Thompson, C.

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This is a repository copy of Clinical decision making in nursing: theoretical perspectives and their relevance to practice – a response to Jean Harbison.White Rose Research Online URL for this paper:https://eprints.whiterose.ac.uk/48/Article:Thompson, C. orcid.org/0000-0002-9369-1204 (2000) Clinical decision making in nursing: theoretical perspectives and their relevance to practice – a response to Jean Harbison. Journal of Advanced Nursing. pp. 134-137. ISSN 0309-2402 eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse Items deposited in White Rose Research Online are protected by copyright, with all rights reserved unless indicated otherwise. They may be downloaded and/or printed for private study, or other acts as permitted by national copyright laws. The publisher or other rights holders may allow further reproduction and re-use of the full text version. This is indicated by the licence information on the White Rose Research Online record for the item. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. JAN Forum: Clinical decision making in nursing: theoreticalperspectives and their relevance to practice ± a response to JeanHarbisonCarl Thompson DPhil RNResearch Fellow & Head of GraduateSchool, Department of Health Studies,University of York, York YO10 5DG,UKE-mail: cat4@york.ac.ukDecision making by nurses is now ®rmlyestablished on practice, policy andeducational agendas. New, constantlyevolving, roles, and a policy context thatis challenging traditional professionalboundaries (for example, the imminentannouncement on United Kingdom(UK) nurse prescribing) mean that, morethan ever, nurses are being givenautonomy and power to be able toexercise their decision choices. With thisfreedom however, comes responsibility.Responsibility to a new professionalbody in the UK, responsibility to anever more informed public, and respon-sibility to service commissioners andcolleagues who ± quite rightly ± expectnursing to demonstrate its worth in thehealth care team and contribution to thehealth care product. Clinical decisionsare both the means by which thisresponsibility is exercised, and ulti-mately, the means by which nurses'contribution to the production of healthwill be judged.Jean Harbison's cogent and timelyresponse to my original paper(Thompson 1999) unpacks some of therather crude arguments of the ®rstpaper. In doing so, the author developsa line of reasoning highlighting thebene®ts of thinking of decision makingalong a continuum (and the rejection ofeither rational or intuitive decisionmodes for all decisions). The paper iswell written and will, I hope, attractresponses from clinicians and academicsalike.Harbison quite rightly implies that thechallenge for nursing is to highlight thecontribution of nurses to the productionof good health care outcomes, `¼theapparent assumption¼is that becausenurses intend to bene®t their patients,their decision making actually does so'.Recent papers from the ®eld of primarycare suggest that, whilst the decisionsmade by nurses may not be optimal interms of quality, their diagnostic andtreatment choices are certainly noworse than those of other professions(Lattimer et al. 1998, Shum et al. 2000,Venning et al. 2000). However, what isrequired ± as Harbison highlights ± isthe production of research evidence toshow the different ways in which nursesmake decisions can be improved.Decisions need to be more accurate(when diagnosing illness ± or indeedhealth), have the most positive impactwhen making treatment choices, or havethe intended impact on understandingor behaviour when choosing what infor-mation to communicate to patientsregarding prognosis, risk or bene®ts.Harbison misinterprets my originalclaim (I can argue this now because ofthe positive effect of hindsight bias)that, `there is no point considering thequality of decisions as we do not haveenough information about what consti-tutes quality'. I stand by my originalassertion that the evidence of whatconstitutes accurate nursing diagnoses,or the optimal nursing interventionchoices for populations of patients isstill (relatively) small when comparedwith the bio-medical literature.However, the argument remains a justi-®cation for more descriptive researchnot less. Not because, as Harbisonimplies, I think there should be morestudies to add to the seemingly endlessvolumes showing how nurses intuitivelyknow what is right without reference toany gold standard (in the case of diag-nosis) or assessment of alternatives (inthe case of interventions). Rather, I wasarguing that what we need is moredescription of the decision tasks facingnursing in its constituent arenas in orderthat we can better match the modusoperandi of the cognitive continuum'scategories with the decision choicesactually faced by nurses. Only bymatching strategies for decision makingto decision tasks in this way, shall wegain a purchase on `what might be' inrelation to steering nurses to makebetter decisions. Of course, havingclaimed that I was wrong Harbison thenpoints out the very point outlined above,`a justi®able decision for descriptiveresearch is to establish what judge-ment/decision tasks nursing practiceactually requires, with a view to consid-ering whether this is being done well'.At York we have recently completed aproject examining the decisions of acutecare nurses (Thompson 1999) and weare currently mapping the decisionchoices of primary care nurses (due forcompletion in 2002).Harbison is incorrect when arguingthat Newell and Simon's (1972) originalresearch on information processing is`value free'. The idea of rationality(bounded or otherwise) as devoid ofvalue judgements is nonsensical. Ration-ality is necessarily, and by de®nition,concerned with ®nding the best (mostef®cient, effective, ef®cacious) route to apredetermined end point. In setting thedesired end point and the `best' route toachieving it, all sorts of value judge-ments creep in. Admittedly, for decisiontheorists there may be philosophicaldevices such as the principles of decisioncomparability and coherence (Lindley1985) which recast these value judge-ments as `science' but the point remains:value judgements and rational decisionmaking are not mutually exclusive.Harbison rightly points out that intu-ition is hardly random and handily shat-ters (the Benner-esque) vision of thenurse as an almost mystical ®gureexpertly exercising intuitive judgementswhich only they can recognize. More-over, her paper shows that simply134 Ó 2001 Blackwell Science Ltdbecause intuitive assessments somehow`feel right' this is no justi®cation forrelying upon them as a sole strategy. Indoing so, she highlights the emotivelanguage adopted by some commenta-tors. Randall and Downie (1996) forexample, speaks of `sensitivity and imag-ination'; Benner and Tanner (1987)speak of `a sense of salience'; Rolfe(1997) speaks of `the fuzzy nurse'.Harbison suggests that `imagination'might be the ability to generate hypo-thetical situations. I would go furtherand suggest that without an appropriateappreciation of alternatives to `intelli-gent guessing' then one might as well setabout generating hypothetical results ofdecisions as well. In fact Harbisonalludes to this situation, when high-lighting the susceptibility to the biaseswe are all prey during cognition (shedraws on the anchoring heuristic as anexample), a theme I have explored morefully elsewhere (Lamond & Thompson2000). Having established that intuitionis not the universal good that any cosmictraveller systematically reviewing theresearch literature on nurse decisionmaking might assume, Harbisonreinforces again the need for moredescriptive research which will enablepractitioners to choose the appropriatecognitive strategy for a given decisiontask. Particularly as evidence alreadyexists to show that the blanket applica-tion of intuitive approaches to decisionmaking is often less effective than moresystematic approaches (Shamian 1991,Letourneau & Jensen 1998, Mosheret al. 1999, Warren et al. 1999).Harbison recognizes that nursing hasby and large rejected Bayesian approa-ches to improving decision making ±although in my opinion I am not surethat we ever really engaged with them inthe ®rst place, unlike our medical collea-gues. However, I think the author'sassertion that this rejection downplaysthe issue of quality in nursing decisionsis a little unfair. Bayesian assessment ofdecision probabilities relies on havingevidence which adequately enables therevision of the likelihood of clinicalevents or decision outcomes. I wouldargue that much nursing research dealswith subjects that are either peripheralto nursing choices and decisions (ques-tion ± do we really need another surveyon clinical supervision?) or else generateresults which have little impact on thebehaviours of nurses (repeat ± do wereally need another survey on clinicalsupervision?). By mapping the real lifedecisions of nurses we can generateresearch which is ®t for the purposesof reducing the uncertainties of real lifenurses. For an example look at the`bottom up' approaches to commis-sioning in Health Technology Assess-ment Programmes in countries such asthe UK (http://www.ncchta.org/main.htm) and Sweden (http://www.sbu.se/sbu-site/index.html).Jean Harbison's paper questions myinterpretation of `correctness' withrespect to the endpoint of decisionanalysis. Of course, I would agree withher that decision analysis has a focus onthe `optimum answer for that decisionowner'. However, the paper's argu-ments could be strengthened simply byreferring to the concept of utility. Deci-sion analysis seeks to maximize utility: anumerical measure of the attractivenessof decision choices. As decisions inhealth care almost always involve anumber of stakeholders it is possible ±indeed it is good practice ± to question`whose utilities?' are being catered for indecisions. What decision analysis offersis the opportunity for patients to seeexactly how much value is attached totheir opinions in the construction ofdecision choices. Decision analysisresults are explicit and amenable toharnessing the power of new technologyas a route to making the processesinvolved easier and quicker. Given theenhanced role (and by implicationweighting) of patient views in decisionanalysis I would agree that the rejection,on moral or ethical grounds, of decisionanalysis is unjusti®ed.If I am interpreting Harbisoncorrectly she claims that, `predomin-antly relevant to practising nurses areintuition and peer decision making,located at modes 6/5 [of the cognitivecontinuum].' I would dispute this.Consider the decisions faced by onemedical staff nurse on an acute medicalward observed in one 3-hour period lastyear (Thompson et al. 2000) (Table 1):The 18 decisions taken by this staffnurse represent one decision task every10 minutes. Clearly, not all of themmerit a full blown scienti®c experiment(mode 1) but neither do they all meritintuitive guesswork (mode 6). That said,time is an important factor in decisionmaking and one might argue that thetime constraints associated with thesedecision choices rule out any othermechanism than intuition. The task fornursing research is to ensure that forthose decisions requiring more system-atic decision making modes, theevidence is summarized concisely andreliably in order that the results can befactored into future (similar) decisions,and analytical reasoningmade as straightforward as possible.Jean Harbison suggests that boundedrationality limits the usefulness ofaccommodating evidence into practice.Again, I would take an opposite tack onthis issue. For me, an evidence basedapproach to decision making with itsemphasis on the explicit balancing ofpatient preference, clinical expertise, theavailable resources and the best qualityresearch evidence (DiCenso et al. 1998)can do more to combat the effects ofbounded rationality than compound it.Reframing clinical uncertainty and deci-sion choices as focused clinical questions(Flemming 1998) sets the boundaries forconsidering decision choices, acts as aframework for the explicit considerationof alternatives, and helps to select themost appropriate framework for theconsideration (appraisal) of evidence.Reframing may exclude some alterna-tives ± but at least this exclusion isexplicit and visible. If it is visible then itcan be challenged, and the frameworkrevised. The ability to revise the proba-bilities one attaches to decision choicesis (for me) the mark of a cognitively`open' clinician. Unfortunately, theevidence suggests that too often nursesare excessively cautious in the revisionof their ideas, preferring ± as Harbisonpoints out ± the anchoring effects oftheir initial hypothesis.Jean Harbison implies that everydaynursing practice may not require the useof complex thinking. This may be true,however, everyday practice does meritthe provision of robust and valid deci-sion solutions. And whilst the decisionmaking processes of nurses may be(or may appear to be to the decisionmaker themselves) relatively simple, theJAN ForumÓ 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 134±137 135application of those choices may not.Decision support and new decisiontechnologies hold the promise of redu-cing the variability associated withsimple decisions and at the same timemaking the complex ones easier tograpple with. Crucially, many of thesesolutions come from disciplines otherthan nursing. A point which reinforcesHarbison's assertion that `[nursing's]reluctance to consider knowledge gener-ated by disciplines other than nursinghas the potential to lead to isolation ofthe profession.' Linkages betweennurses and other professions whichfocus on improving the process ofdecision making are beginning tohappen. A few enlightened researchersare using the accumulated knowledgeof cognitive psychologists and infor-matics experts as a route to improvingthe decisions made in the health carearena and nursing's input into thosedecisions. For example, the NursingResearch Initiative for Scotland isexamining:· How nurses make decisions abouturinary catheterization.· Constant observation and suicide: asocial judgement analysis.· The development and evaluation of acomputerized clinical guidance tree forbenign prostatic hyperplasia and hyper-tension.See http://www.nris.gcal.ac.uk for moredetails on this programme of work.In conclusion then, I welcome thiscontribution from Jean Harbison, and ±perhaps worryingly given that it is acritique of my own work ± ®nd myselfagreeing with many of the paper's argu-ments. Maybe this is because of myability to revise my original views,perhaps it is because of the `rose tinted'impact of hindsight bias, or (as is morelikely) Harbison manages to add valueand weight to the arguments that Iposited originally. The idea of a cogni-tive continuum has much to offer nursesand its potential has yet to befully exploited. The exploration anddescription of the decisions of nursesconstitutes a challenge for researchers.Speci®cally, we need to generate know-ledge able to reduce the uncertainties ofnurses. How the research communityresponds to this challenge will dictatewhether we make the most of the newand emerging technologies that are ableto support the decisions that nursesmake.ReferencesBenner P. & Tanner C. (1987) Clinicaljudgement: how expert nurses use intu-ition. American Journal of Nursing 87, 23±31.DiCenso A., Cullum N. & Ciliska D. (1998)Implementation forum. Implementingevidence-based nursing: some miscon-ceptions. Evidence Based Nursing 1,38±40.Flemming K. (1998) EBN notebook. Askinganswerable questions. Evidence BasedNursing 1, 36±37.Lamond D. & Thompson C. (2000) Intuitionand analysis in decision making andchoice. Journal of Nursing Scholarship32, 411±414.Lattimer V., George S., Thompson F.,Thomas E., Mullee M., Turnbull J., SmithH., Moore M., Bond H. & Glasper A.(1998) Safety and effectiveness of nursetelephone consultation in out of hoursprimary care: randomised controlled trial.BMJ 317, 1054±1059.Letourneau S. & Jensen L. (1998) Impact of adecision tree on chronic wound care.JWOCN 25, 240±247.Lindley D.V. (1985) Making Decisions. JohnWiley & Sons, Chichester.Mosher B.A., Cuddigan J., Thomas D.R. &Boudreau D.M. (1999) Outcomes of 4methods of debridement using a decisionanalysis methodology. Advances in WoundCare 12(Suppl. 2), 12±21.Newell A. & Simon H.A. (1972) HumanProblem Solving. Prentice Hall, Engle-wood Cliff, New Jersey.Randall F. & Downie R.S. (1996) PalliativeCare Ethics. Oxford University Press,Oxford.Rolfe G. (1997) Science, abduction and thefuzzy nurse: an exploration of expertise.Journal of Advanced Nursing 25,2070±2075.Shamian J. (1991) Effect of teaching decisionanalysis on student nurses' clinical inter-Table 1 Observed decisions made by one medical staff nurse in a 3-hour period (afternoon shift) in one UK medical admissions ward(Thompson et al. 2000)· Decides to allow a dressing to stay in place for 3 days on a lady with a large sacral pressure sore· Decides that a patient can be discharged if her blood results are normal· Shared decision with bed coordinator regarding bed management· Decides to check that a patient has signed a consent form· Decides to move patient into a sideroom after chemotherapy· Decides to ring the dietician for advice regarding the management of a diabetic patient and how best to manage a patient previouslytreated with total parenteral nutrition and who is now not eating· Decides what information to impart to patients' relatives regarding conditions· Decides on the appropriateness of meals for the numerous diabetic patients at lunchtime· Decides on the optimal balance of skills during staff lunch breaks for staff· Decides to call the doctor regarding whether or not a patient can have aspirin or not· Decides to refer a patient to the palliative care clinical nurse specialist· Decides to place a patient on a pressure relieving mattress· Decides to give a painkiller as a response to a patient request· Decides to refer a patient with `niggling' chest pain to the doctor· Decides what advice to give a colleague who asks for advice regarding the taking of a wound swab· Decides to refer a patient with a sore mouth to the clinical nurse specialist· Decides that a patient who was to be discharged should now not be the patient doesn't understand her self-medication programme· Decides to phone the colonoscopy clinic for advice regarding the diet of a patient going for endoscopyJAN Forum136 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 134±137vention decision making. Research inNursing and Health 14, 59±66.Shum C., Humphreys A., Wheeler D., Coch-rane M.A., Skoda S. & Clement S. (2000)Nurse management of patients with minorillnesses in general practice: multicentre,randomised controlled trial. BMJ 320,1038±1043.Thompson C. (1999) A conceptual treadmill:the need for `Middle Ground' in clinicaldecision making theory in nursing. Journalof Advanced Nursing 30, 1222±1229.Thompson C., McCaughan D., Cullum N.,Sheldon T.A., Thompson D.R. & MulhallA. (2000) Nurses' Use of ResearchInformation in Clinical Decision Making:A Descriptive and Analytical Study ±Final Report. NHS R & D, NCC SDO,London.Venning P., Durie A., Roberts C. & Leese B.(2000) Randomised controlled trialcomparing cost effectiveness of generalpractitioners and nurse practitioners inprimary care. BMJ 320, 1048±1053.Warren J.B., Yoder L.H. & Young-McCau-ghan S. (1999) Development of a decisiontree for support surfaces: a tool for nursing.Medsurg Nursing 8, 239±248.JAN ForumÓ 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(1), 134±137 137

Clinical decision making in nursing: theoretical perspectives and their relevance to practice – a response to Jean Harbison

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Clinical decision making in nursing: theoretical perspectives and their relevance to practice – a response to Jean Harbison

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