Clinical decision-making skills have been included as an integral part of nursing education curricula for many years in the form of the Nursing Process. However, the changing health care structure has placed ever-increasing demands upon nurses for the use of group decision-making skills and interdisciplinary collaboration. Jenkins (1985? suggests that explicit decision-making language be incorporated into course assignments to build upon the theoretical base of the nursing process. An interdisciplinary group decision-making framework, with experience in its use, will further prepare student nurses for health care delivery challenges. Guided Design (Wales & Nardi, 1984; Wales & Stager, 1977) provides such a framework. This article is a report on the use of Guided Design projects developed, tested and used over the last two years. These projects were incorporated into a third semester baccalaureate nursing role class. The 12-hour unit combines learning objectives for group dynamics observations and group decision-making skills. The unit was designed to provide students with experience in the basic skills of observing group dynamics and participating in the decisionmaking process. As knowledge in the health care field expands geometrically while curriculum delivery time contracts in schools of nursing, the need for teaching processes such as these seems critical.
Guided Design, a strategy for teaching decision making, has been used extensively in many disciplines and includes numerous nursing applications (Hageman, 1979; Selby, 1985; Wales & Nardi, 1984; Wales & Stager, 1977). It allows for easy transfer of the nursing process theoretical framework as students move through the curriculum toward complex group management decisions. These often require interdisciplinary approaches to open-ended problems which have a variety of viable solutions. The Guided Design technique lends itself well to this sort of logical learning sequence and provides practice in group decision making. The steps used to identify the components of a problem, specify the constraints, and the who, what, when, where, why and how questions of the analysis and information gathering steps are especially helpful. The Guided Design process can be used to model the steps required to solve problems, to find the cause of problems or to anticipate potential problems (Wales & Nardi, 1984). Guided Design provides an anatomy of the decision-making process for the learner. It is organized in a written instruction/feedback format. It can take several small groups of students through the decision-making process steps simultaneously at their individual group pace. The instructor feedback is used as a guide, but innovative solutions are encouraged throughout the process with the recognition that there are many possible solutions to complex and multifaceted problems. Student creativity in the decision-making process is encouraged.
Two Guided Design projects were developed by the author. The first, "Dysfunctional Anxiety of Clinical Nursing Students" (Wold, 1984), utilized the findthe-cause decision-making process. The students were asked to project themselves into the role of an ad hoc committee of nursing service personnel and clinical faculty members tasked with investigating the cause of excessive anxiety of students doing their clinical practicum on an acute hospital medical/surgical ward. Concern had been expressed over its effect on patient care, student education and the response of hospital staff members to the clinical affiliâtes. The content was familiar to the students since they had just completed their first acute hospital care clinical experience the previous semester. An unanticipated outcome of the project was the relief expressed by the students at venting their frustrations from the earlier hospital experiences.
The second project, "Ethical Dilemmas in Nursing Management of Ambulatory Alzheimer's Victims in a Skilled Care Facility," was also within familiar territory for the students. Their clinical experiences with introductory nursing care skills and gerontology theory had taken place in skilled care facilities. In this project, they were asked to project themselves into the role of nursing service personnel who were involved with administering the three shifts in the skilled care facility. The group used a solve decision-making process to address the ethical, staff and institutional dilemmas resulting from problematic behaviors of two ambulatory Alzheimer's patients in the facility. The content of both projects was interesting to the students and involved familiar enough situations to allow the students to focus on the process as they used decision-making steps to create their own solutions.
One problem experienced in the initial field testing of the projects needed a solution. The ideal group size for Guided Design projects is five or six students (Wales & Stager, 1977, p. 69). The 40member class was divided into eight groups, but that proved to be an exhausting number of groups for the instructor who had to circulate while they worked through the projects.
The viewing of videotapes used to field test the projects prompted the idea of using the groups "in action" for simultaneous guided group dynamics observations. The group process was very visible on the tapes. The following unit effectively reduced the number of groups in each class session to four.
The first six hours of a 12-hour unit on group dynamics and group decision making was used to present theory and language for the experiential learning that followed. It was accomplished by lecturediscussion, appropriate reading assignments, and explanations of Guided Design and decision-making processes.
Once grounded in theory and language, the 40-member class was divided into two sub-groups of 20 each. The sub-groups were further divided into small groups of five students. Half of the class worked on the first Guided Design project in their small groups. The remaining students did guided group dynamics observations on their classmates. During the next two-hour class session, they alternated activities using the second Guided Design project. This exposed all students to two decision-making processes in slow motion - one observational and one experiential.
The unit evaluation methods included a small group grade on the synthesis and evaluation outlines of their Guided Design decisions, an individual grade on a paper detailing their group dynamics observations and questions on a final test in the course.
Student Evaluation of the Unit
The students generally responded very positively to these experiences. Ninety-five percent of the 160 students from four classes recommended that the projects be used in future classes to model and teach the decision-making process rather than simply presenting theory. Typical written evaluation comments were:
This was a very helpful experience. It allowed me to experience the decisionmaking process rather than just learn the theory.
This experience made the decisionmaking process very clear.
It was very helpful to actually do it instead of simply learning the theory.
Negative comments related to the length of the original project which included both a cause and temporary solution. This was modified for subsequent classes. Two projects, covering two 2-hour class periods, were used. Classroom noise levels bothered six of the students doing observations.
The Guided Design experience gives students excellent grounding in the decisionmaking process and knowledge of a decision-making language that will serve them well in all group decision-making contexts. The detailed component analysis, constraint identifications and the who, what, when, where, why and how questions applied to information gathering and analysis are simple terms, easily understood. The steps are applicable to problems needing a cause identification, solve process, and for anticipating potential problems.
The process can be taught early in the curriculum and utilized throughout with special re-emphasis in leadership and management classes. The strength of the described unit bee in the provision of an introductory, nonthreatening classroom opportunity for practice in the use of decision-making language and an experience with the process using familiar content. The students experience the complexity of group decision making and the interesting variety of solutions possible for each complex problem.
Like the Guided Design process, tbe projects used are improved with each successive experience. Student and colleague feedback provides the challenge.
- Hageman, V. & Wales, S. (1979). Guided design systems approach in nursing education. Journal of Nursing Education, 18(3), 38-45.
- Jenkins, H. M. (1985). Improved clinical decision making in nursing. Journal of Nursing Education, 24(6), 242-243.
- Sampson, E. & Marthas, M. (1981). Group Process for the Health Professionals (2nd ed.). New York: John Wiley & Sons.
- Selby, M. L. (1985). Teaching nursing research by Guided Design: A pilot study. Journal of Nursing Education, 2416), 250-252.
- Wales, C.E. (1984, January). Decision-making skills in the curriculum. Faculty Development Workshop, California State University at Chico, Chico. Ca.
- Wales, C.E. & Nardi, A. (1984). Successful Decision-Making. Morgantown: West Virginia University, Center for Guided Design.
- Wales, C.E. & Stager, R. A. (1977). Guided Design. Morgan town, West Virginia: Charles E. Wales, West Vii^inia University.
- Wfold, J.E. (1984, October». Dysfunctional anxiety levels of clinical nursing students. Paper presented at the meeting of the International Society for Individualized Instruction, Atlanta, Ga.