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.