Education for clinical decision making in midwifery practice Jane Cioffi Objective: to present an approach to developing clinical decision-making skills in midwifery students. Description: use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced midwives are proposed for developing clinical-reasoning skills and acquiring skilled clinical knowledge. Implications: educators are encouraged to recognise that skill acquisition in clinical decision making requires practise before students engage fully in the clinical setting. The process of decision making is emphasised as essential for students to experience so they develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information to reach clinical judgements. By using clinical simulations developed from 'real cases' the process of decision making is able to be experienced by students. Further, if these simulations are accompanied by the collection of verbal protocols, students have opportunities to retrospectively explore their decision making with reflection. In addition, the presentation and use of decision rules of experienced midwives has the potential to enhance the development of skills in students. Jane Cioffi BApp Sc, PGDipEd, MAppSci, PhD, Lecturer, School of Health, Faculty of Health, Humanities and Social Ecology, University of Western Sydney, Hawkesbury, Bourke Street, Richmond 2753, Australia Manuscript accepted 23 September 1997 INTRODUCTION Midwifery practice involves clinical judgements that often have to be made within a short span of time and have major implications for the well-being of the mother and baby. Clinical judgements are dependent on the knowledge and experiences of midwives, and are part of the decision-making process. Such judge- ments are made after client/patient information is gathered and evaluated (White et al 1992). A challenge that faces educators is how to prepare students to become competent decision makers for safe and effective midwifery practice. Hence, teach- ing strategies that develop clinical decision-making skills are crucial. In this paper, the perspective of skill acquisition from the domains of cognitive psychology and artificial intelligence (e.g. Anderson 1987a, 1987b, Benfer et al 1991) are applied to the development of skilled clinical knowledge critical to quality decision making in student midwives. Use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced midwives are proposed for developing clinical-reasoning skills and acquiring skilled clinical knowledge essential for decision making. SKILLED CLINICAL KNOWLEDGE AND ITS DEVELOPMENT In general nursing practice, skilled clinical know- ledge is recognised by Corcoran et al (1988) to be the unwritten practical knowledge and 'rules of thumb' that are not sytematically described, yet are a major part of the knowledge base and decision-mak- ing abilities that nurses need to function effectively. Seldom is the use of this 'skilled' knowledge, held in the clinical decisions of general nursing practice, shared with students. In midwifery practice, a simi- lar situation can be considered to exist. A student midwife comes to the clinical situation with theoretical knowledge acquired through sys- tematic study. This is declarative knowledge and includes the content knowledge of the midwifery domain; that is, facts, concepts and their various relationships (Benfer et al 1991). Such 'textbook' knowledge is essential to practice, as is procedural knowledge, which is intrinsic to processing informa- tion (Evans 1989). Procedural knowledge encom- passes practical expertise and skills providing deci- sion-making strategies that take account of, and show sensitivity to, a multiplicity of situational vari- Midwifery(J998) 14, 18-22 © 1998 Harcourt Brace & Co. Ltd