Shared Decision Making Article Number 2:
"Understanding your limitations"
The first in the series of the articles on decision making ended with this passage;
“The next step in moving into the next phase of better decision making is to understand your
own limitations (gulp). This doesn’t mean you lack competence or ability, but it is something
that you can rely upon to make your practice safe…”
What do we mean by understanding your own limitations?
In the first article we looked at the use of experience and intuition, and how it is vital that you
can (where practical) process and challenge everything you decide to do for your patient, and
by ensuring you can appropriately identify features - such as signs and symptoms - that drive
your decision making (Welsh & Lyon, 2001). From these cues, you will be able to more
effectively and safely derive your actions through rational assessment and processing. Part
of this requires you to be aware of what you know about the elements upon which you make
decisions.
Reflecting on the first article, as well as other reading you may have done; how has this
changed the way you process data, and have you started to challenge things you previous
thought you knew? Maybe you already knew them, but didn’t know why you knew them.
Either way, hopefully you have started to consider differently the way you think, and that this
new insight has changed your practice in a positive way. If it has, let us know by emailing
[email protected]
Hopefully this does not prevent you from practicing confidently – particularly in the high-acuity
setting, where we know that experience appropriately drives your actions (King and Clark,
2002). If you are considering more carefully how you make decisions, you are most likely
making better decisions for your patients, particularly decisions to convey, refer, or discharge
– particularly if you are sharing more decisions and learning from each experience.
Building on this, if you have started to challenge yourself, and you now question what you
thought you always knew, you have already developed an awareness of your own limitations.
This may lead to you becoming more sceptical about what you believe, and this is described
by Cottrell (2011) as keeping an open mind, and thinking more critically. Remember the
(slightly exaggerated) exercise in the first article about identifying the animal as a cat. It was
always a cat, but you were asked to analyse why you believed it was and were able to use
rational thought to arrive at the decision, based on your experience. Ennis suggests that
sceptical reflection and reasoned thought are the two main components of critical thinking
(1987), and the following quote highlights the importance of understanding your own level of
knowledge;
“..scepticism doesn’t mean you must go through life never believing anything you hear and
see. That would not be helpful. It does mean holding open the possibility that what you know
at any given time may be only part of the picture”. (Ennis, Citing Baron & Sternberg, 1987 p2)
Therefore, and considering the points made so far, limitations are not a negative thing in any
way; they are opportunities to inform your own professional development and allow you to
continually improve your knowledge, skills and ability in practice for your patients.
Using enquiry, and sharing your decisions, will speed up the process of learning and give
more satisfaction in practice. Remember that Benner describes five stages on the journey
from novice to expert; Novice, Advanced Beginner, Competent, Proficient, and Expert (1984).
The more insight you have, the more you will be able to recognise where you need
development or support. None of these things should be perceived as diminishing your
ability, and you should assume Benners level of “competent” from an early stage in your
career, whilst aspiring to continually improve.
Consider the journey for paramedics who become students studying for a specialist practice
award. They will realise that in the new areas of study, they return to the level of novice,
despite being very experienced paramedics. Also, practice does not stand still and the
conditions that patients present with are very different compared to twenty years ago, and will
change further as the population ages and becomes more comorbid. The limitations of your
knowledge and skills will change as practice and patient demand changes. It is an excellent
opportunity to drive CPD and to increase your job satisfaction.
The technical term for the science of knowledge or understanding is epistemology, which is a
complex area of study. There is a simplified model you can use which helps break down the
understanding of one’s knowledge, and is particularly useful in clinical practice. The four
statements (below) highlight how those with good levels of insight into their practice can
consider their limitations. Think about each statement and try to think of an example for each.

“I know what I know”

“I don’t know what I know”

“I know what I don’t know”

“I don’t know what I don’t know”
Let’s look at these in more detail and consider some examples in practice which may help to
explain how these four statements affect us all in our professional lives. It is so important to
not consider any gaps in knowledge as negative, and instead use them to build your
continuous professional development around, and also to encourage you to learn through
shared decision making.
I know what I know
“I know that a shortened and rotated leg is a good clinical
indicator of a fractured neck of femur in the elderly faller.”
I know what I don’t know
“I do not know all of the common childhood illnesses which
cause reddening of the cheeks.”
“It turns out I did know that ECG showed a 3rd Degree heart
I don’t know what I know
block. My mentor coached me to demonstrate my
knowledge.”
“I didn’t know that a blood glucose of 3.7 mmol’s should be
I don’t know what I don’t know
considered significant in the diabetic patient who is
asymptomatic. I usually discharge patients rather than refer
them to their GP”
It is usually the case that you find out what you “didn’t know you didn’t know” until it’s too late,
and this supports the importance of reflective practice. Also, it is worth noting and considering
how these principles fit with the shared decision making model in general, and how you can
convert as much of your practice away from not knowing what you don’t know, and creating
as many of the things you know you know (or know you don’t know).
In summary, the limitations you identify in your knowledge and ability are a natural
progression for all clinicians, and are part of your ongoing professional development. All
opportunities to learn should be embraced and the way you are being encouraged to share
your decision making will make your practice safer. Safe practice means that patients are
safer, and will also reduce the times where your practice is subject to scrutiny. As you
encounter more things you don’t know, you will have greater opportunity to learn and
consolidate your skills. Being able to convey, refer and discharge correctly for all your
patients is such a vital part of practice for SECAmb staff, doing it safely and in a supported
environment which drives learning can only be positive. We said limitations weren’t
negatives, didn’t we!
References

Benner, P (1984). From Novice to Expert. Menlo Park, CA: Addison-Wesley

Ennis, RH. (1987). ‘A Taxonomy of Critical Thinking Dispositions and Abilities’ In J. Baron and R. Sternberg (eds), Teaching Thinking
Skills: Theory and Practice (New York: WH. Freeman)

King, l; Clark, JM. (2002). Intuition and the Development of Expertise in Surgical Ward and Intensive Care Nurses. Journal of
Advanced Nursing. 2002 (37).

Welsh, I; Lyons, CM. (2001). Evidence-Based Care and the Case for Intuitive and Tacit Knowledge in Clinical Assessment and
Decision making in Mental Health Nursing Practice: an Empirical Contribution to the Debate. Journal of Psychiatric and Mental health
Nursing. 2001 (8), 299-305.