This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Thinking like a nurse: a research-based model of clinical judgment in nursing.

Aims and objectives.  The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model.

Background.  Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition.

Design.  Literature review.

Methods.  Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005.

Results.  The characteristics of the three models of decision making were identified and the related research discussed.

Conclusions.  Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed.

Relevance to clinical practice.  It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

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A review of clinical decision making: models and current research

Aim. The purpose of this paper is to analyse and evaluate Cognitive Continuum Theory and to provide evidence for its relevance to nurses' decision-making. Background. It is critical that theories used in nursing are evaluated to provide an understanding of their aims, concepts and usefulness. With the advent of evidence-based care, theories on decision-making have acquired increased significance. Method. The criteria identified by Fawcett's framework has been used to analyse and evaluate Hammond's Cognitive Continuum Theory. Findings. There is empirical evidence to support many of the concepts and propositions of Cognitive Continuum Theory. The theory has been applied to the decision-making process of many professionals, including medical practitioners and nurses. Existing evidence suggests that Cognitive Continuum Theory can provide the framework to explain decision-making in nursing. Conclusion. Cognitive Continuum Theory has the potential to make major contributions towards understanding the decision-making process of nurses in the clinical environment. Knowledge of the theory in nursing practice has become crucial. © 2005 Blackwell Publishing Ltd.

Cognitive Continuum Theory in nursing decision-making

This study investigated how fourth-year nursing students learned clinical decision making Seventeen fourth-year nursing students between ages 21 and 37, who were completing their last semester of a baccalaureate nursing program, were interviewed A research team using a modified seven-step process developed by Diekelmann and Allen analyzed the data Five themes or essential components associated with learning clinical decision making were identified, including gaining confidence in their skills, building relationships with staff, connecting with patients, gaining comfort in self as a nurse, and understanding the clinical picture

Clinical Decision Making Among Fourth-Year Nursing Students: An Interpretive Study

Background. This article describes the results of a study which investigated the contextual factors influencing clinical decision-making. Education and experience have been suggested by some as having a positive effect on clinical decision-making, and have been listed as being of high importance. Values, knowledge, clinical setting and stress have also been identified as being important to decision-making, with various rankings given by different researchers.

Aim.  The study was undertaken to determine relationships between occupational orientation (value to role), educational level, experience, area of practice, level of appointment, age and clinical decision-making in Australian nurses. The predictive ability of each factor on clinical decision-making was determined.

Method.  This correlational study examined Australian nurses’ decision-making about some common nursing interventions and ‘occupational orientation’, educational level, experience, level of appointment, area of clinical speciality and age. A model was constructed using stepwise selection regression to predict the ‘weight’ of each variable in clinical decision-making.

Results.  Education and experience were not significantly related to decision-making. The factor that accounted for the greatest variability to clinical decision-making was holding a professional occupational orientation, followed by level of appointment, area of clinical speciality, and age in that order.

Conclusion.  In contrast to other studies, experience and educational level were not found to influence decision-making strongly, the value of role was the most significant predictor. The model developed, however, only accounted for a low amount of variability in decision-making. The findings indicate that there are other factors affecting clinical decision-making that still require identification.

Decision-making in clinical nursing: investigating contributing factors

Purpose: To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making.

Method and Samples: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States.

Findings: Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented.

Conclusions: The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.

Sirkka-Liisa Ekman

Papers

An exploratory study of clinical decision-making in five countries.