Practice standards for quality clinical decision-making in nursing

Clinical decision-making is a critical component of nursing practice, as the life of the patient is at stake. The quality of clinical decision-making is, therefore, essential in delivering quality nursing care. The facilitation of quality clinical decision-making in nursing requires the development of standards to monitor, evaluate and implement remedial actions that improve on the quality of clinical decision-making (Muller, 2002:203; Beyea & Nicoll, 1999:495). However, there are no such practice standards against which the quality of clinical decision-making by nurses can be evaluated and assessed.


Introduction
The development and setting of quality standards are the first and most basic steps in the process o f conducting quality assurance activities.In their Draft Charter for Nursing Practice, the South African Nursing Council (SANC, 2004:10) re-emphasise their commitment to the delivery of high quality nursing care by nurses.Clinical decision-making is a critical component of nursing practice.Nurses make daily clinical decisions that impact on the lives of their patients.The quality of these decisions therefore lies at the heart of the process to deliver quality nursing care.The achievement o f such outcom es re q u ires the developm ent and im plem entation of mechanisms to facilitate the quality of clinical decision-m aking.One such mechanism that can be implemented to ensure the quality thereof, and therefore the quality of nursing care, is to formulate ap p ro p riate p ro fessio n al stan d ard s (Beyea & N icoll, 1999:495;SANC, 2004:29).In this vein , stan d ard formulation is an essential activity of quality improvement.
T he ov erall p ro cess o f q u ality improvem ent includes the setting of standards, practice m onitoring, the evaluation of identified practice problems, and resolving those practice problems (Muller, 2002:203).The development and use of standards are emphasised in the literature about the quality of care, as standards are used to derive criteria against which care, or the processes to deliver such care, are measured for the purposes of quality improvement (Dozier, 1998:22).Standards can be defined as statem ents relating to the scope of nu rsin g p ractice, in clu d in g both standards of care: aspects of the nurse's role such as assessment, planning and e v alu atio n ; and standards of p ro fessio n al p erfo rm ance, such as aspects of the nurse's role in quality assu ran ce and research (A m erican Nurses Association, 1991:1;Deab-Baar, 1993:33).Bachman and Malloch (1998:26) also noted that the concept of standards carries with it incredible confusion.Based on a literature review, Patterson (1988:625) also found evidence of such confusion.She identified and defined two concepts that need clarification: standard o f care and standard o f practice.A standard of care focuses on the recipient of care (the patient) and a standard o f practice focuses on the provider of care (the nurse).A standard of care is written about patient outcomes, whereas a standard of practice is written about the nursing pro cess (Jo h n so n & M cC loskey, 1992:53).Standards of practice are sometimes referred to as professional standards.Alternatively, standards can be classified as regulatory, voluntary and involuntary (Beyea& Nicoll, 1999:495).R egulatory standards are based on regulation usually m andated by the government.Voluntary standards are those dev elo p ed by health care practitioners and are often the work of a p ro fessio n al o rg a n isa tio n .B oth regulatory and voluntary standards can be paralleled with professional standards, which are promulgated by professional o rg an isatio n s, and accrediting and reg u lato ry bodies and in stitu tio n s (Dozier, 1998:22).Involuntary standards are those defined by professional liability insurance carriers.Standards may also be categorised according to the scope of influence, e.g.national, state, local or institutional standards (Beyea & Nicoll, 1999:495).It is important to draw a distinction betw een a standard and clinical guidelines, as these concepts are often confused or used interchangeably.Standards are different from guidelines.
By com parison, guidelines refer to recommended approaches to managing patient/client conditions, focusing on specific aspects of patient care delivery connecting interventions and expected outcomes (Dozier, 1998:23).Clinical p ractice g u id elin es are statem ents designed to assist practitioners with decision-making about appropriate care for specific clinical circum stances.Clinical guidelines reflect the state of current clinical knowledge, as published in the scientific health care literature, reg ard in g the effec tiv en e ss and ap p ro p riaten ess o f procedures or practices (Child & Holmes, 1999:73).However, both guidelines and standards can serve as the basis for many activities, either w ithin nursing or the larger healthcare system.Guidelines reflect standards.They describe care delivery that is consistent with standards.Both can enhance m u ltid iscip lin ary collaboration (Childs & Holmes, 1999:74).
Decision-making is a process carried out by the nurse (the provider of care), but it is focused on the patient (the recipient of care).In this vein, decision-making forms part of the nurse's daily practice.Therefore, standards for quality clinical decision-m aking can be regarded as practice standards, as they focus on the functions of the provider of care.Practice standards on decision-making in nursing refer to descriptive statements that reflect the minimum expected level of care and that settle disputes about the expected level of performance during a nurse's clinical decision-making.
The importance of quality in health care has become more marked in the past few years.Measures to improve the quality of care, in the context of the reduced availability of health care staff, have led to the questioning o f the accepted boundaries of professional roles.One such role in question is that of the nurse as decision-maker.The need to improve the quality of clinical decision-making in nursing is one of the most serious issues facing present clinical nursing practice.Effective and efficient decision-making practices are emphasized in the White Paper on the Transformation of Public Services (1997) in order to achieve a highly efficient public service, including healthcare services.Decision-making forms an integral part to attain the latter.However, the quality of the decisions taken determine whether an efficient health care service is attainable.The incredible amount of healthcare data, com plex and continuing regulatory changes and, most im portantly, the erosion of public confidence in health care quality require significant action.In this vein, Malloch (1999:1) indicates that selected strategies must address the q u ality control needs and the u n p recedented dem ands placed on health care leaders.This is particularly relevant to the service-delivery point in the healthcare sector, where nurses' clinical decisions have a direct impact on the health status of the patient.Thus, developing quality control programmes that identify, m onitor and document quality outcomes is essential to restore public trust and confidence in healthcare.To do so, a collaborative approach to health care decision-making in general, but to clin ical decision-m ak in g in particular, is required.
C linical decision-m aking is both a cognitive and an affective problem solving activity that focuses on defining p atien t problem s and selectin g appropriate treatm ent interventions (B uckingham & A dam s, 2000:981;Deloughery, 1998:47).In a clinical nursing practice setting, nurses work as members of a healthcare team and must communicate decisions to other members of the multi-disciplinary healthcare team to ensure the co n tin u ity and c o ordination of patient care.Therefore, co operative and collaborative efforts during clinical decision-making should be emphasised and reflected in standards of professional practice in terms of clinical decision-making.
Nurses form the largest proportion of the healthcare delivery resources in the Healthcare sector.They therefore play an important role in the delivery of quality healthcare, in general, and in nursing care, in particular.Quality clinical decision making is an important process through which the nurse delivers nursing care.Q uality clinical decision-m aking in nursing refers to a rational, interactive, co llab o rativ e , co n su ltativ e and scientifically-based process.During this process, nurses m ake goal-directed choices between perceived alternatives, based on their abilities, within a specific context, with the purpose of promoting the health of the individual, group or community.These choices coincide with pred eterm in ed standards (A rries, 2002:308;Noone, 2002:21-22).The quality of decision-making will influence 63

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the quality of the outcome, viz.health prom otion and em powerm ent of the individual, group or community.In addition, not only does the n u rse's quality o f clinical decision-m aking influence the outcome thereof, but it also has fin an c ial im p licatio n s for the institution at large.Furthermore, the nurse, as a so -called independent practitioner, is not only responsible and accountable for quality clinical decision m aking to facilitate quality nursing specifically, but also for quality healthcare in general.The nurse therefore requires practice guidelines on clinical decision making that reflect excellence and are presented in the form of standards and criteria that are user-friendly and realistic.

Problem statement
Clinical decision-making in nursing is regarded as an important activity by the nurse, since a decision is a prerequisite for any significant action by the nurse to care for the patient.However, from unstructured observation by studying the South African Nursing C ouncil's (1993Nursing C ouncil's ( -1998) ) disciplinary reports, the following about nurses' clinical decision making has been observed: (i) an increase in the num ber of disciplinary cases am ong n u rses, and (ii) that these disciplinary cases reflect situations within which the nurse had made decisions to either maintain, restore or promote the health of the patient.It was however concluded from these observations that n u rses' clinical decision-m aking is ineffective, as it does not adhere to the framework of clinical, ethical and legal correctness for any nursing action, including clinical decision-making.
As a possible solution to the afore mentioned problem, practice standards for quality clinical decision-making in nursing are required.The aim of these practice standards should be to evaluate, monitor and remedy actions implemented to improve the quality of clinical decision making, a process nurses follow during patient care.However, there are no such practice standards in the South African context, against which one can evaluate and assess n u rs e s ' q u ality o f clin ical decision-making.

Purpose of the study
The purpose of the study is to formulate practice standards for quality clinical decision-making in nursing.

Definition of terms
Practice standards Practice standards focus on the provider of care (the nurse) and are written about the nursing process.A practice standard on clinical decision-making is a written description about the desired level of performance during clinical decision making that reflects the connotative characteristics associated with excellence for measuring and evaluating the actual quality thereof (M uller in Booyens, 1998:606;Dozier, 1998:23).

Quality
Defining the term quality is almost an impossible task, as it has a multifaceted nature (D avis, 1987in Johnson & McCloskey, 1992:45).For the purposes o f this study, quality is defined as reflecting the characteristics of excellence as described in predetermined standards.

Quality clinical decision-making
Q uality clinical decision-m aking, a cognitive-affective problem -solving activity, refers to the outcomes of rational interactive collaborative and consul tativ e dynam ic p ro b lem -so lv in g processes, in which nurses and members o f the m ultidisciplinary health team engage to define patient problems, to select and im plem ent ap p ro p riate treatm en t in te rv e n tio n s, and to communicate decisions in accordance with predetermined standards to ensure the quality, continuity and coordination of patient care in order to facilitate health (Arries, 2002:308).

Research design and method
A qualitative, explorative, descriptive standard formulation research design (Mouton & Marais, 1990:45-46;Muller, 1990:49-55) has been followed to develop standards for quality clinical decision making in nursing.Standard develop ment requires a unique method.
Standard development was based on the prin cip les described by M uller (in Booyens, 1998:607-608;636-637), and co n sists o f d ev elo p m en t and quantification phases that are modified to meet the requirements, as described by Lynn (1986:382-385), for instrument development.The development phase requires input from expert and grassroot level practitioners.The purpose is to determine what specialists in the various fields of nursing practice regard as good practice.Both inductive and deductive approaches can be employed to achieve the latter and ensure ow nership and trustworthiness of the standards.The quantification phase deals with the formal validation of the draft standard and the evaluation of the level of performance in nursing practice.
The above process o f stan d ard development was modified in this study.The quantification phase was omitted, as the researcher argued that by following the principles of logical deduction and induction, credible and re aso n ab le standards could also be form ulated.Both in d u ctiv e and d ed u c tiv e approaches were followed during this process.See Table 1.
The research was conducted in four phases, namely an empirical phase, a conceptualisation phase, a standard formulation phase and the last phase was the conceptualisation of a system for quality clinical decision-m aking in nursing.These four phases w ill be described in detail below.

Phase 1: empirical phase
To meet the first criterion proposed by Muller (in Booyens, 1998:607), that is, input from expert and grassroot level practitioners, empirical exploration and description of the expectations of the stakeholders in terms of quality clinical decision-making were carried out (see Table 1).To obtain richness in data about the expectations of these stakeholders, a multi-method approach was followed.F ocus group interview s (K reu g er, 1994:39-74;De Vos, 1998:313-324), individual interviews (De Vos, 1998:297-312) and naïve sketches (Giorgi, 1985:10-14) were employed.A non-probability, purposive and convenient sample (Bums & Grove, 2001:374;De Vos, 1998:199) of the stakeholders was conducted.Data was analysed by means o f the open coding approach described by Tesch (Tesch, 1990).To ensure the credibility of the results of the first phase, principles of trustworthiness (Lincoln & Guba, 1986:289-331), viz.p ro lo n g ed engagement, triangulation, co-coding, dense-description, step-wise repetition and an investigative audit, were adhered to.

PHASE FOUR: A system for quality clinical decision-making nursing Research method:
-Conceptualisation -Characteristics of a system according to systems theoretical perspective (Bertallaffny, 1950)

Trustworthiness
Standards of good conceptualisation (FUNDISA, 2000) making was carried out.A purposeful selection (Bums & Grove, 2001:376) of both national and international literature sources, viz.thesauruses, journal articles and subject-specific literature on the themes that emerged from the empirical phase, was conducted.The aim of the literature study was twofold, on the one hand to analyse the concept's quality and clinical decision-making respectively and, secondly, to integrate the results with th ose o f the em p irical phase in a conceptual framework, by employing both inductive and deductive reasoning strategies.
This conceptual framework was used as a deductive guide to form ulate the standards for quality clinical decision m aking in n u rsing.To ensure the trustworthiness of the conceptualisation, principles for credible conceptualisation (F U N D IS A , 2 0 00), to g eth er w ith triangulation and scheduled peer group discussions, were employed.
Phase 3: standard formulation phase D uring the th ird phase, p ractice standards for clinical decision-making in n u rsin g w ere fo rm u lated .The formulation of these practice standards was based on the statements logically derived from the conceptual framework.By employing reasoning strategies of an a ly sis, sy n th esis and inference, practice standards for quality clinical d ecisio n -m ak in g w ere derived inductively and deductively.To ensure the credibility of the standards for clinical decision-making in nursing, principles of log ic, p ro lo n g ed engagem ent, triangulation, peer-group discussion, dense description, step-wise repetition and an investigative audit (Lincoln & Guba, 1985:289-331) were applied.Two experts on standard form ulation in nursing were also consulted during this process.
Phase 4: a system for quality clinical decision-making in nursing Based on the findings of the preceeding phases, a system for quality clinical d ecisio n -m ak in g in nursing was co n c ep tu alised .F igure one is the conceptual presentation of this system (see Figure 1).Before embarking on a description of the standards for quality clinical decision making, a description of the conceptual framework, on which the standards are based, is given.

Quality clinical decision making in nursing
Standards can be derived from different sources based on frameworks as diverse as the nursing process, health care needs, body systems or the process of care.Standard developm ent is based on a conceptual framework of a system for quality clinical decision-m aking in nursing (Figure 1).
Q uality clinical decision-m aking in nursin g occurs in a m u lti-le v el, m u ltid im en sio n al co n tex t.
The multidimensional nature of the context within which clinical decision-making occurs has sev eral u n co n tro lled dimensions that influence the quality thereof.It is therefore important for the nurse to consider these dim ensions during clinical decision-making.The context of quality clinical decision making brings about certain expectations of the stakeholders involved in such a decision.In nursing, stakeholders regard factors such as abilities (knowledge, skills and values) and resources (including both material and human resources) as im portant inputs for quality clinical decision-m aking.These inputs are transformed during the process of clinical decision-making into outcomes, viz. the pro m o tio n o f h ea lth and the empowerment of the individual, group or community.Argumentation, the logic of quality clinical decision-making, requires a rational interactive approach.This im p lies th at the nurse engages in d ialo g u e w ith o th e r ap p ro p riate health care p ro fessio n als through a process of collaboration, consultation and arg u m e n tatio n .
R a tio n a l argumentation refers to a communicative and collaborative process of advancing, supporting, criticising and modifying claims, and the reciprocal statement of argum ents that all stakeholders are capable of understanding so that they may grant or deny adherence (Rossouw, 1993:293).
Through a process of rational interaction, collaboration and consultation, nurses engag e w ith m em bers o f the multidisciplinary health team to define patient problems, select and implement appropriate treatment interventions, and communicate decisions in accordance with predetermined standards to ensure the quality, continuity and coordination of patient care (Arries, 2002:308).The 66

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aim of this interaction is to promote the health o f the in d iv id u a l, g ro u p or community through empowerment.

Practice standards for clinical decision-making in nursing
Practice standards for clinical decision making in nursing will be presented.The nurse, as a provider of healthcare, is an independent practitioner who m akes clinical decisions in collaboration with a multi-professional health team.As a decision-maker, the nurse synthesises theoretical, scientific and contemporary clinical knowledge and experience to assess the health status of the individual, group or community, and to promote their h ea lth and em pow erm en t on the wellness-illness continuum of health.
I have indicated elsewhere in this article that practice standards focus on the nurse as a provider o f nursing care.Therefore, these standards are sometimes referred to as professio n al practice standards.Unlike standards of care that focus on the individual patient and his/ her specific health status, and using an accepted scientifically-based process such as the nursing process to address his/her health problems, standards of p ro fessio n al p ractice re la te to the professional behaviour of the nurse while doing that, and particularly using the process of clinical decision-making.The in ten tio n o f p ro fe ssio n a l p ra c tic e standards on quality clinical decision making is to provide direction for nursing practice regardless of the practice setting.S tandards o f p ro fessio n al p ra ctice usually involve dimensions o f quality of care, performance appraisal, education, co lleg iality , eth ics, c o lla b o ra tio n , research and the utilisation of resources (Childs & Holmes, 1999:74).Practice standards for quality clinical decision making in nursing will be discussed under two main clusters: those that relate to p ro fessio n al p ra c tic e , the c lin ic a l dec isio n -m a k in g p ro cess and empowerm ent as the outcom e o f the latter.The dimensions listed by Child and Holmes (1999:74) are integrated in the aforementioned clusters, for the sake of simplicity and understanding.1.2 Clinical decision-making takes place in the relevant professional practicespecific framework of nursing practice: The nurse: 1 .2.1 dem onstrates insight and can describe relevant legislation, standards, policies and procedures that affect his/ her clinical decisions as a nurse; 1.2 .2demonstrates responsibility and accountability for own clinical decisions and professional conduct; 1.2.3 dem onstrates a commitment to ethical practice and a responsible attitude towards patients/families/members of the multidisciplinary team; 1.2.4 maintains current registration as a nurse; 1.2.5 practises clinical decision-making w ithin his/her own level of clinical competence; 1 .2 .6 m eets the req u irem en ts for continuing clinical com petence with regard to clinical decision-making and nursing practice, including investing own time, effort or other resources to meet identified learning outcomes; 1.2.7 m ain tain s ow n p hysical, psychological and emotional fitness for nursing practice; 1.2 .8continually identifies, monitors, and documents evidence of clinical decision making practice accurately and legally in relation to legislation and policies; 1.2.9 continuously refines and adapts practices of clinical decision-making to conform to legislation, standards and policies; and 1 .2 . 1 0 identifies and understands the legal-ethical and clinical implications of his/her clinical decisions.
1.3 T he nurse ap p lies relev an t professional ethics and philosophical frameworks to clinical decision-making.The nurse: 1.3.1 describes the ethical standards estab lish ed by the resp ectiv e professional or registering body relevant to clinical decision-making; 1.3.2upholds the values contained in the South African Nursing Council (SANC) Code of Ethics, namely safe, competent and eth ica l care, ch o ice, dignity, confidentiality, justice, accountability and quality practice environment; 1.3.3consistently demonstrates ethical attitudes, values and behaviours that are conducive to ethical clinical decision making and practice; 1.3.4consistently practises according to the responsibility and accountability statements in the SANC Code of ethics; 1.3.5 identifies key strategies to resolve ethical dilemmas arising from clinical decisions; 1.3.6 critically reflects on the morality of clinical decisions and incorporates current evidence on moral reasoning in clinical decision-making; 1.3.7 is com m itted to h is/h er own professional development as a clinical decision-maker; and 1.3.8dem onstrates a com m itm ent to confidentiality and respect for diversity.
1.4 The clinical context (micro-context) is conducive to rational interaction during clinical decision-making.1.4.1 The nurse understands the context and system s in w hich healthcare is provided, and applies this knowledge to optimise healthcare.1.4.2The organisational structure, culture and climate are conducive to rational, interactive and collaborative clinical decision-making.1.4.3There is evidence of applicable c o lla b o ra tio n , c o n su lta tio n and cooperation am ong m em bers o f the multidisciplinary health team.1.4.4There is evidence of continuous em pow erm ent strategies to develop nursing staff's clinical decision-making competencies.1.4.5There is evidence o f w ritten, re lev an t and u p -to -d a te po licies, guidelines, protocols and procedures that guide clinical decision-making.1.4.6 T he nurse re co g n ises the interdependence between diverse care pro v id ers w hile u n d ersta n d in g the limitations and opportunities inherent in complex systems.1.4.7There is evidence of cost-effective strategies that ensure the availability of relevant resources to enhance the quality of clinical decision-making.1.4.8The nurse considers factors related to safety, effectiveness and cost in planning and clinical decision-making.
1.5 The nurse demonstrates appropriate and relevant clinical co m p eten cies (specialised body of knowledge, skills and values) and utilises evidence from nursing science and the humanities to make clinical decisions..The nurse: 1.5.1 knows how and w here to find relevant evidence to support the making of safe, appropriate and ethical clinical decisions; 1.5.2 interprets and uses current evidence from research and other credible sources to make clinical decisions; 1.5.3 understands and com m unicates nursing contribution to clinical decision making in health care practice; 1.5.4 shares nursing knowledge about clinical decision-making with patients, colleagues, students and others; 1.5.5 uses re la tio n s h ip and communication theories appropriate in interaction with colleagues, patients and others; and 1.5.6 interprets and uses current evidence from research and other credible sources to make clinical decisions.

Clinical decision-making
R ational clinical decision-m aking is believed to refer to an interactive process o f assessm ent, diagnosis, p lan n in g , implementation and evaluation.

(i) Assessment
2.1.The nurse performs a comprehensive fu n c tio n a l, re lev an t and h o lis tic assessment using a developmental, bio p sy ch o -so cial ap p ro ach , as the framework for understanding the nature of health problems patients present with.
The nurse: 2 .1.1 obtains and accurately documents a relevant, comprehensive and problemfocused health history, considering both bio-psycho-social and cultural changes; 2 .1.2 assesses the dynamic interaction between the current complaint and the known acute/ chronic health problems, in accordance with developmental status; 2.1.3performs and accurately documents a comprehensive and problem-focused physical examination, considering both bio-psycho-social and cultural changes; 2.1.4assesses and accurately documents relevant, comprehensive and problemfocused laboratory and diagnostic data, co nsidering b io -p sy ch o -so cial and cultural changes; 2.1.5performs appropriate screening evaluations that are age, gender and development specific (including mental health, su b stan ce abuse, v io len ce, behaviour, speech/language develop ment, learning disabilities, etc.); 2 .1.6analyses the multiple effects of pharmacological agents, including home made rem edies and shop-purchased preparations, relating to the individual/ group/community with health problems; 2.1.7performs and accurately assesses and docum ents the im pact o f the environment on the health status of the individual, group, family or community, co nsidering b io -p sy ch o -so cial and cultural changes; 2 .1.8identifies health and bio-psychosocial and environmental risk factors for the individual, group or com m unity (including developmental level, risktaking behaviour, nutritional status, environmental factors, family issues, social support and immunisation status); 2.1.9analyses roles, tasks and stressors of fo rm al/in fo rm al system s/fam ily caregivers for the individual, particularly for vulnerable and frail groups; 2 . 1 .1 0 discriminates between multiple potential mechanisms causing signs and symptoms of health problems commonly diagnosed in the in d ividual/group/ community; and 2 .1.11analyses and synthesises the data collected to determine the health status of the individual/group/community.(iv) Implementation 2.4 The nurse implements the identified plan of care in a legal-ethical, clinically correct and culturally congruent manner: 2.4.1 The nurse co-ordinates the delivery of care by: 2.4.1.1 employing strategies to promote the health and safety of the environment; 2.4.1.2providing leadership in c o ordination with multidisciplinary health teams for delivering an integrated patient care service.2.4.1.3synthesising data and information to advocate the necessary system and community support measures, including environmental modifications; and 2.4.1.4coordinating resources to enhance the d eliv ery o f care across the multidisciplinary healthcare continuum.

2.4.2
The nurse collaborates with other members of the multidisciplinary health team/patients/families in the identified plan of care, to enhance the abilities of others and to affect change by: 2.4.2.1 functioning as a member of the multidisciplinary health team to provide nursing expertise; 2.4.2.2 integrating the treatment plan with the goals of the multidisciplinary health team; 2.4.2.3 maintaining responsibility for the more specialised health treatment plan goals and communicating these goals to the rest of the multidisciplinary health team: 2 .4.2.4sy nthesising clin ical data, experience and theoretical frameworks and evidence w hen providing consultation; 2 .4.2 .5 facilitating the effectiveness of co n su ltatio n and co llab o ratio n by involving the relevant stakeholders in decision-making and negotiating role responsibilities; 2.4.2.6 communicating consultation and collaborative recom m endations that influence the identified plan, facilitating understanding among stakeholders, en h an cin g the work o f others and affecting change; 2 .4.2.7 co llab o ratin g w ith nursing co llea g u es and o ther health care personnel to implement the care plan, if appropriate; 2.4.2.8 supporting collaboration with nursing colleagues and other members of the health team to implement the plan of care; 2 .4.2.9estab lish in g and sustaining th era p eu tic and e th ic a lly sound relationships with patients/fam ilies/ members of the multidisciplinary health team; 2.4.2.10 advocating and developing policies that clearly outline responsibility and accountability for everyone involved in clinical decision-making; and 2.4.2.11 communicating, collaborating and consulting with registered nurses and other members of the healthcare team ab out the p ro v isio n o f health care services.

2.4.3
The nurse consults with other members of the multidisciplinary health team during the identified plan of care to enhance the abilities of others and to effect change by: 2.4.

(v) Evaluation
2.5 The nurse evaluates progress in the attainment of outcomes by: 2.5.1 conducting a systematic, ongoing and criterion-based evaluation; 2.5.2 systematically evaluating outcomes in relation to the structure and processes prescribed by the plan; 2.5.3 including the individual, group or community involved in the care/situation in the evaluative process; 2.5.4 using ongoing assessment data to revise the diagnosis, the outcomes and the plan, as needed; 2.5.5 evaluating the effectiveness of the planned strategies in relation to patient responses and the attainm ent of the expected outcome; 2.5.6 documenting and disseminating, as appropriate, the results of the evaluation, including any need for managerial action; 2.5.7 evaluating the accuracy of the diagnosis and the effectiveness of the interventions in relation to the patient's attainment of the expected outcome; 2.5.8 synthesising the results o f the evaluation analyses to determ ine the im pact o f the plan on the affected individual, group or community; and 2.5.9 using the results of the evaluation analyses to make recommendations to process or structure changes, including policy, p ro ced u re or p ro to co l documentation, as appropriate.

Outcome: empowerment
3.1 There is written evidence that clinical decision-making in nursing facilitates the empowerment of the individual, group or community, as measured by the following criteria: 3.1.1Individuals, groups or communities are able to make inform ed decisions about id en tify in g and p rio ritis in g problems that affect them.

Critique of the standards
D eveloping stan d ard s re q u ire s a structured approach that can incorporate either an em pirical or a n o rm ativ e approach.

Empirical approach
The empirical approach, also called the inductive approach, requires a survey of w hat is currently regarded as good practice in similar circumstances (Muller, 2002:206).To achieve these criteria, the expectations of stakeholders in terms of q uality clinical d ecisio n -m ak in g in nursing were explored and described.Based on these results, principles for standard formulation were generated by using the in d u ctiv e and d ed u c tiv e re aso n in g strateg ie s o f an a ly sis, synthesis and inference.

Normative approach
In the normative approach, the objective is to determine what specialists in the various fields regard as good practice (Muller, 2002:206).In other words, what ought to happen during clinical decision making.These criteria were met by conducting a literature study on clinical decision-making, i.e. structure, process and outcome.Again, based on these results, p rin cip les for standard formulation were generated using the inductive and ded u ctive reasoning strategies o f analysis, synthesis and inference.
In following the two above processes, it was ensured that reasonable standards were fo rm u lated based on w hat is considered to be "right" inside and outside nursing.A conceptual framework was thus constructed, based on the results of the empirical and normative approaches.The general value system, as set out in the philosophical, legal and ethical framework of nursing, also gives direction to what could be considered to be right and wrong during clinical decision-making.
Standards for quality clinical decision making met the following criteria.They are realistic, understandable, manageable and achievable.

Realistic standards
The standards are realistic as they were inferred from both em p irical and conceptual data.Consensus discussion with two experts on standard formulation confirms the realistic nature of these standards.

Understandable, manageable and achievable standards
The standards are understandable, as they are written in a language known to local nurses in the country.During the literature study phase it was ensured that language and nuances in meaning were overcome through the re-interpretation of the structure, process and outcome of clinical decision-making as it operates within nursing.Thirty-six standards for quality clinical decision-making in nursing were initially form ulated (A rries, 2002:327-354).Follow ing the recom m endations of experts on standard formulation, and considering the criteria of manageability and achievability, these standards were re-organised and categorised.The thirtysix standards were reduced to twelve standard statements, each with its own criteria for measurement.

Conclusion and recommendations
Practice standards for quality clinical d ecisio n -m ak in g in nursing w ere developed.These standards were based on the expectations o f stakeholders regarding quality clinical decision m aking in nursing and an in-depth literature study.In employing the rules of inductive and deductive logic, it is believed that reasonable standards of trustworthiness, based on the empirical findings o f the ex p ectatio n s o f stakeholders and the conceptualisation o f clin ical decisio n -m ak in g , w ere developed.The following recommen dations on how these standards could be used to guide clinical decision-making in nursing are made: Phase 2: conceptualisation phase During the conceptualisation phase, a concept analysis (W alker & Avant, 1995:390) on quality clinical decision-64 Curationis March 2006

Figure 1 :
Figure 1: A System for quality decision-making in Nursing (i) Nursing practice (a) Standards for quality clinical decision making could be utilised as a foundation fo r in terd iscip lin ary and interinstitutional consensus building.(b) By defining the scope of clinical d ecisio n -m ak in g for nurses, these standards could be u tilised as an infrastructure for the development of in stitu tio n al standards o f care and guidelines.(c) Using these standards to link key concepts such as clinical decision making, the contextual dimension thereof, ethics and empowerment outcomes could be utilised as a foundation to reduce fragmentation.(ii) Nursing education, management and research (a) By defining the scope of clinical decision-making, these standards could be utilised as an infrastructure for the co m p eten cy -b ased education p ro grammes; (b) The standards can be utilised to develop educational sessions and for curriculum development emphasising com petencies for clinical decision making in nursing.(c) These standards can be utilised to plan, organise, and evaluate clinical decision-making practices in nursing.(d) Lastly, these standards can be utilise to evaluate and enhance m ultidisci plinary collaboration during clinical d ecision-m aking am ong healthcare professionals.standards: Linking care, competence, and quality.Journal of Nursing Care Quality.12(4): 22-29.F U N D IS A , 20 0 0: (U npublished).Standards for good conceptualisation in research.Johannesburg: Department of Nursing Science.G IE R E , R M 1984: U ndertsanding scientific reasoning.Second edition.New York: Holt, Rhinehart and Winston.G IO R G I, A 1985: Phenomenology and psychological research.Pittsburgh: Duquesne University Press.JOHN SON , M & M CCLOSKEY, JC 1992: The delivery of quality health care.Series on Nursing Administration, 3. St Louis: Mosby Year Book.KRUEGER, R A 1994: Focus groups: A practical guide for applied research.S econd e d itio n .L ondon: Sage Publication.LIN CO LN , YS & GUBA, EG 1985: Naturalistic inquiry.New York: Sage.LYNN, NR 1986: Determination and q u a n tific a tio n o f co n ten t validity.Nursing Research.35(6): 382-385.M ALLOCH, K 1999: The performance measurement matrix: A framework to optimise decision-making.Journal o f Nursing Care Quality.13(3): 1-12.M ORGAN, LD 1998: Planning focus groups.London: SAGE Publication.M OUTON, J & MARAIS, H C 1990 : M etodologie v ir die geestesw etenskappe: Basiese begrippe.Pretoria: Raad vir Geesteswetenskaplike Navorsing.M O U T O N , J 1996: U nderstanding social research.Pretoria: Van Schaik.M ULLER, M 1990: Navorsingsmetodo lo g ie v ir die fo rm u lerin g van verpleegstandaarde.Curationis.13(3 & 4): 49-55.M ULLER, M 2002 : Nursing dynamics.Third edition.Sandown: Heinemann.NOONE, J 2002: Concept analysis of d ecisio n -m ak in g .N u rs in g F o ru m , 37(3):21-32.PATTERSON, C 1988: Standards for patient care: The Joint Commission focus on nursing quality assurance.Nursing Clinics of North America.23:625-638.SOUTH AFRICA (REPUBLIC) 1997: White Paper on the transformation of public service delivery (Batho Pele).Notice 1459 of 1997: Pretoria: State Press.ROSSOUW, G J 1993: Moral decision making amidst moral dissensus: A post m odern approach to moral decision making in business.Koers.58(3): 283-298.S O U T H A F R IC A N N U R S IN G C O U N C IL 2004: D raft C harter for Nursing Practice.Pretoria: SANC.S O U T H A F R IC A N N U R S IN G C O U N C IL 1993-1998: Disciplinary reports.Pretoria: SANC TESC H , R 1990: Qualitative research: Analysis types and software tools.New York: The Falmer Press.VAN VEUREN, P 1993: Kritiese denke as opvoedkundige im peratief.K oers.58(3):273-282.W ALKER, LO & AVANT, K C 1995: Strategies for theory construction in n ursing.T h ird e d itio n .N orw alk: Appleton & Lange.