Chapter 3: Theme of Practice: Clinical Knowledge and Decision-Making

INTRODUCTION

THE IMPORTANCE OF CLINICAL KNOWLEDGE AND DECISION-MAKING

It was not surprising that clinical knowledge and decision-making was a theme found throughout the narratives of clinicians in Nursing and Patient Care Services. Clinicians care for acutely ill patients utilizing cutting-edge technology, complex treatment, and therapies on a daily basis. The patients require clinicians whose practice is current and evidence based and who are able to synthesize large amounts of knowledge.

The theoretical foundation for the Clinical Recognition Program at Massachusetts General Hospital is the Dreyfus brothers’ work on skill acquisition (Dreyfus & Dreyfus, 1986). As described in Chapter 1, skill acquisition is the development of skilled “know-how.” Skilled know-how is essential in any practice discipline. It is what enables a clinician to deliver care to a patient, titrate a medication, or know when a patient is ready for the next step in his or her recovery. Skilled know-how is not innate; it has to be learned through trial and error or guided by someone with experience. Clinicians acquire and maintain skilled know-how through practice. Clinical practice requires both theoretical “knowing that” and experiential “knowing how.”

The knowledge that new clinicians bring as they begin their careers comes mostly from textbooks and lectures, as well as limited exposure to patients. This knowledge enables them to order and structure their clinical assignments and to pass licensing exams. But when these new clinicians gain exposure to the realities of practice, they often feel unprepared and overwhelmed. For experienced clinicians, theoretical knowledge is informed by their involvement in the care of patients and families.

Narratives—Entry Level of Practice

The narratives of clinicians at the advanced beginner or Entry level of practice reflect the work of integrating theoretical knowledge with the actual experience of caring for patients. At this stage narratives often read like a list of tasks and procedures that were accomplished without a true understanding of the “big picture.”

Narratives—Clinician Level of Practice

With continued experience the clinician develops a mastery of the technical skills and becomes increasingly aware of similarities in the patient’s condition and responses, which allow the clinician to anticipate and plan. Narratives at this stage reflect greater understanding of the patients’ condition as well as the limitations clinicians recognize in their own skill, knowledge, and ability.

Narratives—Advanced Clinician Level ...