaker. The laughter validated this and an isolated single incident
did not alter the narrative about Shirley into one of a non-compliant patient, nor
was the incident associated with a deliberate challenge to the nurses' care
management role.
Even patients who challenged the nurses and other sta were not necessarily
regarded as non-compliant, and their behaviour was interpreted through the
nursing lens as a response to health change. This occurred when Jane, a young
woman, was admitted to the ward.
A few days after her admission Jane began to complain about the food that was
being served on the ward. Samantha re¯ected on what the complaint was really
about and interpreted it às a smokescreen really'. She went on to explain her
narrative about Jane and how she had `lots of social problems, including three of her
relatives who also were ill. One [relative] who had been in the intensive-care unit had
since died, although this was before Jane had come to the ward.' Jane's frustration was
attributed to her physical inability to use her hands and òverall she was looking
increasingly tired'. Judgements representing how she was known included `frus-
trated' and ìt was all getting to her'.
One particular day, for a reason that was not given, Jane `blew up' at Samantha,
stormed o the ward and was next heard of from sta in the visitors' dining room.
A report was received that `she had given a hard time to the kitchen sta and had
thrown some food on the ¯oor'. Some patients in the ward had commented that Jane
was òut of order', and had been upset at having to witness the interaction. One of
them had wanted to go home.
When Jane returned to the ward she denied having upset anyone, which
resulted in some direct comments from other patients in her bay that she was a
liar. Samantha mentioned how some patients had been `sticking up for me, which
was more than some of the other sta on the ward'. The nursing team handled the
con¯ict in dierent ways, suggesting that dierent interpretations of the narrative
coexisted: Òne sta nurse did, the other male didn't and wouldn't get involved.' A
further challenge to the nurse's control of the patient within the ward occurred
when Jane stated that she wanted to discharge herself. Samantha explained how
Ì told her that I wouldn't advise it and that the doctors wouldn't take her back on very
readily.'
During her days o duty Samantha con®ded that she was worried: ìt's on your
mind, isn't it?' She revisited her narrative and mulled over what had been
happening with Jane. During this time she spoke of feeling isolated from peer
support: `The senior sister was o, I carried a bleep, there it is ± only 6 years post
registration, and having been acting sister for 20 months. I didn't feel that there was
anyone to talk to.' When Samantha returned to work she `left it . . . I didn't go and
talk to her [Jane], she could have gone either way ± blow up and here we go again, or an
apology. It was dicult because I avoided her when I came on duty after my days o.'
Her apprehension about possible further con¯ict made Samantha question the
point of being a nurse: Ì feel that we do our best and then that's what you get. You feel
that sometimes with all this why the bloody hell are you doing this, but I enjoy it really and
so stick with it.'
Samantha's decision was about what to do ± whether to tackle Jane or not. This
decision implied a global judgement of the patient in Samantha's narrative as a
`problem'. At some point Samantha checked her narrative: `When I came back after
my days o her attitude was dierent.' She indicated that if it had not changed Ì
would have had to formally sit down with her and discuss it, but as she had changed her
attitude I decided to leave it.'
The narrative was developed and this patient was no longer known by
Samantha as a `problem'. New information contributed to this change: Èventually
she came and apologised and said she was out of order. I said ®ne, I'm just here to give you
the best care I can. I feel that. I don't hold grudges, there was just a need to give her the care
and then get her home. That's what she wanted, she wanted to get ®t and go.' Further
narrative development depicted Jane as someone with improving health: Ì was on
duty for two more weeks on nights and that was that, no more problems. She was so
dierent after the steroid treatment. She got use back in her hands, looked refreshed and
was like a dierent person.'
Global judgements and non-compliance

Smart-arse sarcastic man.
Non-compliance could be interpreted dierently, and the patient's interaction
with nurses did lead to global judgements being made about them in relation to
nurses' care management role. Scottie became known for how he interacted with
nurses beyond any considerations of knowing him in terms of his nursing care
needs or medical treatment. As a result, the narrative about him developed from
an initial judgement of àll right' to one of getting `sick of it [him]'. How this
narrative development occurred is recounted below.
I was initially told about a `problem' patient by Tom, a charge nurse. As I
listened, I privately thought that he was giving a personal impression of the
patient based on his own narrative rather than one shared by the whole team.
However, during a subsequent report Scottie was described by a sta nurse as à
smart-arse sarcastic man', who during his stay on the ward had initially been judged
as àll right', but soon became known as `dicult'. His continuing sarcasm towards
the nursing sta had led to others in report con®rming that they had `got sick of it
[him]', and they cited an episode of abusive verbal behaviour to con®rm this.
Moira, a sta nurse, updated the four sta nurses and two care assistants listening
to report on what had happened over the previous two days when some of them
had been o duty. The patient was no longer on the ward. Alan, a sta nurse,
oered some background information about the patient:
We had a smart-arse sarcastic man. He played on it as well. At ®rst it was all
right, but we got sick of it. He also had MRSA. He was brought on to the ward
and went down to theatre. When he got in the patient lift a few other sta also
got in and made polite conversation. A medical records woman, just to make
polite conversation, said `You're in the best place.' He got angry, saying things
like `You're all right, you can walk, not like me', and he went o at her,
swearing his head o. Everyone in the lift was embarrassed. I thought `You
childish little bastard ± shut up.' When he was in theatre he was a bit warm
and the nurse in theatre felt his head and remarked about it. He said
sarcastically Ìt's called a fever ± don't you know that?'
Moira took up the story following his return to the ward: `When he came back up to
us post op. we got him transferred to a urology ward, giving the reason that it was because
he needed urology care post op.' Helen, a sta nurse, summed up the team's feeling of
approval of this development: `We were jumping up and down.' A few days later, in
private conversation, Tom validated the narrative and corroborated the decision
that had been made: `Later on, after a few days, he [the patient] met the sta nurse
[Alan] o the ward and asked if he had been transferred because he was rude in the lift.
The sta nurse said he had been.'
What can be made of this narrative? The judgement across all narrative
categories about the patient took a few days to develop, but did go through a
transition from àll right' to being a problem (`smart-arse'). This was a result of
compounding judgements shared by several sta over a few days during report.
The corroborated narrative validated knowing the patient as a `smart-arse'. This
validation was summarised in the phrase `we got sick of it'. Knowing the patient in
this way impacted on the nurse's role as care manager and expectations of
cooperation and compliance from the patient. Although the incident in the lift
precipitated someone (whose identity was not known, but possibly it was Alan,
who was in the lift at the time) to make a decision to seek Scottie's transfer to
another ward, there was wider corroboration for this on the basis of Helen's
narrative: `We were jumping up and down.' It suggests that the decision sought was
right for the nursing team regardless of what might have been the appropriate
place of care and treatment for the patient. An additional role of the nurse
emerges here in that medical sta were implicated in colluding with this decision
and authorised the transfer to another ward. The process whereby nurses
in¯uenced and challenged medical decisions through the nurse±doctor game is
explored in Chapter 5.
Global judgements and the contribution of the

healthcare team
It's tragic.
Another global judgement was the empathetic ìt's tragic' type. An analysis of this
in Table 3.1 shows how it was constructed across all three narrative categories as a
broader interpretation of knowing the patient in relation to their hospitalisation
and health change. This is evident in the following excerpt from a long report: `Mr
A Smith, 45, history ± had on Tuesday a CT biopsy and frozen section, now diagnosed as
astrocytoma. Wife to see doctor tomorrow, tragedy isn't it? She saw the doctor and is aware
of it.'
This global judgement was a statement about the patient's poor prognosis and
an evaluation of the extent to which nursing and medical intervention could
eect restorative health change. It in¯uenced how nurses interpreted the patient
Table 3.1 A summary of a long report narrative showing how the patient was known
as a tragic case*
Global Narrative category Narrative Narrative data

judgements judgements categories
(across
narrative)
Lunchtime ± Whole Character: Nursing . `Diet and ¯uids taken'
long report nature of the . `He is lovely' (nutrition)
narrative Compliance: . `Bowels opened small
. `Tragic' . Àn absolute amount' (elimination)
gentleman' . `Catheter patent and
Ownership: draining' (elimination)
. Ì'm taking him
. `Patient observations'
home' (monitoring)
. `He is an absolute gentleman'
(judgement)
. Ì'm taking him home'
(ownership)
. Ì'm taking him home for a
garden gnome ± he is lovely'
(judgement/ownership)
Stability: Medical . `Had on [date] CT biopsy and
. Judgement of frozen section, now diagnosed
instability as astrocytoma'
(investigations)
. `They have veri®ed the
diagnosis, discuss altering
diagnoses? (diagosis)
Treatment regimes, comments
on size of pt for drug dose,
note that CDs are due any
investigations outstanding'
(treatment plan)
. `The nurse noted changes of
type and doses of drugs'
(treatment plan)
. `She also compared the
patient's current condition
with previous observations
(e.g. vomiting)' (judgement)
Management . `Name, 45, history ± had on
[date]' (identi®cation and
chronology)
. `Wife to see doctor tomorrow'
(liaison)
. `She saw the doctor and is
aware of it' (liaison)
. `Transfer p.m. tomorrow'
(trajectory marker)
* In this table the data are grouped into narrative categories. Within-category judgements of knowing the
patient are identi®ed, and a global judgement is also identi®ed across all three categories of knowing the patient.
and their actions. The term `tragic' implies a sense of empathy with the patient's
plight, and contrasts sharply with global judgements made about patients who
were not cooperative or compliant.
Judgements within and across narrative categories represented information
processing to construct how the patient was known. The process of report and the
ward information hierarchy moderated and promoted an agreed way of knowing
the patient. However, there were occasions when dierent narratives coexisted
and this resulted in the patient being treated dierently by dierent members of
the same sta team.
Competing narratives
She's lazy . . . no, she's ill.
A case occurred where a female patient was diagnosed as having a rare cerebral
infection. Following a course of intravenous medication she was categorised as
needing rehabilitation, and spent a few weeks on the ward convalescing. She
tended to be lethargic. Most nurses on the ward had not nursed a patient with this
type of infection before and were unfamiliar with typical patterns of post-
infection recovery. Two competing judgements emerged about this patient.
Some junior nurses focused on the need to progress with physical rehabilitation.
The care plan recorded a broad goal of ìncrease mobility' under the Activities of
Daily Living `mobility' section, but lacked speci®c action step details and time-
scales. The junior nurses had decided that the patient should comply with their
interpretation of the plan of progressive exercise (e.g. sitting out of bed,
supervised walking). However, the patient was frequently reluctant to get out
of bed and even less inclined to attempt to walk. The junior nurses interpreted her
lack of cooperation with their rehabilitation plans as due to her being lazy rather
than incapable.
The senior nurses, in contrast, identi®ed the underlying medical problem as the
cause of the patient's response, and interpreted her state as lethargic rather than
lazy. When they became aware, through a comment made by a concerned
relative, that some junior sta appeared to be forcing the patient to mobilise
against her wishes, they took action to regulate the agreed narrative. An
information bulletin was retrieved from a clinical website that gave details
about the infection and the typical experience of the patient. This was circulated
to all sta, and was discussed at report and used to challenge the judgement that
the patient was lazy. The peer-review role of senior sta established the global
judgement of the patient as lethargic due to consequences of an infection, and
discarded the competing view that the patient was lazy and posed a challenge to
nurses' control of care management.
Conclusion
Narratives have both scope and depth. Scope refers to the categories included in
the narrative, and depth refers to the narrative content. Information was
processed by making judgements within and across narrative categories.
Within-category judgements often referred to health change (an improvement
or deterioration) or health stability. Across-category judgements represented the
patient's relationship to the team (for example, as an object to be managed) and

their relationship to the established hierarchy of decision control. Patients who
challenged the status quo, sometimes by breaking informal rules, could become
known as problems. This was not always the case, but when their behaviour
developed a consistent pattern the narrative adapted to re¯ect this and the patient
could be labelled as a problem. The nurses' decisions in those circumstances were
directed towards managing the patient as a problem rather than focusing on the
patient's problems. Thus a subtle shift occurred that tended to satisfy the nurses'
needs as carers rather than the patient's care needs.
Narrative development was a team activity as well as the work of individual
nurses. The team (through discussion during report) and individual nurses
(through information hierarchy peer review) acted as a check and a balance
on narrative development. The combined eect was to promote an agreed
narrative. However, this did not always happen, and there were cases where
patients were known dierently and treated dierently by dierent nurses
within the same team. Narratives in nursing records were also dierent to
their verbal counterparts told at report. These dierences will be examined in
the next chapter.
Chapter summary box

. The narrative has scope and depth.
. Narrative construction has individual and team involvement.
. Information processing involves judgement making either within narra-
tive categories or globally across them.
. Global judgements include statements about the patient as compliant
with informal rules and nurses' control over decision making.
. Global judgements include statements about the patient in relation to the
contribution of the healthcare team.
. Dierent nurses can develop dierent narrative variants for the same
patient.
Stop and think

This chapter has discussed the ways in which narrative information is processed
through judgement making. These judgements contribute to making statements
about how the patient is known. The following exercises ask you to consider your
decision-making practice, particularly how you make sense of information
processing, labelling patients and the eect that this has on the actions (decisions)
that are taken.
Narrative scope and depth

. Re¯ect on your own decision making and identify cases where your
narratives dier in scope. In what ways are the decisions dierent in
narratives that dier in scope?
. Why are some narratives limited in scope?

. Are there any other developments in the narrative scope beyond the
nursing, care management and medical lens described in this book? If so,
what are they and how does this shape how the patient is known?
Dierent narratives about the same patient

. Identify cases where the same patient has had competing narratives. How
did the dierence arise and how was it resolved?
. To what extent are competing narratives evident in nurses' records?
Narratives and labelling the patient

. When processing information about patients, what types of judgement
do you make?
. How do your information-processing judgements make statements about
the patient in relation to yourself as a healthcare professional?
. To what extent do patients in¯uence the global judgements that are
made about them?
. Consider cases where global judgements have led to decisions being
made about the patient that addressed nurses' needs to manage the
patient rather than addressing the patient's needs. What can be learned
from these cases? To what extent is it acceptable for the needs of the team
to override the needs of the patient?
Chapter 4
Demonstrating narratives: dierences

between verbal and written narratives
Introduction . Why nurses write records . How nurses use records . The
quality of written records and a need for change . How the patient is
represented in a written narrative . Information loss between verbal and
written narratives . The nurse's note sheet: an informal record . Conclusion
. Stop and think
Introduction
Nurses make decisions through the creation and development of a narrative
about the patient. These decisions should be recorded. There are many reasons
why it is necessary to record decisions, including: professional obligation; so that
the employing organisation can demonstrate that holistic, safe and eective care
is being given; and fault trace when this does not occur, as part of governance and
risk management. The patient also has a right to request access to their own
records, and a court may subpoena nurses' records for use in legal proceedings. At
the level of care delivery, these records should be used as a communication sheet
by the whole team. It is interesting, therefore, to identify dierences between the
verbal and written narratives. The nature of these dierences supports conclu-
sions about the role of the written record in day-to-day clinical decision making.
The implications of this necessitate revisiting the ways in which nurses work and
the extent to which a document ± be it paper or electronic ± can capture what
nurses do. Indeed, given that care can be given without recourse to written notes,
it is necessary to recognise the value of the verbal narrative and to consider how
that should be recorded.
I shall begin by examining nurses' accounts of why they wrote records, and
move on to consider what they chose to write about their patients. An example of
a care record will be compared with a corresponding verbal narrative to show
how these diered and what implications this had for decision making.
Why nurses write records

Written records are necessary to satisfy organisational and professional require-
ments. The United Kingdom Central Council (UKCC)1 and the Nursing and
Midwifery Council (NMC)2 require nurses to maintain contemporaneous records
and to use them as a central feature of care delivery. This stance was at variance
with the views of ward nurses, who did not support the notion of centrality, and
described record keeping as `documentation that we have got to do' and à task to be
done after giving care'. Generally, nurses saw record keeping as something that `had
to be done' for legal reasons, acknowledging the need to defend their practice
against potential complaints: `We might be dragged into court.' The design of the
record and the time available to complete it were cited as reasons why records
were not central to caregiving. Peer pressure existed: Ì think they [other sta]
spend too much time on Kardex', which suggested that writing was regarded as an
administrative task rather than as work central to nursing care. Paradoxically,
insucient time was cited as a reason for not reading other records, even if they
were thought to be relevant to decision making: Ìf we had more time we would read
the medical notes and ®nd out more about the patient.'
How nurses use records

Records were secondary to verbally communicated information, and were used
for reference purposes: Ìf I need to I will [look at them], but I get to know the patients
and the discussion in report gives a picture before I go and care for them.' Typical
reference actions were to `check something' such as à lab report' or `to compare a
written wound report with a current observation', and were part of judgement making
about health change `to see if it [the patient] had worsened or not'. Nursing records
were also used as a notepad or aide-memoire: Ìt [the record] has a list of things to
look for and check o.' Nurses tended to refer to the record after spending time
getting to know the patient: Ìf I need to I will [look at the nursing record], but I get
to know the patients and the discussion in report gives a picture before I go and care for
them.'
The question arises as to what else contributes to records having a low value in
day-to-day care. The comment Òn here they [records] don't mean a lot . . . they get
done . . . updated' was linked to knowing the patient. One answer lies in the way
that nurses described their work as based on thinking rather than on reading: Ì
know the work o the top of my head.' Ward sisters also concurred that a dierence
existed between real-world and theoretical practice (`care is planned informally and
the plans are written up retrospectively'), thus lending support to the informal oral
tradition of decision making.
Even in instances of apparently good record keeping, criticism was levelled at
how accurately the patient was represented: `Some [wards] are wonderful for care
plans but [these] don't relate to how the patient actually is.' Judgements about the
quality of content, and thus about the implied ®tness for purpose of records,
strengthened existing views about their value in day-to-day caregiving.
The quality of written records and a need for change

Although notes were written contemporaneously with caregiving (a requirement
of NMC professional guidance), there was some evidence that this did not equate
with a real-time representation of the patient: Ìf you look at these they are not kept
up to date, and if you're honest I don't think that anyone does keep them up to date.'
Records were typically written retrospectively àt the end of the shifts', two or three
times each day. This relied on recall of events during the shift, as patient
information is àll kept in your head and then written up later away from the patient'.
Demonstrating narratives: dierences between verbal and written narratives 53
This resulted in omission of information because `you don't get to write everything
down at the time, and then when you are at home you remember it and the next day try to
remember what you should have written'.
Comments about the quality of records raised questions about where else
nurses looked for information about what is happening with a patient. One
source that was cited was a ward-round book. This was a notepad containing
instructions given during ward rounds by medical sta, and it was `better for report
as it has the latest details from the round'. It was described as:
a good source of ®nding up-to-date information as it has the latest notes on
medical treatment, what doctors ordered on rounds, and can be used to quickly
check back for investigations and results. In theory the sta should be able to go
into the oce to get information they need to answer queries. It is useful when
relatives telephone the ward to ask when a consultant's round would be and
what was said at the last ward round.
This suggests that medical information was part of the narrative scope, and it hints
at the dominance of the medical lens in shaping how the patient was known.
Nurses needed to ®nd out what was happening to the patient ± shorthand for a
nursing, medical and management summary ± and the failure of records to
demonstrate this was discussed by a specialist nurse. He described nursing records
as `sometimes okay for the social needs, but they are poor for real information. I ®nd that
they are vague and give continuous reports of ``had a good day, slept well and quiet
afternoon'' but don't actually tell you what the shift was like for that patient.' His
remarks about needing to `know' what is happening to a particular patient reveal
an interpretation of the lived experience of the patient, a feature of the oral
narrative. The volume of information within records, described by some as
`jumbled', did not always support narrative development: `You . . . ®nd yourself
looking through piles and piles of paper in the medical and nursing notes. There are lots of
pieces of paper and reports not ®led in order, and it's very dicult to ®nd what is going on
with the patient. That is the problem ± you can't go into the notes and ®nd out quickly
what is wrong.'
The problem of poor-quality records (in terms of knowing the patient and what
was wrong with them) led nurses to favour verbally communicated information:
`The notes don't tell you whether the patient is getting better, worse, or what. The notes are
just a short comment, a change in treatment but without the discussion or reasons behind
it. That's why the report is important to me, that's where I ®nd out about what is going on.
The care plans are so vague that two dierent people could give dierent care from the same
care plan.' It was more practicable to ask someone than to read through a patient's
record.
Nursing records also included additional assessment sheets produced by non-
nursing sta (e.g. a dietetics department nutritional assessment tool). These
additions were regarded as ìrrelevant', `vague' and òpen to interpretation'. Comple-
tion of these was also seen as a chore that was done grudgingly in order to avoid
`being picked up on if they didn't ®ll [them] out'. Poor design, the time resource
needed, poor quality and an apparent lack of ®tness for purpose all contributed to
these additional records having a secondary place to discussion in decision
making.
This situation was freely acknowledged: `We know that they should be central to
care but are not.' If this was to happen, change was needed that would have to alter
nurses' existing practice of relying on verbal reports and their own note sheets.
Nurses' informal practice was of little consequence in the face of legal, profes-
sional and organisational requirements, and it was recognised that a `culture
change was needed in nursing to get care plans to be used as a central document'.
The time that nurses have available to write records, the quality of record
system design and the real-time usefulness of other notebooks (e.g. a ward-round
book), are all reasons why nursing records have a secondary role in real-world
decision-making practice. Although nurses recognised their professional and
organisational obligations to record their decision making, they prioritised
attending to patient care over other considerations. They were aware of the
legal implications of neglecting record keeping, but clearly the existing record
system had de®ciencies with regard to supporting clinical decision making. The
need for change was recognised, even if the method of achieving change was
unclear.
So far I have explored why records were written, how they were used and
quality issues linked to questions about their ®tness for purpose. I shall now
examine the way in which the patient is represented in the nurses' record.
How the patient is represented in a written narrative

The assessment sheet
The written record consisted of an assessment sheet, a care plan and a free-text
continuation sheet. The assessment sheet allowed dierent types of information
to be recorded. It included information to identify the patient (name, age, address,
NHS number, next of kin and preferred name), medical information (a brief
medical history, current medication, diagnosis and medical reason for admission)
and social information (such as type of home and dependants). This was all
recorded on the ®rst page. The next two pages were devoted to nursing care
information based on an Activities of Daily Living model of nursing, and included
sections for free text under headings such as diet, mobility, dressing and
grooming. The fourth page contained some checklists for planning the patient's
discharge from the ward.
The continuation sheet

The A4 free-text continuation sheet had three lined columns, the ®rst for the date
and time of entry, the second for the text and the third for the nurse's signature.
The following narrative written on a continuation sheet is analysed to reveal the
narrative categories and how these are interpreted to represent how the patient is
known (see Table 4.1). This brief record, when analysed, demonstrated evidence
of the dierent ways in which the nurse sought information about the patient
using nursing, management and medical lenses (see Table 4.2).
In this narrative, the nursing, management and medical information about the
patient located them on a care trajectory (type and route of admission). The
medical information included a history (`s.o.b.' ± shortness of breath), investiga-
tions, treatment and a marker indicating that the treatment process would not be
initiated until the patient had been seen by a doctor (`for review'). The nursing
information included observations of the patient's physical condition together
Table 4.1 Free-text entry in a continuation sheet

Date and time Continuation record Signature
10 March 1999, Emergency admission from coagulation clinic. Started with S/Nurse Smith
10.20 increasing s.o.b. [shortness of breath], chest pain and
palpitations. On arrival on ward pain-free and palpitation
settled, but continued to complain of shortness of breath.
Very anxious on arrival. Simon states over the last few
days he has been using his home oxygen more frequently
and getting less relief from his nebuliser. ECG, bloods, O2
at 2 litres.
For review by medical doctor.
with remarks about how they understood their health needs (`Simon states . . .').
The patient's remarks that were abstracted for inclusion in the record omitted any
details about their perception of needs, or any reference to their participation in
decision making. Information processing is evident in the judgement referring to
the patient's health stability (`palpitation settled').
This narrative focused on the patient's respiratory problem and represented
them as a medical case being managed along a trajectory, denoted by the
narrative marker `for review by medical doctor'. Two decisions were implicit in
this record, the ®rst about the nurse undertaking investigations to generate
information for inclusion in medical diagnostic decision making (ECG [electro-
cardiograph], bloods), and the second about immediate treatment (oxygen
administration).
Continuation sheets: sequential entries

Continuation-sheet entries could be brief, as in the example shown in Table 4.3 of
a chronological sequence of entries made about a patient over a 24-hour period.
An analysis shows how the patient was portrayed through nursing and medical
narrative categories. Nursing information included remarks about hygiene,
toileting and mobility, while medical information included cardiac monitoring,
blood pressure recording and a report on a pacemaker function.
Information had been processed within these categories and included com-
parative judgements denoting health change ± for example, `dizzy' (compared
with not dizzy), and BP (blood pressure) `shows signi®cant dierence.' Others
highlighted continuation of a particular health state ± for example `neurologically
unchanged'. The whole sequence lacked a global judgement about the patient, and
recorded aspects of `what is' but omitted references to care or treatment plans. A
plan, whether formal or informal, is suggested in the monitoring activities
reported.
The care plan

Care plans were written on blank template sheets (see Box 4.1). These were often
kept at the foot of the patient's bed clipped to an observation board, or stored with
the nursing record in the oce. Regardless of where a care plan was kept, it was
used infrequently and was only occasionally reviewed and updated. This did not
Table 4.2 Analytical summary of a free-text entry in a continuation sheet

Record entries How the data Conceptual lens Interpretation of categories
(data) were labelled category
(data codes) (data categories)
Date/time, Type and route Management The patient is represented as
emergency of admission moving along a trajectory of care,
admission from and progression is currently
coagulation clinic paused until a medical ocer has
seen them. This implies that
For review by Stage of Management control of progression is, at this
medical doctor narrative
stage, dependent on the
development regulation of the medical ocer
On arrival to Nursing Nursing The nurse represented the

coronary care, observation/ patient's experience of ill health
pain-free and judgement and their recent health trend. A
palpitation settled judgement was used to mark the
level of stability about one aspect
but continued to Nursing abstract Nursing of this trend (palpitations)
complain of s.o.b. of patient
(shortness of perspective
breath)
Simon states over Nursing abstract Nursing
the last few days of patient
he has been using perspective
his home oxygen
more frequently
and getting less
relief from his
nebuliser
Very anxious on Nursing Nursing
arrival observation
ECG, bloods Medical Medical The nurse included three aspects
investigations of the medical narrative (medical
ordered history, investigation and
treatment) that represented the
O2 at 2 litres Medical Medical patient as a case to be managed
treatment plan and an object of professional
Started with Medical history Medical interest
increasing s.o.b.,
chest pain and
palpitations
Table 4.3 Sequential continuation-sheet entries over a period of 24 hours

Date and time Continuation record Signature
12 March, 05.50 Neurologically unchanged, lying and standing BP S/Nurse Smith
shows signi®cant dierence. Mobile to toilet. (night shift)
12 March, 14.00 BM = 5.7 mmol at 12 md. Self-washed and showered S/Nurse Adams
with assistance. Dizzy this morning, shows no (morning shift)
episodes observed or reported.
12 March, 14.50 Sitting BP 101/56, standing 90/50, pt starting to S/Nurse Adams
wobble slightly on standing for a long period. (morning shift )
Measured for TED stockings.
12 March, 9 p.m. Mobile with one. No c/o (complaint of) drop attacks. S/Nurse Craig
(evening shift)
13 March, 6 a.m. Lying and standing BP recorded at 10 p. m., lying S/Nurse Smith
90/56, standing 78/31. Doctors on call contacted and (night shift)
suggested cardiac monitoring. Visited pt and stated
that monitor was showing that pacemaker was
working. Up to toilet 3 a.m., felt dizzy, BP 88/49.
mean that care was not planned or regularly reviewed. On the contrary, nurses
developed their informal care plan incrementally through the narrative develop-
ment process. Care plans had a problem-solving design that identi®ed the
patient's problems under an Activities of Daily Living category. Nursing inter-
ventions were stated together with a series of associated action steps.
Box 4.1 Blank template sheet for care plan

Name Number
Activities of Daily Living category Date/time
Problem
Aim
Action steps 1
2 etc.
A limited number of pre-printed care plans were used, which addressed

selected tasks, such as completion of the admission process. However, even
though these had been an innovation aimed at reducing the amount of time
spent writing records, many nurses preferred to write their own care plans:
We have pre-printed care plans, there are a number in the oce. I prefer to
write them myself ± it makes you lazy, the pre-prints. We used to have
computerised care plans, which I liked, but people didn't keep them up to date.
If you look at these they are not kept up to date, and if you're honest I don't
think that anyone does keep them up to date.
The sta nurse who made the above comment followed it with one that
emphasised the oral tradition of care through discussions between sta: `The
care is discussed on a daily basis and you get to know your patients. You should be doing
that anyway.' When asked if care was planned informally, she replied `Yes, things
get sorted as they happen.'
Even if care plans were used, they could be incomplete, notably omitting action
steps, as illustrated in Box 4.2, which shows care plans with and without action
steps. As was mentioned earlier, care was informally planned and delivered even
if it was never fully recorded. On one occasion a patient had been admitted to a
ward and received care for ®ve days before a care plan was written.
Box 4.2 Care plans with and without action steps

Care plan with action steps
ADL category: Maintain a safe ADL category: Washing and dressing
environment
Problem: Review medication Problem: Hygiene
Aim/goal: For tablet change to be Aim/goal: For high standard of
eective cleanliness to be
maintained
Action: 1 Administer medication Action: 1 Oer assistance as
as prescribed required
2 Monitor eect 2 General bath/shower
3 Oer support as as required
necessary 3 Oral hygiene
4 Change bed linen daily
Care plan without action steps

ADL category: Maintain a safe ADL category: Breathing
environment
Problem: Pt has reduced mobility Problem: Pt has s.o.b.
Aim/goal: 1 To regain his mobility Aim/goal: 1 To treat and relieve
to the best of his ability
Action: (None recorded) Action: (None recorded)
ADL = activities of daily living, s.o.b. = shortness of breath.
Information loss between verbal and written narratives

Nurses' support of the centrality of the narrative as the chief information source
for decision making drew attention to information loss between verbal and
written accounts of the patient. To illustrate this, Box 4.3 shows a comparison
between a verbal narrative given during report and its written counterpart.
In this example both versions of the narrative included all three information
categories (nursing, management and medical), but the verbal narrative consist-
Box 4.3 A comparison of written and verbal admission accounts

Written narrative Verbal narrative
Data `Patient admitted via A and E. The nurse explained having
Collapsed one day ago and now has `received a patient via A and E who
right-sided numbness. Bloods came as a result of the pressure of
(ticked), ECG (ticked), CXR, PEARL the daughter. She had had a funny
Ven¯on, BM 6.8 mmol. Baseline turn and collapsed, and was
observations satisfactory, initial transferred on to Cherry Ward. No
nursing observations satisfactory. diagnosis as yet as she had been seen
Initial nursing assessment made, by the paramedics only. The patient
awaiting medical review.' Signed was able to talk.'
SN Smith
Accounts analysed by narrative category

Major Subcategories Subcategories
categories
Management Route of admission Route of admission
'Patient admitted via A and E' Added further data:
'who came as a result of the pressure
of the daughter'
Management Management plan Management plan
'awaiting medical review' Added what was being awaited
in the medical review
(diagnosis)
'No diagnosis as yet'
Medical History History
`Collapsed one day ago and now has Added details of the collapse
right-sided numbness' `She had had a funny turn and
Bloods (ticked), ECG (ticked), collapsed, and was transferred on to
CXR, PEARL Ven¯on Cherry Ward'
Nursing Observations Observations
'BM 6.8 mmol, baseline Omitted to state observations
observations satisfactory, initial Added additional details about
nursing observations satisfactory' the physical assessment of the
patient
'The patient was able to talk'
ently added extra information. The additional information added context to how
the patient was known, such as reasons why they were admitted (`pressure of the
daughter'), the precursor to their collapse (`funny turn') and a feature of their
improving health (àble to talk'). In contrast, the written narrative included details
of observations and investigation tasks that had been completed. Overall, the
verbal narrative emphasised the patient who was ill, whereas the written account
emphasised the illness associated with the patient.
The nurse's note sheet: an informal record

Nurses made notes at report on scraps of paper. These were kept in their pockets
and were occasionally referred to during the shift. An analysis of these note sheets
revealed a sequence of information recording that encompassed one or more of
the three narrative information categories (nursing, management and medical).
When these ®ndings were triangulated with nurses' comments about their note
taking, an explanation was formulated of the purpose of this informal record in
narrative development. A typical note sheet written by a nurse during report
about a patient is illustrated in Figure 4.1. Accompanying this is Table 4.4, which
shows four particular features of the content (sequencing, annotations, colours
and narrative categories), and Table 4.5, which shows the indicative content
associated with each information category.
Figure 4.1 A nurse's personal note sheet written during report.
Note sheets like that shown in Figure 4.1 were written in blue or black ink and
included annotations (circles, squares or underlining) which indicated the nurse's
personal coding of tasks to be completed. Dierent colours were also used to denote
priority tasks, such as red ink circles, and ticks were used to indicate task
completion.
p For example, a con®rmed diagnosis was marked with a tick as MS +
MEP . Mandy, a sta nurse, explained that Ì use two colours, blue for name, age,
diagnosis, and red to highlight jobs to be done, like ®nding results.' These were notes
rather than longhand accounts, and included abbreviations such as for diagnosis
and AB for antibiotic. The information recorded matched the sequence given by the
nurse in report, and included management, nursing care and medical information
categories: Ìt's things like name, age, what they came in with, past medical history.'
Management information included patient identi®cation (`name, age, diag-
nosis'), while nursing category information included Activities of Daily Living
Table 4.4 Four features of a nurse's personal note sheet written during report
Category Content
Sequencing Room, name, age, diagnosis, observations, ADL information

Content categories Management ± patient administration information
Medical ± diagnostic information/investigation information/
treatment plan information
Nursing ± nursing care (ADL) information
Annotations Ticks ± tasks completed
Circles ± tasks to undertake
Underlining ± priority of tasks to be done
Box ± priority of tasks to be done
Colours Red ± priority of tasks to be done
Black ± standard colour for recording notes
ADL = Activities of Daily Living.
Table 4.5 Indicative content of a note sheet associated with each narrative
information category
Category Indicative content
Medical
p
Patient as diagnostic MS + MEP cellulitis (multiple sclerosis and cellulitis ± a
category tissue in¯ammation)
Patient requiring AB (antibiotics prescribed)
treatment plan
interventions
Management
Patient as object in a ?To see scans (investigation reports to be brought to the
liaison process doctor's attention)
Nursing
Patient as recipient of ?Incont ?Microlax (assessing whether the patient is
nursing care tasks incontinent and determining a possible nursing-initiated
intervention to manage the incontinence)
issues, such as a mobility report that the patient could transfer independently (`tfr
independ') and a concern about their continence (`?Incont'). Medical category p
information included investigations such as specimen collection (`MSU '),
questioned whether or not the patient required an enema (`?Microlax'), and
included a note about information to tell a doctor (`?To see scans'). The frequency
of note taking was linked to the nurse's familiarity with the patient narrative: Ì
only usually write stu down if I have been o for a few days.' More notes were made
when patients were not known: `When I come o holiday, like for 2 weeks, I have to
take a bit more information and interrupt to remind them that I don't know the patient.'
Note taking involved abstracting information from report because there was `too
much information to remember'. It also helped to clarify what to ask: Ì sometimes ask
more, depending on the type of report' because `some are not as factual as others.' In
doing so this called into question how relevant some reports were. Information
was abstracted on the basis of personal relevancy: Ì write things down which seem
relevant to me for that particular shift.' This short-term focus, `mainly about the speci®c
tasks needed for that patient on that shift', was concerned with care management
(`what needs to be done').
The extent of note taking varied according to `how much you know your patient'
and diminished to the point of being ùnnecessary after a few days of consecutive shifts'.
Once the narrative had been committed to memory, the note sheet as an aide-
memoire was dispensed with. Malcolm, an experienced sta nurse, con®rmed
this: Ì get to know the patient and after a few days I have it in my mind what is
happening with the patient.' Likewise, Monica, a sta nurse, commented that
knowing the patient was the overall aim of taking report, so she sought speci®c
information during it:
I always ask in report, they give a lot of irrelevant information ± like who has
had a bath. You need to know what is happening to the patient. I look in the
notes for the results and tests and things like that. `What do you write down
at report?' I only usually write stu down if I have been o for a few days.
Anything speci®cally I need to do I write down, usually a list of phone calls or
other things that need doing straight away. I don't write diagnoses down
unless I have been o, because you tend to get to know them, there is not that
big a turnover on the ward.
Once written, these notes were seldom referred to (ònce I have made a note of it I
tend to remember it and don't need to look at it again'), although some nurses did refer
to them when giving report. The main purpose of writing notes was to remember
the narrative so that decisions could be made: Ì pick up as much as I can, quickly,
and ®lter it through my brain and plan something therapeutic for the patient.' Knowing
the patient and being able to give a narrative about them was valued by nurses,
particularly experienced sta. However, those who could not do this courted
disapproval from their peers.
This happened during a lunchtime report when a junior sta nurse did not
know the patient that she was speaking about. She read from the Kardex old and
possibly irrelevant information (Àppendix operation in the 1960s'). The other
nurses in the room did not appear to be giving her their attention, and passed
non-verbal signals (rolling their eyes) between themselves. Sensing this, she
giggled, in apparent embarrassment, and asked the others questions to elicit
additional information about the patient. No one responded to her.
The nurse's note sheet played a part in committing the narrative to memory
and also served as a shorthand reference to prioritise and check on the completion
of some tasks. Two systems were in operation with regard to decision making in
the wards ± formal and informal. The formal system involved compilation of a
nursing record, whereas the informal system included ad hoc documents and the
oral tradition of care. There was a dierence between the two versions of accounts
about a patient.
Conclusion
Dierences exist between verbal narratives and their written counterparts. These
dierences modify the way in which the patient is represented. If the oral tradition
of care is rendered invisible in nursing records, as indeed it is, additional
information about the context of the patient is lost. It is this type of information
that helps to explain the patient's experience of healthcare. Without such
information the record can tend to portray the nurse's work as task orientated
and dominated by a medical assistant role. Nurses' discussions about patients
included more information about their experience of care and gave a broader
representation of the nurse's role. This included nursing care (e.g. work with
patients in physical and social realms), care management (e.g. liaison work,
coordinating services and resolving con¯icting plans) and medical assistant roles
(e.g. gathering information to support medical decision making, and implementing
and monitoring the progress of prescribed treatment). In addition, the peer review
of narratives by experienced sta and the nursing team during report as part of the
decision-making process is observable in practice, but is rarely detectable in the
record. Dierences between verbal and written narratives will continue to occur
until the record system is central to decision making and is thus able to capture the
process of decision making in a way that makes the record ®t for its use and
purpose. The existence of informal record systems in the form of nurses' note
sheets and ward-round books highlights the fact that alternative systems are used
as adjuncts to the oral tradition of care planning. Such records could be rendered
redundant if there was a closer alignment between practice and the formal record
system.
The implementation of electronic patient records represents a development in
document design and is a tool for information management. However, it remains
to be seen to what extent this development will impact on the merging of two
parallel systems (informal and formal) into one at the heart of clinical decision
making.
Narratives are at the heart of clinical decision making, and nurses use them to
in¯uence decisions outside the scope of their practice, namely medical decisions.
How they do this will be examined in the next chapter.
Chapter summary box

. Nurses record their clinical decision making using a formal record-
keeping system.
. This system is designed around a problem-solving approach to care, and
incorporates a model of nursing.
. The existing record-keeping system does not capture the extent of
information that is contained in a verbal narrative.
. The existing record-keeping system is not central to nurses' clinical
decision making.
. Nurses use informal records (e.g. personal note sheets and ward-round
books).
. Information is lost between verbal narratives and their written counter-
parts.
. The verbal narrative adds context to information about the patient.
Stop and think

This chapter has drawn attention to the dierences between the formal and
informal representations of the patient in decision making. All clinical care
settings that involve a team of sta will include multiple discussions about care,
whether on a one-to-one basis or in a scheduled team forum. It is likely that in
your clinical area more is spoken about care than is actually written down about
it. The following questions are intended to prompt further exploration of what is
lost between verbal and written accounts of your patients.
Formal records
. What formal record-keeping system do you use?
. Which models, if any, are incorporated into this record?
. How does the design of the record shape the way in which the patient is
represented?
. To what extent does the record capture team contributions to decision
making?
. How often is the record used during a shift?
. Should it be used more frequently, and if so, what would promote such
use?
Informal records
. Do informal records exist in the clinical area?
. If informal records exist, what are they and who compiles them?
. How are informal records used?
. When are they discarded?
. If they are discarded, what is lost from inclusion in the formal record
system?
Dierence between written and verbal records

. Compare a written account of a patient from your formal record system
with the verbal account given at report. In what ways are these similar
and dierent?
. If there is a dierence, how does it shape dierent representations of the
patient?
. What impact does acting on dierent representations of the patient have
on decision making?
References
1 United Kingdom Central Council (UKCC) (1998) Guidelines for Professional Practice.
UKCC, London.
2 Nursing and Midwifery Council (NMC) (2002) Guidelines for Records and Record Keeping.
NMC, London.
Chapter 5
The games nurses play: making

narratives known to doctors
Introduction . Nurses, doctors and the context of clinical decision making .

Dierent types of relationship between nurses and doctors . Improving
nurse±doctor relationships . Non-confrontational tactics that are used to
make narratives known . Confrontational tactics that are used to make
narratives known . The historical legacy of resistance to recognising nurses'
ways of knowing patients . Conclusion . Stop and think
Introduction
Knowing the patient is at the heart of an oral tradition of decision making in
which the narrative is used to identify needs and match them to intervention
options. Nurses' narratives are not the only way of knowing the patient, and
other healthcare sta, notably doctors, can hold dierent views about the
patient's needs with regard to care management and treatment. Nurses recog-
nised this dierence and used their own narratives to challenge doctors and
in¯uence their decision making. In this chapter the nurse±doctor relationship will
be described together with the communication tactics that nurses used to make
their narratives known to doctors.
Nurses, doctors and the context of clinical decision

making
In ward settings tension existed concerning who owned and controlled the
environment of care and the patient within it. Nurses claimed ownership of the
ward on account of their continuous presence: `The nurses are here all the time, 24
hours a day.' Nurses have had responsibility for managing the environment of care
since Nightingale's day through management of the patient in the sick-room
(ward) to allow the laws of health and nature to act on them. Doctors had the role
of intervention in the health and healing process. These responsibilities translated
into contemporary nursing practice as a care management role with responsi-
bilities for regulating a safe clinical environment through the oversight of health
and safety arrangements, such as the ordering, maintenance and safe use of
clinical equipment and the storage and disposal of hazardous substances and
clinical waste. Nurses also coordinated the contributions of other sta who visited
or worked in the ward. The ward manager was the hub of this process.
The games nurses play: making narratives known to doctors 67
Doctors frequently assumed control of care and treatment when they were in
the wards, and by implication challenged the scope of nurses' eorts to manage
care. This has been recognised elsewhere. For example, Gair and Hartery1
commented on how doctors saw the patient in the ward as their territory due
to their legal accountability for patient care. Such challenges to nurses' claims of
ownership were typi®ed by remarks about doctors `coming on as if they own the
place', and provoked a response to reassert territorial control: `The sta are good at
dealing with bombastic doctors.' Part of asserting this control included supervising or
policing activity within the ward. For example, one sister worked around the
oce close to the ward entrance and monitored who visited the ward as well as
the work that was going on within it. When junior doctors visited, she exerted her
control by directing them to undertake tasks written by nurses in a communi-
cation notebook (such as inserting intravenous lines, collecting blood specimens
and writing prescriptions). The clearest reversal of nurses' control of the ward
environment occurred during consultant-led ward rounds, in which nurses were
expected to ensure that patients and their records were present to be reviewed by
the medical sta, and junior nurses had to keep away so as not to interrupt the
round. It was in the context of nurse±doctor relationships that a particular
communication game existed. Both groups had a stake in managing patients'
care and treatment. Nurses assumed ownership of the ward and work within it.
Doctors drew on their positional power within the organisation, and their claim of
legal responsibilities towards the patient as a `medical case', to assume a decision
authority that directly aected the work of others in the ward. The nurse±doctor
relationship was integral to shaping decisions made about the patient and about
care management. So what was the relationship between nurses and doctors?
Dierent types of relationship between nurses

and doctors
The nurse±doctor relationship varied from good to poor, with some doctors being
regarded as `likeable' because they acknowledged nurses' views. Some doctors
were described positively (`he seems to listen'), while others were referred to as
`horrible', àloof ' and `rude' because they `didn't generally talk to nurses' or patients.
Poor relationships were attributed to the lack of interpersonal skills of doctors, not
nurses, and were associated with a perception of how the doctor `saw' the patient.
This was principally from a medical case management perspective. Poor relation-
ships were grounded in judgements about how doctors dealt with others, includ-
ing an ìnhuman . . . bedside manner' that was `prescriptive' towards the patient and
`dictatorial', àrrogant ', àngry', `disapproving' and `moody' towards nurses. Senior
doctors were implicated in in¯uencing junior doctors' attitudes towards nurses:
`Some will only take notice when the consultant listens to you on a round, then they start to
give you a bit of respect.'
Nurses held a range of views about the doctor±nurse relationship. Junior sta
were described as being à little in awe of doctors' and timid in their presence. Some
were ùneasy' when certain doctors were on the ward, and tried `to keep on the right
side of him'. Circumspect timidity was compounded by previous experience of
making unsuccessful complaints about doctors' behaviour: Ìf we complain they
[doctors] go to management; management always assume they are right.' The organ-
isational power of doctors was alluded to in comments made about the indirect
pressure that they could bring to bear on nurses: `They say [to the hospital
managers] things like `Ì'm leaving if you don't do something about the attitude of
sta.'' ' This could result in admonitions (`you end up getting told o ') or being sent
formal letters: `Consultants have occasionally sent letters criticising sta for reacting to
doctors. We replied back that they come with the attitude that they expect a nurse to be at
their side. We don't ignore them but go with them [to see patients] when we can.'
Experienced sta took a more con®dent stance, describing doctors `not as some god,
but here to do a job', and challenged the hierarchical doctor±nurse relationship: Ì
speak to them like I always do.'
Some junior doctors did seek nurses' views and asked for their advice about
patient treatment (for example, `what do you do here?' and `what do you think?').
Nurses also regarded doctors' agreement with their comments as a form of `peer
review' or validation of their narrative. This gave them `con®dence to approach
doctors', particularly when acting as advocates `for the patient', whether this
concerned observance of hospital `policy' or presenting a `challenge from the team
[nurses]'. Advocacy could be dismissed when it was seen as a challenge to medical
decision making: Ìt depends on the consultant. With old-fashioned doctors we make no
suggestions as we know damn well that they will do the opposite to what we suggest.'
Other doctors did listen to nurses, even though there is implied decision authority
in the reference to `taking no messing': `With others we can discuss the patient with them
and make suggestions. Dr Marham we have known for a long time, he came through here
as a senior reg., but he is strong and takes no messing.'
Some consultants supported the sisters' role at the top of the ward information
hierarchy and preferred only to speak with them. This gave rise to problems, as it
was `dicult when a lot of doctors come together' and then did not want a sta nurse
to accompany them on a ward round: `You will get that with a consultant, they want a
navy blue dress ± even the younger consultants. Some are not as bad and will do a round
with a sta nurse, but you can see that they want the sister on the round.'
One aspect of doctors' attitudes towards nurses lay in their expectations of
nurses' work and the information that could be given to support medical decision
making. Nurses were expected to know their patients, speci®cally with regard to
social care issues rather than medical details: `They [doctors] expect you to know the
patient and you try to give the information needed but don't get too involved in the rest of
it. The social circumstances you need to know, and it is very embarrassing if you don't
know it.'
Some nurses recognised limitations in their ability to provide this information:
Ìt's a pain really . . . as doctor expects you to know more about the speci®c patient than you
[actually] do.' Sometimes they tried to de¯ect doctors' questions to hide their lack
of knowledge by claiming that they `had only just come on [to the ward]'. Others
questioned doctors' professional self-interest and their limited view of nurses'
work: `The doctors . . . come on and want the sister to go and attend to just what they want
and don't seem to realise that she has sta as well as 28 patients to manage.' Their
approach towards nurses could be prescriptive and lack awareness of their wider
role in the ward: À doctor came on to the ward complaining about a lack of equipment
and gave the nurse an order. He said ``just get it'' and didn't want to listen to excuses. He
thinks nurses are always having breaks and sitting down, but they don't see the whole
picture [of nurses' work].'
However, although nurses valued their own work, some acknowledged that its
vague, àiry-fairy' nature contributed to its invisibility: `When we have a dependent

ward it is busy with patient care. We see that as our nursing priority and are taken up with
washing, dressing and feeding of patients. This is the important role of the nurse. That can
take all morning and the doctors don't seem to appreciate it.' Steps were taken to
improve poor relationships, although these were not always successful.
Improving nurse±doctor relationships

Sister Julie explained how a doctor avoided discussing the problem of fractious
relationships on the ward, stating that `he didn't want a relationship with a member of
sta ', but others were open to discussion: `We can discuss the patient and make
suggestions.' Nurses also wanted good relationships to satisfy their own informa-
tion needs: `There is only so much info the nurse can give because the doctor doesn't
always give the full picture and so you will really have to talk to him.' Nurses could not
rely on doctors always to tell them medical information about patients, and so
resorted to reading the medical notes: Ì was looking in a set of medical notes to see the
updated care of patients and discovered that a discharge had been planned without telling
the nursing sta. Good of them to tell us [said sarcastically].' There were occasions
when doctors held private discussions in the ward oce and only passed on brief
instructions to the nurse in charge, without including a rationale. On other
occasions they would make a note in the medical record and omit to inform the
nurses. Neither act was satisfactory, as nurses needed to coordinate the manage-
ment of the patient and make this meaningful in their discussions with them.
Often they acted as an interpreter for the doctor, not from English into a foreign
language, but from technical language to one that could be understood by
patients. For nurses, knowing why the medical sta had made a particular
decision was as important as knowing what decision they had made. Communi-
cation with doctors was vital to understanding the medical perspective and to
making the nurse's narrative known so that they could act as a patient advocate.
Whenever nurses thought that medical decisions were not in the patient's best
interest, they played a communication game to make their narratives known.
This is called the nurse±doctor game. The goal of the game was to shape decision
making, the focus was knowing the patient, the players were doctors and nurses,
and the moves were communication tactics. The speci®c moves in this game
included non-confrontational and confrontational tactics, such as making indirect
comments, ¯irting, reasoning, refusal, going to more senior doctors and sanction-
ing a change in the locus of decision control.
Non-confrontational tactics that are used to make

narratives known
Being ùnhappy'
Nurses indirectly challenged medical decisions by using non-speci®c phrases
about the patient (not the doctor), such as `not being happy' or Ì'm concerned'.
This was non-confrontational as it was the nurse's statement of her own
perception about a situation, rather than a direct reference to anything in
which the doctor was implicated, as if the nurse was letting the doctor eavesdrop
on her own private musings. However, it did signal an invitation for the doctor to
discuss this concern further.
Flirting
Some female sta attempted to in¯uence medical decisions by ¯irting with and
¯attering doctors. This was a deliberate ploy that went beyond normal social
niceties such as including a doctor in a sta tea break on the ward (doctors never
had lunch or took tea breaks with nurses in the sta canteen). They made doctors
drinks, deliberately sat next to them, engaged in social rather than clinical
conversation, and used their body language as a precursor to stating what they
required. Sister Julie demonstrated this, after telling me that she wanted a doctor
to change his decision. She ¯irted (by maintaining prolonged eye contact and
making her breast pro®le visible to a doctor) and introduced in conversation the
need to revise a patient's treatment plan. The doctor considered the nursing
information provided and subsequently revised the treatment plan. If a junior
doctor tried to ¯irt with nurses they were rebued and their actions led them to
being privately described as a `creep'. This highlighted a dierence in interpret-
ation of the use of this communication tactic. Flirting was used on some
occasions, but the norm was to discuss concerns by reasoning why a decision
needed to be challenged.
Reasoning: improving care and saving lives

Reasoning was described as `setting your stall out' and was frequently used to
in¯uence medical decisions. Tom, a charge nurse, explained how he had
successfully argued for the postponement of a planned operation for a patient
who was due to have a percutaneous endoscopic gastrostomy (PEG) (a feeding
tube inserted through the abdominal wall). He had judged that the patient was
un®t to undergo the procedure (this was his global judgement about the patient
within his narrative): `The doctor was wanting to PEG a patient and I said ``not now, as
I think that you would lose him''.' Tom went on to add how he reasoned with `Dr
Smith that I needed three days to nasogastric feed the patient, build him up and then take
him down for a PEG next week'. Tom's view that without this delay the patient
might die was accepted, and Dr Smith replied `right, we will do that', with Tom
adding, `That's when they respect and listen to your judgement.' Other nurses
concurred with the use of reasoning: Òn a ward round, if you tell the consultant
about a wound, you need to set your stall out and give reasons for what you did, not just a
statement like I think that that will be best, e.g. this has a wick with an absorbent aquacell
(dressing) and permeable pad on the top.' Reasoning was not always listened to, so
nurses might resort to confrontation to get the attention of the doctor so that they
would listen to their narratives.
Confrontational tactics that are used to make narratives

known
Direct refusal
Refusal of a medical instruction was a high-risk strategy that was likely to bring
the nurse into sharp con¯ict with doctors, but did sometimes result in the nurse's
narrative prevailing to alter the care management plan. Alan, a sta nurse,
described a typical instance of this:
A patient had diarrhoea and we don't start a treatment until we know what
the causative organism is. The doctor wanted to prescribe loperamide. He was
told that it was OK if he wanted to prescribe it but it wouldn't be given unless
we knew the cause of the diarrhoea. You see if it was infectious diarrhoea and
you give a drug to slow down the bowel, you can cause other problems such as
toxic megacolon and the patient can become really ill, making things worse.
This direct refusal of a medical instruction along with a supporting rationale was
likely to promote confrontation. It did not always de¯ect some doctors from
insisting on their prescribed plan for the patient, so nurses exercised the option of
ignoring the medical instruction and appealing for support from a higher-grade
doctor. This in eect entailed using one of the same tactics mentioned earlier for
which they had criticised doctors, namely being dismissive of their views.
However, resorting to confrontational tactics implied the failure of trying to
reason with doctors.
Going to more senior doctors

Referral to a more senior doctor was not readily undertaken. Persistent reasoning
was often employed to make their narratives known, variously described as
`telling', `reasoning', `tell and tell again' and `badgering' doctors. The threat of `going
to a senior doctor' was sometimes successfully used to pressurise a junior doctor to
alter a medical decision. If they did not make the decision that the nurse thought
necessary, a more senior doctor was contacted:
We have just got a change of house ocers and they are scared of their own
shadow at the moment. They haven't got to know us and to trust our
judgement yet. In that case I would go and bleep the SHO, who has been
here a little longer and has a little more consideration behind their decisions. In
this case she said that we could change the drug and she would come and write
it up. She bleeped a house ocer and sent him up to do it. That's why he
questioned what the cancer nurse said but went along with it in the end.
This type of challenge could create tension between medical sta, and to avoid
this situation developing, some junior doctors sometimes complied with the
nurses' requests, especially when these focused on administration issues such
as completing pharmacy prescriptions: Ì have had a run-in with a couple of them and
have to go above them to the SHOs to get some drugs written up.' The overriding
consideration in making the narrative known to challenge medical decisions was
the nurse's focus on the patient and their needs:
I will [challenge the doctor] on anything, that's me, junior sta will not
have the con®dence. I tell them that if they are not happy [with some patient
care] then to tell the doctor, even to the point that I would ring the consultant
if I was not happy. A couple of the juniors might not.
Mary, a sister, went on to state her priority when dealing with these concerns:
Ùltimately the responsibility is nursing the patient and that's the point, not pleasing a
doctor.' Narrative-based decision making is all about patient-centred care ±
knowing the patient. The narrative could favour an emphasis on any one of
the three categories of knowing the patient (nursing, management and medical),
but it was the nurse primarily acting as an advocate and adopting a holistic view
that encompassed a full-scope narrative which spurred on the challenge of
medical decision making.
Although the doctor±nurse game existed, several factors shaped whether it was
actively played. These included the nurse's con®dence in the scope of their role,
particularly their ownership of care management, their con®dence in knowing
the patient and their awareness of how dierent medical sta treated nurses.
Whenever the game was played, control of patient management within the
clinical territory was a foreground issue between nurses and doctors. There were
occasions when doctors relinquished control of the patient. This was when the
patient moved towards discharge from the ward.
Sanctioning the transfer of the locus of control from medical to nurse

decision making
Once the medical sta had evaluated that the treatment plan had achieved
particular goals, and there was no further need for the patient to be on the ward,
they decided that the patient could be discharged. This suggested that the doctor
had a veto on control of the patient along the care trajectory. Sometimes, when
doctors made this decision and announced it to the nursing sta, it was
immediately challenged:
A doctor will say they can go home and I will say `Slow down, we have to get
things sorted.' The doctors here do look at the whole and ask `Sister, what are
the social circumstances of this patient?' The nurses are good here for
advocating what the patient wants; things are discussed with the patient to
see if there can be a compromise if they don't want the care.
At this point, nurses played the major role in overseeing the ®nal progression of
the patient to the end of the care trajectory and discharge from the ward. This
included taking responsibility for a range of administrative and liaison tasks, and
ensuring that there was appropriate referral to post-discharge support services.
Although this represented nurses having control over part of the trajectory, it
appeared to be at the sanction of doctors, which implied that this control could be
transferred back to medical sta if the patient's medical condition altered and
necessitated further medical intervention.
The historical legacy of resistance to recognising nurses'

ways of knowing patients
Historically, challenges to medical decision making have met with resistance from
the medical profession. The articulation of nurses' narratives and new roles with
enhanced decision authority present challenges to the prevailing medically led
ways of knowing the patient. This speci®cally probes the boundaries that preserve
power, decision authority and interpersonal relationships within wards. It is not
surprising, therefore, that a challenge to the status quo which preserves medical
control over management and treatment of the patient along the trajectory of
care meets with resistance from doctors. One example of this resistance is doctors'
questioning of the direction of professional nursing practice, as noted by Maslin-
Prothero and Masterson2 in their comments on Short's headline in the British
Medical Journal, `Has nursing lost its way?',3 which advocated a return to the òld'
nursing values. Maslin-Prothero and Masterson2 made the point that it was
unlikely that the work of medicine and doctors would be discussed in such a way
in a nursing journal.
Resistance and the communication tactics used by nurses have been recognised
elsewhere, particularly in Stein's `doctor±nurse game'4 as a feature of medical sta
hegemony in the clinical setting. Although Ho¯ing and colleagues5 wrote about it
®rst, Stein4 is attributed with labelling the relationship as a game. Its origin is in
the èssentially patriarchal' doctor±nurse relationship6 in which nurses had
traditionally conformed to a gendered family role as a female carer, and it is
characterised by a dominant±subservient male±female relationship.7 The main
rule of the game, according to Stein,4 was that open disagreement between the
players must be avoided: `The nurse can communicate her recommendations without
appearing to be making a recommendation statement. The physician, in requesting a
recommendation from a nurse, must do so without appearing to be asking for it.'
A later review of the doctor±nurse game by Stein et al.8 concluded that nurses
had unilaterally decided to stop playing it. Nurses, these authors claimed, were
now hostile, stubborn rebels, and associated this with becoming autonomous
healthcare professionals. In a similar way, Sweet and Norman6 con®rmed that
although previously this game had been played àlmost without exception', it was
now rarely observed in hospital settings. This was attributed to broader changes in
the improved status of women in society. Findings from the study on which this
book is based suggest otherwise, principally indicating that nurses can play the
`stubborn' role but are also quite capable of adopting tactics or game playing to
ensure that doctors hear their narratives, in order to in¯uence medical decision
making. These tactics were often used when vying for control of the patient's
progress along the trajectory of care, and such `turf wars' are likely to continue so
long as there are dierences in decision authority that favour doctors' ultimate
sanction over nurses' decisions. Some of these dierences are between nurses'
and doctors' views of their roles in the ward. According to Snelgrove and
Hughes,9 doctors viewed themselves as the key ®gures in the management of
treatment, so the decisions that needed to be made were essentially medical ones
based on medical knowledge.
Similar comments to those discussed earlier in this chapter about doctors'
attitudes towards nurses have also been reported elsewhere ± for example, in the
description by Adamson, Kenny and Wilson-Barnett10 of doctors as àuthoritative,

powerful, assertive, prestigious, autonomous and complacent'. Castledine,11 a nurse,
attributed this àrrogance' to the way in which doctors see the nurses' role and
their ignorance of what nurses are achieving. To be sidetracked into a medical
assistant role was a move away from the `real issues' of professional role
development. The recently coined term `maxi nurse' further emphasises the
development of nursing rather than a transition into medicine as a `little doctor'.
A lack of understanding of the role of nurses highlights the invisibility of their
work to doctors. Nurses as advocates can provide a safeguard that actually
protects the patient from decisions which could cause them more harm than
good. Nurses' contributions have historically been selectively silenced.
Chiarella's analysis of Australian case law between 1904 and 199912 reported
how nurses' voices and experiences were excluded to the extent that they were
historically portrayed as little more than extensions of doctors. Furthermore, their
actions were only given weight when the doctors said so. This represents
successful medical hegemony, and the review by May and Fleming13 of socio-
logical accounts of interprofessional relationships concluded that nurses are
subordinate to doctors. They went on to discuss how nursing is more concerned
to construct dierence than `to compete on the same terms, for the same turf'. The
construction of dierence, they claimed, had been given insucient priority in
sociological accounts. A departure from a purely medical model way of knowing
the patient (that supported the generation of medical lens knowledge) was
needed, which involved examining dierent ways of constructing the patient,
not from distinctions arising from organisationally constituted boundaries, but
through professional discourses. The doctor±nurse game represents the interface
of this discourse at ward level, involving short-term interaction and game playing
within the status quo of existing roles and decision authority. A wider discussion
of recon®guring the roles of clinicians in health service delivery is the place where
more enduring change is likely to occur. With a latent professional tribalism as
the subtext to this debate, some have accused nurses of adopting a strategy of
closing themselves o from biomedicine to represent their work in terms of
holism.13 This was not found to be the case in the study that underlies this book,
as nurses straddled the divide between themselves and doctors, standing on the
common ground of patient management, which might be taken to mean the
common `turf '13 that was referred to earlier.
Conclusion
It is one thing for nurses to know their patients and make care decisions on the
basis of the narrative. It is another for them to use their narratives to in¯uence
medical decision making. The context of ward work has some features that
perpetuate the need for nurses to play communication games in order to
in¯uence medical decisions.
These included dierences in the scope of decision making between nurses and
doctors. Other professionals held assumptions about nurses' work that were
largely invisible in written records and to those who visited the ward for short
periods. There was also an organisational culture that supported a professional
hierarchy, and there was evidence that nurses' complaints could be minimised in
order to placate doctors. These features perpetuate the status quo with regard to
the way in which healthcare work is carried out. However, drivers for change in
nurses' roles arising both from within the nursing profession and from outside it
(e.g. opportunities arising from changes in government health policy) lend
support to challenging of the status quo. The extent to which real change will
be achieved or resisted by participants will determine whether the nurse±doctor
game is still needed, or whether it is discarded in favour of an equal contribution
and consensus over and agreeing of a care and treatment plan.
Chapter summary box

. Nurses have a historical role that includes management of the care
environment as well as care for the patient within it.
. There is a dierence between nurses' and doctors' decision making.
Treatment prescription is traditionally the remit of the doctor.
. The continual presence of the nurse with the patient supports the
generation of a dierent way of knowing the patient compared with
other healthcare professionals.
. Nurses make their narratives known in order to in¯uence and alter
medical decisions.
. Several factors in¯uence the communication tactics employed by the
nurses to make their narratives known to doctors.
Stop and think

In this chapter the nurse±doctor relationship has been explored together with the
communication games that are played in order to make the nurse's narrative
known. The following questions ask you to examine the interprofessional
relationships in your clinical area and to consider their eect on decision making.
Professionals involved in decision making

. What are the key professional groups involved in ward decision making?
. Does any particular professional group exert control over decision
making?
. In what way do they express this control?
. How could the scope of their control be altered so that decision making
involves a more equal contribution by professionals and the patient?
. What do doctors understand the role of the nurse to be in your clinical
area?
. How does their view of the nurse's role shape their information seeking
from nurses' narratives?
. What is the culture of a ward round? Who leads discussion and what is
the nurse's contribution? How does the way in which ward rounds are
conducted support or inhibit making nurses' narratives known to
doctors?
Communication tactics
. Do any informal rules of nurse±doctor communication exist? If so, what
are they?
. Do some nurses ignore these rules? If so, what is the eect of this on the
nurse±doctor relationship?
. What range of communication tactics are used?
. Which ones are used frequently?
. How are new nursing sta made aware of the nurse±doctor game and
how do they learn informal rules of nurse±doctor communication?
. How should pre-registration nursing training prepare students to under-
stand the context of clinical decision making?
. How should pre-registration nursing training be a tool to eect cultural
change among nurses with regard to their acceptance or rejection of the
nurse±doctor game?
Advocacy
. What circumstances tend to lead to silencing of the nurse's narrative?
. What eect does silencing have on the decisions that are made about the
patient?
. Are there any examples in your clinical area where nurses have
succeeded in altering medical decisions?
. Analyse some case examples where nurses have altered medical deci-
sions. Identify the communication tactics used and why particular ones
were chosen. Compare these cases with other attempts that have failed to
alter medical decisions. Can you identify in these case studies any factors
that support making narratives known to doctors?
. Are there certain types of medical decision that can be changed by
making narratives known and some that typically are not changed?
References
1 Gair G and Hartery T (2001) Medical dominance in multidisciplinary teamwork: a case
study of discharge decision making in a geriatric assessment unit. J Nurs Manage. 9: 3±
11.
2 Maslin-Prothero S and Masterton A (1999) Nursing and Politics: power through practice.
Churchill Livingstone, London.
3 Short JA (1995) Has nursing lost its way? BMJ. 311: 303±4.
4 Stein LI (1967) The doctor±nurse game. Arch Gen Psychiatry. 16: 699±703.
5 Ho¯ing C, Brotzman E, Dalrymple S, Graves N and Pierce C (1966) An experimental
study in nurse±physician relations. J Nerv Ment Dis. 143: 171±80.
6 Sweet SJ and Norman IJ (1995) The nurse±doctor relationship: a selective literature
review. J Adv Nurs. 22: 165±70.
7 Gjerberg E and Kjolsrod L (2001) The doctor±nurse relationship: how easy is it to be a
female doctor co-operating with a female nurse? Soc Sci Med. 52: 189±202.
8 Stein LI, Watts DT and Howell T (1990) The doctor±nurse game revisited. NEJM. 322:
546±9.
9 Snelgrove S and Hughes D (2000) Interprofessional relations between doctors and
nurses: perspectives from South Wales. J Adv Nurs. 31: 661±7.
10 Adamson BJ, Kenny DT and Wilson-Barnett J (1995) The impact of perceived medical
dominance on the workplace satisfaction of Australian and British nurses. J Adv Nurs.
21: 172±83.
11 Castledine G (1998) Clinical specialists in nursing in the UK: 1980s to the present day.
In: G Castledine and P McGee (eds) Advanced and Specialist Nursing Practice. Blackwell
Science, Oxford.
12 Chiarella M (2000) Silence in court: the devaluation of the stories of nurses in the
narratives of health law. Nurs Inquiry. 7: 191±9.
13 May C and Fleming C (1997) The professional imagination: narrative and the symbolic
boundaries between medicine and nursing. J Adv Nurs. 25: 1094±100.
Chapter 6
Narratives and expert decision makers:

creating and using narratives
Introduction . Describing nurses as decision makers: a continuum of

decision-making skill . Moving along the continuum: the inexperienced
decision maker . Moving along the continuum: the experienced decision
maker . Moving along the continuum: the expert decision maker .
Conclusion . Stop and think
Introduction
Previous chapters have examined narrative development and its use in making or
in¯uencing decisions. Narratives have multiple participants, individual variation
in scope and depth that sometimes leads to dierent versions of knowing the
same patient, and dierent uses. Within the ward, an information hierarchy
(individual and team peer review) was a safeguard against competing narratives
and engendered a group consensus of knowing each patient. The existence of an
information hierarchy implied a typology of nurse decision makers. A popular
typology already exists1 that describes nurses as being on a continuum between
novice and expert, and which has shaped nursing curricula in the UK. A dierent
continuum is introduced in this chapter that uses the narrative model as its
reference point. Its value lies in oering an explanation of how participant,
process and context need to be understood in order to know patients, identify
needs, make decisions and in¯uence other decisions. It is not uncommon to hear
and read of references made about nurses as expert decision makers, whether in
job advertisements or clinical conversations, but how can an expert decision
maker be recognised? Furthermore, to what extent is decision-making expertise a
static quality of a practitioner? Can it be assumed that a nurse follows a linear
trajectory from their initial registration through to some stage in their career at
which point they make consistently expert decisions? Or is expertise context
dependent, whereby the skill is transferable but has to be adapted to the speci®c
situation that is encountered? In this chapter these questions will be explored. As
mentioned in earlier chapters, although I do not claim that the narrative model
necessarily explains your area of practice, it could be a useful reference when
examining decision making in your own clinical domain.
Narratives and expert decision makers: creating and using narratives 79
Describing nurses as decision makers: a continuum of

decision-making skill
Nurses' clinical decision making involves people, a process, an outcome and a
given setting. Assuming that it is accepted that decision making is a generic skill
developed from childhood, it is reasonable to claim that people can apply this skill
to a range of dierent scenarios. When applied to a nursing context, decision-
making skill involves the participant utilising what they have within the
circumstances of where they are to determine what to do. The combination of
person, process and outcome action requires learning dierent things in order to
be able to arrive at the end point of a decision. With regard to narrative-based
decision making, this is accomplished via knowing the patient and includes
learning how ward teams work, how they use information, how nurses' roles
are understood and which stakeholders participate in decision making. The model
discussed in Chapter 1 (see Figure 1.1) illustrates these domains of learning ±
person, process, context and outcome ± and can be used to explain dierent types
of decision maker according to their skills of narrative creation and use. The types
of decision maker associated with this learning can be marked on a three-stage
continuum (see Figure 6.1) ranging from an inexperienced to an experienced and
ultimately an expert decision maker. A summary of the skills that an expert
decision maker has developed will be presented next.
Figure 6.1 Areas of accountability in nursing practice.

Given that the decision-making process has narrative creation and use at its
heart, each nurse has to learn how to construct how patients are known and,
once this has been attained, they need to know how to use that knowledge to
make a decision. Each nurse brings a unique set of knowledge and experiences to
decision making, and utilisation of knowledge bases is implied both in narrative
development (interpreting and generating narrative category information) and in
narrative use (an intervention knowledge base). Decisions are made in a speci®c
setting that shapes how the patient is known and de®nes boundaries of acceptable
outcomes. Healthcare delivery involves multiple participants and incorporates
individual and team peer review of the developing narrative. Furthermore,
professional, legal and organisational boundaries inform each nurse of their
scope of practice and the nature of acceptable decision outcomes. The decision-
making process thus takes account of the context, participants and outcome,
allowing a nurse to use the narrative in two ways, namely to make a decision
within the scope of their legitimate role and to in¯uence non-nursing decisions.
An expert decision maker understands the interplay between self, process,
context and outcome, has acquired a comprehensive skill set and is experienced
in its application. Other nurses have to develop these skills and accrue experience
of their application.
An overview of this decision-making skill set is given in Table 6.1 and is linked
to aspects of narrative development and use within the wider conceptual
framework of participant, process, context and outcome. A nurse's progression
along the decision-making skill continuum will be examined next.
Moving along the continuum: the inexperienced decision

maker
The trajectory towards expert decision-making practice requires the nurse to
know the patient, which involves learning how to create and develop a narrative.
This stage characterises the location of the inexperienced decision maker and
requires some propositional learning and some learning that can only be gained
through experience of local practice. Chapter 1 outlined why nurses have a
decision-making role, and explained how this had developed over many decades
and how contemporary descriptions of the nurse's role could be understood. This
type of learning, drawing on sources that contribute to an awareness of the
historical, sociological, professional and legal contexts of nursing practice, allows
the nurse to understand their professional identity and determine their roles.
These are areas of propositional knowledge. In contrast, experiential knowledge
requires the nurse to learn how to create and develop narratives within a speci®c
clinical setting. This includes understanding formal and informal rules of organ-
isational systems and, within the latter, how people work, particularly the ward
team.
Understanding dierent roles

The nurse had at least three dierent roles (described in Chapter 2) ± as nurse
carer, care manager and medical assistant. It might be that in other clinical
disciplines or other countries, nurses have dierent or additional roles. Whatever
Table 6.1 The decision-making skill set based on the narrative model
A continuum Creating and Using a narrative Using a narrative Decision outcome
between: developing a to make decisions to in¯uence
narrative non-nursing
decisions
Inexperienced Narrative scope Limited domain Might be aware of Limited to parts of
The inexperienced knowledge need to challenge the narrative
nurse has partial- Decisions made on as a patient
scope narratives parts of the advocate, but has
narrative not yet learned the
The inexperienced
informal rules or
nurse has partial-
tactics to achieve
scope narratives
this
and limited
domain knowledge
The inexperienced
nurse has to
recognise the
dierent roles that
a nurse performs in
the clinical setting
Experienced The experienced Decisions made Recognises the Limited to within

nurse has full- across all three clinical landscape the scope of the
scope narrative narrative but tends to narrative
categories and in operate within its Satis®es the
relation to the boundaries. constraints of the
patient in a holistic Decisions therefore clinical landscape ±
way remain within the policy, regulation,
legitimate scope of more powerful
the nurse's role stakeholders
Expert The expert nurse Decisions are made Recognises the Can extend
has full-scope within the clinical landscape beyond the scope
narratives legitimate scope of and actively seeks of the narrative
the nurse's role to use the narrative Can challenge the
and are made to in¯uence and clinical landscape
across all three alter non-nursing and be a catalyst
narrative decisions where for change whilst
categories giving a this is deemed operating within
holistic view of the necessary de®ned boundaries
patient.
The clinical
landscape is
understood as the
narrative is used to
shape non-nurse
decisions
these are, each nurse has to identify their roles. While propositional knowledge
informs them what the role should be, experiential knowledge informs them how
that role is interpreted locally. At some stage in their development every nurse
compares the ideal with reality and decides which roles have a predominant place
in their decision-making practice. Inexperienced nurses, due to their limited
exposure to care management, tend towards a care role that typically involves a
designated group of patients within the whole ward. Increased experience widens
their scope of supervision and so draws them deeper into a range of care
management considerations.
The generation of holistic knowledge of the patient requires learning to extend
narrative construction beyond using the lens associated with their care role to
include information relating to the care management and medical assistant roles.
In this way the inexperienced nurse needs to learn to create a full-scope
narrative. They also have to understand how their roles and their use of the
care record shape information seeking.
Understanding dierent systems

The inexperienced decision maker has to learn how the system of healthcare is
structured at general and local levels. General knowledge includes awareness of
the policy framework that shapes the requirements of healthcare delivery. This
includes awareness of legal and professional regulation frameworks that shape
the scope and standards of practice and establish boundaries of acceptable
decision outcomes. Such knowledge facilitates understanding of the context of
nurses' work. Locally speci®c knowledge of the ways of working within the care
organisation is also needed. This can only be gained through experience as part of
a healthcare team and immersion in the local working culture and practices.
These local characteristics are shaped by personalities, interpersonal relationships
and team practices.
Inexperienced decision makers also need to learn how formal and informal
systems in¯uence the use of information, and what might be considered as
èvidence' to include in the process.
Formal systems: records, rounds and reports

Ward practice has repetitive features that punctuate each working day or week.
These are shift handover report, record keeping and medical rounds. Their
importance lies in organisational sanction of periodic review and discussion of
individual patients. Associated with this is an awareness of how the record system
is used to represent the patient and to render them visible within the care process.
Within these systems there are ways of recording patient information and
rendering visible dominant ways of representing them. The social processes of
ward rounds and reports also reveal how dierent sta groups demonstrate their
assumptions about the interprofessional and patient±professional relationships,
which by implication mark where the locus of control in decision authority lies.
Learning about the location, function and content of nursing records in decision
making allows the inexperienced nurse to identify other informal places and
information sources that are used in decision making. This develops their
appreciation of the role of informal systems in decision making.
Informal systems: personal note sheets and diaries

Informal systems are the ìnvisible' practices that complement or compete with
formal systems and that can be summed up as `how things are really done
around here'. The dierence between verbal and written accounts of patients
discussed in Chapter 4 highlighted the role of an oral tradition of care decision
making in preference to using a record system at the centre of the process. The
peer review system (described earlier as an information hierarchy) was an
example of an informal system that was characterised by interpersonal
dynamics. It shaped the structure, assumptions and permitted discussion
during shift handover reports. Nurses needed to learn what the information
hierarchy was and how it was used to guide their practice. Such local knowledge
can only be gained during practice, but an examination of it could be included
during pre-registration nurse training.
Formal and informal systems relate to the context of narrative development.
Nurses also have to learn about the development of narrative content. This relates
to narrative scope and depth and implies the use of dierent knowledge bases.
Understanding narrative domain knowledge

Nurses draw on a range of knowledge bases when processing narrative-category
information (nursing, management and medical). Some of this can be learned
apart from the clinical setting (propositional knowledge) and is used to establish
an atlas of personhood, health and ill health (disease). Continuing study adds
detail to the atlas, which typically contains general-level information, but clinical
experience oers exposure to a range of variations on general themes. Develop-
ment of experience facilitates the generation of a richer atlas that incorporates a
catalogue of variants of typical cases. Knowledge development in these areas is
necessary for nurses to process narrative-category information in order to
generate knowledge of patients as individuals rather than as cases aligned to a
particular diagnostic label. The curriculum of pre-registration nurse training
should outline the atlas of the nurse's role and requisite knowledge bases
sucient to prepare them for practice. However, this is a foundation, and once
they are registered, nurses need to add detail to the atlas in relation to a chosen
domain of clinical practice. In this way the atlas (narrative-category domain
knowledge) is extended by accruing clinical experience. As nurses develop this, so
the intellectual capital of the ward team is enhanced and ultimately becomes a
resource to guide the practice of other less experienced nurses.
An inexperienced nurse decision maker requires an atlas (domain knowledge
relating to general cases) together with experience of variations of general case
examples so that narratives are individualised and grounded in the local context.
It follows that nurses will have dierent levels of propositional and experiential
knowledge, but decisions need to be made that are holistic, individualised and
safe. A tension exists here that is addressed by the ward information hierarchy.
Peer review featured highly in the practice of inexperienced nurses, and acted as a
safeguard against poor decision-making outcomes. This is one reason why
inexperienced nurses have been described as rule driven and reliant on the
guidance or instructions of senior sta. However, it is important that inexper-
ienced nurses don't merely copy the practice of experienced sta, which would be
ritualistic, but that they understand the processes underpinning decision making
so that they can be applied to other situations.
Inexperienced nurses need to learn how to develop full-scope narratives and
concurrently develop their domain knowledge through experience of practice. It
is one thing to know how to construct and develop a narrative and another to
know what to do with that knowledge. A transition therefore has to occur
between these two stages, and this makes a distinction between the inexper-
ienced and experienced decision maker.
Moving along the continuum: the experienced decision

maker
Nurses need to know how to use the narrative to make decisions. You might recall
occasions when a student has witnessed a patient's health crisis and not known
what to do, while other sta have acted swiftly with a range of actions to stabilise
the situation. A typical example of this occurs in the moments before a patient
suers a cardiac arrest. It is one thing to look at a patient and another to recognise
that a problem has become apparent and select the appropriate intervention in
response to it. Narrative use involves knowing the patient in order to recognise
their needs or problems both within and across categories. Intervention choices
are based on generating decision options in relation to identi®ed needs, and these
choices imply the existence of an intervention knowledge base, which is an atlas
of interventions organised according to the nurse's dierent roles (care, care
management and medical assistant). The process of choosing between decision
options takes into account anticipated decision outcomes which imply that the
experienced decision maker is aware of the boundaries of their decision making
and makes decisions that fall within these.
Experienced decision makers and guidance on decision outcomes

Exposure to dierent types of intervention with dierent patients within the
same category (for example the dying patient or the patient with emphysema) is
learned experientially and is supported by an informal system of peer review.
Experienced ward nurses are a key source of intervention information, and the
intellectual capital of their accrued wealth of intervention-domain knowledge
(propositional and experiential) is integral to developing other nurses' decision-
making experience. Through this, inexperienced nurses discuss intervention
choices and uncover the locally speci®c rationales that guide intervention choices
in relation to identi®ed needs. Formal and informal systems, such as clinical
supervision, re¯ection on practice and group discussion in report, contribute to
the development of each nurse's intervention-domain knowledge.
Nurses' decisions have to fall within the boundary of their legitimate scope of
practice and so satisfy legal, organisational, professional, personal and patient
requirements. In the UK, nurses have a legal duty of care2 and standards to
maintain under their obligations in the Code of Professional Conduct,3 which
form boundaries to their legitimate scope of practice (discussed further in Chapter
7). Although inexperienced nurses will be aware of these, they require the
guidance of experienced sta to ensure that intervention choices will lead to

outcomes that fall within the scope of these boundaries.
Progression from inexperienced to experienced decision maker requires skills of
narrative development and use. This in turn necessitates parallel development of
narrative category and intervention domains of knowledge. Experienced nurses
make decisions that fall within the legitimate scope of their role and contribute to
the ward information hierarchy and the guidance of less experienced nurses.
Moving along the continuum: the expert decision maker

An expert decision maker takes decision making further in order to in¯uence
decisions beyond their legitimate scope of practice. To be able to do this they have
to read the clinical landscape and decide to make their narrative visible so that it is
acknowledged as a factor to consider in non-nursing decisions. Reading the
clinical landscape involves recognising trends and detecting changes in the
patient's situation (using the narrative). The decisions made by other participants
in the ward environment are considered in relation to their impact on the
patient's well-being. Sometimes this includes proposed decisions, and the
expert decision maker considers how the narrative would develop if the decision
was implemented, and anticipates the outcome. Anticipated narrative develop-
ment is used to identify whether there is a need to intervene in non-nursing
decisions, chie¯y medical ones, that aect the patient, and to decide which nurse±
doctor communication tactic to use according to their knowledge of interpersonal
relationships.
Learning how to become an expert decision maker was commonly spoken of as
an experiential process, as on-the-job development that was described as `learning
by Nelly' and thought to be the `correct way' of developing decision-making skills.
Experienced decision making could be recognised when a nurse could `know the
patient and can do the care' by identifying `what's wrong' while understanding the
patient in a wider context, `where the patient ®ts into the whole thing, how it works,
and how their illness has impacted on them.' Expert decision making was recognised
when the nurse acted as an advocate for the patient and succeeded in securing a
change in decisions which they considered were not in the patient's interest.
A continuum of decision-making skill: oscillations

The development of expert decision-making skills depends on several factors.
These include developing propositional and experiential knowledge. The quality
of clinical experience and the way in which individual nurses derive bene®t from
the learning opportunities are more important than the mere passage of time
spent in clinical practice. Movement up the continuum involves engagement
with the clinical context, its processes, systems and participants, and expert
performance is context dependent. The continuum marks a transition from
knowing patients and making clinical decisions within the nurse's scope of
practice to recognising how others know patients and make decisions that (at
times) are not thought to be in the patient's interest. Such decisions can only be
eectively challenged when the local clinical landscape is understood. To
challenge non-nurse decision makers without knowing which communication
tactic is likely to be successful with particular individuals runs the risk of the
nurse's narrative being dismissed or rendered invisible.
The decision-making continuum is a convenient means of identifying particu-
lar points of skill development. However, once they are performing at an expert
level, a nurse might oscillate back and forth between experienced and expert
status. There could be dierent reasons for this, one being the currency of aspects
of their knowledge bases (e.g. the latest evidence-based treatments and nursing
interventions). If an expert nurse moves to a dierent ward within the same
clinical discipline, there will be a period in which they assimilate the local features
of the clinical landscape, principally the informal systems and interpersonal
dynamics. It would be anticipated that an expert decision maker would be able
to work this out rapidly and operate at an expert level. Even at the margin of an
experienced/expert-status decision maker they would be likely to challenge
doctors, but the ®nesse of knowing how to play the nurse±doctor game would
need to be attuned to the individuals in that particular ward.
On the other hand, if an expert nurse moved to a new clinical area, their
decision-making skills would be transferable but there would be a period of time
spent familiarising themselves with the new local clinical landscape and devel-
oping the atlas relating to that clinical specialty. It is likely, therefore, that in that
particular discipline area they would revert to being an experienced decision
maker until these de®cits were resolved. Thus there is the possibility of oscillation
between expert and experienced decision-maker skill levels.
The invisibility of decision expertise

Nurses' attempts to in¯uence medical decisions were not recorded in their
records, and decision-making expertise was acted out rather than written
down. Whenever nurses' decision-making practice is invisible in their records
they are liable to be seen by doctors and other healthcare professionals as medical
assistants and information providers. Given the existing clinical landscape, a case
exists for nurses to make their narratives visible so that their expertise is valued by
others. Steps in this direction will ultimately challenge the need to play a doctor±
nurse game and alter the inter-professional relationships and views of nurses'
roles.
The collective resource of decision-making knowledge and experience amounts
to the intellectual capital within the ward nursing team. This is often overlooked
by non-clinical service managers, who consider wards in terms of economics,
systems and targets. However, intellectual capital is a necessary part of regulating
decision making and protecting the patient against non-nursing decisions which
are thought not to be in their best interest. Proposed changes to the skill mix of
the team and to systems of work must anticipate the eect that they will have on
patient care. This speci®cally includes consideration of the eect on the ward
information hierarchy, the development of experienced decision-making skills in
inexperienced sta and the con®dence that patients have in the healthcare team.
Furthermore, loss of experienced and expert sta has to be recognised as a
de®cit in intellectual capital, and steps need to be taken to maintain and protect
team stability. Proposed changes thus need to take a broader view of sta
retention and to maximise investments made in sta development.
Organisational change also has to be scrutinised in order to assess the impact
that it has on enhancing or inhibiting decision making. An example of this might

be changes to local systems, such as altering the place of report and its
participants, or moving from written to computer records without examining
how this will aect narrative development and use.
The use of temporary sta to cover absences due to sickness and vacant posts
needs to be examined in relation to its eect on narrative development, narrative
use and intellectual capital. The strongest information hierarchy exists when
there is team cohesion and stability. It is unlikely that ad-hoc sta will do much
more than contribute to narrative development and have limited time to engage
with learning the locally speci®c formal and informal systems of care delivery. If
this is the case, it is likely that the ward team will have to consider how it can
make visible its ways of working in order to facilitate cohesive working and draw
upon the potential contribution of temporary sta. There is always the possibility
that temporary sta might be made to feel like outsiders with regard to the ward
culture and, as occurred in the study that underlies this book, concern themselves
with the care of individuals according to their own narrative while avoiding the
broader scope of management and medical matters.
Decision expertise was largely invisible, particularly in the nursing records, yet
it was integral to how nurses actually worked. Ways in which it can be developed
need to be considered in order to support sta development and valuing of the
ward information hierarchy. Nurses also need to ®nd ways of making this aspect
of their work visible so that others recognise its importance in promoting the
delivery of safe and eective care and coordinating the contributions of the multi-
disciplinary team.
Conclusion
Dierent levels of decision-making skill can be described using a continuum that
spans inexperienced, experienced and expert decision makers. Progression from
inexperienced to expert status is via competency development in narrative
creation and use both within and beyond the nurse's legitimate scope of practice.
It also requires understanding of the broader context of narrative development
and use, namely participants, clinical context and outcome. In addition, nurses
need to develop their knowledge bases relating to narrative categories and
interventions. Although some of this can be propositional knowledge learned
through professional education and forming a general and later specialty-based
clinical atlas, knowledge derived from experience is also necessary.
Expert and experienced nurses make a vital contribution to the intellectual
capital of the ward team, and through the information hierarchy they provide a
safeguard against threats to knowing patients, and promote safe and eective
decision outcomes. This is often invisible and liable to be overlooked in organ-
isational changes within the ward. In order to safeguard and value decision
making and intellectual capital as a central part of nursing work, nurses need to
make it visible. The next chapter examines what needs to be made visible and
oers a way of demonstrating decision making through an analysis of existing
records.
Chapter summary box

. An inexperienced nurse has to learn how to create and use a narrative.
. An experienced nurse decision maker knows how to create and use a
narrative and make decisions within their scope of practice.
. An expert nurse decision maker makes decisions within their scope of
practice and in¯uences decisions made outside this.
. Decision-making experience and expertise represent intellectual capital
within wards.
. Changes in the ward team and organisational design are a threat to the
intellectual capital.
. Organisational changes can directly impact on how patients are known
and the decisions that are made about them.
. Nurses need to make visible their decision making in order to promote its
value as part of their work.
Stop and think

This chapter has provided an explanation of how decision-making expertise is
developed. This might assist you as you examine your own description of
decision-making expertise. The following questions direct you to explore deci-
sion-making expertise in your own clinical area and draw your own conclusions
about what it is and how it can be recognised.
A decision-making continuum
. To what extent is the continuum useful for explaining your own level of
expertise?
. How would you develop the descriptions of dierent types of decision
maker?
. How are decision makers described in your healthcare organisation's job
speci®cations? How do these dier from the descriptions given in this
book?
Expertise and learning

. How do you think decision-making expertise is developed?
. What enhances learning about decision making in the clinical setting?
. How would you describe the intellectual capital within your clinical
area?
. What threats exist to preserving the intellectual capital of the ward?
. In what way, if at all, is the intellectual capital of the ward recognised and
valued?
. How can the intellectual capital be preserved and developed?
. How can an expected loss of sta (e.g. due to retirement or promotion) be

managed so as to minimise a de®cit in intellectual capital?
. How would you teach others about informal decision-making processes?
. How would you explain the ward information hierarchy and how it is
used in decision making?
Making decision making visible

. What are the formal and informal systems of decision making within
your clinical area?
. How does change to the formal system aect informal processes of
decision making?
. Is apprenticeship the best model of developing decision-making expert-
ise?
. What role could simulation play in developing decision-making expert-
ise?
. What are the limitations of a simulation of a clinical scenario in
developing decision-making expertise?
. How should nursing records be developed to show expertise in decision
making?
Atlas ± domain knowledge

. What would you de®ne as the minimum atlas needed by a registered
nurse?
. How should the atlas be developed during practice?
. How could the learning value of experience be maximised?
. What benchmarks would you use to establish distinctions between
inexperienced, experienced and expert decision makers?
. Can there be any short cuts to developing decision-making expertise?
. If you were interviewing applicants for a nursing post, what would you
ask about their decision-making skills?
. What role could electronic access to `knowledge bases' play in replacing
the ward information hierarchy?
. How adequate is decision-making skill oscillation as an explanation of
the dynamic nature of decision-making status?
References
1 Benner P (1984) From Novice to Expert: power and excellence in nursing practice. Addison
and Wesley, Menlow Park, California.
2 Department of Health (1979) The Nurses, Midwives and Health Visitors Act. HMSO,
London.
NMC, London.
Chapter 7
Nurses as decision makers: where next?
Introduction . De®ning decision making . Demonstrating decisions: what

nurses are required to do . Accountability . Nurses' clinical decision making:
where next? Professional development implications . Educational implica-
tions . Organisational implications . Patient±professional relationship im-
plications . Conclusion . Stop and think
Introduction
In previous chapters I have discussed dierent aspects of nurses' clinical decision
making. Their decision-making role developed as a consequence of the eect of
intrinsic and extrinsic factors on its contemporary organisational, professional
and legally de®ned scope of practice. The development of expertise, discussed in
the previous chapter, demonstrated the need to make nurses' practice visible in
order to highlight its value in patient care. The loss of decision-making expertise
in clinical areas may not be recognised until problems have occurred. Given that
nurses are accountable for their practice, there is a requirement to demonstrate
this in clinical records. Although existing record systems do not capture the
cognitive work between assessment, plan and intervention choice, there needs to
be a means of recording these decision processes and `capturing' the value of
expert decision making and the ward information hierarchy.
The ®rst part of this chapter revisits a de®nition of decision making and nurses'
accountability. Having identi®ed what nurses have to demonstrate, the narrative
model is used as a tool to analyse decision making in their records. This could be
valuable in teaching or re¯ective practice situations involving retrospective
analysis of decision making. Future developments with regard to nurses' decision
making will then be considered.
De®ning decision making

Nurses as decision makers can be de®ned as having an occupational role that is
legally de®ned and organisationally bounded. Development of nursing identity,
the scope of their work and the place of its legitimate boundary will continue to
be subject to intrinsic factors (e.g. nurses' professionalisation) and extrinsic factors
(e.g. social, political, economic and technological developments). When nurses
move into autonomous decision making the role becomes a professional and
occupational one. In the ward work described in this book, nursing therapy
decisions were autonomous, but nurses were also subject to the in¯uence of
Nurses as decision makers: where next? 91
medical instructions and decision making that made assumptions about their
work. These assumptions (about their role as medical assistant) cast nurses as a
part of medical decision making, not as fully independent decision makers.
Nurses' decision making involves participants, a process, an outcome and a
particular setting, namely the clinical landscape of the ward (see Figure 1.1). The
nurse uses a narrative-based process to generate decision options and select an
intervention, leading to an outcome. This is decision making either about a
patient care-related intervention or to in¯uence non-nursing decision making
(e.g. medical decisions). Ward nurses work in a team context, so the clinical
landscape refers to multiple participants in narrative development and also the
working practices, both social and physical (e.g. shift reports, peer review, ward
rounds, books, case notes and other records). You will have noticed that the study
cited in this book revealed a hierarchical social clinical landscape in which nurses
acted as advocates for patients, particularly when considering the impact of
medical decision making. Therefore patients were only active in decision
making as far as the process was regulated and mediated by nurses. Patients
were often involved in understanding the decisions made about them and how
they could cooperate in their successful implementation, but were rarely involved
in controlling the decision-making process. This implies a decision-making locus
of control between patient and professional. Legal and professional obligations of
care provision shape nurses' decision-making practice, so can account for why the
locus can reside in their domain. The patient, on the other hand, needs to be fully
involved in the process and to own any decisions that are made, otherwise they
will be relegated to being passive recipients of care and treatment. Service
developments that aimed to arrange care services around the patient implied
that some features of the existing service design wrapped patients around the
processes and choices of hospital sta. Patient-centric care requires more than
organisational redesign to make their journey along the care trajectory seamless.
It means revisiting the ways in which people work within clinical organisations,
and particular understanding of formal and informal systems of work. Formal
systems alone were not sucient to capture how the patient was known and how
nursing decisions were made. Informal systems, such as team discussions, use of
note sheets and individual peer review, all shaped how the patient was known.
To move the locus of decision-making control towards the patient as a full
participant in decision making requires these systems to be examined. Further-
more, particular consideration needs to be given to the eect that any such
changes will have on narrative development and use. Often formal systems are
changed without considering the impact on how people actually work (informal
systems) or the eect that this has on knowing patients.
Demonstrating decisions: what nurses are required to do

An examination of nurses' accountability is useful for identifying what nurses are
required to demonstrate about their decision making. Figure 7.1 shows areas of
nurses' accountability re¯ecting intrinsic and extrinsic factors that shape the
scope and boundary of their work.
The professional regulator is concerned with monitoring whether standards of
practice are upheld so that nurses satisfy their legally based duty of care. When
working as employees of a health service provider, nurses also have responsi-
Figure 7.1 Areas of accountability in nursing practice.
bilities to comply with local policies and practices that constitute a visible
expression of the organisation's function as a care provider. In addition, nurses
represent part of the wider profession and must uphold its standards of practice
while at the same time remaining true to their own cultural values and beliefs.
Above all, nurses have to be able to demonstrate their accountability to patients.
This has been referred to as a nurse's primary accountability, and nurses should
expect to be able to demonstrate clinical decisions for the patient's bene®t. Given
these dierent forms of accountability, a brief examination of professional
guidance (using an example from the UK) allows conclusions to be drawn
about how nurses can demonstrate their decisions.
Accountability
Individual decision makers
An assumption in the Code of Professional Conduct1 that each nurse is individually
accountable for their decisions is questionable, given that decisions are made in a
team context and that nurses are not solely accountable for speci®c patients over
a period of days. The demonstration of decisions is therefore complicated by the
multiple participants and the evolving nature of needs identi®cation and decision
making.
Department of Health policy requirements also highlight individual account-
ability for the delivery of care within a framework of clinical governance: `quality
. . . services . . . high standards of care . . . and excellence in clinical care'.2 This refers to
the quality of decision outcomes and the use of evidence in the process. Aspects of
demonstrating proper consideration with regard to the requirements of clinical
governance include cost conservation and quality outcomes, and a decision
outcome which is measurable and framed in standardised language. This has
been argued to enhance the visibility of nurses' work, allowing them to `seize the
opportunities [of change] so that nursing's in¯uence on healthcare outcomes will be
known'. A standard nursing language does not exist, nor are there established
ways of measuring nurses' decision making, so this claim remains an aspiration of
the empowerment of nurses within a wider healthcare team, rather than one of
current practice.
Decision outcomes
When referring to decision outcomes, nurses often used descriptions such as
`good' or `poor'. It is useful to know the meaning of these terms, as this informs
what should be included when demonstrating the quality of decisions. Given that
inexperienced nurses have to learn how to construct a narrative and identify a
patient's needs in order to make decisions, the term `good' can refer to both the
process and the outcome.
A `good' process can be understood as the nurses' demonstration of their
construction of a full-scope narrative with a depth of narrative-category informa-
tion. Nurses with dierent levels of experience will be able to demonstrate how
they used the narrative to make decisions within their legitimate boundary of
practice, or to in¯uence non-nursing decisions. This dierence has been reported
elsewhere, in a UK-based survey3 of general ward nurses' clinical decision making
in which inexperienced novice nurses were described as `not knowing their patients'
and made decisions that `lacked knowledge', `full information' and the exercise of
`clinical foresight'. They were also rule driven.
A factor in nurses' acceptance of responsibility for errors, and the implied
labelling of these as good or poor, has been associated with their interpretation of
the Code of Professional Conduct.1 Demonstration of good, safe and demonstrable
decisions by justifying the actions taken requires self-evaluation. It has been
argued that a `feeling of having made the right decision, irrespective of outcome in terms of
action' was a part of the process.4 A small-scale study of 12 expert nurse decision
makers (5 years post registration) supported the use of a problem-solving process
and identi®ed a cluster of objective and subjective factors that included a personal
philosophy of care as in¯uences on decision making. In the study referred to in
this book, one of the subjective factors was the doctor±nurse interaction. There
were occasions when nurses had a preferred decision which they considered was
in the patient's best interests, but they sometimes had to lay this aside in order to
conform with a medical way of knowing the patient. This highlighted the
in¯uence of context on judging decision making as good or poor. This has been
reported elsewhere in a claim that it was dicult to hold nurses accountable for
speci®c patients, and it was recognised that they sometimes placed èmployers'
priorities above patient priorities'.
Decision process
An organisational requirement for nurses' work to be visible was implied in a
discussion of an out-of-court settlement about a case of malpractice that was
attributed to a lack of clear, concise documentation (`the record was silent regarding
the charge nurses' response to these reports').5 The outcome of this settlement
included a list of recommendations about a verbal communication information
hierarchy (team leader, senior sta) through which guidance could be given on
decision making. These recommendations also included seven points that nurses
needed to record about their decisions (problem identi®cation, communication
with others, reports to higher-level managers, any request made for equipment,
the response of providers or managers, any recommendations or guidance
provided by the team leader, and reassessment of the patient's condition). This
list highlights aspects of a decision process that relied on communication, peer
review and evaluation, and lends support to the oral tradition that is a part of
nurses' narrative-based decision making. The oral tradition was favoured over the
use of written records in decision making. This was discussed in Chapter 4, when
it was mentioned that nurses reported that records were written to satisfy legal
and organisational requirements (reported as avoiding `being dragged into court'
and `something we have to do'). In the UK their legal duty of care is outlined in the
Nurses' Act,6 Rule 18a of which describes their role as having a problem-solving
approach to care with decision-making steps (assessment, planning and imple-
mentation) and an outcome (evaluation). It implies that nurses have to demon-
strate a decision-making process and outcome.
How much to record

Professional regulation exists alongside this legal duty of care to protect the public
by ensuring that professional standards are upheld. Three principles underpin
professional regulation, namely promoting good practice, preventing poor prac-
tice and intervening in unacceptable practice.7 This was explained by the UKCC
as sharing evidence of good practice and working within a framework of the Code
of Professional Conduct 1 to ensure that care delivery does not put clients at
increased risk of harm. However, use of the ill-de®ned terms `good' and `poor'
implies that practice is judged by norms within the wider profession. Subsequent
NMC Guidelines for Records and Record Keeping8 oered insights into a de®nition of
good practice. Each nurse had to make their own choice (`professional judge-
ment') about when and what to record about their practice, but it had to include a
`full account of the assessment and the care . . . planned' and `relevant information' and
èvidence that you have honoured your duty of care and have taken all reasonable steps to
care for the patient or client and that any act or omissions on your part have not
compromised their safety in any way'.
Once again, demonstrating decisions includes an implied problem-solving
approach to decision making (assessment, implied problems, care plan and
consideration of outcomes). Within this is an assumption that decisions can be
easily recognised and a sequential process can be deliberatively represented.
The concept of assessment includes notions of scope (relevant information), but
falls short of quantifying the meaning of the term `full scope' or how this can be
recognised when constructing knowledge about a patient. Use of the term
`relevant' also implied an assumption about the usefulness of dierent categories
of information used to identify a patient's problems. This pragmatic approach
using a problem-solving sequence, which is a part of Rule 18a (assess, plan,
implement and evaluate), almost suggests that the nurse is an information
gatherer, that information is available to be gathered, and that it can be accrued
in sucient quantity to allow the diagnosis of a problem. If this is the case, there is
an assumption that all assessment information, problems identi®ed and corres-
ponding interventions could be recorded. The narrative section of the record
should include notes on the evaluation of goal achievement and problems solved.
Nurses' records (in the study referred to throughout this book) did have a
problem-solving format. However, even some of those records did not contain
a full problem-solving process. Furthermore, it supports the view that at any
given recording point one nurse is identi®ed as the sole participant in decision
making, when in fact they are part of a care team.
Ways of improving records

Two approaches could be taken to addressing the problems of making decisions
visible in nurses' records ± ®rst, to impress on nurses their responsibilities with
regard to maintaining good records, and second, to revisit record design in order
to ®nd ways of capturing how nurses work. The ®rst approach is periodically
revisited,9 and opportunities for the second are available wherever provider
organisations sanction development of their record systems. The advent of a
national record system as a òne-size-®ts-all' approach is a threat to this second
option, as there is no guarantee that it will improve on existing attitudes towards
care record usage in decision making. Furthermore, it remains to be seen how
developments such as an electronic national care record can align record keeping
to nurses' ways of working and capture the processes involved. Whatever the
failings of the existing record systems, nurses have to demonstrate their account-
ability. The record system therefore needs to be reviewed to determine how it can
be developed to capture nurses' practice.
The narrative decision-making model, if it represents how decisions are made,
could oer a framework to be incorporated in the redesign of records. Develop-
ments in this area could make nurses' roles and information categories visible,
formalise judgements as information processing, and identify decision options
and decisions taken. The narrative model could also be useful for analysing
nurses' decisions in existing care records.
Using the narrative model to demonstrate decision making

Use of the narrative decision-making model can facilitate giving a response to the
meaning of the statement in professional guidance that a nurse has `taken all
reasonable steps to care for the patient or client'. Formerly, under the UKCC,10 nurses
had to `demonstrate their properly considered clinical decisions', and `having taken all
reasonable steps' can be interpreted as recording decision making in such a way
that it satis®es the range of a nurse's accountability (legal, regulatory, professional
and personal, and to the patient) and captures the real-world processes of clinical
decision making. The narrative model can be a useful tool to identify ®rst the
processes involved (narrative creation and development), and second, how the
narrative (knowing the patient) is used to make nursing decisions or in¯uence
other decisions. The following example outlines a way in which this model could
be used within clinical supervision, clinical teaching or re¯ective practice to
examine decision making.
The dierent parts of the narrative model can be transposed into a table, as
shown in Table 7.1. This table has column headings of information type, narrative
category, judgements within categories, global judgements of how the patient is
known and statements of movement along the care trajectory as a `trajectory
marker'. These columns represent narrative development. The last four columns
represent narrative use and include problems identi®ed, intervention options,
decisions made and decision outcome. The text of the record is divided into
chunks and inserted into the ®rst two columns, the ®rst being an index number
relating to each data chunk. The table could also be used to analyse a transcript of
a shift report so that written and verbal accounts of the same patient could be
compared.
Table 7.1 The narrative decision model transposed into a table to be used to
analyse transcripts of nurses' records
Narrative data Narrative creation Narrative use
Problems identified
Intervention option
Narrative category
Trajectory marker
Text of narrative
Decision outcome
Decision made
(in categories)
Information
Data chunk
Judgements
Judgements
(global)
1
2
3
4
An analysis of a brief text example using this table format is shown in Table 7.2. In
this analysis the patient is represented as a medical case requiring treatment. The
nurse's role is cast as supporting medical contribution, and chie¯y marks the stage
of the patient's progression along the care trajectory. Although there are hints of a
nurse±patient discussion, nothing was recorded about other needs that the
patient might have or of any nursing actions that were taken. Similarly, there
were hints of using the nursing lens and demonstrating that the patient was
known as an individual within the healthcare process. In summary, this brief
analysis portrays the patient as a medical case and the nurse's role as that of a
medical assistant and care manager. As a result, other nursing work is rendered
invisible.
This table is divided into columns which indicate the overall process of
narrative creation and use leading to the decisions made. The columns identify
various aspects of each stage.
The text used in this analysis is taken from a nursing record:
Reason for admission: To see the doctors for IV methylprednisolone.

Final diagnosis: ?Retrobulbar neuritis.
Past medical history: Had some tests but doesn't know what.
History: Had an episode of numbness and altered sensation up to her waist,
which has resolved. Four days ago she developed blurred vision in the left eye.
Nurses' clinical decision making: where next?

Nurses have to make their decision making accountable for a number of reasons.
Demonstrating narrative-based decision making has implications in several areas.
These include professional development considerations of nurses as decision
makers, educational implications with regard to the process of nurses' decision
making and development of expertise, and organisational implications with
regard to the means of recording nurses' work and judging the quality of decision
Table 7.2 An example of the use of the analytical table to analyse a nursing record excerpt
Narrative data Narrative creation Narrative use
Data chunk
Text of narrative
Information
Narrative category
Judgements
Judgements
Trajectory marker
Problems identified
Intervention option
Decision made
Decision outcome
(in categories)
(global)
1 Reason for admission: Treatment Medical A medical To see Needing Needs medical
To see the doctors for IV case doctor treatment intervention
methylprednisolone waiting to
see a doctor
2 Final diagnosis: Diagnosis Medical Diagnosis Potential
?Retrobulbar neuritis diagnosis
3 Past medical history: Investigation Nursing Individual
Had some tests but
doesn't know what
4 History: Had an episode Patient report ± Nursing Health Individual Blurred
of numbness and altered limbs stability vision
sensation up to her Patient report ± Health
waist, which has vision change
resolved. Four days ago
she developed blurred
vision in the left eye
Nurses as decision makers: where next?
97
outcomes. Patient±professional relationships in participation in and control of

decision making constitute a further area of development.
Professional development implications

There are good reasons to support the case for intrinsic development of the
nurse's role as a decision maker. Nurses are well situated to coordinate care and
extend the scope of their role to oer a broader contribution to patient care. This
can include moves into what was formerly the territory of other professionals,
and has led to questions of whether nurses are becoming `mini doctors' or `maxi
nurses'. Economic and organisational expediency might move professional
development in this direction as new ways are considered to eciently deploy
limited medical sta resources. The scope of nurses' decision making is to a large
extent bounded by extrinsic factors. Nurses could take advantage of existing
resource pressures on healthcare organisations and pursue a path towards
autonomous practice. If they do this they will need to be able to identify the
nature of extrinsic factors that shape their role and the mechanisms by which
they establish a boundary to their legitimate scope of practice. Awareness of this
could be used to inform their professional development strategies.
Ways of representing nursing work also include the terminology used. At
present a universally agreed nursing vocabulary does not exist. Such a nomen-
clature could be useful, especially when developing consistent coding systems
that could be used to identify parts of the decision process. However, national
health services are a collection of many local services that have their own
particular social and organisational subculture. It is likely that these services
employ dierent terms to describe their practice, and until these are known the
establishment of an (inter)national vocabulary system will be limited.
Educational implications
Traditionally the development of decision-making skill has been learned òn the
job' through clinical experience. It is possible to use the narrative model to
identify key steps in decision making and to ®nd ways of developing related
learning in classroom rather than clinical settings. It should be possible to use the
conceptual framework to explain decision making and the narrative model (for
example) to examine details of the processes involved. Given this model, pre-
registration nurses could be guided to examine the development of their own
decision-making skills, while their clinical mentors could use it as a reference to
identify within the local setting where and how these skills can be developed. The
continuum of decision-making expertise is also useful for registered sta to use in
re¯ective practice and self-assessment for decision-making skill and goal setting
for professional development.
Organisational implications
Those responsible for service provision need to consider how eective their record
systems are in representing nurses' work, particularly decision making, and
especially in relation to the extent that these systems facilitate demonstration
of accountability in decision making. Before any organisational change such as
the introduction of a new record system, the implications for the formal and
informal systems need to be thought through with a view to anticipating the
eect that the change is likely to have on patient care. Organisational change also
has to take account of the impact that it might have on team stability, cohesion
and the intellectual capital of the ward, as these all aect the decision-making
process.
Modern health services are target driven and have to be accountable to
patients. The quality of decision outcomes is a relevant measure that forms a
useful starting point for examining the process used. Moves to de®ne the quality
of decision outcomes are also useful for establishing collaboration between expert
practitioners and expert patients.
Patient±professional relationship implications

The participation of patients in the decisions that are made about them can
frequently be limited. The locus of control in decision making is not necessarily
®xed, and can alter, for example as a result of policy measures that espouse full
patient participation in shared decision making. The locus of control is likely to
alter according to the preferences of each individual patient, their health status
and their interaction with sta. Demonstration of nurses' decisions needs to
account for these dierences and display where the locus of decision making
predominantly lies. This could be useful for oering a response to policy moves
that insist on a single approach to decision making based on the assumption that
the patient wishes to, or is capable of, making and owning decisions about their
own health needs.
Conclusion
Nurses' decision making is complex. To suggest that nurses just provide care and
equate this to task performance is to overlook a central feature of their work.
There is therefore a need to make nurses' decision making visible, and this
requires understanding of the processes involved and use of a terminology that
makes these meaningful. The value of championing nurses' decision-making
work is ultimately for the patient's bene®t, although it also oers advantages for
developing professional identity. We have seen that the clinical landscape
in¯uences the decisions made about patients, and that this can be dominated
by the medical model and doctors. Nurses are with the patient for 24 hours a day,
and their way of knowing the patient can, if they have a full-scope narrative, be
holistic and generate an understanding of the patient's experience as they
progress though the experience of clinical care and treatment. It is the strength
that comes through knowing patients in this way that makes it necessary to
challenge any moves that decentre the focus of healthcare delivery away from the
patient as an individual ± be it other professionals, policies or organisational
change.
Chapter summary box

. Nurses have a range of accountabilities.
. Written records are the primary source of demonstrating nurses' work.
. Written records do not capture all that nurses do, and when these records
are redesigned, consideration needs to be given to methods of capturing
the scope of nurses' decision-making work.
. The narrative model can be used to analyse existing records in order to
demonstrate some aspects of nurses' decision making.
. Nurses are in a unique position of knowing patients on account of their
24-hour presence with them on the ward.
. Nurses' use of their narratives is necessary to challenge any moves that
decentre the patient and their needs from the focus of healthcare
delivery.
Stop and think

In this chapter, ways and implications of demonstrating decisions have been
discussed. The ®nal `stop and think' questions ask you to look ahead to work out
what the immediate implications are for yourself and your decision-making
practice.
Demonstrating decisions
. Select a sample of your own record keeping and analyse it using the table
given in this chapter to evaluate how you have represented the patient
and the decisions that you have made concerning them (you might need
to seek local organisational approval to use an excerpt from a formal
record).
. Consider your ®ndings and explore what you could have written and did
not, and how, if it had been included, this would have altered the
representation and decisions made about the patient.
Challenging the in¯uence of the clinical landscape

. Consider a series of your written records and try to identify other factors
in the clinical landscape that have in¯uenced the decision-making
process.
. Are these explicit in the records or do they spring to mind when you are
reading through them?
. If in¯uences in the clinical landscape are not explicit, to what extent
should these be recorded to show how a decision was shaped?
. Would the threat of a complaint against the nursing team alter the
content of what was written about the patient?
. If the content is dierent, in what way would it be so?

. Can you think of examples where the preferred decision made about the
patient was altered to one in¯uenced by someone else?
. If you can, examine these as case studies to determine what you would
do dierently to counter the identi®ed in¯uences.
. Are there any implications for developing your own practice so that you
can be con®dent of success in challenging moves that, according to your
knowledge of the patient, would decentre them from the focus of care
delivery? What are those implications?
References
1 United Kingdom Central Council (UKCC) (1992) Code of Professional Conduct. UKCC,
London.
2 Department of Health (1998) Information for Health. The Stationery Oce, London.
3 Gurbutt R (2005) Demonstrating nurses' clinical decision making. PhD thesis. University of
Central Lancashire, Preston.
4 Maas ML (1998) Structure and process constraints on nursing accountability. Outcomes
Manage Nurs Pract. 2: 51±3.
5 Mahlmeister L and Koniak-Grin D (1999) Professional accountability and legal
liability for the team leader and charge nurse. J Obstet Gynecol Neonatal Nurs. 28: 300±9.
6 Great Britain (1979) The Nurses, Midwives and Health Visitors Act. HMSO, London.
7 United Kingdom Central Council (UKCC) (2001) Professional Self-Regulation and Clinical
Governance. UKCC, London.
NMC, London.
9 The Health Service Ombudsman.
10 United Kingdom Central Council (UKCC) (1993) Standards for Records and Record
Keeping. UKCC, London.
Appendix
Suggested lesson plans
The following module description and learning units are oered as a possible way
of using the text as a focus for decision-making study. The module could be
adopted in its entirety, or alternatively it could form learning units that are
embedded in other programmes of study.
Module description
Module Clinical decision making
title
Module aims
The aims of this module are to:
. examine the role of nurses as decision makers
. examine a narrative explanation of real-world decision making
. examine local clinical practice and consider decision making in relation to the
narrative-based decision-making model
. examine the process, context, outcome and participants in decision making
. examine decision makers and decision expertise
. examine decision-making accountability.
Module content
The module comprises seven learning units. Each one focuses on an aspect of real-
world decision making and links examination of published evidence and policy to the
student's own area of practice.
Learning Unit 1
Setting the scene: the clinical landscape of decision making
Learning Unit 2
Making clinical decisions: a model of nurses' decision-making
Learning Unit 3
The narratives that nurses generate: ways of knowing the patient
Learning Unit 4
Demonstrating narratives: dierences between verbal and written
narratives
Learning Unit 5 The games nurses play: making narratives known to doctors
Learning Unit 6 Narratives and expert decision makers: creating and using narratives
Learning Unit 7 Nurses as decision makers: where next?
Suggested lesson plans 103
Skill development
The development of a range of skills forms part of the module activities, including
developing communication skills (group discussion and learning feedback), IT (liter-
ature searching), problem solving (discussing solutions to dilemmas such as record
keeping) and managing one's own learning (planning what to study and using
resources eectively). These will support the professional practice and participation in
a range of clinical leadership and healthcare delivery activities.
Teaching and learning strategy

The module will be delivered using a range of learning and teaching strategies designed
to meet the learning outcomes. There will be a combination of formal teaching, blended
learning (e.g. Web-based materials), supplementary reading to extend learning, group
work, re¯ection and discussion exercises that facilitate students' development of
analysis and review of theory and practice.
Students will prepare short talks based on their re¯ective work and extension exer-
cises that examine aspects of workplace decision making. Each session includes a
period of group feedback on extension learning and re¯ections from practice.
Students will keep a re¯ective diary to help to inform their professional development
plan.
Learning outcomes
On successful completion of this module a student will be able to:
1 Explain the role of nurses as decision makers and factors that have shaped its
development
2 Explain the scope of decision-making enquiry in their chosen clinical ®eld
3 Evaluate published evidence about nurses' real-world decision making and
evaluate the adequacy of theoretical models to explain practice in the student's
clinical area
4 Describe local processes involved in decision making
5 Evaluate the role and contribution of record keeping in decision making
6 Identify the boundaries of nurses' decision making and how non-nursing
decisions are in¯uenced
7 Examine concepts of experienced and expert decision makers and decision
making
Assessment of learning
Assignment
The assignment options oer students the opportunity either to examine literature-
based accounts of decision making in a chosen area of practice, or to examine and
analyse a real-world decision made in their own practice.
The assignment can be adapted to dierent levels of academic assessment through
substitution of dierent terms in the guidance given (e.g. describe, synthesise,
analyse, critically analyse).
Module pass requirements
Completion of the assignment to the agreed minimum threshold mark for a pass.
The weighting of the assignment is 100%.
Learning units
Learning Unit 1 Setting the scene: the clinical landscape of decision

making
Lesson aims
1 Examine the historical development of the role of the nurse.
2 Examine the legal, professional and organisational requirements for nurses' practice
as decision makers.
Text reference ± Chapter 1.
Learning outcomes ± 1 and 2.
Learning content Sta contribution Student activity Learning resources
1 De®ning the role Introduce the Student group Seek a range of
of the nurse. subject by discussion ± de®nitions of
discussion, create a `nurse' in texts/
perhaps a popular taxonomy of journals/policy
press depiction of nurses' work. documents.
nursing practice. Summarise the Compare and
taxonomy as a contrast these.
paragraph
de®ning `nurse'
and the nurse's
role.
2 Professional and Examine Examine abstracts For example,

policy views of contemporary of statements Nursing and
the nurse's role. de®nitions of the about the legal Midwifery
nurse's role. and professional Council (2002)
role of the nurse Code of Professional
in health policy Conduct, and the
documents and Nurses Act
professional (1988).
guidance.
3 Factors that have Identify historical Explain how this Refer to articles/
shaped the role of and sociological role has changed texts on nursing
nurses as decision accounts of over a chosen history.
makers. nursing period of time
development. (e.g. 100 years).
Draw out
political,
economic, social,
educational and
professional
factors that have
shaped the
de®nition of the
nurse's role.
4 The clinical De®ne and Students discuss Whiteboard.

landscape ± the examine the and write on a Flipchart.
context of nurse features of the ¯ipchart/
decision making. clinical landscape whiteboard all
in a the factors that
contemporary they can identify
clinical setting as parts of the
(e.g. a ward): clinical landscape.
. participants Students try to
. organisational group these into
design and categories to
culture formulate a
. technological summary
factors explanation of
. health policy. the clinical
landscape.
5 Summary. Conclude the 1 Select an area

learning unit with for further
a review of the study and
nurse's role as a pre-reading
decision maker for next
and its context. learning unit
(Chapter 2).
2 Make notes in a
personal
re¯ective diary
of the type and
number of
decisions that
you make
during a shift.
Note the
dierent types
of decision
made by
dierent grades
of nurse.
Learning unit summary

By the end of this learning unit students will have examined the role of the nurse as a
decision maker, and factors which shape the development of that role, and will have
established through reference to key documents a contemporary de®nition of the scope
of practice of the nurse's role as a decision maker.
Suggested areas for further study
1 The history of nursing practice
Examine literature on the history of nursing with a view to identifying references
made about the nurse's role as medical assistant and support of medical decision
making. Which developments in nursing practice have marked a move towards
making nursing decisions in contrast to supporting medical decision making?
2 The scope of existing enquiry in a chosen area of practice
Undertake a literature search of nurse decision making in your chosen discipline
area over the past 20 years. Identify the number of papers that have the keywords
`decision making' and `nurse' and from the ones that you retrieve, summarise the
types of study that have been undertaken (the methodological approach), the
research questions that have been asked and the ®ndings/claims that are made
about nurses' decision making. What can you identify about the need for further
study of nurses' decision making?
3 Doctors' views of nurses and their work
Examine medical literature (e.g. the British Medical Journal) for articles that discuss
nurses' roles, and identify how these are portrayed in terms of educational levels,
decision authority and clinical activities. Compare your ®ndings with current
policy statements and professional guidance about the nurse's role.
Learning Unit 2 Making clinical decisions: a model of nurses'

decision-making
Lesson aims
1 Examine the types of decisions that nurses make and which nurses make these
decisions.
2 Examine the number of nursing decisions that are made during a period of duty.
3 Examine how decisions are made.
4 Examine the theoretical explanations of decision making.
Learning outcomes ± 1, 2, 3 and 4.
Learning content Sta contribution Student exercises Learning resources
1 Introduction. Having 1 Recap learning
established the and feedback
role and context from previous
of nurses as learning unit.
decision makers, 2 Students give
the focus of study feedback on
moves on to how their ®ndings
decisions are from their
made. further study.
3 Selected
students report
back on the
types and
number of
decisions made
in practice.
2 The decisions that Refer to selected 1 Group exercise Reference to

nurses make. literature and to develop a dierent types of
highlight the description of decisions
range of decisions the scope, types reported in recent
reported that and frequency nursing
nurses make. of decisions literature.
Compare made in
literature-based practice.
accounts with 2 Group work to
those generated categorise the
by students. decisions.
3 Do dierent Examine the 1 Discussion Reference to role

nurses make dierent about the descriptions of
dierent responsibilities dierences in sta nurses,
decisions? that dierent decisions made junior sisters/
types/grades of by dierent charge nurses,
nurse have and designations of senior sisters/
the common nurse. charge nurses,
responsibilities 2 Examine a ward specialist
that all nurses selection of nurses, clinical
have. nursing role managers.
Examine the links descriptions
between nurses' and identify
decisions and the ways in
types of nurse which decision
decision makers. making is a part
Refer to examples of the role and
of role diers between
descriptions. dierent grades
of nurse.
4 How decisions are Introduce Referral to Reference to

made ± the students to a Chapter 2 papers oering
narrative model descriptive model (narrative dierent theories
as a way of of decision model). of nurses' real-
explaining how making and 1 Compare the world decision
patients are identify the model with making.
known. participants, experience of
processes and local practice,
information to identify
processing. similarities and
Discuss the dierences.
conceptual lens as 2 Discuss any
a means of dierences and
explaining how how these
role and impact on
information representing
seeking are how the
related. patient is
known.
5 Theoretical Introduce Discuss the Refer to selected

explanations of students to advantages and decision-making
decision making. prescriptive and disadvantages of review articles on
descriptive the two main prescriptive and
explanations of theoretical descriptive
decision making. explanations of decision making.
decision making
in connection
with learning
how to make
decisions and
represent patients
and their needs.
6 Summary. Conclude the 1 Decide an area

learning unit with for further
a review of study and pre-
dierent ways of reading for
explaining next learning
decision making. unit
Identify further (Chapter 3).
learning in 2 Record in a
selected areas of personal
theoretical re¯ective diary
knowledge and some examples
practice. of how
dierent
patients are
known and
described in the
chosen clinical
area.

By the end of this learning unit students will have examined the scope and types of
decisions that nurses make and the dierences between dierent grades of nurse. The
real world of clinical practice will have been discussed in order to estimate the number
of decisions made during a typical period of duty. The process of decision making will
have been examined, including the narrative model (Chapter 2) which is used as a
reference to focus discussion about the participants, processes in knowing patients and
making decisions. This will have included consideration of role and the conceptual lens
in information seeking.
1 Re¯ection on observed or personal practice
Observe/re¯ect on a shift spent in a clinical area and identify the range of decisions
made, and which decisions are made most frequently, and compare these with the
description of a nurse's decision-making role (Learning Unit 1). Do nurses need to
make all of these decisions? Should some decisions be delegated to non-nurses?
Are there other decisions that nurses could make but currently do not?
2 Explaining local decision making
Discuss with dierent members of the nursing team in your chosen clinical area
how they think their decisions are made. Re¯ect on the accrued responses and
draft a tentative description of the real-world decision-making practice of the local
nursing team. Consider to what extent this description is useful for identifying the
information processes involved. Is there anything missing? Is this description
suciently explicit to explain to a student how to make decisions?
3 Decision processes: focus on report ± where does it occur, what is communicated and how is
this information used?
Examine the literature on the nursing report and identify dierent accounts of its
purpose, place and content. Consider how dierent types of report aect the
construction of a narrative of the patient.
Learning Unit 3 The narratives that nurses generate: ways of knowing

the patient
Lesson aims
1 Examine dierent ways in which the patient is known.
2 Examine narrative scope and depth.
3 Examine the processes of narrative development ± handover report.
4 Examine how dierent sta contributions and judgements shape how a patient is
known.
1 Introduction. Having examined 1 Recap learning
how decisions are and feedback
made using the from previous
narrative model, learning unit
attention is now and feedback
directed towards from further
how the narrative study.
can be used to 2 Selected
explain how students give
patients are feedback on
known. their re¯ective
accounts of
how patients
are described
and known in
their clinical
area.
2 How much is Examining the Commencing Peer-reviewed

known about the meaning of with individual literature that
patient? `knowing the re¯ections on discusses
patient'. practice-based concepts of
examples of `knowing'
dierences in patients.
knowing patients,
students consider
the extent to
which narrative
scope and depth
can be used to
explain these
dierences.
3 How much is Introduce the 1 Discuss Chapter 3.

enough concept of whether
knowledge about narrative scope knowledge
a patient? and depth. about a patient
Discuss the can be
variation between summarised as
sta in knowing ènough' or
patients and why `not enough'.
this might be. 2 Discuss what
the criteria
should be to
quantify
`sucient
knowledge'
about a patient
needed to
make decisions.
4 What do we tell Examine the 1 Re¯ect on and Chapter 3.

others? Handover process of nursing discuss the Peer-reviewed
report. report. content, place papers about the
and process of role of handover
handover report.
report.
2 Using a
whiteboard,
generate a
summary of
how reports are
performed in
dierent
clinical areas.
Examine the
similarities and
dierences, and
consider how
these shape
knowing
patients.
5 How are patients Examine the 1 Discuss/re¯ect Re¯ective

described? dierent on local ways accounts of
Judgements. examples of of describing clinical practice.
judgements made patients.
about patients 2 Examine cases
(Chapter 3). of patients
Explore how being described
information is in ways that
processed to oer portray them as
summary objects rather
representations of than as people,
knowing patients. and analyse
why this is so.
6 Summary. Conclude the 1 Decide on an

learning unit with area for further
a review of study and pre-
possible ways of reading for the
knowing patients next learning
and the ways in unit
which global (Chapter 4).
judgements are 2 Obtain
used to (assuming
summarise how permission is
patients are given) an
known. anonymised
excerpt from a
nursing record
of patient care
to use in
classroom
discussion.

By the end of this learning unit students will have examined ways of knowing patients,
the scope and depth of a narrative, the report process and judgements used to
summarise how patients are known.
1 Knowing patients
Examine the nursing literature for accounts of `knowing' patients. Identify how
knowing patients is or is not valued and the variation in explanations of the
meaning of `knowing' patients.
2 Judgement
Conduct a literature search in the linked areas of ìnformation processing' and
`nurse decision making'. Search for the use of the term `judgement' within
nursing decision-making papers and identify how this term can have dierent
meanings.
3 Report
Observe a nursing shift handover report. Identify where it occurs, the participants,
the information given and its sequence, the documents used and the interactions
that take place. Re¯ect on your observations and consider what other ways of
`doing report' might be more eective in communicating about knowing patients
and their needs. Consider the implications of altering the local method of report
for the way in which patients are known by the nursing team.
Learning Unit 4 Demonstrating narratives: dierences between verbal

and written narratives
Lesson aims
1 Examine the design of nursing records.
2 Examine the dierences between verbal and written accounts of patients.
3 Examine the use of informal records in wards.
4 Explore the implications of omitting information from formal nursing records.
the narrative and feedback
explanation of from previous
knowing patients, learning unit.
attention is 2 Students give
directed towards feedback on
comparing and their ®ndings
identifying of their further
dierences study about the
between written use of the term
and verbal `judgement' in
accounts of the clinical decision
patient. making.
2 How is the Present the 1 Class members Professional

account about a nursing process as present their guidance.
patient and their a problem-solving examples of Peer-reviewed
care recorded? approach to anonymised literature about
documenting nursing the use of the
nursing work. records. nursing process.
Examine 2 Compare the
examples of dierent
nurses' records. formats of
Discuss what representing
would constitute the patient, the
the ideal record categories of
for supporting information
clinical decision recorded and
making. points where
decisions are
identi®ed.
3 Dierences Discuss problems 1 Compare what Health service

between what is with record is said during ombudsman
said and what is keeping ± make report with reports.
written. references to legal what is written
cases where about a patient,
nursing records and try to
have been identify the
criticised (e.g. for dierences and
omission). their
implications of
knowing the
patient.
2 Discuss what is
often omitted
from written
records.
4 Informal records. Discuss the use of 1 Examine local Examples of

a range of examples of informal records.
informal records informal Chapter 4 ±
(note sheets, records. nurses' note
diaries, oce Consider why sheets.
whiteboards) and these are used
their function as and why they
information are not
sources used in superseded by a
decision making. single record.
2 Consider how
the
introduction of
electronic
healthcare
records will
impact on the
use of informal
paper records
in wards.

learning unit area for further
with a review study and pre-
of the legal reading for the
requirements next learning
with regard to unit
documenting (Chapter 5).
care, and the 2 Make notes in
problems of your re¯ective
capturing the diary about the
scope of dierent inter-
information professional
seeking and relationships in
processing in the the ward.
record. Include
the problem of
formal and
informal records
when examining
complaints
against nurses'
care decisions.

By the end of this learning unit students will have examined the dierences between
written and verbal accounts of the patient, the use of informal records and the legal
implications of record keeping.
1 Literature search
Examine the legal requirements concerning nurses' record keeping and the
speci®c guidance of the professional regulating body on what nurses should
record. Examine a case of clinical negligence (look for reports published by the
professional body) and identify the use of the record in explaining the nurse's
actions, noting any criticisms that were raised about it. What can be learned from
analysis of a clinical negligence case about recording practice? How can a nurse
defend their practice if the formal record omits some information?
2 Informal records
Identify the range of informal records used in the ward. How are these used in the
process of decision making, what types of information do they contain and what
would happen if these records were removed from use?
3 Verbal narratives
Consider the verbal narrative ± that is, the information that is held in a nurse's
memory about a patient. How can the full range of information that nurses discuss
be captured in the written record? Or is this not possible?
Learning Unit 5 The games nurses play: making narratives known to

doctors
Lesson aims
1 Examine the nurse±doctor relationship.
2 Examine explanations of dierences in nursing and medical decision making.
3 Examine how nurses can play communication games in order to in¯uence medical
decisions.
how decisions are and feedback
made and from previous
recorded, learning unit.
attention is 2 Students give
directed to the feedback on
ways in which their ®ndings
nurses in¯uence from their
(medical) further study.
decisions that lie
outside their
legitimate scope
of practice.
2 Nurse±doctor Consider the 1 Feed back Literature

relationships. context of acute re¯ections on reporting on the
care delivery the nature of nurse±doctor
and the inter- game.
organisational, professional
professional, relationships
social, within wards.
educational and 2 Examine the
policy factors that reasons why
support particular dierences in
roles (legitimate decision
scope of practice) authority and
and behaviour organisational/
(hegemony). positional
power exist in
the workplace.
3 Communication Discuss the Discuss and Policy documents

tactics. dierent tactics evaluate how the on patient-
used in the game is played (if centred services
nurse±doctor at all) and how it and advocacy
game. might be removed services.
Examine the rise from nurse±
in patient doctor
involvement in interactions in
decision making hospital wards.
as a consequence
of a move to
patient-centred
services.
4 Just knowing. Discuss the 1 Explore Literature on the

concept of an explanations of nature of
ìntuitive' feeling intuitive or `gut intuition and its
that a problem feelings' about value in clinical
exists and how a patient and practice.
nurses might their needs.
explain this. 2 Examine
relevant
literature on
the value of
intuition as an
àrt' in nurses'
decision-
making
practice.

learning unit area for further
with a review study and pre-
of the clinical reading for the
landscape and the next learning
dierences in unit
decision authority (Chapter 6).
concerning 2 Make notes in
patient care your re¯ective
and care diary about
management. nurses whom
you consider to
be expert
decision
makers.
Describe
expertise and
how it is
demonstrated
in the practice
of these nurses.

By the end of this learning unit students will have examined the nature of inter-
professional relationships in the ward, and dierences in decision-making authority.
The learning unit will also have included an exploration of the ways in which nurses
seek to alter or challenge medical decisions. Consideration will also have been given to
nurses' intuitive knowledge that a patient problem exists and how this can be under-
stood and used to alter medical decisions.
1 Literature search
Examine the literature on the nurse±doctor game and consider how this relates to
hegemony in the clinical workplace. What impact does playing the nurse±doctor
game have on the way in which nurses and their work are represented? Given the
prevalence of the medical model in the design of care services, to what extent
should nursing practice, and its limits, be de®ned by the medical profession?
2 Game playing
Try to ®nd examples of clinical areas where the nurse±doctor game is and is not
played. Compare these and seek to identify similarities and dierences. What
reasons can you suggest to account for the need for game playing in one area and
not the other?
3 Organisational design
Examine the organisational context of care delivery and identify factors that
empower/support nurses in making a contribution or challenge to non-nursing
decisions. In a similar way, identify factors which you consider inhibit contrib-
uting to or challenging non-nursing decisions. Why do these factors exist and can
they be minimised? Are there any reasons to support the continued existence of
these empowering/resistance factors?
Learning Unit 6 Narratives and expert decision makers: creating and

using narratives
Lesson aims
1 Examine descriptions of nurses as inexperienced, experienced and expert decision
makers.
2 Examine decision-making skills.
3 Explore the concept of intellectual capital.
4 Examine how expertise can be learned or developed.
Learning outcomes ± 7.
Learning content Sta contribution Student Learning resources
contribution
how and feedback
interprofessional from previous
realtionships learning unit.
shape decision 2 Students give
making, attention feedback on the
is now turned to notes made in
nurses as expert their re¯ective
decision makers. diaries about
decision-
making
expertise.
2 What is decision- Examine the 1 Discuss, Chapter 6.

making concept of a referring to the NHS Knowledge
expertise? decision-making narrative and Skills
skills continuum model, how Framework (NHS
ranging from understanding KSF).
inexperienced to roles, domain
expert decision knowledge and
maker. systems
knowledge
in¯uence skill
development.
2 Discuss the
elements
necessary for a
knowledge and
skills
framework to
be developed.
Compare this
with existing
frameworks
(NHS KSF).
3 Intellectual The knowledge 1 Using the Chapter 6.

capital. and skills that a narrative
nurse possesses model, identify
can be described points where
as intellectual narrative
capital. Examine development
the eects of and use draw
organisational upon the
change on team intellectual
stability, and the capital of the
impact on ward team and
intellectual role models.
capital. Explore 2 Determine the
how this might eect of loss of
aect the intellectual
decisions made capital at these
about patients. points on
decision
process and
outcome.
4 Expert decision Is decision- 1 Examine a Job descriptions/

makers and role making skill range of role speci®cations.
descriptions. explicitly sought descriptions
in role and abstract
descriptions for information
nursing jobs? indicating that
Examine a range decision
of role making is
descriptions to recognised as
develop an part of the
answer to nurse's role.
questions of the 2 Examine the
extent of implicit
invisibility of assumptions
decision making about how
in the nurse's nurses make
role. decisions, how
If the term èxpert they are
nurse' is used, recognised and
how is this how they can
understood be evaluated as
within the role expert
descriptions decisions.
examined?
5 Leaning to be an Is there a `best' 1 Group Chapter 6.

expert decision method of discussion Refer to
maker. developing about literature-based
decision-making approaches to accounts of how
expertise? learning how to decision making
Examine make clinical is learned.
educational decisions in
Examine a pre-
approaches to practice.
registration
developing 2 Explore what nursing
decision-making can be learned curriculum to
skills using away from identify where
vignettes, practice. decision-making
simulations and 3 Discuss the role development is
practice-based of re¯ection explicit.
learning. and critical
Discuss the incident
usefulness of analysis to
re¯ection and enhance the
critical incident quality of
analysis. learning from
experience.
6 Summary Conclude the 1 Decide on an

learning unit with area for further
a review of a study and pre-
continuum of reading for the
decision-making next learning
expertise and unit
approaches to (Chapter 7).
teaching the 2 Make notes in
development of your re¯ective
decision-making diary about
skill. how you
anticipate the
nurse's
decision-
making role
will develop in
the future.

By the end of this learning unit students will have examined concepts of expertise, a
continuum of decision-making expertise, the concept of intellectual capital and ways of
developing decision-making skill.

1 De®ning expertise ± comparing theory with practice
Conduct a literature search that is limited to a speci®c domain of clinical practice,
and examine descriptions/de®nitions of decision-making expertise. Compare your
®ndings with theoretical accounts in nurse education journals to determine to
what extent practice understandings are explained by theoretical accounts of
expert nursing and expert decision making. Would your description allow you to
recognise an expert in your clinical area?
2 Intellectual capital
How might you quantify the intellectual capital in the ward in which you work?
What eects on patient care decision making can be detected when there are sta
vacancies/losses from the clinical team? How can the intellectual capital of the
team be enhanced?
3 Skills of decision making
Examine your own role/person speci®cation in order to identify what it states, if
anything, about the required level of decision-making skill. If there is any
evidence of this, what assumptions exist about how decisions are made and the
skills that you need in order to make them? If it contains nothing about decision
making, what would you include if you were rewriting this speci®cation, and how
would it alter the way in which you are portrayed as a nurse?
Learning Unit 7 Nurses as decision makers: where next?

Lesson aims
1 Examine decision accountability.
2 Examine and apply a narrative model as a method of demonstrating nurses' clinical
decision making.
3 Examine and discuss the electronic record and its value in demonstrating decisions.
Learning outcomes ± 1 to 7.
a range of issues and feedback
about decision from previous
making this ®nal learning unit.
learning unit 2 Students give
examines feedback on
decision their ®ndings
accuntability and from their
considers how further study.
this might be
achieved.
2 Decision Examine the Through group

accountability. framework of discussion
professional develop an
guidance on account of the
record keeping range of
and professional accountability
accountability. that a nurse has
Explore what in the clinical
nurses are workplace.
accountable for
and to whom.
3 How do you Discuss methods Examine how Chapter 7.

demonstrate of demonstrating decisions are Examples of
clinical decisions? decision process demonstrated in anonymised
and decision examples of nursing records.
outcomes. nursing records.
Use the narrative
model as an
analytical tool to
analyse the text of
a nursing decision
(as shown in
Chapter 7).
4 Will the Examine the Evaluate how the Examples of

electronic record design of an format of an electronic patient
enhance the electronic health electronic patient record design (if
demonstration of record. Discuss record will available).
clinical decision the underlying in¯uence what is
making? model and how demonstrated
this renders about nurses'
nurses' roles decisions.
visible or Discuss whether
invisible. all registered sta
To what extent in identi®ed
does the clinical clinical areas have
team have access the skills to search
to electronically for and retrieve
based decision particular
support? Are database
there any barriers information (e.g.
to accessing best practice
electronic guidelines). To
information? If what extent can
so, what are these electronic
and how can they information
be overcome? substitute for
clinical
experience and
oset de®cits in
the intellectual
capital of the
ward team?
5 Module Review the 1 Complete

conclusion. module. Gather module
student feedback feedback
using a module questionnaire.
evaluation 2 Discuss
questionnaire. assignment
Discuss the preparation.
module
assignment.

By the end of this learning unit students will have examined decision accountability
and considered how this can be demonstrated.
Assignment
The completion of the module includes the submission of an assignment. Two options
are suggested, one involving analysis of literature and the other involving analysis of a
practice-based decision.
Suggested assignment: a literature review

A literature study of decision making in a chosen area of nursing
practice
Guidance: Students are to select a chosen area of clinical practice (e.g. respiratory nursing,
stroke nursing, Accident and Emergency nursing) and explain the rationale for their
choice. They are to identify the search strategy they used to generate the results and the
selection criteria they used to determine which papers to include in their study. The
examination of the results needs to be structured around a conceptual framework. Using
this, the assignment should explain the scope of existing enquiry in this ®eld, the
terminology used to explain nurses' decision making, and ways in which theory is used
to explain how nurses make decisions. Examination of the literature should include a
critique of reported dierences and similarities in decision-making practice. In addition, it
should include the decision-making context and its boundaries (e.g. legal, professional and
organisational) and how these are visible in the literature examined. The conclusion of the
assignment needs to identify gaps in existing enquiry and implications for future study.
Weighting: 100%.
Word limit: 3,000 words.
Suggested format of assignment

1 Title.
2 Introduction.
3 Search strategy and summary of results.
4 A conceptual framework.
5 Discussion of the dierent domains of the conceptual framework, to include:
. decision-making de®nitions
. theoretical explanations of decision making in this area
. explanations of nurses as decision makers in this area
. decision-making context.
6 Conclusion ± include a summary and identify gaps in the existing ®eld of enquiry.
7 References.
Suggested assignment: analysis of a clinical decision

An analysis of a real-world clinical decision
Guidance: Students are to identify and record an anonymised patient care decision and
produce a chronological transcript of this. The decision will then be analysed. This should
include the use of a conceptual framework to explain and examine the decision type,
process, context, outcome and participants, and should speci®cally include examination of
the roles of nurses in the decision and their interactions with non-nurses while making the
decision. The analysis should also include an examination of the scope of decision making
and nurses' decision authority. In addition, the analysis must include consideration of the
role of formal and informal records, the decision context and how it shaped the process and
subsequent decision made. Discuss the decision maker(s) and how their experience and
knowledge shaped the decision process and outcome. The discussion section of the assign-
ment should include a brief re¯ection on learning through having undertaken the analysis,
and should identify how this will inform their approach to clinical decision-making practice.
Weighting: 100%.
Word limit: 3,000 words, excluding transcript.
Suggested format of assignment

1 Title.
2 Introduction.
3 Identi®cation of the decision chosen.
4 A conceptual framework ± this needs to include the decision participants, decision
process, decision outcome and decision context. Explain how the framework will be
used to examine the chosen decision example.
5 Analysis of the decision, to include:
. decision process
. formal and informal records
. decision participants
. decision outcome
. decision context.
6 Discussion ± include a re¯ection on learning drawn from the analysis and implications
for clinical practice.
7 Conclusion.
8 References.
9 Appendix ± transcript of the chosen decision.
Index
Accident and Emergency sta 21 and decision making, overview 104,105

accountability, medical 8, 92, 92, 95, 98 hierarchical nature of 91
nurses' 90, 92±6, 100 nurses and 11
accounts, verbal and written 83 clinical negligence 115
Activities of Daily Living (ADL) model 7, Code of Professional Conduct, nurses (2002)
23±4, 29, 48, 54, 57, 58, 60, 61 84, 92, 93, 94, 104
Adamson, BJ, DT Kenny and J Wilson- communication games 46, 75, 66, 72, 73,
Barnett 73±4 86, 116±8
ADL see Activities of Daily Living resistance and 71±3
administrative narrative see narrative communication tactics 76, 117
admission narrative see narrative competing narratives see narratives
advocacy 68, 76, see also nurses as conceptual lens 19, 28, 31, 37, 39, 40, 44,
advocates 53, 54, 74, 108
assessment sheets, non nursing 53 consultants 24- 25, 26, 27, 67, 68
continuation sheets 54±5, 56±7 continuum, decision making 85±6
nursing 54 critical incident analysis 121
atlas of personhood, health and ill-health
83 decision accountability 123
domain knowledge 89 decision makers 2, 3, 11, 66, 79 , 103,
119
biomedicine 74 inexperienced 80
British Medical Journal 73, 106 expert 79, 81, 85, 120
becoming an expert decision maker 121
care decisions 3, 74 decision makers and narratives 78
care delivery 51 decision making
care environment 75 context 2, 7, 8, 12, 108
caregiving 20 decision making knowledge 86
care management 27, 30, 66, 82 de®ning decision making 90±1
care management role, nurses 44, 46, 66 dierence between doctors' and nurses'
care tasks 26 66, 74, 75
improvement of 70 expertise 119
care plan 55±8, 67, 56±7 informal processes in 82, 83±4
care trajectory 20, 27, 28n, 36, 54, 55, 56, and intellectual capital 86
72, 96, 47 invisibility of 87
care, nurses legal duty of 84 knowledge 86
care, patient centred 28n locus of control 91
Chiarella M ± analysis of Australian case medical professionals' involvement 75
law 74 and nurses 79
class-component in nursing 7 nurses' considerations of 71, 72
clinical decision making, 18, 66, and organisational change 86±7
107±9,113 and problem solving 1
de®nitions 102±3 skills 122
clinical judgements 11 decision making, nurses
clinical landscape 10, 11, 13, 81, 85, 86, and accountability 96
103, 117 categories of 8
challenging the in¯uence of 100±1, 105 categories of and continuum 79±86
128 Index
decision making, nurses (cont.) expertise, de®ning 121

descriptions and de®nitions 1 expertise and learning 88±9
elements of 13 and decision making 119
expert decision making, processes of 121 de®ning expertise 122
need to make visible 87, 88, 89 understanding narrative domain
nurses' decision making, future knowledge 83±4
developments in 96±9, 96, 97
and organisational change 86±7 ¯irting among nurses and doctors 70
organisational developments 98±9
origins of 12±13 Gair, G and T Hartery 67
professional developments 98 game theory 3±4, 26, 66
and terminology 9 see also communications games
and types of nurse, process 8 General Nursing Council (UK) 7
oscillations in ability 85±6 general practitioners 21
real world 39, 40, 109 Georgetown University Home Healthcare
see also problem solving, skills, Classi®cation (HHCC) 9
acquisition of 85±6 Guidelines for Records and Record Keeping 94
decision making process guidelines, nursing 10±11
theoretical explanations 8±10, 108
context of 10, 38 healthcare systems and accountability to
expertise 79±87 patients 99
making, visible 89, 92 health service provider 91
oral tradition of 52, 58, 66 health visitors 8
systems 62 health, general rules of 5
decision outcomes 8, 83, 93 healthcare delivery 99, 100
process of 93 healthcare policy 11
decisions, demonstrating 100 healthcare professionals 86
Department of Health 92 nurses as 73
doctor±nurse game 73, see healthcare system 82
communications games healthcare teams 27, 41, 86
doctor±nurse professional relationship, 75 nurses' experience increased by being in
hierarchical 68 82, 92
doctors 26, 27, 28, 66, 67, 69±70 healthcare work 74±5
doctors' views of patient needs 66 hegemony, medical 74, 116
and ¯irting 70 HHCC see Georgetown University Home
legal accountability 67 Healthcare Classi®cation
and medical decision making 4 hierarchy clinical landscape 68, 91
possible breakdown in nurse±doctor hierarchy, communication information 93
relations 73±4 historical resistance to recognising nurses'
and professional relationship to nurses narratives 73±4
4±6, 27, 43, 67 , 86 Ho¯ing, C. 73
view of nurses' activities 67, 74, 106 holistic view of nursing 25, 28, 51, 72, 81,
and ward management 67, 73 83, 99
ward rounds 43 hospital rules/etiquette 5
see also legal accountability, nurses'
perceptions of 67 ICNP see International Classi®cation for
domain knowledge 79, 81, 85, 89, 119 Nursing Practice
informal systems and ìnvisible' practices
educational developments, nursing 98 83
see also nursing curricula information hierarchy 78
electronic records 37, 51, 114, 124 necessity for verbal communications
see also record keeping hierarchy 93
experience see knowledge see also ward information hierarchy
Index 129
information processing 37, 39, 40, 41, 49 medicine, and nurses' decision making 10
information loss 58±9, 59 resistance to nurses' narratives 73±4
information seeking and tools 23±6 methodological approach to decision
information seeking 1, 23±4, 28, 40 making 4
and pre-admission accounts 19±20, midwives 8
21±3, 35, 36, 37 monitoring of narratives 55
admission account 23, 36
information sources, making use of 34 NANDA see North American Nursing
and role 40 Diagnosis Association
information sources 36±7 narrative 56, 81, 110±112, 113±5
loss 40 dierences between verbal and written
institutional culture 5 narratives 58±9, 63, 83, 113, 114
intellectual capital 120, 121, 122 dierences in narratives 34, 40
de®cit in 86 examining the narrative 113±5
intensive care 8 and global judgements 46±8, see also
International Classi®cation for Nursing judgements
Practice (ICNP) 9 and judgements 41
interpreting and generating narrative narrative based decision making 79
category information 80 narrative categories 39, 40, 48±9
Interprofessional relationships 82, 118 narrative content 48±9
intervention choices 84 narrative scope 39 , 49, 72
intervention information 84 narrative depth 40, 49
nurses' narrative 66,71
judgements, making 40, 41, 48, 52,111 nurses, process of learning how to
ownership judgements 41, 42±5 create and use a narrative 79±81, 113
global judgements 45±6, 48, 49 50, 55, and record keeping 53
70 reports, short 30±1 see also reports
and non-compliance 45±6 reports, long 31±2, 33 see also reports
and healthcare team-46±8 47 and temporary sta 87
use of narrative 84
Kardex system for notes 30, 52, 62 using narrative model to demonstrate
knowledge, areas of 80 decision making 95±6
development of 83±5 verbal narrative 115
narrative decision making model 95±96, 96
legal accountability, doctors' and nurses' as a means of demonstrating nurse's
51, 52, 67, 84, 91, 95, 104, 114, 115, accountability
116 narrative development and clinical
lens, conceptual see conceptual lens decision making 18, 19, 22±3, 35, 39
locus of control in decision authority 82 , 51, 54, 78, 79, 81, 110±112
acquiring skills 79±81
malpractice 93 administrative 19±29
management information 60 anticipated narrative development 85
managers, service 86 caregiving 34
Maslin-Prothero and Masterson 73 competing narratives 48, 49
May C, and C Fleming 74 creating and using narratives 78, 81
McFarlane, Baroness 7 decision making 38
medical case management 67 dierences between verbal and written
medical diagnostic decision taking 28, 91 29, 112, 113, 114
medical hegemony, doctors 74, 116 doctors and healthcare professionals
medical lens see conceptual lens interpretation of nurses narratives 86
medical professional tribalism 74 and expert decision making 119
medical records 23 information loss between verbal and
Medical Registration Act (1858) 4 written narratives 58±9
130 Index
narrative development and clinical medical ward 28, 52, 91

decision making (cont.) neonatal 8, obstetric 8
narrative development cycle 34, 35±6 perioperative 8
nurses techniques with doctors 69±7 practitioners 4
report 29±34, 37 prescribing 8
participants in 78 as sickroom managers 4
perceptions of validity of narrative 21±2 sta 27
providing holistic overview 99, see also ward sister 5, 27, 52, 68,
holistic approach ward manager 25, 66
skills of narrative development 85 nurses
stages of 19±35, 37±8, 85 accountability 90, 91±2, 92±6, 124
used to in¯uence decision making 74 as advocates for doctors and patients 26,
narrative domain knowledge 83±4 43, 68, 72, 74, 76, 81, 91, 117
narrative model as autonomous decision makers 90
and educational possibilities 98 becoming autonomous healthcare
as reference point 78 professionals 73
and table construction 95±6, table 96 breaking of communications rules 76
national record system, development of 95 care decisions 74
see also records systems as care manager 26±7, 44, 80
NHS Knowledge and Skills Framework as carers 25±6, 73, 80
(NHS KSP) 119 challenging medical decisions 69±72,
NHS no smoking policy 43±4 73±4
NHS Plan 11 claiming ownership of patients 41, 42±5
NIC see Nursing Interventions claiming ownership of ward 4, 66, 67
Classi®cation clinical decision making 18, 79±82, 79,
Nightingale, Florence 4, 5, 66 81
NMC see Nursing and Midwifery Council and clinical landscape 11
NOC see Nursing Outcomes Classi®cation confrontational tactics with doctors 71±2
non-nursing decisions 81, 86 considering themselves as information
North American Nursing Diagnosis hub 26
Association (NANDA) 9 as decision makers 1,4, 35 51, 96, 123±4
note taking 20, 60±3, see also reports demonstrating decisions 91±2
Notes on Nursing (Nightingale) 4 describing patients 43±6, 48, 111, 112
nurse's role, description of 12, 28 as expert and control of patients'
changes in 75 environment 22
historical role 75 and ¯irting 70
nurses ± advanced practice 8 information needs 69
community 8 information seeking 26±7
consulting 4 intuition 117
coronary care 8 knowing how to create narratives 79,
critical care 8 110±2
emergency 8 and knowing patients 29, 39, 79, 111,
inexperienced 79, 81, 82, 83±5, 87. 88, 112,113
93, 119 knowledge of patients 6, 40, 79, 83±4,
inexperienced as rule driven 93 110±111, 112, 113,
experienced 79, 81, 84, 85. 87, 88, 119 learning by 80
expert 8, 26, 85, 86, 87, 88, 119, 120 legitimate scope of practice 84
general practice 8 as medical assistant 28, 74, 80, 91
intensive care 8 non-confrontational tactics in handling
junior 26, 27, 40 doctors 69±70
junior, being task orientated 26 nurses' narrative see narrative
junior and limited scope narratives nurses' skills 78
40,110±112 nurses' views of doctors 28, 67±8, 75
Index 131
opinion makers 78 typology of decision making 78

ownership of care 26 nurse±doctor games see communication
patient management 69 games
and patients' needs 71±2 nurse±doctor working relationships 26, 28,
as problem solvers 9, 94 67, 116
and process of decision making 99 improving 69
and professional relationship to doctors potential breakdown in 73±4
4±6, 43, 66, 67 nurses and doctors, relationship with
professional assumptions about 91 patients 4, 6, 7, 75
professional relationship with doctors nurses notes 6, see also narrative
43, 67 nurses, inexperienced, experienced and
professionalism 90 expert, decision making process and
and record keeping 51 learning thereof 78±87, 119
responsibility for errors 93 Nurses' Act (UK) 94
seeing patients as objects 42 Nursing and Midwifery Council (NMC)
subservient position to doctors, 51, 52, 104
historical 4±6 nursing care, examples of potential
training 83 problems 2±3
understanding of ward teams 79 nursing curricula 78, 98, 103, 121
understanding roles 80, 82 Nursing Interventions Classi®cation (NIC)
use of reasoning 70 9
using narrative to in¯uence decision nursing knowledge base, development of
making 69, 70, 72, 74 4, 6, 103
view of patients 74 nursing language see nursing
view of role in wards 73 nomenclature
views of nurse's role 104 nursing lens 37, 44, 96 see also conceptual
ward management 66 lens
wish to acquire medical knowledge 5 nursing models and decision making 7±8,
nurses' decision making 28
decision making process 1, 3, 4, 6±7, 8, development of and changes in 7, 105
12±1390±2, 103, 105, 106, 107±109, diagnoses 4, 6, 7
112 identities 90
clinical decision making, model of 18, as a team activity 49
78, 106 nursing nomenclature, universal, absence
contexts of 8±9, 10±11 of 92, 98
de®ning role of 104 nursing orders 7
developments 96±9 Nursing Outcomes Classi®cation (NOC) 9
doctors' making use of nurses' nursing practice 13, 53±4
observations 6, 68 descriptions of 4±8
future of 96±9, 96, 97 nursing record, as information seeking
game theory and 3±4, 66 tool 23±6, 62
historical basis of 4±7, 10 dierences between verbal and written
levels of experience and decision record 62, 63
making 79, 90, 108 nursing roles 37, see also historical role
nurses' note taking 6 nursing therapy decisions 90
and nursing roles 37 nursing, history of 4±5, 105, 106
narrative development 21±4
organisational basis 4 Omaha System 9
origin of 3 oral tradition in nursing 53, 58, 83, 94
process of decision making 3, 51 , 89 information loss between verbal and
professional development of 98 written records 58±9
as signi®cant component of work and organisational change, and impact on
professional identity 99 decision making 86±7
132 Index
organisational culture 74 reasoning, nurses' with doctors 70, 71

design 118 record keeping 20, 51, 82, 84, 94, 100,
organisational systems, formal and 103, 113
informal rules 81, 82 formal records 64
outcomes, medical, and decision making informal records 60±2, 64, 114, 115
9±10 legal aspects 115,51, 52
ownership judgements 41, 42±45 maintenance of 51±4
Ozboldt partnership 9 note sheets 60±2
oral records 66
oral tradition 83
patients problems of present system 63,90
care of 67, 99 problems with 114
decentring of 99, 100 quality of 52±4
and decision making 91, 99 records and practice of nursing 52
knowing 111, 112 system 63
labelling as compliant 42±3 verbal and written, dierence between
management 42±5, 74 64, 114
medical descriptions of 111 ward round record 52
medical professionals' view of 85, 108, ways of improving 95
109 see also electronic records
needs of 18 record making, reasons for 51
as objects, medical sta viewing 7, 42, records systems
48±9, 50, 111 and organisational implications 98±9,
observation of 6 100
record keeping of see record keeping development of national record system
representation of 82 95
seen as problem or non-compliant 43±6, quality of 53, design of 53±4
48 use of records 52
see also under doctors, nurses regulator, professional 91
patients' experience of healthcare and relations, professional, between doctors
hospitals 2, 26, 27, 42±5, 63, 91 and nurses 67±9,116±8
patient information, recording of 82 improving professional relationships 69
representation in narrative 54±8, 110 report, process of 30
patient-professional relationship 42±5, 82, content of 30±1
99 time constraints on 30
patriarchalism in the medical profession 7, see also narrative
73 report, shift handover 20, 29±30, 35, 47,
peer review 39, 48, 49, 63, 68, 78, 83, 84, 52, 62, 82, 91, 95, 111, 112
91, 93±4, 110, 111 residential care 8
positivist and non-positivist approaches, rules, context free 11
nursing, adoption of 7
practice errors 8
prescriptive care management 42 service provision, records systems and
problem solving and decision making 1, 7, accountability 98±9
9±10, 113 shift handover report see report, shift
problem solving approach 7, 63, 94 handover
problem solving format 94 Short 73
see also decision making silencing of nurse's narrative 76
professional development, nurses, skill development 103
economic and other considerations 98 Snelgrove S, and D Hughes 73
eects of loss of professional sta 86 standards of practice, nursing 91
professional hierarchy 74 Stein LI 73
protocols, nursing 10±11 Sweet, SJ, and IJ Norman 73
Index 133
tactics, non confrontational and nurse± USA and nursing decision making 9
doctor relationships 69±70
confrontational 71±2 ward culture 87
teaching and learning strategy 103 decision making 75
team cohesion 87 environment 85
temporary sta, use of 87 ward information hierarchy 39, 83, 85, 86,
terminology and decision making 9 87
and lack of precise de®nitions 8 see also information hierarchy
trajectory of care see care trajectory ward management 4, 66
triage decisions 8 ward practice 82
typology of nurse decision makers 78 ward rounds 67, 91
culture of 75, 82
UJC see University Hospital Consortium record 52, 54
UK, nurses' legal responsibilities in 84, ward round book 53
90 ward teams 79
UKCC see United Kingdom Central social process of 82
Council intellectual capital within 86
unauthorised practitioners, exclusion from operation of 79
medicine 4 perceptions by doctors and nurses of
United Kingdom Central Council (UKCC) roles within 66, 67±8, 73
51, 95 ward work, patterns of 5
University Hospital Consortium (UHC) 9 workload pressures, and note taking 24

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Nurses' Clinical

# 2006 Russell Gurbutt

All rights reserved. No part of this publication may be reproduced, stored in a

British Library Cataloguing in Publication Data

ISBN-10 1 84619 037 1

Typeset by Anne Joshua & Associates, Oxford

1 Setting the scene: the clinical landscape of decision making 1

2 Making clinical decisions: a model of nurses' decision making 18

3 The narratives that nurses generate: ways of knowing the patient 39

4 Demonstrating narratives: dierences between verbal and written

5 The games nurses play: making narratives known to doctors 66

6 Narratives and expert decision makers: creating and using

7 Nurses as decision makers: where next? 90

Appendix: Suggested lesson plans 102

Chapter 1 Setting the scene: the clinical landscape of

Chapter 2 Making clinical decisions: a model of nurses'

Chapter 3 The narratives that nurses generate: ways of

Chapter 4 Demonstrating narratives: dierences between

Chapter 5 The games nurses play: making narratives

Chapter 6 Narratives and expert decision makers:

Chapter 7 Nurses as decision makers: where next?

Setting the scene: the clinical landscape

Introduction . Raising questions . Origins and developments . Knowledge

Origins and developments

uncertain conditions and has been linked to applications in economics and

Knowledge and decision making

Rules and decision making

discipline'.9 The potency of such socialisation into non-questioning obedience to

Assistants in medical decision making

Breakout: developing nurse decision making

Nursing models and decision making

Decision-making enquiry about dierent types of nurse

Decision-making enquiry about dierent types of decision

Decision-making enquiry about process

Decision-making enquiry and the use of dierent

Decision making and problem solving

Decision-making process: theoretical explanations

The context of decision making: the clinical landscape

Chapter summary box

Stop and think

. What points do they make about the process of decision making?

Sub-area of nursing practice

The elements of decision making

The clinical landscape

Making clinical decisions: a model of

Introduction . An overview of narrative development . Stage 1: Pre-

An overview of narrative development

Stage 1: Pre-admission and admission stages

Figure 2.2 The trajectory of care.

Narrative development stage 1: Pre-admission accounts

The pre-admission account

As in the earlier account of John, this also included medical information

Pre-admission account decisions

The admission account

Shaping information seeking

Role and information seeking: nurse as carer

These expressions of responses to needs identi®cation by implication demon-

Role and information seeking: nurse as care manager

Role and information seeking: nurse as medical assistant

4 Demonstrating narratives: dierences between verbal and written

Chapter 4 Demonstrating narratives: dierences between

Decision-making enquiry about dierent types of nurse

Decision-making enquiry about dierent types of decision

Decision-making enquiry and the use of dierent

. Could the information be made available in a dierent way (for example,

Dierent narratives about the same patient

Demonstrating narratives: dierences

Dierence between written and verbal records

Dierent types of relationship between nurses