Clinical decision making in district nursing
The two studies described here address the question of how District Nurses determine
patients' nursing problems and plan care. The theoretical framework for the
investigation is derived from Information Processing Theory. A process tracing
methodology was used to capture the content of District Nurses' thinking during an
assessment visit to a newly referred patient. Data was collected in the natural setting
to ensure ecological validity. The assessment visits were tape recorded and
immediately following the visit a stimulated recall session was conducted in which
the nurse was asked to describe her thinking during the assessment, prompted by the
tape recording. This session was itself tape-recorded. Thus two verbal protocols
were elicited for each assessment: a visit protocol and a recall protocol.
Data were analysed by content analysis. The verbal protocols were assessed to ensure
that they met the criteria for validity and reliability of the coding schedules was
established using two measures or interrater reliability.
The first study sought evidence of hypothetico-deductive reasoning by nurses and
describes the type of decisions made by nurses. Although evidence of hypothesis
generation and testing was found, nurses' knowledge was found to determine how
they interpreted data initially and what data they sought. It was therefore concluded
that a model of diagnostic reasoning that focused on cognitive processes alone was
insufficient to explain the dynamics of clinical problem solving.
The second study, therefore, sought to establish the structure and content of District
Nurses knowledge and the cognitive processes they used during an assessment. The results suggest that nurses attend to both clinical and personal phenomena in order to
make a judgement about the state of the patient and that their knowledge is organised
internally as schema. This provides an explanation of how nurses recognise salient
information and determine what further data is required. Four key cognitive activities
were identified: search, inference, action and plan. The study concludes by drawing a
line of reasoning to show how nurses integrate knowledge and reasoning processes to
accomplish clinical problem solving.