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Professional Nursing Education:
Cognitive Processes Utilized in Clinical Decision Making
Kathryn A. Smith Higuchi
Educational Psychology and Counselling
McGill University, Montreal
November, 1997
A dissertation submitted to the Faculty of Graduate Studies and Research in
partial fulfillrnent of requiremen ts of the degree of Doctorate of Philosophy in
Educational Psychology.
O Kathryn A. Smith Higuchi, 1997.
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Acknowledgements
My gratitude is extended to the nursing administration and the medical records
staff at the Queensway-Carleton Hospital for their support and participation in this
project. I especially thank those nurses who generously shared their tirne and
insights about nursing practice.
I am indebted to my advisor, Dr. Janet Donald, whose mentorship allowed me
to grow professionally. I will always feel very privileged and fortunate to have had the
opportunity to learn ftom her expertise. Janet's knowledge and guidance greatly
contributed to making my doctoral studies such an intellectually challenging and
enriching experience. I also wish to thank the members of my thesiç cornmittee; Dr.
Susanne Lajoie, Dr. Alenoush Saroyan, and Dr. Dorothy Thomas-Edding, for their
guidance.
I am very grateful for the support of several nursing colleagues and friends;
Jean Jenny, who graciously shared her nursing expertise during numerous
discussions; Barbara Foulds, who challenged rny thinking about nursing practice and
education; Vicky Satta, who was an enthusiastic research assistant; and Erlinda
Morales-Mann, who provided encouragement during the difficult times.
I also wish to thank new friends and colleagues at the University of Lethbridge
School of Health Sciences for their assistance; Dr. Virginia McGowan, who offered
thoughtful insights during the final editing, and Wendy Herbers and Darlene
Sutherland who provided secretanal. and technical support in the preparation of this
document,
This dissertation is dedicated to my farnily. My husband, Howard, provided
constant encouragement and numerous hours of technical expertise, while my
children, Michaei and Karen, willingly provided assistance when needed. To my
parents, Ken and Ann Smith, my thanks for their support over al1 the years,
Abstract
Clinical decision rnaking is essential to clinicai practice, yet research into the
cognitive processes underlying clinical decision making is limited. The purpose of
this study was to invesügate the cognitive processes utilized by nurses in actual
clinical decision making situations. Using a criterion sarnpling technique, eight
experienced medical and surgical nurses from an acute Gare wmrnunity hospital
were selected as participants for in-depth interviews about clinical decision rnaking in
nursing practice. Actual clinical data documented by the eight nurses were obtained
from a review of 100 randomly selected hospital records of patients discharged over a
one year period. The study examined the influence of contextual factors (nursing sub-
group, Problem Oriented Rewrding [PORI charting. system and primary nursing
system), task variables (complexity of clinical problems), and clinician characteristics
(nursing expertise) on clinical decision making. The dependent variables included the
accuracy of nursing diagnosis documentation and the utilization of specific thinking
processes. Donald's rnodel of thinking processes provided a .framework for the
a analysis of the data.
The results suggest that clinical decision making is a complex cognitive
process requiring numerous thinking skills and operations. Five different categories
of thinking skills and 14 difTerent operations were identified in the narrative notes. The
clinical situations were categorized into three types based on the complexity of clinical
problems. Nurses from both hospital units documented a wider range of thinking
skills and operations in situations of greater cornplexity. The findings also suggest
that structured charting formats such as SOAP narrative notes encouraged the use of
higher order thinking processes. The introduction of the prirnary nursing patient
assignment systern did not result in significant changes in the documentation of
nursing diagnoses or thinking processes utilized by nurses. The nurses were
grouped into two levels of expertise according to Benner's categories: expert and
proficient, with differences more evident in the medical nurses. An important outcome
of this study was the development of nursing exernplars and illustrations of thinking
processes that can provide a working vocabulary to describe the underlying cognitive
processes used in clinical decision rnaking.
Sommaire
La prise de d8cisions cliniques est essentielle à la pratique clinique; pourtant
les recherches sur les procédés cognitifs sous-jacents aux prises de decisions
cliniques sont peu nombreuses. Le prbsent travail s'est donné pour but d'étudier les
procéd6s cognitifs utilisés par des infirmières dans des situations réelles de prise
de décisions cliniques. Au moyen d'une technique d'échantillonnage de critères, on a
sélectionn6 huit infirmières expérimentées en médecine et en chirurgie d'un hôpital
communautaire de soins intensifs pour participer à des interviews en profondeur à
propos des prises de décisions cliniques dans la pratique des soins infirmiers. Les
huits infirmières ont documenté leurs données cliniques à partir de l'étude de 100
dossiers d'hôpital pris au hasard concernant des patients renvoyés en la période
d'une annee. L'étude a examiné l'influence de facteurs contextuels (sous-groupe
infirmier, systeme de diagramme et système infirmier primaire du type Relèvement
Orienté sur le Problème [ROP] ), de variables de tâches (complexité de certains
problèmes cliniques) et de characteristiques du clinicien (compétence infirmier) sur
la prise de décisions cliniq ues. Les variables dépendantes comprenaient I'exactitu de
de la documentation du diagnostic infirmier et l'utilisation de procédés spécifiques de
réflexion. C'est dans le cadre du modèle de procédés de réflexion Donald que s'est
faite l'analyse des données.
Les résultats suggèrent que la prise de décisions cliniques est un procédé
cognitif complexe nécessitant de nombreuses capacités et opérations de réflexion.
Dans les annotations narratives, on a identifié cinq catégories différentes de
capacités de réflexion et 14 opérations. On a classé les situations cliniques en trois
catégories selon la complexité des problèmes cliniques. Les infirmières* qui
provenaient de deux hôpitaux, ont &montré un éventail plus grand de capacités de
réflexion et d'opérations lors de situations d'une plus grande complexité. Les
rdisultats suggèrent aussi que des formats de diagrammes structurés, comme les
annotations narratives SOAP, favorisaient des procédés de réflexion supérieurs a la
normale. L'introduction du systéme primaire d'affectation des soins au patient n'a pas
démontré d'importantes modifications dans la documentation des diagnostics
infirmiers ou des proc6d6s de rkflexion des infimi8res. On a class6 des infirmières
en deux groups de compétence selon les cat6gories de Benner: experte et
compétente, avec les différences plus évident dans les infirmieres en medecine. Une
conséquence significative de cette Btude fut la mise en valeur de modbles infirmiers
et d'exemples de procédés de réflexion pouvant fournir une nomenclature
professionnelle apte à décrire les procédés cognitifs sous-jacents à la prise de
décisions cliniques.
Table of Contents
Acknowledgements ............................................................................................. i
Abstract ..................................................................................................................... ii
... Sommaire ................... ......,... ................................................................................... III
Table of Contents ................. .......... ................................................................
List of Tables ................................... .., ...............................................................
List of Figures ........................................... i*............... .............................................
List of Appendices ................................................ ... .............................................. ............................ ......................................................... Introduction ................. ..
............................................... .................................. Conceptual Framework .. Nu rsing Process ......................................................................................... N ursing Diag nosis Process ...................................... .......................... Diagnostic Reasoning Process ................................................................ Ins tructional Strategies Utilized in Teaching Clinical Decision Making ......................................................................................... Measuring Clinical Decision Making Skills .............................. .......... ..... Cognitive Processes Underlying Clinical Oecision Making ................ Clinical Decision Ma king in the Practice Setting ...................................
Contextual Factors .......................................................................... Task Variables ......................................................................... ........ Clinician Characteristics .............................................................. Communication of Clinical Decisions ..........................................
Statement of the Problem ...................................... .......m............................ ....................................................... ....................... Research Design ...
............ ......................................... Site ,.).... ....... Selection of Nursing Units ...............................+........................
.................................................................................................... Documents .................................................................. ................... Procedure .................
Preliminary Meetings ................... .... .......................O............. Data Collection from Patient Charts ................... .... ............. Participants ....................................................................................... Selection of Chart Sample ............................................................. Field Observations ............. ......................e...........................
......................................................................................... Interviews
v
vii
viii
ix
2
Data Analysis .................... ... .............................................................................. 32 ........................ Nursing Diagnosis Docurnentaüon ...... .................. 32
Coding of Thinking Processes ......................................... ................ 33 Analysis of Inteiview Data .................................................................. 38
Results ..................................................................................................................... 39 ................... Primary Nursing and Nursing Diagnosis Documentation 39
Primary Nursing and Thinking Processes .......................... ....... . 41 ........................... Thinking Skills Utilized in Clinical Decision Making 42
............. Thinking Skill Operations Used in Clinical Decision Making 45 ................... Distribution of Thinking Processes in Clinical Elements 50
....... Thinking Skills Evidenced in Three Types of Clinical Situations 52 .................... .......................*........ Type 1 Clinical Situations .. 52
Type 2 Clinical Situations ........................... ..... ...................... .. 53 .............................................................. Type 3 Clinical Situations 56
......................................... Thinking Processes and Charting Format 61 Clinican Characteristics ...................................~....................................... 64 Interview Data ............................. .. ........................................... .... ............... 65
Nurses' Use of Thinking Skills in Clinical Decision Making ........................ ... ....................................... 69
Discussion .......................................................................................................... 76 Contextual Factors .. ............ ................... ....... .......................................... 76 Tas k Variables ........................................................................................... 79 Clinician Characteristics ........................................................... ...... .......... 80 Thinking Skills Utilized in Clinical Decision Making ............................ 81
Description ................... ... ...................................................... 82 Selectjon ........ ... ................................. ....... *........................... .. ......... 82 Representation .................... .. .................................................... 83 Inference ........................... .. ........................................................ 84
................... .......................*......................................... Synthesis .. 85 Verification ....................... ......... ........................... 86
............................. lm plications for Professional Nursing Educa tion 87 Implications for Nursing Practice ....................................................... 90
...................................................................... Contribution to Knowledge 92 Recomm enda tions ................................................................................ 94
Conclusions
References ........................................ ........................................................ 1 00
Appendices ................... ....... ........................................................................ 1 10
v i i
List of Tables
Table 1 Cornparison of Clinical Decision Making Models Used in ............................................................................... Nursing Practice 6
........................................................... Table 2 Model of Thinking Processes 15
Table 3 Nursing Exemplars and Illustrations of Thinking Processes ............................................................................... 34
vi i î
Figure 1 .
Figure 2 .
Figure 3 .
Figure 4 .
Figure 5 . Figure 6 .
Figure 7 .
Figure 8 .
List of Figures
Frarnework For Inveçtigating Clinical Decision Making .......... 17
.................... ...... Multiple Time Series Research Design ... 23
Thinking Skills Evidenced in Clinical Episodes .......................... 43
........................... Thinking Skills Evidenced in Clinical Notes 44
......... Thinking Skills Evidenced in Type 2 Clinical Situations 54
Thinking Skills Evidenced in Type 3 Clinical Situations ......... 57
Thin king Skills Evidenced in Surgical Clinical Notes .................. with and without SOAP Format ................................... 61
Thin king Skills Evidenced in Medical Clinical Notes with and without SOAP format ...................................................... 62
List of Appendices
Appendix A . Definitions of Operations of lntellectual Skills in Higher Education ........................................ ...... ............... 1 il
Appendix B I . Description of Chart Documents ................... .. ..... ...... 11 4
Appendix 82 . Patient Record Data .............................................................. 115
Appendix C . Request for Support from Queensway-Carleton Hospital ..................... ............................................. ........ 116
AppendixDl . Consent Form .......... ......................... ................................. 117
Appendix D2 . Ethical approval: Queenway-Carleton Hospital ................ 118
Appendix D3 . Ethical approval: McGill University ............................. .......... 1 19
Appendix E .
Appendk F I . Appendix F2 .
Appendix G .
Appendix H l .
Appendix H2 .
Appendix I .
Appendix J I .
Appendix J2 .
Appendix K .
Appendix L .
a Appendix Ml .
Participants ....................................................................... 120
Average Admission Days by Patient Chart ......................... 121
Average Age of Patients During Hospital Admission ....... 122
Example of Coded Narrative Note .................................... 123
Clinical Episodes Documented by Nurses in Each Obsewation PeRod ....................................................... 724
Clinical Notes ~ocumented by Nurses in Each Observation Period ..................................................... 125
Interview Schedule .................................................................. 126 Coding of Labelling Accuracy of Nursing Diagnoses ........ 130
Coding of Diagnostic Accuracy of Nursing Diagnoses ..... 130
Frequency of Documentation of Nursing Diagnoses and Clinical Notes in Patient Charts ................................... 131
Hospital Charting Procedure ................... .. .................. 132 Diagnostic Statements and Eüologies with Accurate
....................................................................................... La bels 133
@ Appendk M2 .
Appendix M3 .
Appendk N I .
Appendix N2 .
Appendix O1 .
Appendix 02 .
Patient Charts with Documented Nursing .............................................................................. Diagnoses 133
Medical and Surgical Charts that Omitted Nursing .......................... ...................... Diagnoses ....................... 134
Clinical Episodes and Clinical Notes Documented .................... ................... in Medical and Surgical Charts .. 135
Thinking Skill Categories Evidenced in Clinical ................... Notes ...................,..................0............................ 135
Thinking Skills Evidenced in Clinical Episodes ................................................................................. and Notes 136
........ Nurnber of Operations Evidenced in Clinical Notes 136
Appendix 03 . .
Appendix 04 .
Appendix P l .
Appendix P2 . Appendix P3 .
Appendix P4 . Appendix P5 .
Appendix P6 .
Appendix Q I .
Appendix Q2 .
......... Operations in Medical and Surgical Clinical Notes 137
Distribution of Clinical Elements by Thinking Skills ...................................................................... in Clinical Notes 138
........................ Distribution of Types of Clinical Situations 139
............................ Operations In Type 1 Clinical Situations 139
Number of Operations Evidenced in Type 2 Clinical Notes ........................................................................ 140
............................ Operaüons In Type 2 Clinical Situations 141
Number of Operations Evidenced in Type 3 Clinicai Notes .......................................................................... 142
............................ Operations In Type 3 Clinicat Situations 143
Thinking Skills Evidenced in SOAP and NonSOAP ...................................................................... Formatted Notes 144
Operations in Type 2 Notes With and Without SOAP Format ...................................................................................... 145
Appendix 43.
Appendix Q4.
Appendix Q5.
Appendix RI.
Appendix R2.
Appendix R3.
Appendix R4.
a Appendix R5.
Appendk S.
Appendix T.
Number of Operations Evidenced in SOAP and NonSOAP Fomatted Notes in Type 2 Clinical Situations .................. 146
Operations in Type 3 Notes With and Without SOAP Format ............................... ,....... .......................................... 147
Nurnber of Operations Evidenced in SOAP and NonSOAP .................. Forrnatted Notes in Type 3 Clinical Situations 148
Number of Clinical Notes Documented by Expert ..................... ......................... and Proficient Nurses ....., 149
Distribution of Thinking Skill Elements Documented ....... by Expert and Proficient Nurses .............................. 150
Number of Thin king S kill Categories Docurnented ................... by Expert and Proficient Nurses .................... ... 1 51
Distribution of Types of Clinical Situations Documented ........... by Expert and Proficient Nurses ......................... .. 152
Distribution of SOAP and Non-SOAP Formatted Type 2 and 3 Notes Documented by Expert and
................................................................... Proficient Nurses 153
Interview Data: Thinking Skills Utilized in .......... Clinical Decision Making .................................... .... 154
.... Thin king Processes Underlvinci the Nursino Process 1 56
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Introduction
The quality of teaching in Canadian universities is receiving increasing
scruüny (Smith, 1991). Universities are now charged with preparing students
who will be able to function effectively in the workplace. In particular, graduates
of professional programs must be able to identify and manage complex
problem situations in the practice setang (Cavanaug h, 1993; Dinham & Stritter,
1986; Schon, 1987). In professional prograrns such as nursing, clinical
courses serve the purpose of iinking theory and practice; in clinical courses
students must interact with real or simulated patients in settings such as
hospitals, clinics and homes (Reilly & Oermann, 1992). The teaching process
in clinical courses exposes students to real life problem sitüations where they
must learn to rnake decisions in the context of the practice setting.
Research into professional education ernphasizes the importance of
iden tifying the thin king processes utilized b y professionals in their practice
(Cavanaugh, 1993; Harris, 1993; Wales, Nardi, Stager, 1993). However, the
literature provides minimal guidance to nursing educators in developing
instructional strategies that promote the thin king skills necessary for manag ing
cornplex patient situations (Kelly & Young, 1996; Tanner, l987a). Research
shows that nursing students and graduates continue to experience difficulty in
identifying clinical problem situations (Andersen & Briggs, 1988; Plunkett,
1992; Watkins, 1992). Although models of clinical reasoning and decision .
rnaking in nursing have been developed (Carnevali & Thomas, 1993; Gordon,
1 982; 1994; Ziegler, Vaug han-Wrobel, & Erlen, l986), the cognitive processes
are not well defined and extensive empirical testing is lacking. What is needed
to enhance learning in professional nursing programs is a well defined body of
knowledge that clearly describes the thin king processes u tilized by nurses in
clin ical practice.
Given the increasing need for professional nurses to manage complex
problem situations, an important contribution to our understanding of the
clinical decision rnaking proceçs would be an investigation into the thin king
processes utilized by nurses in actual practice. In tum, knowledge of these
processes could assist nursing educators in developing instructional
drategies to enhance the clinical decision making skills of nufsing students.
The purpose of Uiis study therefore, was to delineate the thinking processes
needsd by .nurses in clinical practice so that they can be taught as part of
nursing education. Specifically. what cognitive processes are utilized by nurses
in clinical decision making?
Conceptual Framework
Clinical decision making is a problem solving activity that focuses on - defining patient problerns and selecting appropriate treatment interventions
(dela Cruz, 1994; Gordon, 1994; White, Nativio, Kobert & Engberg, 1992).
Clinical decision making in medical and nursing practice has been studied
extensively using theoretical perspectives arising from decision theory and
information processing theory (Christensen & Elstein, 1991; Elstein, Shulman,
& Sprafka, 1990; Hamers, Abu-Saud, 8 Haifens, 1994; Le Breck, 1989;
McGuire, 1985; Radwin, 1990; Tanner, 1986, 1987b). Using a decision theory
perspective, mathematical rnodels predict how individuals would select a
particular course of action. No single model has consistently predicted the way
individuals behave in problem solving situations (Anderson, 1990; Tanner,
1986). For example, decision making rnodels such as Brunswik's Lens' rnodel
(Hamrnond, 1964) and the Bayesian model (Hammond, Kelly, Schneider, &
Vancini, 1967) were tested, but were found to be unçuccessful in predicting all
clinical decision making behaviours of nurses.
Another approach to clinical decision rnaking has utilized an information
processing frarnework (Elstein, et al., 1990; Tanner, Padrick, Westfall, & .
Putzier, 1987). When presented with a patient problem situation, physicians
and nurses formulate initial hypotheses based on the patient's complaints. The
initial hypotheses guide further data collection to confirm, refine, or reject the .
hypotheses (Elstein, et al., 1990; Tanner, et al., 1987). The accuracy of clinical
decisions is associated with relevancy of the information gathered and the
subsequent accurate cue interpretation (Tanner, 1986). Thus, the clinical .
decision making process utilized by physicians and nurses includes the
collection and analysis of patient data, and the formulation of hypotheses to
guide treatment decisions.
Research into clinical decision making in nursing (Grier, 1984;
Leprohon, 1991; Tanner, 1987b; Tanner et al., 1987) is not as extensive as
investigations in medicine (Elstein et al., 1990; Gale & Marsden, 1983; Neufeld,
Norman, Freightner, & Barrows, 1981) and the differences in the professional
focus between medicine and nursing limit the wmparisons thaï can be made
between the two disciplines. For example, medicine has a more definitive
focus on the diagnosis and treatment of disease (Carnevali & Thomas, 1993;
Eisenhauer, 1994; Gordon, 1994), while nursing has a broader interest in the
quality of health with a focus on the concepts of nursing, person, health, and
environment (Fawcett, 1995). Thus, contextual differences in the clinical
decision making process occur as a result of the different professional foci of
nursing and medicine. The diagnosis and treatment of pathological conditions
has been an important component in rnedical professional education
programs for decades (Patel, Groen, & Norman, 1993). On the other hand,
fomal instruction in the diagnosis of health related problems is a relatively
recent developrnent in nursing education (Gordon, 1994). To be able to .
understand clinical decision making from a nursing perspective, the models of
clinical decision making currently used in nursing practice are examined in the
following section.
In the nursing literature, clinical decision making is commonly described
using models such as the nursing process (Oermann, 1991; Ziegler et al.,
1986). nursing diagnosis process (Gordon, 1982, 1994), and diagnostic
reasoning (Carnevali & Thomas, 1993). In order to compare the extent to which
the models describe clinical decision making, I compared the elements in
each of the models and developed the following table (Table 1). These models
focus on different aspects of the decision making process and Vary in the
degree of specificity of steps. In nursing education, the nursing process is the
most widely used of these models, and encompasses the entire series of
decisions, including decisions involved in the planning and selection of
interventions to address patient problems, and evaluation of outcornes.
However, the nursing process makes minimal teference to underlying cognitive
processes, while the nursing diagnosis process and the diagnostic reasoning
process provide more elaboration. Although the nursing diagnosis process
and the diagnostic reasoning process provide more specific descriptions, they
are Iimited to collecting patient information and açsigning a diagnostic category -
d
or label to the patient cues or cue clusters. Because nursing practice has relied
on these rnodels since the 1950's. they have çerved as the basis for teaching
dinical decision making. Each madel is examined in detail in the following
'section.
Table 1
Comparison of Clinical Decision Making Models Used in Nursing Practice
-- -
Nursing Process Nursing Diagnosis Process
Diagnostic Reasoning Process
Assessrnent Collecting Pre-encounter data information collection
. -
Entry into patient situation
Data collection
lnterpreting information
Data coalescing
Priority cue selection
Clus tering information
Diagnostic explanation
Comparison of present situation with previous ones
Nursing diagnosis Naming cluster Assignment of diagnosis
Planning
Note. This table has been developed from an analysis of the steps involved in - each model. The table fias been structured to indicate the equivalent steps
across the three models.
Nursinq Process
The nursing process was introduced in the 1950s as an approach to
analyzing nursing problems, based on the scientific method (Doenges &
Moorhouse, 1992). The nursing process continues to be used extensively in
nursing education to introduce novice students to clinical decision ma king, as
evidenced by the number of cumcular resources that utilize the nursing
process as content organizers (Clemen-Stone, Eigsti, & McGuire, 1995; Kuhn,
1991; Oermânn, 1991). The nursing process includes 5 steps or phases;
assessment, problem identification or nursing diagnosis, planning,
irnplementation, and evaluation (Doenges & Moorhouse, 1992; Fischbach,
1991; Oermann, 1991; Ziegler, et al., 1986). Assessrnent consists of a
systematic collection of patient data. Problem statements or nursing
diagnoses are then developed from an analysis of the patient data. The
planning phase consists of developing specific outcomes to address the
identified patient problerns. Nursing interventions, such as teaching the patient
about lifestyle changes that could reduce the risk of heart attacks, are
implernented. Finally, the nurse evaluates whether the patient outcomes were
achieved. Unsuccessful interventions are assessed, and based on the data
derived from these assessments, new plans are generated, new actions
implernented, and again evaluated.
The nursing process, as described in the literature, provides a list of
sequenaal procedures, but falls short of providing insight into the thinking
processes utilized in each step. For example, during the assessment phase,
patient data are collected from several sources, but guidelines for prioritizing
the data are not well delineated. In addition, research indicates that nurses
may, in fact, not use the nurshg process sequence when making clinical
decisions. For example, experienced nurses consider patient problems and
interventions simultaneously rather than in a step-wise, linear pattern (Grobe,
Drew, 8 Fonteyn, 1991). Therefore, the nursing process, as currently described
provides a list of specific tasks, with minimal elaboration as to the thinking
skills that students rnust develop to make competent clinical decisions.
Nu rsing Diaclnosis Process
According to Gordon (1994), the nursing diagnosis process includes
four cornponents: collecting information, interpreting the information, clustering
the information, and naming the cluster. Information collection is conducted
dunng the initial encounter with the patient as well as during subsequent
interactions. Extensive clinical knowledge is essen tial for appropriate and
sensitive gathering of data fiom the patient. When interpreting information the
nurse assigns meaning to the data collected in terms of its perceived
relevance for the patient situation. Information is clustered when the nurse
assigns a tentative hypothesis to the relevant patient cues. The final step in the
process is to apply the category name or diagnostic label to the cluster of cues.
Nursing diag nosis comprises a systern of diagnostic categorization and
a description of the cognitive processes used in making clinical judgements
(Gordon, 1994; Miers, 1991). Several definitions of nursing diagnosis as a
system of diagnostic categorization have evolved since its inception in the
1970s (Mills, 1991). At the Ninth Conference of the North American Nursing
Diagnosis Association [NANDA] in 1990, the General Assembly agreed that
nursing diagnosis refers to "a clinical judgernent about individual, family, or
comrnunity responses to actual or potential health problemsllife processes.
Nursin g diagnoses provide the basis for the selection of nursing interventions
to achieve outcornes for which the nurse is accountable" (NANDA, 1994, p.8). In
other words, the identification of patient problems as nursing diagnoses
provides a focus for the planning and irnplementation of nursing care
(Carnevali & Thomas, 1993; Gordon, 1994).
Since the formation of NANDA in 1973, professional nursing
organizations such as the College of Nurses of Ontario [CNO] have included
the identification of nursing diagnoses in their standards of professional
practice-(CNO, 1990). This system of diagnostic categorization,-now known as
the nursing diagnosis taxonomy, was developed to clarify the role of nursing in
patient care as distinct from the role of medicine. Nursing diagnosis is viewed
as an attempt to develop a common language to describe the patient situations
for which nursing has responsibility (Carpenito, 1992; McCloskey & Bulechek,
1994) and to guide professional nursing practice (Fitzpatrick, 1990).
Diagnostic Reasoning Process
The model of the diagnostic reasoning process combines assessment
and problem identification (Carnevali & Thomas, 1993), as does the nursing
diagnosis process mode1 (Table 1). The diagnostic reasoning model however,
is more extensive and specific. According to Carnevali & Thomas (1993), the
eight steps involved in this process are:
1. Collection of pre-encounter data about the patient situation. . Knowledge of key information about the patient helps the nurse form working
hypotheses about the nature of the patient's problems.
2. Entry into the patient situation. In the initial few seconds of contact with
the patient, the nurse scans for urgent life threatening problems such as
breathing or circulation problems. Depending on the responses of the patient,
the nurse may select to focus data gathering using a specific approach.
3. Collection of .data using either a screening or a problem oriented
approach. A screening approach to data collection refers to a pre-determined,
systematic rnethod for ensuring that a general assessment of al1 possible
health problems is achieved. If any unusual problems are revealed within a
particular section, the nurse asks specific questions to reveal additional
information. When using a problem oriented approach, the nurse would begin
with a specific problem area, identified by either the nurse or the patient.
4. Coalescing of data into related '%hunksn in working memory.
According to the literature, experts are able to organize their knowledge base
into meaningful patterns or chun ks (Chi, Glaser, & Farr, 1988). Therefore,
expert nurses are expected to more readily perceive meaningful patterns in the
information obtained from patients.
5. Selection of cue or cue cluster of highest priority for initial diagnosing.
Patient cues or patterns of patient data which are potentially life threatening
receive the first priority. Patterns which are less urgent are selected later.
6. Retrieval of possible diagnostic explmation or patient instances from
long-tetm memory. Expert nurses have organized previous patient experiences
into meaningful chunks (Chi, Glaser, & Farr, 1988) so that they can quickly
retrieve similar clinical situaüons from long terrn memory. Understanding of the
clinical situations is based on knowiedge structures or "illness scriptsn
acquired from previously encountered clinical situations (Schmidt, Norman, &
Boschuizen, 1990).
7. Utilization of recognition features associated with the retrieved
diagnostic concept, problem script or patient instances. An expert nurse, with
extensive experÏence in a wide variety of problern situations, would be able to
recognize the distinctive features of a particular situation from previous
experiences (Benner, 1984).
8. Assignment of a diagnosis. The diagnostic process leads to the
selection of a nursing diagnosis. In some situations, the level of confidence in
the diagnosis may be low. The nurse must then gather additional patient data
to confirm or negate this tentative diagnosis.
This diagnostic reasoning process (Carnevali & Thomas, 1993) allows
for the possibility of several co-existing patient problems and therefore, .is truer
to the phenomenon of clinical decision ma king u tilized by experienced nurses.
In addition, the cognitive processes underlying data collection and
interpretation are more clearly defined. However, empirical testing of this n
has not yet been reported in the literature.
In surnrnary, each mode1 focuses on different aspects of the clinical
decision making process. They are thus complementary, but each is
incomplete in terms of providing guidance for teaching clinical decision
making. In addition, because the models were developed to guide practice,
they provide limited insight into the educational processes that would enhance
nursing students' ability to make decisions. To prornote clinical decision
making in professional nursing education, it iç important to review those
instructional strategies that have been more effective in teaching clinical
decision making in professional nursing programs.
Instructional Strategies Utilized in Teaching Clinical Decision Makinq
Clinical decision making is regarded as an essential component in
professional nursing education and most students are introduced to the
nursing process model of clinical decision making eariy in the program
(McLane & Kim, 1989). Most instructional approaches in clinical decision
making have utilized lectures and discussions of simulated patient situations
in short instructional workshops. These strategies have resulted in minimal
irnprovernent in diagnostic reasoning skills (Gordon, 1989; Spies, Myers, &
Pinell, 1 989).
More recent instructional approaches have attempted to model the
cognitive processes required in clinical decision making. For example, one
strategy utilizes a self-directed learning approach to guide students in deriving
meaning from patient cues through visual representations of patient problems
and strengths (Jeffreys, 1993). After a clinical encounter with an assigned
patient, students must draw and label significant patient attributes on the
prepared worksheet. Students are then guided through the process of
interpreting patient cues and selecting and prioritizing the diagnoses. This
strategy is unique in that students are guided to make clinical decisions in the
context of actual nurse-patient interactions.
Another self-directed learning strategy is theBUquality audit tool" (Herman,
Pesut, 8 Conrad, 1994) which guides students through an eight step process
to diagnose patient problems and to develop appropriate interventions.
Questions are posed within each section to encourage the students to reflect
on their knowledge and confidence levels at each step of the tool. Although
these instructional tools have not yet been examined for learning gains, the
attempts to develop cognitive and metacognitive skills were perceived by the
students as effective in helping thetn to understand clinical decision making
(Jeffreys, 1993; Pesut, & Conrad, 1994).
Measuring Clinical Decision Making Skills
Although nursing educators acknowledge the importance of developing
clinical decision making skills, the majority of graduate and undergraduate
nursing programs do not require nursing students to acquire a specified level
of cornpetence in diagnostic reasoning prior to graduation (McLane & Kim,
1989). The lack of a clear description of the cognitive processes involved in
clinical decision making could be expected to contribute to the difficulties in
assessing those skills and the desired skill level.
The clinical decision rnaking skills of nurses, however, have been
investigated in simulated patient situations by examining (a) the clinical
decision itself, and (b) the cognitive processes utilized in reaching a clinical
judgernent (EtherÏdge, Bos, & Bos, 1992; Tanner et al, 1987). The clinical
decision is evaluated in terms of "labelling accuracy" and "diagnostic accuracy."
The wording of the clinical decision or nursing diagnosis label is compared to
the current NANDA taxonomy to determine the labelling accuracy of the clinical
judgement. The accuracy of the diagnostic label in terrns of data presented in
the case study is compared to those diagnoses selected by "expert panels"
(Cholowski & Chan; 1992: Etheridge et al., 1992) or by predetermined criteria
(Andersen & Briggs, 1988; Minton & Creason, 1991).
The cognitive processes used in clinical decision making have been
examined using think aloud protocols collected during simulated patient
situations (Grobe et al., 1991 ; Tanner et al., 1987; Tschikota, 1993; White et al.,
1992). Simulated case studies have provided standardized and controlled
complexity in patient situations presented to nurses (Lunney, 1992). Simulated
patient situations have also perrnitted the cornparison of the behaviours of
nurses with varying levels of experience within a controlled setting (Tanner et
al., 1987). However, researchers investigating clinical decision making in
nursing have noted limitations to simulated case study situations. One
limitation is that nurses participating in case study simulations are not under
the time constrain ts normally encountered in actual working environments
(Etheridge et al., 1992). A second limitation is that the increased awareness of
a research situation may cause nurses to report more data than usually
documented in patient records (Maas, Hardy, & Craft, 1990). In spite of the
concerns regarding simulated patient situations, little research has been done
on clinical decision making in actual work settings.
Cognitive Processes Underlyin~ Clinical Decision Makinq
The approach taken by researchers to date has provided lirnited
understanding of the cognitive processes underlying clinical decision making.
What is needed is an approach that investigates the thinking skills utilized by
nurses in actual clinical decision making situations. A model for investigating
the thinking processes utilized across disciplines in higher education (Donald,
1985; 1992) provides a frarnework which could be applied to examining the
thinking skills employed in actual clinical decision making situations.
According to Donald (1992), the cognitive skills utilized in different disciplines
can be conceptualized in a working model of thinking processes and sub-
operations. Developed from an analysis of the processes used in
postsecondary learning situations such as critical thinking and problem
solving, the model (Table 2) provides operational definitions of thinking
processes (Donald, 1985, 1992).
The thinking processes are organized into six skills; description,
selection, representation, inference, syn thesis and verificaüon. Each s kill is
sub-divided into four to seven operations for a total of 30 different thinking skill
operations (Donald, 1992). Descripüon refers to the delineation or definition of
a situation or form of a thing. Selection is the deliberate choice in preference to
another. Representation refers to the depiction or portrayal through enactive,
iconic or symbolic means. Inference is the act or process of drawing
conclusions from premises or evidence. In synthesis, parts or elements are
combined into a complex whole. In verification, the accuracy, coherence,
consistency or correspondence is confirmed. Definitions for the thinking
processes are found in Appendix A.
In a study utilizing the model, expert teachers from six pure and applied
disciplines confirmed that the processes of description, selection,
representation, inference, synthesis, and verification were developed in their
respective fields (Donald, 1992). The emphasis piaced on the thinking
processes varied according to the particular discipline. For example, the
problem solving process was important in engineering courses, and
professors focused on the development of the thinking processes of selection,
representation, synthesis and verificaüon. On the other hand, the development
of the students' abilities to analyze and make judgements was important in
teacher education courses, and professors focused on the development of the
thin king processes of description, selection, represen tation, inference,
syn thesis, and venfication (Higuchi & Donald, 1993, 1994). If clinical decision
making is considered to be a type of problem solving activity, then one could
expect that the thinking processes in the model would be applicable in nursing
education.
In reviewing the individual steps in the clinical decision making rnodels
used in nursing practice (Table l), it is apparent that nurses utilize some of
Donald's model of thinking processes in clinical decision making. For
example, inference is used when the nurse develops a nursing diagnosis. One
could expect that the thinking processes in the model would be useful in
elucidating the processes to be taught in professional nursing educaüon. The
thinking process model would have to be tested for its applicability in a
particular context, that is within the actual clinical setting.
Table 2
Model of Thinking Processes (Donald, 1992)
Skill Operations
Description ldentify context Conditions List facts List fu nctions State assumptions State goal
Selection
Representation
- Inference
Synthesis
Choose relevant information Order information in importance ldentify critical elements ldentify critical relations
Recognize organizing principles Organize elements and relations Illustrate elements and relations ModiS elements and relations
Discover new relations behrveen elernents D iscover new relations between relations Discover equivalences Categorize Order Change perspective Hypothesize
Combine parts to form a whole Elaborate Generate missing links Develop a course of action
Verification Compare alternative outcomes Compare outcorne ta standard Judge validity Use feedback Confirm results
Clinical Decision Making in the Practice Setting
Clinical decision making takeç place within a particular context, that is, it
is situated in a practice setting such as a hospital. It is thus influenced by
several sets of variables. According to Tanner (1986), variables that influence
both the process and outcornes of clinical decision making include (a) context,
(b) task, (c) clinician, and (d) risklbenefit variables. Contextual variables refer to
the features of the clinical setüng, çuch as the type of patient assignment
system, in which the clinical decision is made. Task variables are the aspects
of the problem situation that contribute to the complexity of the problem.
Clinician variables include the characteristics that the decision maker brings to
the task, such as knowledge and previous experïence with similrir situations.
Risklbenefit variables refer to the potential consequences of actions resulting
from the clinical decision. Knowledge of the consequences of actions
(risklbenefit variables) can be considered to be a component of clinician
knowledge or characteristics, and for the purposes of this study risklbenefit
variables and clinician characteristics will simplified as one variable; clinical
characteristics. In this study, clinical decision rnaking will be exarnined in terms
of the three variables; contextual factors, task variables, and clinician
characteristics.
The conceptual framework for clinical decision making that will be used
in this study is illustrated in Figure 1. The independent variables under
consideration in this study include (a) con textual factors: the nursing sub-
groups of medical and surgical nursing (as components of adult care), the
primary nursing patient assignment syçtem, and the charting system (problem
oriented charting), (b) task variables: the complexity of patient problems as
defined by the number and clarity of patient cues, and (c) clinician
characteristics: the expertise of the nurse as confirmed by the cornpleteness of
patient assessrnent data documented in patient records and the nomination by
colleagues and supervisors. The dependent variables that measure clinical
decision making are evident in the communication of clinical decisions and
include (a) accuracy of docurnented nursing diagnoses, (b) type and frequency
of thin king processes documented in the patients' records.
Contextual Factors
nursing sub-group primary nursing charting syçtern
Task Variables
cornplexity
I
Clinician Cha racteristics
expertise
Clinical Decision Making
l nursing diag nosis accuracy thinking processes 1
Figure 1. Frarnework for investigating clinical decision making
Contextual factors. Contextual factors are the characteristics of the
setting in which clinical decision making occurs. Clinical decision rnaking by
nurses occurred more frequently in community hospitals (Prescott, Den nis, &
Jacox, 1987) where medical staff are on site for lirnited time periods. When
physicians were unavailable, nurses frequently made decisions usually
considered within the scope of medical practice (Joseph, Matrone, & Osborne,
1988). Small, specialized units with fewer staff and situations with rapidly
changing patient conditions were associated with independent decision
making situations for nurses (Baumann & Bourbonnais, 1982; Prescott et al.,
1987). The effect of contextual factors, such as hospital size and nursing
çpecialization, on the clinical decision making process has received Iittle
attention in the literature.
Another contextual consideration in clinical decision making is the
system of patient assignment, such as primary nuning. Primary nursing is a
system of patient assignrnent where an individual nurse has the authority and
responsibility for the nursing care given to specific patients 24 hours per day, 7
days per week (Manthey, 1980). Other nurses accept responsibility for patient
care when the prirnary nurse is not in attendance. Investigations into the
benefits of prïmary nursing for patients and nurses have produced mixed
findings and have exhibited rnethodological problems (Giovannett i, 1986;
Macdonald, 1988). However, nurses involved in a multi-site study consistently
reported that primary nursing enhanced their patient knowledge, perrnitting
increased opportunities for participation with physicians in clinical decision
making situations (Prescott et al., 1987). The differences in clinical decision
making as a result of primary nursing systems have received Iittle attention in
the literature, but such a mode1 of practice might have a significant effect on
clinical decision making.
The type of charting system used by a health care institution can affect
the clinical decision making process. In particular, the problem oriented
. recording [PORI system assists the health care professional in thinking
through the identified patient problems (Gordon, 1994). In problem oriented
recording, the narrative notes in hospital records are organized in a "SOAP"
format for each patient problem. SOAP represents the structure of narrative
chart entries to include; subjective data (S) reported by the patient, objective
data (O) collected by the nurse, assessrnent of the situation (A) or problem
identification, and planned interventions (P). In one study using sirnulated
patient situations, nursing students were able to more clearly document patÏent
problems and subsequent plans €0 address those problems when they used
the POR system (Mitchell & Atwood, 1975). Although the cognitive processes
utilized by the nurse in clinical decision making are more readily evident with
the POR system (Gordon, 1994), there is little empirical evidence to support the
preference of one charting system over another.
Task variables. In clinical practice, health Gare professionals face
complex and ill-defined problem situations (Schon, 1983). Problem situations
can be considered on a continuum fiom well-structured to ill-structured (Voss &
Post, 1988). In well-stnictured problems, the solution strategies are
constrained and relatively well defined. Ill-structured problems are more
arnbiguous with no clearly defined solutions readily available. During the
solution process, ill-structured problems are decomposed or analyzed into
smaller, well-structured sub-problems (Voss & Post, 1988).
According to Wesffall, Tanner, Putzier, and Padrick (1 986) the complexity
or difficulty of a patient problem situation is defined by (a) the presence of
multiple diagnoses (as compared to a single diagnosis) and. (b) the presence
of ambiguous or subtle cues, or nurnerous exlraneous cues. For example, a
physical cue such as a fou1 smelling draining wound leads to a ready
diagnosis; a wound infection. On the other hand, a patient complaining of
headaches, lethargy, a sense of hopelessness and powerlessness
represents a problem of greater complexity. These patient cues could
represent diagnoses as varied as clinical depression, dysfunctional grieving,
or rape trauma syndrome. The nurse must collect additional information to
clarify the ambiguity of the initial cues presented by the patient.
Task complexity can also be defined by the extent to which established
interventions or protocols are available for specific patient problems (Corcoran,
1986). For example, standardized nursing care plans are protocols that provide
specific directions for nursing inteiventions associated with specific patient
problems. Thus, 'the availability of specific protocols, the ambiguity and number
of the patient cues, contribute to the complexity of the task and affect the clinical
decision making process.
Clinician characteristics. Differences in clinical decision making have
been examined in light of characteristics such as knowledge, experience, and
educational level. In an attempt to discem the components of clinical decision
making, the processes utilized by novices and experts have been compared
using sirnulated patient situations (Lesgold et al., 1988; Patel & Groen, ?WI,
Tanner et al., 1987). Nurses considered to be experts in their field are defined
as having extensive dinical experience in a particular nursing specialty and are
recog nized by their supervisors and peers as having outstanding clinical
decision making skills (Benner, 1984). Expert nurses have acquired a
"perceptual awarenessm that allows them to distinguish relevant from irrelevant
information and to see patient situations as a whole rather than isolated parts
(Benner & Wrubel, 1982). ln conttast, nursing students have difficulty
discriminating between important and superfluous data in clinical situations
(Thiele, Holloway, Murphy, Pendarvis, & Stucky, 1991). Expert nurses are better
able to develop a broad understanding of the patient, whereas novices (defined
as nursing students and new graduates) tend to focus on single problems
(Corcoran, 1986).
Another important characteristic is "knowing the patient" (Jenny & Logan,
1992; Tanner, Benner, Chesla, & Gordon, 1993). Knowing the patient refers to
an immediate and in-depth understanding of patient situations and the
patient's pattern of responses (Tanner et al., 1993) gained through experience
in the practice setting (Benner, 1984). When persona1 relationships with
patients have not been established, nurses lack in-depth patient knowledge
and report diminished confidence in. their. ability to make appropriate clinical
decisions (Jenks, 1993).
Experienced nurses also acknowledge the role of intuition as a rational
process in decision making, especially when data . are incornplete or
ambiguous (Rew, 1988): Intuition refers to a type of skilled pattern recognition
and "understanding without a rationale, based on background understanding
and skilled clinical observation" (Benner & Tanner, 1987, p. 30). Rew (1988)
suggests that intuitive knowledge is particularly strong when it is related to life-
threatening situations. Although these studies indicate a relationship between
clinician characteristics and decision making strateg ies, there is a paucity of
investigations that have exarnined the influences of clinician characteristics in
actual clinical decision making situations.
Communication of dinical decisions. In clinical practice settings,
nurses work as members of a health care team. Therefore, clinical decisions
must be commuriicated to other members of the health care tearn to ensure
the conünuity and coordination of patient care (Fischbach, 1991). The
standards of nursing practice also require nurses to formulate and to
document patient problems as nursing diagnoses (CNO, 1990, lW6a).
Nurses reported that they document clinical decisions in the form of nursing
diagnoses to identify patient problems, communicate with other team
members, and to plan or improve patient care (Higuchi et al., 1995).
Hospital records in the form of patient charts and cornputerized care
plans can be used to examine the clinical decision making process. Studies of
nursing diagnosis documentation in patient records by hospital nursing staff
have not yielded a consistent pattern. Using a randomized sample of al1 patient
records from hospital units that had implemented nursing diagnosis, evidence
of nursing diagnosis documentation in the patient charts varied widely from
26% to 94% (Duff, Higuchi, & Laschinget, 1993; Johnson & Hales, 1989;
Lessow, 1987). When patient records with at least 1 documented patient
problem were examined, 67% to 87% of the diagnoses were wrrectly worded
according to the currently accepted NANDA taxonomy (Martin et al., 1989;
Minton & Creason, 1991). Nursing diagnosis documentation was found only in
hospitals where formal educational and implementation programs existed
(Higuchi et al., 1995; Thomas & Newsome, 1992). To date, investigations into
the communication of clinical decisions in patient records have examined the
frequency of clinical decisions. The cognitive processes underlying the
communication and documentation of clinical decisions in actual practice
settings, on the other hand, have received little attention.
Statement of the Problem
A primary goal of professional education in nursing is optimal clinical
decision making. If effective instructional strategies for professional n ursing
education are to be developed, the knowledge and cognitive processes utilized
by nurses need to be delineated. The purpose of this study therefore, was to
investigate the thinking processes utilized by nurses in actual clinical decision
making situations. To examine the contextual factors, task variables and
clinician characteristics that influence clinical decision making, the following
questions were addressed.
1. What thinking processes are used in clinical decision making?
2. How does the nursing sub-group (medical and surgical nursing) affect
the clinical problern situations encountered and the thinking processes
utilized by the nurses?
3. Are there changes in the thinking processes utilized by nurses in clinical
decision making after the implernentation of primary nursing?
4. Are there differences in the documentation of clinical decisions when
nurses use structured charting formats?
5. Are there differences in the thinking processes utilized in clinical
problem situations of varying complexity?
6. How does the level of nursing expertise influence the documentation of
clinical decisionç and the thinking processes utilized in clinical decision
making?
Research Design
To examine the contextual factors (nursing sub-group, primary nursing,
and charting system), the task variables (clinical problem complexity), and the
clinician characteristics (nursing expertise) that influence clinical decision
making, a quasi-experimental multiple time series design (Campbell &
Stanley, 1966; Cook & Campbell, 1979; Roberts & Burke, 1989) was selected.
A quasi-experimental approach was utilized since the variables under study
were naturally occumng and the participants (as subjects in this study) could
not be randomly assigned to experirnental and control groups. In using a
multiple time series design, changes in the documentation of nursing
diagnoses and the thinking processes (dependent variables) were rneasured
over an extended time period. Cornparison of the medical and surgical units
within the same institution provided a more robust design (Campbell & Stanley,
1966). Changes in clinical decision making that occurred as a result of the
introduction of primary nursing (X) could be interpreted by comparing the
medical and surgical nursing units, as well as obsetving changes that
occurred on the medical unit after the implementation of primary nursing
(Figure 2).
Med Unit 0 1 4 X 0 3 O4 0 s Obs
Surg Unit 01 4 4 O4 4 Obs
Data Collection Dec Feb Aprhlay Jul Sept Nov MayiJune 93 94 94 94 94 94 95
Figure 2. Multiple time series design
The simultaneous multiple observations of the medical and surgical
nursing units, characteristic of multiple tirne series designs, offered several
advantages in controlling the effect of extraneous variables, and thus,
contributing to interna1 validity. The effect of regreçsion was controlled through
the randornized selection of patient charts over several tirne periods. Since the
charts were seiected retrospecü~ely, the effect of rnortality was controlled.
Additional data obtained through observations and interviews with nursing staff
on the medical and surgical units controlled the effect of history. Since the
participants were unaware of chart data collection until after observation time
five (O5), the testing and maturation effect was avoided. Consistent use of the
same procedures and masures during al1 observation periods prevented any
instrumentation effects.
Method
Site - The Queensway-Carleton Hospital is an acute care cornmunity hospital
situated in Nepean, Ontario. This 21 1 bed general hospital opened in 1976,
and offers health care services to adults in areas such as medicine, surgery,
psychiatry, geriatrics, and critical care. It was selected as the site of the
research study for several reasons. First, it is representaüve of many health
care facitities across Ontario and Canada in terms of the number of beds and
the level of education of its nursing staff. In Canada, 84% of hospital beds were
situated in health care institutions of more than 100 beds (Canadian Hospital
Association, 1994). In Ontario, general hospitals employed 55% of the total
workforce of 82,069 nurses (CNO, 1996b). Of the 45,236 nurses empleyed in
general hospitals, 83% had diploma level educational preparation (CNO,
l996b). At b i s hospital approxirnately 89% of the nurses had diploma level
preparation (Duff et al., 1993). Therefore, this site is representative of many
nursing practice settings in Ontario and Canada.
Second, clinical decision making opportunities are likely to occur more
frequently for nurses in cornmunity hospitals (Prescott et al., 1987) where
medical staff are on site for limited time periods. Third, as of 1982 nursing
policy and procedure changes have been introduced in this hospital that could
affect clinical decision making. For example, the POR systern is utilized on
rnost hospital units and nursing staff are required to document nursing
diagnoses based on the clinical assessrnent data. More recently, in April 1994,
two nursing units introduced a patient assignment- system known as primary
nursing in an effort to enhance nursing autonomy and improve the qwality of
nursing care. Nursing administrators support an examina tion of primary
nursing and clinical decision making to provide empirical evidence necessary
for future decisions regarding policy and procedural changes (L. Taylor,
personal communication, November 28, 1994).
Fourth, the nursing staff population has rernained stable over many
years so that it is possible to examine nursing documentation over an extended
familiar with the hospital and key nursing
as a nurse educator from 1981 until
time period. Fiffh, the researcher was
personnel from previous ernployrnent
1983, and as a researcher (Duff et al., 1993; Higuchi et al., 1995). This
knowledge reduced the orientation time and was an advantage in gaining
access and recruiting participants.
Selection of Nursing Units
At this hospital, the medical and surgical nursing units were selected as
the data collection sites for two reasons. First, medical and surgical units
represent the largest group (39%) of acute care hospital beds (Canadian
Hospital Association, 1 994). Second, because of extensive nursing experience
in nurnerous medical-surgical hospital settings, the investigator had the
necessary expertise to understand the patient problems on the medical and
surgical units. The medical and surgical units selected at this hospital were
similar with respect to nursing staff-patient ratio and administrative
organization.
AIthough hospital units tend to be organized according to specializations
within the medical profession, nursing specialîzations tend to be organized
across population groups such as adult care. For example, nursing curricula
are organized so that medical and surgical nursing care are combined as adult
care (Burrell, 1992; Smeltzer & BareJ992). In professional nursing programs
the clinical component of adult care is usually situated in either medical or
surgical hospital units. Thus, the comparison of medical and surgical hospital
units is justifiable from a nursing perspective since they are sub-groups within
the nursing specialization of adult care.
Documents
Chart documents in use at the hospital, patient record data forms, and
interview record forms were essen tial documents in this study. Each hospital
chart contained numerous documents that various health professionals used
to record specific information concerning patient assessrnent and interventions
irnplemented during hospitalization. To establish the context in which nurses
documented clinical decisions, all the patient chart documents were exarnined.
Several documents such as the Nursing Data Base, Medication Record,
Graphic Chart, and Fluid Balance Record were common to both units. Other
documents such as Nursing Kardex-Medicine, Cardiac Teaching Record, and
Diabetic Teaching Record were specific to the medical nursing unit.
A description of the most commonly used chart documents is
summanzed in Appendix BI. The documentation frequency varied depending
on the purpose of the chart document. For example, the Nursing Data Base
contained patient data collected at the üme of the patient's initial admission to
hospital, and this information was therefore documented only once.
Assessment and intervention information were recorded at least daily (q. day),
every shift (q. shift), or as required (p.r.n.) on documents such as the
Medication Administration Record, Graphic Chart, and Progress Notes. Data
collected from patient records were documented on the Patient Record Data
forrn (Appendix 82).
Procedure
Preliminary meetings. During a series of meetings with key hospital
administrators including the vice-president of patient services, the director of
nursing practice, nurse managers, the nurse educator, and the medical
records manager, the proposed research study was outlined. To explain the
purpose and nature of the study, one meeting with senior nursing
administrators and three meetings with the nursing staff of the two selected
hospital units were conducted. A summary of the research proposal and an
outline of the nature of the involvement required by the hospital staff (Appendix
C) were posted in the nursing conference rooms on each unit. During the initial
obsenration days on each hospital unit the nurses received individual
explanations of the study and prospective participants signed copies of the
consent forrn (Appendix Dl). Ethical approval was granted from the
Queensway-Carleton Hospital Consents and Research Committee (Appendix
D2), and the Research Ethics Committee of the Faculty of Education, McGill
University (Appendix D3).
Data collection from patient charts. To measure the thinking processes
utilized in clinical decisions documented by nurses, a chart audit of patients
discharged from the medical and surgical units was conducted. The medical
records department randomly selected a total of 100 charts (10 in each time
period for each unit) for patients discharged during December 1993, February,
July, September, and November 1994. This approach ensured a suficient
sample to permit the examination of multiple clinical situations over an
extended time period. Seasonal fluctuations in charting were controlled by
randomly sampling charts over one full year (Cook & Campbell, 1979). To allow
for the adjustment to the primary nursing patient assignment system, data
collection was suspended during the two month implementation period (April
and May, 1994).
Information collected from patient records included medical diagnoses,
nursing diagnoses, date and time of each chart entry, and nurse author code.
Verbatim patient assessrnent information. documented by nurses was
collected from nursing history records, standardized nursing care plans,
progress notes, and flow sheets. A total of 120 nursing staff were identified in
the 100 patient charts; 67 staff frorn the medical unit, and 53 from the surgical
unit. In addition to permanent full time and part tirne registered nurses, casual
nursing staff and registered practical nurses were also identified. To be able to
link the nurses' documentation of clinical data over the five obseivation periods,
nurses participating in the study were selected from the full time and part time
staff..
Participants. A total of 15 nurses volunteered for this study. Using a
criterion sampling technique (Patton, 1987), a total of eight nurses were then
selected as participants. The nurses selected from each unit were matched in
terms of work experiences and current employment status. All the nurses had
diplorna level educaüon, and had from 11 to 28 (M = 20) years experience since
graduation, and 6 to 19 (M =12) years experience on the particular hospital unit
(Appendix E). To represent the normal distribution of work rotations, half the
nurses selected worked days/evenings, while half worked dayslnights. To
a represent the normal patient assignment pattern, three full time nurses, and
one part time nurse were selected from each unit. Nurses "A" to "Dm worked on
the medical unit and nurses "En to "Hm were from the surgical unit.
To be able to investigate how clinician characteristics influence cl inical
decision making, the nurses from each hospital unit were grouped by h o
levels of experüse (Benner, 1984; Siegel & Castellan, 1988). Although al1 eight
nurses had extensive work experience, the four "expeK nurses (Benner, 1984)
had more than 20 years of work experience since graduation, and at least eight
years of full üme experience on the particular nursing unit. The expert nurses
frequently assumed leadership roles as unit team leaders, and were viewed
as mentors by their peers. The "proficient" nurses (Benner, 1984) had more
than 11 years experience since' graduaüon. In the proficient group, two nurses
had worked 6 to 11 years full time, and two nurses had worked 6 to 14 years
part tirne on their particular unit. The expert nurses were nurses A, 5, Et and F,
while nurses C, D, G, and H cornpised the proficient group.
From the 50 randomly selected patient charts reviewed from each
nursing unit, the eight nurses had been assigned 11 to 19 patients each (M =
15). The nurses from the medical unit recorded a total of 42 to 81 day, evening
or night shifts (M = 56), while the surgical nurses recorded a total of 25 to 35 ((M
= 32) shifts in the 50 patient charts from each unit. Therefore, the number of
shifts recorded per patient chart ranged from 2.3 to 5.1 (M = 4) on the medical
unit and from 1.8 to 2.5 (M = 2) on the surgical unit. The shiffs worked
represented opportunities to document patient problem situations. From the
group of assigned patients, the medical nurses each documented narrative
notes in a total of 7 to 14 (M = 10) patient charts while the surgical nurses
documented narrative notes in 4 to 14 (M = 9) patient charts. To delineate the
thinking skills of nurses in actual clinicat situations, only patient charts with
narrative notes documented by the eight nurses were selected for further
analysis.
Selection of chart sample. The information from each chart was
examined as an individual patient record, and also linked to the eight nurses
selected for the study. The eight nurses had each been assigned to Gare for 11
to 19 out of the total of 50 randomly selected patients from their respective
units. The patient charts selected for further analysis al1 contained at least one
narrative note documented by one or more of the eight nurses. A total of 25
charts from the medical unit and 25 charts from the surgical unit then
comprised the chart sample.
The 25 charts from each unit included 15 female and 10 male patients.
The medical patients had a wide range of diseases including pulmonary and
cardiac conditions such as congestive heart failure, rnyocardial infarcüon,
chronic obstructive pulmonary disease, pneurnonia, and other conditions such
as cerebral vascular accident (stroke) and diabetes. On the surgical unit, the
patients had undergone orthopedic surgical procedures such as total hip
replacement and repair of fractured limbs, and general surgical procedures
such as inguinal hernia repair, and cholecystectomy (gall bladder removal).
Five patients were off service or medical patients who were admitted to the
surgical unit because no beds were available on the medical unit at the tirne of
admission. Thus. the nurses on both units were responsible for providing care
to adults with a wide range of acute and chronic conditions.
To establish the representativeness of the total population of patient
charts with the selected sampte of charts, the average hospital admission days
and the average age of the patients were compared. The number days in
hospital for patients on the medical unit ranged from 1 to 78 days (M = 9, SD =
12), and from 1 to 15 days (M = 4, SD = 4) on the surgical unit (Appendix FA). In
the sample of 25 charts the average nurnber of days was 13 days (SD = 15) on
the medical unit and 4 (Si3 = 4) days on the surgical unit. The average nurnber
of days in the total population and sample surgical charts were comparable.
The mean number of days was higher in the sarnple frorn the medical unit.
This can be partly explained by the inclusion of one patient (chart 448) during
the first observation period, who had a very lengthy (78 days) hospital stay.
However, the nursing and medical records staff reported it was not unusual to
have patients on the medical unit with lengthy hospital stays.
The average age of the patients on the medical unit rangNfrom 61 to 78
years (M = 69, SD = 21 years) (Appendix F2). The average age on the surgical
unit was lower, with a range of 47 to 63 yean (M = 54, SD = 20 years). The
average age of patients from the sample charts was 72 (SD =16) years on the
medical unit and 55 (SD = 20) years on the surgical unit In the sample charts
the average medical patient was 17 years older than the average surgical
patient, but the samples were representative of the patient population on each
unit.
To investigate the thinking processes utilized in actual clinical decisions,
the verbatim records of al1 narrative notes documented by the eight nurses
were examined at three levels; clinical element, clinical note; and clinical
episode. Narrative notes were docurnented when a nurse made a decision to
communicate information about a particular patient problem or situation. A
clinical elemenf refers to the smallest unit or phrase within the narrative notes.
An example of a narrative note is found in Appendix G. The narrative note
example haç been structured so that each line represents a clinical element or
phrase. Each handwritten narrative nursing note contained the date and time
as well- as the nurse's assessment of the patient problem situation. A clinical
note refers to the infonation about 'the patient situation documented by the
nurse at a specific time. The sample in Appendix G is an example of one
clinical note. During an 8 hour shR the nurses documented from 1 to 6 clinical
notes in responçe to the changes in clinical situations. A ciinical episode
contains the group of ciinical notes documented by a nurse duhg a parficular
shift.
The eight nurses documented a total of 100 clinical episodes, 142
clinical notes, and 934 clinical elements in the 50 sample charts. By individual
nurse, the total number of documented clinical episodes ranged from 11 to 22
(M = 17) on the medical unit and 4 to 14 (M = 8) on the surgical unit (Appendix
Hl). The total number of clinical notes documented by each nurse ranged from
14 to 39 (M = 25) on the medical units, and f i m 5 €0 17 (Ad = 10) on the surgical
unit (Appendix H2). To be able to conduct further analyses, the total number of
clinical episodes and dinical notes were grouped because there were no
documented clinical episodes or clinical notes during one or more observation
times by six out of the eight nurses. The Jack of docurnented clinical episodes
and clinical notes during one or more of the observation tirnes is to be
expected, as the nurses could be absent from the hospital units because of
holiday leave or illness.
Field observations. In studying the decision making skills of nurses, it
was important that the tasks were realistic and within the real life working
environment (Klein et al., 1 993; Radwin, 1 995). Interviews and observations of
nursing staff provided data about the context of the clinical decision making
process utilized by nurses. The pattern of nursing activities varied with each
shiff, and weekday versus weekend routines. Therefore, al1 shifts were
observed to gain a comprehensive view of usual nursing activities (Evertson &
Green, 1 986). To facilitate accep tance as a participan t-observer, the
investigator followed the scheduled shift patterns of the nursing staff.
The obsetvation schedule began with a general introduction to the units
during a day shift (0730-1530), followed by an evening (1 530-2330), or a night
shift (2330-0730). Once the nurses agreed to be interviewed, the observation
shiffç were organized according to the work schedules of prospective
participants. The focus of the observations was the set of activities related to
clinical decision making, such as the documentation of patient information. To
prevent disrupüon in their work schedules, the nurses were observed as they
in teracted with patients, and other health care professionals in public areas
such as corridors, and nursing conference rooms. The busy work schedules of
the nurses limited the amount of possible interaction during "on duty" shifts.
Therefore, informal interviews and discussions about clinical decision making
were conducted duhg the nurses' break times.
Interviews. lndividual tape-recorded, semi-structured interviews were
conducted in quiet areas such as the nurse manager's office, or an unoccupied
patient lounge. Three nurses elected to have their interviews scheduled after
working day, evening, and night shifts respectively. Three intennews were
conducted during the day shift and two during the night shift. The total intewiew
üme ranged from 55 to 139 minutes with a mean of 87 minutes. The interview
schedule (Appendix 1) elicited information about (a) educational and work
experiences of the participants, (b) clinical decisions nomally encountered in
practice (c) a clinical situation as a focus for further discussion of clinical
decision making, (d) communication of clinical decisions (e) thinking skills
invalved in clinical decision making, (f) primary nursing and clinical decision
making, and (g) the participant's perceptions of the importance of rnaking
clinical decisions in nursing. The questions were organized so that
straighfforward, general questions about the participant's background were
posed first, followed by increasingly cornplex and controversial topics (Patton,
1987). The questions conceming primary nursing were excluded in the
interviews with the surgical nurses. Ail the nurses were advised that they
should not feel constrained by the interview questions (Donald, 1990), and
were encouraged to fully descri be the clinical decision making situations.
Two months after the interviews were completed. the nurses reviewed
transcripts of their interviews to confimi the accuracy of data collection (Brink,
1991; Donald, 1990). Several nurses included additional comrnents about the
thinking processes utilized in clinical decision making when they returned their
revised versions of the interview. For example, one nurse described her use of
intuition in clinical decision making. Another nurse requested a second
interview to share additional comments on clinical decision making,
Data Analysis
Nursing diagnosis documentation. To investigate changes in clinical
decision making as a result of the introduction of primary nursing, nursing
diagnosis documentation patterns were examined over a one year period. In
each of the five observation perÏods, 10 patient records were randomly selected
from each unit to provide a sample of 100 patient records. The nursing
diagnoses documented in the 100 charts were examined to determine (a)
labeling accuracy and (b) diagnostic accuracy. The labeling accuracy of each
nursing diagnosis documented in the care plan was evaluated according to the
currently accepted NANDA taxonomy of nursing diagnoses (NANDA, 1994)
(Appendix JI). For example, any statements that were worded according to the
current NANDA taxonomy were classilled as "accurate." Any problem
statements or etiologies that did not meet the criteria for accurate label were
coded as an "attempt." Any nursing diagnoses selected in the standardized
care plan were coded as an "accurate labeln since all standardized care plans
were based on the currently accepted NANDA taxonomy.
Next, the diagnostic accuracy of each nursing diagnosis waç evaluated
in ternis of documented patient assessment data. Relevant patient
assessment data documented prior to the selection of a nursing diagnosis
was coded as an "accurate diagnosis." Nursing diagnostic statements with
diagnostic errors (Carnevali & Thomas, 1993) were coded as "incorrect
diagnosis, unsupported diagnosis, unspecified diagnosis or omitted
diagnosis" (Appendix J2). It waç not possible to conduct further analyses on the
. thinking processes (evidenced in the narrative notes) associated with nursing
diagnosis documentation because of the limited sample site. Only one nurse
documented more than three nursing diagnoses and three clinical notes in
more than three patient charts (Appendix K).
Coding of thinking processes. To invesügate the thinking processes
uülized in clinical decision making, each clinical elernent or phrase in the
narrative notes documented by the eight nurses, was coded by thinking skill
and operation. A table of nursing exemplars and illustrations of thinking
processes (Table 3) was developed by comparing the chart data with the
definitions in the model of thinking processes (Appendix A). The table inciudes
only those thinking skills and operations that were found in the narrative notes.
Consensus was achieved as to the nursing exemplars and illustrations for
each thinking skill operation after numerous discussions between the
invesügator and 3 other researchers. The coding of the data was verified by an
independent researcher and achieved an inter-rater reliability level of 93%
agreement for the thinking skills and 84% for the operations. Mutual agreement
was then reached for any quesüonable exernplars.
Each thinking skill and operation were assigned a code number. For
example, description was coded number "lm, selection was "T, and so on.
Identify context, the firçt operation under description was coded number "1.1 ". To ensure accurate coding of each clinical element or phrase, the
context of the each clinical note was established by reviewing the information
documented by preceding nurses. The narrative account of each documented
clinical situation was examined for statements that identified problern
situations, previously documented problem situations, and nursing actions. If
the nurse included a problem staternent in the clinical note, such as a patient's
complaint of chest pain, then the documented chest pain complaint was coded
as the selection operation identiw critical elements. In the example found in
Appendix G, the chest pain represented patient data relevant to an identified
problern situation. However, if the situation was not identified as a problem
situation, the docurnented chest pain would be coded as the selection
operation choose relevant information, since the chest pain was relevant to the
clinical situation. If the problem of chest pain had been identified in a previous
shift, and/or the nurse reported that interventions such as oxygen therapy or
medications were administered, then the reported level of chest pain would be
coded as the verïfication operation judge validity. ln this instance the report of
chest pain would be patient data that confirmed the effectiveness or
ineffectiveness of specific nursing actions. Thus, to consistently code the
appropriate level of thinking skill and operation for each element or phrase, the
context of the current, and prior clinical situations was first established.
The specificity of the nursing interventions was also considered. For .
example, statements of general nursing actions such as "monitor chest pain"
or "follow nursing care plan" would indicate a general direction for nursing care
and would be coded as the descriptive operation state goal. Statements of
nursing actions that indicated that the nurse had made clinical decisions
based on the synthesis of multiple clinical data and were more individualized
or patient specific were coded as the synthesis operation develop course of
action. In the example found in Appendix G the nurse documented 'notify Dr. in
am re chest pain." In this example the nurse used the synthesis operation
develop course of action since her analysis of the patient cues indicated that
the patient's chest pain did not warrant an imrnediate consultation with the
physician. Thus, the nursing action was specific to the patient situation at this
particular tirne.
Since the narrative notes documented in the chart data contained
summaries of the nurses' thinking and decisions about clinical situations, it
was not possible to analyze the camplexity of clinical problem situations by
criteria such as the arnbiguity or clarity of patient cues. Instead, each
documented clinical note was assigned to one of three categories based on
the type of clinical situation. The coding of the clinical situations were verified by
two other independent researchers and achieved an inter-rater reliability level
of 92%. Mutual agreement was then reached for any questionable situations.
Type 1 clinical situations included the recording of information required by the
hospital charting procedure (Appendix L), such as the documentation of patient
transfers to and from other hospital units. In type 2 clinical situations, clinical
data were documented without a problem staternent. For example, nurses on
the surgical unit documented post-operative assessrnents of patients following
unevenfful surgical procedures. Narrative notes that included an identified
problem staternent were coded type 3 clinical situations. For example, nurses
on the medical unit recorded clinical situations such as a patient's cornplaint of
chest pain, and the su bsequent nursing interventions implemented to alleviate
the patient's discornfort. Thus, to determine the thinking processes utilized in
clinical problem situations, the type and frequency of thinking processes were
determined and grouped into one of three types of clinical situations.
To hvestigate the differences in the documentation of clinical decisions
when nurses used structured charting formats characteristic of the PO R
charting systern, the narrative notes were grouped by SOAP versus non SOAP
formats. Those clinical notes coded as SOAP format contained data organized
to include subjective (S) or objective (0) data, assessrnent (A) information, and
proposed plans (P). Narrative notes that were documented without a structured
format were classified as non SOAP format. The type and frequency of thinking
processes were determined for the SOAP and non SOAP fonnatted clinical
notes,
The coded chart data were then entered and analyzed using "Systatn
statistical cornputer software program. The variables included chart number,
nursing unit, observation time period, nurse author, date and time of chart entry,
clinical situation type, thinking skill and operation. To describe the thinking
skills utilized in clinical decisions documented by nurses in the chart data,
frequency counts of the thinking skills and operations in each clinical episode
and clinical note were calculated by nursing unit, nurse, observation üme
period, clinical situation type, and SOAP format. Since the dependent variables,
the thinking skills and operations, constituted nominal or categorice! data, non-
parametric statistical tests such as the chi square test for two independent
sarnples (Siegel & Castellan, 1988) were employed in the data analysis.
Analysis of intetview data. Transcripts of tape recorded interviews were
subjected to qualitative data analysis procedures (Bogdan & Biklen, 1992;
Miles & Huberman, 1984, 1994). Using content analysis, the major themes and
patterns relevant to the clinical decision making process were identified
(Patton, 1987). The coding of the data was verified by a second independent
nursing researcher and achieved an inter-rater reliability level of 92%
agreement. Mutual agreement was then reached for any questionable
categories.
Results
Pn'mary Nursing and Nursing Diagnosis Documentation
Prirnary nursing was implemented on the medical unit during April and
May, 1994, that is, between observation times O2 and 03. Structural changes to
the medical nursing unit occurred so that two srnall team conference rooms
were combined into one large conference room. Nursing staff and the unit
administrator jointly developed new policy and procedures that reflected the
increased nursing responsibiliües for patient Gare as a result of the
introduction of primary nursing. The changes in patient assignment procedures
were introduced through written memos and informal discussion groups. The
designated primary nurse was indicated only through a temporary chalkboard
listing in the unit conference roorn, and was not permanently recorded on any
chart documents. Therefore, it was not possible to invesügate the
documentation of clinical decisions by the designated prirnary nurse in specific
charts of discharged patients. Thus, charts from the medical unit were grouped
by observation period to determine if there were any changes in nursing.
diagnosis documentation and thinking processes as a result of the
implementation of prirnary nursing.
To investigate changes in clinical decision making as a result of the
introduction of primary nursing, the nursing diagnosis documentation was
exarnined in the total sample of 100 charts. A total of 138 nursing diagnoses
were documented in 40 of the 100 patient records (20 medical records and 20
surgical records). The majority of diagnostic statements (134 out of 138) were
documented by checking the appropriate nursing diagnosis and etiology on
standardized chart forms. The remaining 4 diagnostic statements were nurse
generated and hand written on individualized nursing care plans. U tilization of
standardized nursing care plans resulted in almost perfect labelling accuracy
in the diagnostic statemen ts and accompanying etiologies for both surgical
(1 00%) and medical (97%) charts, including one handwritten diagnostic
statement (Appendix Ml). The three rernaining hand written diagnostic
statements from the medical unit had "attempted labels and etiologiesn since .
the diagnostic statements were not worded according to the currentiy accepted
NANDA taxonorny (NANDA, 1994).
The diagnostic accuracy of the documented nursing diagnoses was
determined by comparing each diagnostic statement with documented
assessrnent data such as health problems identified &y the patient and health
care professionals. All the diagnostic statements (100%) were coded as
accurate because patient data were present to support the nursing diagnoses
selected. However, only 40 out of the 100 patient charts (20 medical and 20
surgical charts) contained documented nursing diagnoses (Appendix M2). The
finding of a 40% nursing diagnosis documentation rate in patient charts is
within the range (29% to 56% of charts per unit) reported by Johnson & Hales
(1989). Thus, an ornitted diagnosis was the most cornmon diagnostic error
(60%) found in the 100 charts (Appendix M3). The chi square test results were
not significant indicating that the proportion of charts with omitted diagnoses
did not Vary significantly between the medical and surgical units across the five
observation periods. The results indicate that significant changes in nursing
diagnosis documentation were neither present between the units, nor occurred
after the introduction of primary nursing.
The lack of documented nursing diagnoses in patient charts can be
partly explained by the status accorded nursing diagnoses within nursing
practice and the health care system. Although the identification and.
documentation of patient problems as nursing diagnoses are expectations of
professional nursing practice (CNO, 1 WO), the legal requiremeot to document
nursing diagnoses within the health care system is not as evident. For
example, medical records staff must ensure that there is a rnedical diagnosis
documented on the chart of every discharged patient, but there is no
corresponding requirement for nursing diagnoses. Since the introduction of the
nursing diagnosis taxonomy, nurses have been ambivalent toward the value of
docurnenting nursing diagnoses in patient charts. Nurses who question the
value of nursing diagnoses suggest that the awkward wording of the diagnostic
labels contributes to difficulties in utilkation (Higuchi et al., 1995; Murphy &
Stem, 1993). In addition, many nurses lack the knowledge and experience to
confidently document nursing diagnoses (Howse & Bailey, 1992; Murphy &
- Stem. 1993). In this study the lack of nursing diagnoses did not affect the
investigation of cognitive processes, since other chart data, namely, the
narrative notes contained documentation of the nurses' thinking processes
utilized durhg actual clinical situations.
Primary Nursing and Thinking Processes
To determine if any changes occurred in thinking processes utilized in
clinical decision making as a result of primary nursing, al1 the narrative notes
documented by the eight nurses were examined. A total of 100 clinical
episodes documented by the eight nurses were exarnined for changes across
the five observation pen'ods and differences between the medical and surgical
units, The medical nurses 'documented more than twice the number of clinical
episodes (n = 68) as cornpared to the surgical nurses (n = 32) (Appendix NA).
The results of the chi square test were not significant indicating that there were
no significant differences in the relative proportions of clinicai episodes
documented over the observation time periods between the medical and
surgical units.
A similar pattern occurred in the distribution of clinical notes. From a total
of 142 clinical notes, 102 (72%) were documented by the nurses from the
medical unit, while 40 (28%) were from the surgical unit. Again, the results of
the chi square test were not significant indicating that the relative proportions of
clinical notes documented in each observation period were not significantly
different between the medical and surgical units.
A possible explanation for the greater numbers of clinical episodeç and
clinical notes documented in charts from the medical unit is that patients from
the medical unit tended to be older and have longer hospital admissions.
Consequently, there were more opportunities for the nurses to document
clinical notes because of the greater potential for problems associated with
elderly patients. Also, the longer hospitalizations of medical patients would
have permitted the nurses to increase their patient knowledge and sensitivity to
changes occumng with their patients. A possible explanation for fewer
documented surgical notes is that the charting procedure used on the surgical
unit resulted in greater uülization of fiow sheets specific to patient assessment,
and less use of narrative notes. Therefore, fewer documented surgical clinical
notes can be explained partly by the differences in the patient population and
partly by differences in charting procedures.
To determine if the thinking skills changed across the five observation
periods or between the medical and surgical nursing units, the clinical notes
were examined for evidence of thinking skills. Both the medical and surgical
clinical notes contained evidence of five categories of thinking skills;
description, selection, inference, synthesis and verification. There was no
evidence of any representation thinking skills in the documented narrative
notes. The number of different categories of thinking skills found in the clinical
notes ranged from 1 to Be(Appendix N2). The majority of medical (77%) and
surgical (86%) dinical notes contained examples of h o or more categories of
a thinking skills. That is, more than three quarters of the clinical notes contained
evidence that nurses used several thinking skills in the documentation of
clinical decisions. The results of the chi square test were not significant
indicating that the proportion of clinical notes with different categories of
thinking skills did not Vary significantly between the medical and surgical units.
Thus, there were no significant differences in the proportions of thinking skill
categories utilized by nurses from the medical versus surgical units when
documenting clinical decisions. In other words, the introduction of pnrnary
nursing did not affect the medical nurses' tendency ta document clinical
decisions or result in changes to the number of thinking skill categories
evidenced in the chart data.
Thinking Skills Utilized in Clinical Decision Making
The overall utilization of specific thinking skills was determined by
examining al1 the clinical episodes and clinical notes documented by the eight
nurses (Appendix 01). All the narrative notes documented over a particular shift
were grouped to f om a ciinical episode. The overall distribution of thinking
skills documented in the clinical episodes is illustrated in Figure 3. Ahost all
the medical (94%) and surgical (100%) clinical episodes contained evidence of
description. The nurses used description when they recorded clinical
information such as the transfer of patients from one hospital unit to another.
Selection was used in more than 75% of the surgical and medical clinical
episodes. Nurses used selection when they recorded patient cues and other
clinical data such as 'patient complaining of chest painn that was relevant to the
clinical situation. About three quarters (72%) of the surgical clinical episodes
and half (46%) the medical clinical episodes contained evidence of inference.
Nurses used inference when they recorded conclusions about clinical
situations such as 'patient stablen following surgical procedures. Synthesis
was found in 53% of medical and 25% of the surgical episodes. Nurses used
synthesis when they recorded statements such as specific nursing
interventions based on an analysis of multiple clinical data. Verificaüon was
documented in 46% of the medical and 9% of the surgical clinical episodes.
Verification was used when the nurses documented clinical data that gave
evidence as to the effectiveness of previous n ursing interventions.
Ski I ls
Description
Selection
l nference
Synt hesis Verification
O 10 20 30 40 50 60 70 80 90 100
Percentage of Clinical Eplsodes
4 Surgery
Figure 3. Thinking skills evidenced in clinical episodes.
The thinking skills utilized in a particular clinical situation at a specific
üme were determined by examining each clinical note. The overall distribution
of categories of thinking skills docurnented in the clinical notes indicated a
similar trend to that of the clinical episodes as illustrated in Figure 4.
Description was found in al1 the surgical notes and more than three quarters
(79%) of the medical notes. The majority of medical (69%) and surgical (88%)
clinical notes also contained evidence of selection. Nurses documented
evidence of inference thinking skills in the majority (58%) of surgical notes and
about one third (33%) of medical clinical notes. Evidence of synthesis was
found in almost half (48%) the medical and 20% of the surgical clinical notes.
Evidence of verification was found in 36% of the medical and 8% of the surgical
clinical notes. Thus, the distribution of thinking skills in clinical episodes
documented over an entire shift indicated a similar trend to the clinical notes
documented at specific points in üme. To further examine the thinking skills
utilized during a particular decision rnaking situation, the thinking skills and
operations were analyzed by clinical note and clinical element or phrase.
Thinktng Skil ls
Description
Selection
lnference
Synthesis
Verification I
I Surgery El Medicine L J
O 10 20 30 40 50 60 70 80 90 100
Percentage of Cllntcal Notes
Figure 4. Thinking skills evidenced in clinical notes.
Thinking Skill Operations Used in Clinical Decision Making
The clinical notes were examined to detemine which thinking skill
operaüons were utilized in a parücular clinical decision making situation.
Fourteen different operations were identified in the medical clinical notes and
12 operations in the surgical clinical notes. The number of different operations
ranged from 1 to 8 (M = 3.2 operations per rnedical note and M = 3.8 operaüons
per surgical note). More than three quarters of the medical and surgical notes
contained two or more different thinking skill operations (Appendix 02). ln other
words, there was evidence from the narrative notes that nurses used several
different thinking skill operations when documenting clinical information and
clinical decisions. It was not possible to determine if there were significant
differences in the proportions of clinical notes with different categories of
thinking skills operations behiveen the two units since more than 20% of the
cells had frequencies of less than 5 notes (Siegel & Castellan, 1988, p. 123.).
- Under description, five different operations were identified; identim
context, list conditions, iist facts, stafe assumptions, and state goal (Appendix
03). Evidence of the operation identjm context, was found in 50% of the surgical
notes and 22% of the medical notes, Nurses described the context of the
situation in the title of the narrative notes, as required in the POR charting
systern. Since nurses on the surgical unit tended to document narrative notes
with titleç more frequently, they used the operation identifL context more
frequently than the medical. nurses.
Only the medical notes contained evidence of the operation iist
conditions, although infrequently (7% of the notes). Nurses used the operation
list conditions when they documented information such as "side rails were up x
2 and the cal1 bel1 pinned to the bedn that described features of the clinical
environment that were important to record when the patient's condition
warranted such routine safety measures.
The operation stafe assumptions was found less frequently, but in
almost equal proportions in the surgical (13%) and rnedical (12%) clinical
notes. Nurses used the operation sfafe assumptions when they documented a
rationale for routine nursing interventions. For example, in chart 430, Nurse D
documented that analgesia was given "for cornplaints of headache." The
administration of analgesic medications in response to a patient complaining
of a headache was a routine nursing action when the patient did not have other
conditions, such as neurological or vascular problems.
List facts was the predominant operation overall and within the
description thinking skill category. Alrnost al1 (95%) the surgical clinical notes
and the majority (61%) of medical clinical notes contained information such as
routine nursing actions and other clinical information as evidence of utilization
of the operation iist facts. Since patient records are legal documents, nurses
are responsible for recording information such as consultations witb the
physician during unexpected changes in a patient's condition. Hospital prcjiocol
mandates the documentation of information such as patient transfers to and
from the hospital' unit (Appendix L), to indicate a transfer of responsibility for
patient care from one unit to another. Thus, the legal responsibility to ensure
that there are complete and accurate recordings of information such as patient
observations and actions taken by health care personnel partly explains the
frequent occurrence of the operation list facts in the clinical notes.
Almost half (45%) of the surgical notes and a quarter of the medical
notes contained the operation state goal. When a specific problem situation did
not exist, such as when a patient returned to the surgical unit in stable
condition following an unevenfful course of surgery, the nurses docurnented
general goals such as "follow standard nursing care plan," modelling the
exampie provided in the charting procedure manual. Thus, nurses used the
operation state goal to indicate a general direction for future nursing actions
when specific patient problems were not identified.
Evidence of two selection operaüons were found in the surgical and
medical clin ical notes; choose relevant information and identifjt critical
elements. The operation choose relevant infornafion was Uie second most
predominant operaüon overall, and was the most frequently occurring selection
operation in both the surgical (83%) and medical (48%) clinical notes. For
exarnple, in chart 434, Nurse A documented that she had spoken to the
patient's son and "he informed me that no resuscitation was to be instituted ... just keep him cornfortable.* This information was relevant to the decision not to
insütute heroic measures on an elderly, confused patient whose condition was
deteriorating. Thus, nurses used the operation choose relevant infornation
when they documented information that was relevant to a specific clinical
situation.
The other selection operation identiw critical elernenfs was used more
frequently in medical (27%) than surgical (13%) clinical notes. Nurses used the
operation idenfify critical elements when they recorded clinical information that
was relevant to a specific and identified problem situation. For exarnple, in
chart 341, Nurse E documented that a patient was experiencing a possible
allergic reaction to the bandage tape used post-operatively. Nurse E recorded
that the W in areas are red from previous tapes removed earlier today &
replaced with paper tapen and that the "pt says area is very itchy." This
information was relevant to the identified problem of a possible allergic
reaction. The nurse also included the following information about the patient's
general post-ope rative status; "pt passing g as R [rectally] ." This observation
was relevant to the patient's progress following abdominal surgery, but was not
specific to the problern of the possible skin allergy reaction. Thus, nurses used
the operation idenfify-cnfical eiements when they included clinicat data that
was specific to an identified problem situation, and choose relevant information
when they documented data that was relevant to a non problem situation.
There was evidence of three operations under inference; categorize,
hypothesize, and discover new relations between eiements. Categotize was
the most frequently used inference operation, evidenced in almost half (48%)
the surgical notes and 15% of the medical notes. The nurses used the
operation cafegorize when they made a judgement about the patient's overall
condition or status. For exarnple, in chart 325, Nurse. F documented in a post-
operative note the following data; p t drowsy but rouses easily, incisions x 4 to
abd [abdomen], dry 8 intact, IV RL pntravenous solution] 500 cc TBA [to be
absorbed], patent & infusing well." The nurse used the operaüon categodze
when she concluded that the patient's condition was 'stable" following
surgery. In fact, the operation cafegonze was uülized in al1 the post-operative or
shift assessment situations in Vie surgical clinical notes (n = 18) under the "A"
(assessment) component of the SOAP format, modelling the example provided
in the charting procedure manual. Thus, nurses used the operation categodze
to document their conclusions regarding the patient's condition when a
problem situation did not exist
The operations hypothesize and discover new relations between
elernents were found in less than 10% of the clinical notes and were used
when nurses documented their conclusions in identified problem situations.
For example, in chart 443 Nurse A recorded that the patient was "still having a
lot of pain in RT wrist and RT leg, c &c [colour and circulation] is good, warm to
touch, fingers & toes- O swelling, movement good." Nurse A used the operation
hypothesize when she concluded that the patient had "pain due to trauma"
0 since she documented a diagnostic statement with a proposed etiology.
The nurses used the operation discover new relations between
elements when they documented a diagnostic statement, but did not include a
possible etiology. For example, in chart 448 Nurse A documented that the
patient was 'complaining of abdominal painn and that "abdomen quite
distended. Some faint bowel sounds present. Bowels moving poorly according
to graphic. Three small pellets of stool felt in rectum and disimpacted of same."
In this example Nurse A used the operation discover new relations behveen
elements when she concluded 'pt constipated" since she recorded a
diagnostic statement without a possible etiology. In sumrnary, nurses used the
operations hypothesize and discover new relations befween elernents when
they documented their conclusions as to the patient's condition in problem
situations, and the operation categorize in non-problem situations.
The clinical notes contained evidence of two synthesis operations;
develop course of action and combine paris tu fom a whole. In almost half
(47%) the medical notes and 15% of the surgical notes the nurses used the
operation develop course of acfion when they documented specific nursing
actions to identified problem situations. For example, in chart 448, Nurse B
was assigned to a patient who was recovering from a stroke and a broken hip
and documented that the patient was "complaining of chest pain more on the rt
side than the left and pain 'al1 ovet . Cl2 [oxygen] started at 3Vmin and Tylenol#3
given." The decision to administer oxygen and pain medication indicated that
the nurse had synthesized the clinical data and had developed a specific
nursing action in response to the patient's complaints of discornfort. Thus,
when the nurses used the operation develop course of action they had
synthesized multiple clinical data to reach a decision to follow a parücular
course of nursing action.
The operaüon combine parts to form a whole was found infrequently in
the medical (3%) and surgical (5%) clinical notes and was used when nurses
synthesized multiple clinical data into a statement about the overall clinical
situation. For example, in chart 306, the patient had recently been diagnosed
with a brain tumour. In addition to recording patient complaints about
headaches, Nurse H documented that the patient was uverbalizing re possible
Rx [treatrnent] & concerns re surgery & tumour."
Two verification operations were found in the clinical notes; judge validity
and confirm results. The operation judge validify was found more frequently in
the medical (34%) than surgical (5%) clinical notes. The nurses used the
ope ration judge validity when they documented specific clinical data that
confirrned the effectiveness or ineffectiveness of prior nursing actions. For
example, in charî 446, Nurse C documented the following:
Re chest pain
S. "1 need a nitro. My chest pain is back."
O. Pt up to BIR & returned to bed d o anterior chest pain local at first. BP
142/90, p-84. Nitro given xi at 0704 hrs. One min later pt stated pain is
going down to his arms. Nitro repeated. O2 put on, HOB + [head of bed
increased]. Then pt stated chest pain is going away.
When the patient commented that the %hest pain is going away," the nurse
used this informaüon as evidence that her nursing actions had been effective in
relieving the patient's initial cornplaint of chest pain.
Evidence of the operaüon confm resuits was found only in the medical
(4%) clinical notes. Nurses used the operaüon confirm results when they
commented on the general effectiveness of nursing actions, without reference
€0 a specific problem situation. For example, in chart 410, Nurse D documented
that the patient was "eating much better on her own with cueing." In this
situation Nurse D decided that it was important to communicate that "cueing"
the patient during meal times resultëd in increased food intake, but she did not
specifically comment that there was any problem with the patient's eating
pattern. Thus, the verification operation confirm resuits was used when nurses
commented on the general effectiveness of nursing actions, whereas the
operation judge vaiidity was used when specific clinical data was used to
judg e the effectiveness of specific nursing actions.
Distribution .of Thinking Processes in Clinical Elements
To determine the distribution of thinking processes in the chart data,
each clinical element or phrase in the clinical notes was coded by thinking skill
and operation. A total of 934 clinical elements were documented in the 142
clinical notes. The 102 medical clinical notes contained from 1 to 19 elements
(M = 6) per clinical note. The 40 surgical clinical notes contained from 1 to 23
elements (M = 8) per clinical note. There were significantly more clinical P
elements (66%) in medical than surgical (34%) charts (x2 (4, N = 934) = 68.2,
pc.001). This finding is to be expected since there were more than twice as
many medical clinical notes docurnented as compared to surgical clinical
notes.
Selection accounted for the largest proportion of clinical elements in
both the medical (38%) and surgical (46%) charts (Appendix 04). In other
words, the majority of information documented by nurses were multiple patient
cues and clinical data relevant to the clinical situation. This finding is
noteworthy, given that nurses feel generally that lime value is attributed to their
chart documentation (Howse & Bailey, 1992). The surgical nurses documented
more selection clinical elements in each narrative note (M = 3.7) than the
medical nurses (M = 2.3). Description accounted for the next largest proportion
of clinical elements in both the medical (32%) and surgical (42%) charts.
Again, there were more description clinical elements per surgical narrative note
(Ad = 3.4) than medical note (M = 1.9). It appearç that overall, the surgical
nurses documented fewer dinical notes, but the surgical clinical notes
contained evidence of more description and selection clinical elements. The
availability of specific flowsheets to document routine post-operative patient
data rnay account for the reduced number of clinical notes on the surgical unit.
The hospital protocol requirement to document complete patient data in post-
operative situations may partly explain the increased number of description and
selection clinical elements in the clinical notes documented by surgical
nurses.
The number of inference clinical elements ranged from O to 2 (M = 0.35)
in the medical notes and O to 2 (M = 0.63) in the surgical notes. The finding of a
maximum of two inference clinical elements documented in the medical and
surgical clinical notes is not unexpected, given that nurses must document
multiple data to support a conclusion regarding a specific clinical situation.
The number of synthesis clinical elements ranged from O to 5 (Ad = .85) in the
medical notes and O to 3 (M = .28) in the surgical notes. It is not surprising that
few clinical elements were documented in the clinical notes since nurses used
synthesis when they documented information such as a specific nursing
intervention in response to multiple patient cues. The number of verification
clinîcal elements ranged from O to 3 (M = 0.56) in the medical notes and O €0 1
(M = .08) in the surgical notes. Since verification was used when nurses
evaluated previous nursing interventions, it is not unexpected that few
verification clinical elements were documented in the clinical notes.
Thinking Skills Evidenced in the Three Types of Clinical Situations
To in-ügate ihe thinking skills utilized in different types of clinical
situations, the clinical notes were examined and categorized according to three
types of clinical situations. Type 1 clinical situations included hospital protocol
situations such as patient transfers to and from the hospital unit. Type 2 clinical
situations included patient assessment situations without a documented
problem statement. In type 3 clinical situations there was an identified problem
situation with documented clinical data.
On the medical unit about half (47%) of the clinical notes were type 2
clinical situations, and almost haif (47%) were type 3 clinical situations
(Appendix Pl). The remaining notes (6%) were type 1 clinical situations. On the
surgical unit the majority of clinical notes (65%) were type 2 clinical situations.
The rernaining notes were divided almost equally between type 1 (20%) and
type 3 (1 5%) clinical situations. Therefore, the majority of clinical notes on the
med ical unit represented clinical situations of patient assessmen t with and
without identified problems, while the majority of clinical situations on the
surgical unit represented patient assessment situations without an identified
patient problem.
Type 1 clinical situations. There were few type 1 clinical situations in the
medical (n = 6) and surgical (n = 8) charts, indicating that the majority of
narrative notes documented by nurses were related to patient assessment
situations. The medical nurses used only description in type 1 clinical
situations (Appendix P2). For example, in chart 430, Nurse D documented 'Out
on day pass with husband." Nurses used description to record information
such as patient transfers to and from the hospital unit, as mandated by hospital
protocol. The recording of patient transfers has legal implications since there
was a transfer of responsibility for patient Gare from one nursing unit to another,
and consequentiy, nurses have an obligation to document this information.
In type 1 clinical situations the medical nurses used three descriptive
operations: identjw contexf, lis[ facts, and state goal, as illustrated in the
following example documented in chart 419, by Nurse A:
Re: discharge
O. Pt says she's going to location X for convalescence tomorrow &
that her dt [daughter] is making the arrangements.
P. poss DIC [possible discharge] Tues.
In this example of a type 1 clinical situation, information of an administrative
nature regarding discharge planning was communicated to other health care
personnel in the patient's chart. Nurse A used the operation identifL context
when she entitled the narrative note. The operation list facts was used when
Nurse A recorded information about the post hospitalization discharge
arrangements. All the medical and surgical type 1 notes contained evidence of
the operation list facts. Nurse A used the operation state goal when she
documented "poss DIC Tuesn to indicate the general plan of nursing action.
Thus, description was the predorninant thinking skill utilized in type 1 clinical
situations.
Although al1 the surgical clinical notes contained description, half the
surgical notes also included. evidence of selection. For example, in chart 332,
Nurse F documented the following, "seen in POAC [Pre-Operative Admission
Chic]. BP 130J90 P72." In this situation, Nurse F used the selection operation
choose relevant information when she documented patient assessrnent data
(blood pressure and pulse measurements) obtained du ring the patient's visit
to the POAC in the narrative notes, instead of the graphic sheet that is normally
used once the patient is admitted to hospital. Thus, both medical and surgical
nurses used predominantly description in type 1 clinical situaüons, while
selection was used in half the surgical type 1 situations.
Type 2 clinical situations. In type 2 clinical situations nurses
documented clinical data and decisions in the absence of any clearly defined
problem situations, such as a post-operative assessments following an
uneventful surgical procedure. Type 2 clinical notes contained examples of five
categories of thinking skills; description, selection, inference, synthesis and
verification, as illustrated in Figure 5. Description was used in al1 the surgical
and rnedical type 2 notes. More than half the surgical notes also contained
evidence of selection and inference, while more than one third of the medical
clinical notes contained evidence of selection, synthesis, and verificaüon.
Description
Selection I l nference
Synt hesis
Ver if ication I 1 1 1 1 I
O 10 20 30. 40 50 60 70 80 90 100 Percentage of Type 2 Clinlcal Notes
Finure 5. Thinking skills evidenced in type 2 clinical situations
There was evidence of 11 different operations in the type 2 rnedical
notes and 9 different operations in the surgical notes. Of particular interest was
the finding that the majority (69%) of the type 2 medical notes contained less
than four different thinking skills operations, whereas the rnajority (70%) of
surgical notes contained evidence of four or more different operations
(Appendix P3). A possible explanation for the greater number of operations in
the surgical notes is that the type 2 situations documented in the surgical
charts were more structured; only 17% of the type 2 rnedical notes utilized the
SOAP format compared to 69% of the type 2 surgical notes. The structure of the
SOAP format seemed to encourage the nurses to use a greater range of
thinking skill operations when documenthg type 2 clinical situations.
On the surgical unit the rnajority (69%) of type 2 clinical situations were
post-operative assessments or I%ondition reportsn in which the nurses
documented clinical data and decisions regarding the patient's health status.
In fact, the surgical nurses uülized the SOAP format to structure the
documentaüon of al1 the "post-op notes" or "condition reportsn (n = 18). The
following narrative note from chart 320, documented by Nurse F, was an
example of the structure of a typical type 2 surgical clinical note:
Post-op note
O. Arrived from RR [recovery room] via stretcher- pt awake & alert.
Cast spiit - CSM [colour, sensation and movement] to L fingers
good - sensation has returned - IV 213 113- 550 TBA [type of
intravenous solution with 550 ml to be absorbed] patent &
infusing . A Stable post op.
P. See NCP re ORlF # wrist [see nursing care plan for open
reduction and intemal fixation for fractured wrist].
ln the above example, Nurse F used five different operations in a
relatively short narrative note. Nurse F used the descriptive operation identiw
contexf when she entitled the narrative note. The nurses used the descriptive
operation idenfi@ confext in almost al1 (94%) the surgical type 2 clinical
situations in which they used the SOAP format (Appendix P4). The descriptive
operation lisf facts was used in almost al1 (96%) of the surgical type 2 clinical
situations when nurses recorded information such as the post operative
transfer of patients from the recovery room to the surgical unit. This clinical
information was important from a legal perspective since there was a transfer
of responsibility for patient care from one nursing unit to another. There was
evidence of the descriptive operation state goal in the majority (62%) of type 2
surgical clinical situations and in 16 out of 18 SOAP formatted notes. Nurses
used the operation stafe goal when they described a general plan for patient
care such as "follow nursing care plan," modelling the example in the hospital
charting procedure manual. Nurse F used the synthesis operation categorize
when she concluded that the patient's condition was 'stable post-op". In the
above example, Nurse F used the selection operation choose relevant
information to record relevant patient cues such as "CSM to L fingers goodn.
The operation choose relevant information was used in the rnajorîty (92%) of
type 2 clinical situations.
On the medical unit the type 2 situations documented by the nurses
were less stnictured and represented clinical situations such as the
assessrnent of the patient's health status and response to nursing
interventions, the communication of patient and family concerns such as the
preparation for care following discharge, or do not resuscitate decisions. The
predominant operations used by the medicai nurses in type 2 clinical notes
were the descriptive operation list facfs (75%), the selection operation C ~ O G S ~
relevant information (73%), and the synthesis operation develop course of
action (35%).
Thus, in the rnajority of type 2 clinical situations nurses on both units
used the descriptive operation list facts and the selection operation choose
relevant information. On the surgical unit the rnajority of notes also contained
the descriptive operations identm context and state goal, and the inference
operation categorize.
Type 3 clinical situations. Only six type 3 clinical situations were
documented in the surgical patient records, whereas 48 clinical notes were
recorded in the medical patient records. The limited number of identified
problem situations documented ,in the surgical charts is not surprising, given
that most surgical patients undergo an uneventful recovery following surgical
procedures. The cornplexity of type 3 situations was evident from the finding
that in the majority (58%) of both medical and surgical notes, nurses used four
or more different thinking skills to document clinical decisions in identified
problem situations (Appendix P5).
More than half the medical and surgical type 3 clinical notes contained
evidence of four thinking skills; description, selection, inference and synthesis
as illustrated in Figure 6. Evidence of verification was found only in the medical
clinical notes. Thus, nurses used multiple thinking skills in the documentation
of type 3 clinical situations with identified clinical problem problerns.
Description
Selection
Inference 1 1 1 1 Medicine
Synthesis 1 1 1 1 Verification
O 10 20 30 40 50 60 70 80 90 100
Percentage of Type 3 Clinical Notes
Figure 6. Thinking skills evidenced in type 3 clinical situations.
Of the six surgical type 3 notes, four notes were single chart entries
documented in one shift, and one nurse documented two clinical notes within
the same shift. On the medical unit 14 out of the 48 type 3 clinical notes were
single entries documented in one shift. The majority (71%) of the type 3
situations on the rnedical unit were multiple chart entries docurnented over one
shift. In other words, the majority of identified patient problem situations (type 3)
documented in the medical charts tended to continue over several hours, and
necessitated the documentation of up to six clinical notes over an eight hour
shiff. For example in chart 446, Nurse C closely monitored a patient's
cornplaint of chest pain during a night shift so that she chronologically recorded
the following clinical data and nursing decisions in three chart entries within a
one hour period:
0600: Re Chest pain
Pt retumed from BR [bathroom] to bed CIO [complaining ofl chest pain,
anterior, non-radiating. O2 on @ present. P-76. BP-162/90. Skin warm to
touch. Pt had been up X2 dunng the night without chest pain. Nitro X1
given. Will observe re effecüveness of nitro.
0602: Checked on pt & stated that al1 the pain is just about gone.
0700: Pt up to BR & had a good BM. Retumed to bed & d o chest pain. BP
140170. P-80. As staff taking his VIS [vital signs] stated chest pain is
easing off slightly once he is in bed & O2 put on. Nitro given X I with
effect.
There was evidence of 12 different operations in the rnedical type 3
situations and ten different operations in the surgical type 3 clinical notes
(Appendix P6). In the example above, Nurse C used a total of six different
operations in the three clinical notes. The descriptive operation identify context
was used when she entitled the note "re chest pain." Although this clinical note
was titled, the nurse did not use the SOAP format to structure the chart entry.
About one third of the type 3 medical and surgical notes wntained the
operation identify context The descriptive operation list facts was used when
Nurse C documented that she "checked on pr. The operation list facts was
used in iess than half (44%) the medical notes, but in the majority (83%) of
surgical type 3 notes. Nurse C used the descriptive operation state goal when
she recorded "will observe re effectiveness of nitro," as this was a general and
routine nursing action usually implemented after medication administration.
The operaiion state goal was used in about one third of the medical and
surgical notes. The operation lisf conditions was not found in the surgical notes
and found infrequently (13%) in the medical notes. The nurses used the
operation state assumpfions in only 2 medical and 2 surgical clinical notes.
Thus, in type 3 situations, the descriptive operations were found in less than
half of the clinical notes (with the exception of the operation list facts that
occurred in the majority of surgical notes).
The most predominant selection operation, identw critical elements,
was found only in type 3 clinical situations, and used in the majority of both
medical (56%) and surgical (83%) type 3 clinical notes. In the above example,
Nurse C used the operation identiv critical elements when she recorded
patient cues such as "do chest pain, anterior, non-radiating" that were relevant
to the problem of chest pain. The other selection operation choose relevant
information was used in the rnajority (83%) of surgical notes, but less
frequently (29%) in the medical type 3 situations. Thus, the majority of type 3
clinical notes contained evidence of selection when nurses documented
patient cues and clinical data relevant to the identified problern situation.
Three inference operations were found in the type 3 clinical situations
documented in charts from both units. The operations discover relations
between elements and hypothesize were found only in type 3 clinical situations
and in approximately equal proporüons in the medical (21% and 23%
respectively) and surgical (both 33%) notes. Nurses used the operation
discover relations between elements when they documented a diagnostic
statement without an etiology, and used the operation hypothesize when they
recorded a diagnostic statement with a possible etiology. The operation
categorize was also used, but less frequently in both the medical (1 3%) and
surgical (1 7%) notes.
The synthesis operation develop course of action was the most
predominant operation overall (65%) in the rnedical notes and was found in
half the surgical notes. In the chart example above, Nurse C used the synthesis
operation develop course of action when she recorded specific nursing
interventions such as 'nitro given XI" in response to the patient's cornplaint of
chest pain. It is significant that nurses documented specific nursing actions in
the majority of identified problern situations. There was no evidence of the other
synthesis operation combine parts to f o m a whole in type 3 situations.
The verification operation judge vaiidify was found only in the medical
notes. In the above example, Nurse C used the operation judge validfy when
she documented specific patient cues such as "stated the chest pain is easing
off slightly once he is in bed 8 O2 put onu that provided specific evidence as to
the effectiveness of previous nursing actions. There was no evidence of the
operation c o n h resulfs in either the medical or surgical type 3 clinical notes.
Thus, medical nurses recorded specific clinical evidence as to the
effectiveness of previous nursing actions in identified problern situations.
Thus, in the majority of type 3 situations on both units, there was
evidence of the selection operation identify cMical elements, and the synthesis
operation develop a course of action. In the surgical type 3 notes the descriptive
operation /kt facts, and the selection operation choose relevant information
was also found. It is significant that üiree thinking skili operations were found
only in identified problem situations (type 3); the selection opew!ion identify
critical elements, the inference operations discover relations between elements
and hypothesize.
In summary, the findings indicate that nurses documented different
thinking skills in the three types of clinical situations. In type 1 situations nurses
used only description and selection, whereas in type 2 and 3 situations
description, selection, inference, synthesis and verification were documen ted.
Three operations were found only in type 3 clinical situations; the selection
operation identify critical elements, the inference operations discover relations
between elemenfs and hypothesize. The majority of type 2 surgical clinical
situations were post-operative assessments or condition reports in which the
nurses utiiized a structured SOAP format, modelling the example found in the
charting procedure manual. The type 2 medical situations tended to be less
structured and represented a range of clinical situations. The majority of the
type 3 situations on the medical unit continued over several hours, and
necessitated the documentation of up to six clinical notes over an eight hour
shift. On the other hand, there were very few type 3 clinical situations
documented in the surgical charts, which was not unexpected, given that most
surgical patients have an unevenfful recovery following surgical procedures.
Thus, the results revealed that there were different thinking processes utilized
in each of the three types of clinical situations.
Thinking Processes and Chartinp Format
To detenine if there were differences in the documentation of thinking
processes when nurses uülized a structured charting format, the SOAP
formatted narrative notes were compared to the non SOAP format. There were
significant differences between the medical and surgical units in the number of
clinical notes documented in the SOAP versus non SOAP formats
(x2(1 *142)=6.98, pc.01). The SOAP format was found in the majority (58%) of
surgical notes, whereas the non SOAP format wasfound in the majority (67%)
of medical notes. On the surgical unit almost al1 the SOAP formatted notes
contained evidence of description, selection and inference (Appendix Q1). In
fact, there was no evidence of inference and synthesis thinking skills in any of
the non SOAP formatted surgical clinical notes, as illustrated in Figure 7.
Thlnking Skl t ls
Description
Selection 4 I I I I I I I
lnference
Synthesis
Verification
O IO 2 0 30 40 50 60 70 80 90 100
Percentage of Surgical Clinical Notes
Figure 7. Thinking skills evidenced in surgical clinical notes with and without SOAP format.
On the medical unit, the majorïty of SOAP formatted notes contained
description; selection, inference, syn thesis and verification thin king s kills,
whereas the majority of non SOAP formatted notes contained description and
selection thinking skiils (Figure 8). Thus, it appears that the structured SOAP
62
format encourages nurses to ua'lize higher order thinking skills such as
inference and synthesis when documenting clinical decisions.
Description
Selection
l nference
Synt hesis
Verification
Percentage of Medical Clhical Notes
Figure 8. Thinking skills evidenced in medical clinical notes with and without SOAP format.
. . The nurses did not uülize the SOAP format in any of the type 1 clinical
situations.- .ln type 2 clinical situations, the surgical nurses u tilized the SOAP
format more frequently (69%) than the medical nurses (17%). In type.3 clinical
situations, the SOAP format was used in five out of six surgical clinical notes,
and about half (54%) the medical clinical notes. Thus, the stnictured SOAP
format was utilized more frequently by the surgical nurses in both type 2 and
type 3 situations.
There was evidence of 10 different operations in the SOAP forrnatted
medical notes and 9 different operations in the surgical notes. The non SOAP
forrnatted medical notes contained 11 different operations, while the non SOAP
surgical notes contained only four different operations. There was, however,
greater utilization of specific thinking skill operations in the SOAP fomatted
notes when compared to the non SOAP forrnatted notes. The majority of non
SOAP type 2 notes on both units contained evidence ofonly two operations; the
descriptive operatiori list facts and the selection operation choose relevant
information (Appendix Q2).
On the other hand, the majority of both medical and surgical SOAP
formatted type 2 clinical notes contained evidence of five different operations.
The majority of medical type 2 clinical notes contained the descriptive
operations list facts and sfate goal, the selection operation choose relevant
information, the synthesis operation develop course of action, and the
verification operation judge validiy. All the surgical type 2 SOAP formatted
notes contained evidence of the descriptive operation iist facts, the selection
operation choose relevant information and the inference operation categorize.
The majority of surgical notes also contained the descriptive operations idenfifL
contexf and state goal.
A greater number of different thinking skill operations were utilized in the
type 2 SOAP fonatted notes. More than three quarters of the medical and al1
the surgical SOAP notes contained four or more operations, whereas the
majority (83%) of medical and ail the surgical non SOAP fomatted notes
contained less than four different thinking skill operations (Appendix (23). Thus,
e the structure of the SOAP format encouraged the nurses to document a wider
range of thinking skill operations in type 2 clinical situations.
On the medical unit twelve different operations were found in the type 3
SOAP formatted notes wmpared to nine operations in the non SOAP notes. On
the surgical unit, ten different operations were used in the SOAP formatted
notes compared to only two operations in the single type 3 non SOAP note. In
type 3 clinical situations on the medical unit, almost al1 the thinking skill
operations were-found more frequently in the SOAP formatted notes than the
non SOAP formatted notes (Appendix Q4). The majority of medical clinical
notes contained the descriptive operations identjw context, k t facts and sfate
goal. Of particular interest is the finding that the selection operation identify
criticai eiemenfs was found in 85% of the SOAP notes compared to 23% of the
non SOAP formatted notes. In other words, the-structure of the SOAP format
encouraged nurses to record clinical data and patient cues that were relevant
to the problem situation. Two of the inference operations discover relations
between elements and hypothesize were found only in SOAP formatted notes.
Thus, when medical nurses utilized the SOAP format in identifîed problem
situations they documented a wider range of thinking skill operations in the
majority of type 3 notes. On the surgical unit, five out of six type 3 notes were
SOAP formatted and uülized the descriptive operation list tacts, the selection
operations choose relevant informafion and identiljr cntical elements, and the
synthesis operation develop course o f action in at least 60% of the notes. The
one non SOAP fomatted notes contained only the operations list facfs and
choose relevant information.
A greater number of thinking skill operations were utilized in the type 3
SOAP forrnatted notes. All the medical and the majonty (80%) of surgical type 3
SOAP notes contained four or more operations, whereas the majority (90%) of
medical and the surgical non SOAP formatted notes contained less than four
different thinking ski11 operations (Appendix Q5). In a pattern similar to the type
2 situations, the SOAP format encouraged nurses to utilize a wider range of
thinking skill operations in type 3 surgical and medical clinical notes.
a Clinician Characteristics
To investigate the influence of nursing .expertise on clinical decision
making, al1 the narrative notes documented by the four expert and four proficient
nurses were examined. There were no significant differences behveen the
number of clinical notes documented by the expert versus proficient medical
nurses and the expert versus proficient surgical nurses (Appendix RI). There
was evidence in the clinical notes that both the expert and proficient nurses
utilized five categories of thinking skills: description, selection, inference,
synthesis, and verification. There were no significant differences in the
distribution of clinical elements in the five thinking skill categories documented
by the expert versus proficient medical and surgical nurses (Appendix R2).
Thus, the level of nursing expertise neither affected the nurses' tendency to
document clinical decisions, nor the overall utilization of thinking skill
categories. These findhgs can be explained by the fact that all the nurses in
the study had extensive work experience (as compared to novice nurses).
Overall, these nurses would be expected to have a similar approach to
documentation of clinical decisions.
To determine if there were differences in the number of thinking
categories utilized in the clinical notes, the clinical notes were grouped
65
the
skill
according to the number of thinking skill categories evidenced. The expert
medical nurses documented significantly more (x2 (4, N = 102) = 11.5, p = .02)
clinical notes that utilized four and five different categories of thinking skills than
the proficient nurses (Appendix R3). This finding can be explained partly by the
differences in the types of clinical situations documented by the expert versus
proficient medical nurses. The expert medical nurses documented significantly
more (X (2, N = 102) = 7.26, p=.03) type 3 clinical situations (Appendix R 4)
which would necessitate the utilization of a greater range of thinking skill
categories. There were no significant differences in the utilizaüon of SOAP
formatted type 2 and 3 clinical notes documented by the expert versus proficient
medical nurses (Appendix R5).
On the surgical unit, there were no significant differences in the relative
proportions of thinking skill categories utilized in the clinical notes documented
by the expert versus proficient nurses. There were also no significant
differences in the relative proportions of clinical situation categories or SOAP
formatted notes documented by the expert versus proficient surgical nurses.
These findings may be explained partly by the more consistent utilization of the
SOAP format by both the expert and proficient surgical nurses, and the Iimited
number of identified problem situations (type 3) on the surgical unit. In
summary, the expert and proficient surgical nurses displayed similar patterns
of documentation in clinical decision making. On the medical unit the expert
medical nurses documented significantly more type 3 problem situations, and
used a wider range of thinking skill categories than the proficient medical
nurses.
Intetview Data
To describe the context of clinical decision makîng in nursing, the
. participants were asked to comment on topics such as the importance of
decision making in nursing practice, the decisions normally encountered in
clinical situations, factors that influence the decision making process, and the
communication of clinical decisions.
All eight nurses emphatically agreed that clinical decision making was
very important to nursing practice. Clinical decision making differentiated
between "good" and %adn nurses and was regarded to be as important as life
and death. Nurses spent considerable time getting to know their patients and
felt that nurses were key people in the health care system.
We see the person 24 hours a day, whereas somebody else might see
them for only 30minutes. So we can sort of have a better handle on it. A
lot of people do rely on us, on our assessrnents, to make their
decisions. (Nurse E)
The decision of whether to contact the physician was cited by almost al1
(88%) the nurses as an example of a daily decision. The decision to contact the
physician involved understanding the significance of the changes in the
patient's condition. The nurses rnust decide whether the changes required
irnmediate or delayed consultation with the physician. The nurses recognized
their responsibility to thoroughly mllect and report essential patient cues to
assist the physician in the decision making process.
It's your assessrnent and your skills, and those of your colleagues, that
determine whether or not you contact a physician. And he's basing his
diagnosis or ordering, on the information that you're giving hirn. (Nurse
FI
Most (88%) of the nurses acknowledged the importance of discusçing
challenging clinical situations with their nursing colleagues. Consultation with
other nurses provided confirmation that their decisions were valid, or led to the
development of other strategies. In addition to nursing colleagues on the unit,
nurses also consulted with nurse managers, and other health care
professionals such as pharmacists, dietitians, physiotherapists and pastoral
care tearn members. In crisis situations, however, nursing colleagues on the
unit provided the most support by validating decisions, and assisting in the
management of patient care.
If I'm not sure I go to another girl and l'II give her the details. And 1'11 Say I
was going to do this, what do you think? You go to people that maybe
have a little bit more experience than you. Sometimes, most of the time,
it is something that you really feel, oh, I really should cal1 the doctor on
this. l'II just nin it by them. It solves two problems. Because numt-er one,
the fioor is then aware there's a real problern. Usually it is life
threatening. It's not trivial, like whether or not you think you should get
somebody up or not. You run it by someone else, and that brings them
into the picture, and they can then say, "Weil, l'II keep an eye on them,
while you phone the doctor." They c m gather al1 the personnel around
that they need, that kind of thing. They're thereto help you once you start
getting new orders. So it serves two purposes that way. (Nurse H)
The nurses in this hospital viewed knowledge about their patients as an
essential component to being confident about their patient care decisions,
confirming the findings of other studies (Jenks, 1993; Jenny & Logan, 1992;
Tanner et al., 1993).
Knowing the background, the patient's background, the history of the
patient, the background history, that's most important [information] that
you have to know. (Nurse C)
The nurses from the medical unit felt that primary nursing allowed them
to know their patients better and to feel more responsible for the outcornes of
their care.
I keep the patients and you get to know them, instead of having them
here for one day, and somebody else the next day. They get to know you.
They seem to appreciate that They know when you're going ta show up
and just exactly what you're going to do. (Nurse B)
I look at the patient with the fact that I'm responsible for the outcome.
That's important, that you're going to have more chance to interact with
the family, with the doctor, and with the therapist. That we're free to
involve-other disciplines in the plan of this person. (Nurse A)
The nurses discussed the limitationsof the current chart documentation
system and their reliance on verbal communication (especially end of shift
taped clinical reports) to gain important information about the olinical situation.
This confirms the findings of Lamond, Crow, Chase, Doggen, and Swinkels
(1996) who identified verbal interaction as the most frequently cited source of
clinical information for nurses.
I don't think Our nursing Gare plans are sufkient enough for someone to
just go in and look after a patient. Here, there's so rnuch passed on in
report, that's not on the nursing care plan, that you could really miss
something. (Nurse B)
Sornetirnes you really only document problems. Flowsheets, I think
sometimes, are a little bit vague. But I think most of the information is
passed on fairiy well from shift to shift, via the tape. (Nurse F)
In spite of the preferences for verbal communication, one nurse
commented that nurses needed to acknowledge the importance of written
documentation in clinical practice.
I think it is important that you can Say what you do. And be able to write it
down. Because I know thatvs what they're asking for in every kind of
business or profession. It's not just here. And in the past we've never
done it. And so now when we want to prove that we're needed as part of
the health care team, we have to be able to have sornething to back it up.
(Nurse D)
Nurses' use of thinking skills in clinical decision rnakinq. Of the eight
nurses, two rnedical and two surgical nurses (one proficient and one expert
from each unit) expressed some dificulty in using the mode1 of thinking
processes and wnfiming whether they used certain thinking skiils and
operations in clinical decision making. The difficulty may be partiy due to the
nurses' limited experience with the vocabulary associated with clinical decision
making. Nurse G cornmented, "Itk very difficult to look at this [the list of thinking
processes and definitions], and to read this, and there is not one word of
nursing. Yet, If you had time to think it through, you could. I'm sure, put al1 this
into perspective in nursing ." With encouragement, however, most of the nurses
were able to present a thoughfful commentary about the thinking skills and
operations that they used in clinical decision making. According to the nurses,
the most important thinking skills utilized in clinical decision making were
selection (88%), verification (75%), synthesis (63%), description (63%),
inference (50%), and representation (13%) (Appendix S). Using the model of
thinking skills as a guide (Appendix 1), the eight nurses also commented on the
specific operations that they used in clinical decision making. At least half the
nurses acknowledged that they used 24 out of the total of 30 thinking skill -
operations. In the following section selected cornments obtained during the
interviews reveal how nurses use the thinking skill operations in clinical
decision making and clinical practice.
More than half the nutSes agreed that they used the following descriptive
operations: identrfy context, lisf condifions, iisf facts, stafe assumptions, and
state goals. Nurse D used the operation identify context 'to define the
situation." Being able to describe the condit!ons in the patient situation was a
crucial component of patient assessment. Nurse H explained:
Do they have al1 the capabilities to manage crutches or colostomy care?
1s their eyesight good enough or is their dexterity good enough to do
teaching with them? Or are they going to require someone to come into
the home to help them with colostomy care?
Nurses used the operation list facts when they documented information about
the patient's history as part of the nursing data base. According to Nurse G, the
operation state assumptjons was used when "you are assurning that
evetything is going to be .fine. We don't assume any problerns. We anticipate
them sometirnes." Nurse F used the operation state goal when she planned
the day's activities. 'Even when you first come on the floor, before you even see
your patients, you sort of start getting your mind set, already. You're starting to
Say, this is sort of what I want to accomplish today." Thus, at least half the
nurses agreed that they used five descriptive operations in clinical decision
making.
Three selection operations (choose relevant information, order
information, and identify criücal elements) were used by the majority of nurses.
The operation choose relevant information was used when nurses collected
and documented specific patient cues. For example, Nurse H commented:
"They give you a lot of information, patients can ramble on and on. You have to
be able to pick out the things that are important to them, if you're taking a
history, for example." Nurse E used the operation order information when she
selected specific patient data to communicate to other health professionals:
T o u select information that is pertinent and you arrange it according to
importance, especially if you're going to communicate to somebody else."
Nurse C used operation identify cdfical etements when she identified crucial
patient data in a problem situation; "if the patient, they fell, the hip is bruised, he
is kind of di-. Then you start to think, maybe he hit his head, maybe we should
have a neuro consult." Nurse C used the operaüon identify crifical relations
.when she determined the connections between the patient cues: "You look at
the vital signs, you know if the blood pressure is really up or down, or the pulse
goes up or down, you're thinking maybe there's intemal bleeding." Thus, the
majority of nurses agreed that al1 the selection operations were important in
clinical decision making. In fact, selection was regarded as one of the most
important skilis used in clinical decision rnaking by seven out of the eight
nurses.
Half the nurses expressed difficulty understanding the vocabulary
associated with the representation thinking processes, and consequently,
were uncertain whether representation was used in clinical decision making.
Six nurses agreed that they used the operaüon recognize organizing
pnhciples, but had difficulty providing examples from clinical practice. Nurse A
used the operation illustrate elernents and relations when she explained
information such as physiological processes to patients: "I would choose
maybe a mechanical thing to relate the problem with a man. This is your spark
plug and it's al1 corroded up. This is your artery and it's all corroded up." Thus,
at least half the nurses confirmed that they used two representation operations
in clinical practice.
The majority of nurses agreed that they used the following inference
operations: discover relations between elements, categorize, order, change
perspective, and hypothesize. Nurse C used the operation discover relations
befween elernents when she made a judgement about the patient's health
status. 'You compare, any deviation from the normal, from the patient's routine
or activity or behaviour." The operation categoize was also used in the
judgements about the patient's health status. Nurse C explained: "Neuro wise,
musculo-skeletal wise, cardia-vascular wise, you monitor the movements, the
strength, the mental status. In a situation like that, you do categorize. You go
from head to toe." Nurse F used the operation hypofhesize when she tried to
determine the cause of a patient problem situation.
Like with our patient in 22. He's got this grossly edematous leg and you
try to differenüate between - is this potenüally life threatening? You have
some ideas on what it might be. The tests are saying - he's got this, he's
got that, and you're wondering if this is happening, or forming some
ideas in your mind. And then you sort of work to rule out - corne to an
understanding what might be going on here. (Nurse F)
Nurse F used the operation change perspective when she aitered her
understanding of a clinical situation as a result of receiving new information:
"Sometimes your perspective of them changes just from sitting in on report and
somebody tells you about a patient."
Nurse H believed that several inference operations are used
simultaneously in life threatening decision making situations.
Categorize, order, change perspective, hypofhesize. Any tirne you're
making a life threatening decision you have to use al1 those four. You
have to have in your mind what's going on. You have to arrange al1 the
information in your head, review it all, and then make a decision as to
what's going on. Before you make a cal1 into the doctor. (Nurse H)
Thus, at least half the nurses agreed that five out of seven inference operations
were used in clinical decision making.
At least half the nurses agreed that al1 four synthesis operations were
used in clinical decision making: combine parts to form a whole, elaborate,
generate rnissing links, and develop course o f action. Half the nurses
acknowledged that they used the operation combine parts to form a whole
when they assessed patient problems.
Patients are multifaceted now. They've got more than one problern and
what we try and do is Say, OK, because you have this problem, it's going
to do ais. And you also have this problern. So you do these two things
collectively, and the outcome is an overall better healing process. (Nurse
4
Five nurses agreed that they used the operaüon genemte missing links in
situations such as developing an individualized nursing Gare plan.
Weil, filling in the gûps is what we're doing when we're doing a nursing
care plan. And it can't quite be created the way it's written up, in a way.
You know, we have some routine ones, but this patient doesn't fit the
groove ... And so we have to make sorne choices, changes. (Nurse D)
It is noteworthy that al1 the nurses agreed that they uçed the operation develop
course of action in situations such as developing a nursing care plan to meet
the specific needs of a particular patient.
You have to look at the total picture again, and see what's involved. I'rn
thinking in terms of ortho. You have to take into consideration al1 the
things. Like sornetimes they're poorly, a lot of times they're elderly. Are
they going to have enough care at home? And make out a plan that way.
And make a decision whether you're going to ask the doctor for home
care, that type of thing. All gearing towards getting thern home. (Nurse H)
Thus, at least half the nurses acknowledged that al1 four synthesis operations
were used in clinical decision making.
At least half the nurses agreed that al1 the verification operations were
important in clinical decision making including: compare alternative oufcomes,
compare outcorne to standard, judge validity, feedba ck, and con f i m resulfs. Three quarters of the nurses agreed that they used the operaüon compare
alternative outcornes when they examined the potential consequences of
different actions in problem situations, such as a patient experiencing nausea
as a side effect of morphine administration following surgery.
If someone is in a fair amount of pain and they have a morphine infusion
pump, yet they are having sorne nausea. Do 1 stop the morphine pump?
Or, do I give her a gravol and let's see how she's going to be in rnaybe 2
to 4 hours? I guess that's sort of compa&g an alternative. (Nurse G)
The operation compare outcome to standard was used when nurses
compared the patient tesponses with standardized guidelines so that they
could determine the best nursing intervention.
We do have criteria for Our PCA [patient controlled analgesia] pumps,
which does say that if anyone is nauseated due to a morphine pump ... we are sometimes to DIC [discontinue] the morphine pump. But there's
a gray area there. How long do you wait? Do you do it right away? Or
does this patient settle down with gravol right away? And then she's
having a fair amount of pain and she still needs the morphine pump.
(Nurse G)
Nurses used the operation judge validiiy when they utilized resources such as
reference texts to confirm whether their action was sound. Nurse D explained,
"You said something or did something, and you checked in the book, and it
says that you definitely did do the right thing." Nurses used the operation
feedback when they sought confirmation for a novel approach to a situation,
and consequentiy adjusted future actions as a result of the information
received from other colleagues, for example. Nurse D explained, "Other people
Say to you, 'You did that properly,' or 'Wow, that made a difference.' Then it
makes you feel good, and you go on and do better, in the future." Although more
than half the nurses agreed that they used the operation confim results, they
had difficulty providing examples from clinical practice. Thus, at least half the
nurses acknowledged that they used al1 the verificaüon operaüons and in fact,
the majority (75%) agreed that verification was an important thinking skill in
clinical deciçion making.
In summary, in spite of the difficulties associated with the vocabulary in
the thinking skills model, at least haif the nurses were able to provide
confirmation (with examples from clinical practice) that they used the majority of
thinking skills operations in clinical decision making. At least half the nurses
agreed that the thinking skills of description, selection, inference, synthesis,
and verification were used in clinical decision making, which provided
validation to the findings from the chart data.
Discussion
Nursing educatorç involved in a Delphi survey identified research into
clinical judgernent as the second most important pn'ority in nursing education
research (Tanner & Lindeman, 1987). This study has contributed to the
understanding of clinical judgement though an investigaüon into the cognitive
processes involved in clinical decision making. The influence of contextual
factors (nursing sub-group, primary nursing patient assignment system,
Problem Oriented Recording [PORI charting system), task variables (complexity
of clinical problems), and clinician characteristics (nursing expertise) on
clinical decision making was investigated in this study. How the contextual
factors, task variables and clinician characteristics influence clinical decision
rnaking is discussed in the following section.
Con textual Factors
The nursing literature does not suggest that there are differences in the
diagnostic or thin king processes across different nursing units. However, this
study revealed that differences exist between the two nursing sub-groups
within adult care, medical and surgical nursing, in the documentation of clinical
. decisions, the types of clinical situations encountered, and the thinking skills
utilized in clinical decision making situations.
Overall, more clinical notes and clinical elements were docurnented in . * the charts frorn the medical unit. This finding can be explained partly by the
differences in the patient population and partly by differences in charting
procedures. On the medical unit the patients were older and had longer
hospital admissions resulting in more opportunities for the nurses to
document clinical problems in the chart. The charting procedure on the surgical
unit utilized specific flowsheets for patient assessrnent resulting in the
documentation of fewer clinical notes. - Another difference behnreen the two nursing sub-groups was the
utilization of specific thinking skills evidenced in the documented clinical notes.
The rnajority of surgical clinical notes contained evidence of description, .
selecüon and inference, whereas the majority of medical notes contained
evidence 'of description, selection, synthesis, and greater uülization of
verification. These findings can be explained partly by differences in the clinical
situations encountered on each unit, and partly by differences in charting
procedures. The rnajority of surgical narrative notes were post-operative or
admission notes. The nurses used description when they recorded information
such as the transfer of patients from one hospital unit to another as required by
hospital protocol. Selecüon was used when the nurses recorded clinical data
concerning the patient's health status following surgery or admission. Surgical
nurses more frequently used inference when they documented a conclusion
regarding the patient's curent health status. The structured SOAP format used
.more frequently by the surgical nurses encouraged the use of inference when
the nurses recorded an assessment statement regarding the patient's health
status, modelling the example in the charting procedure manual.
There were many more identified problem situations (type 3) in the
medical clinical notes than the surgical notes. The medical nurses used
0 . . syn thesis more freqrien tly when they recorded s pecific nursing actions, and
verification when they recorded data to indicate the effectiveness of their
nursing interventions. On the surgical unit, few identified problem situations
were docurnented. Thus, specific nursing interventions to address the cliniwl
problerns and the ensuing evaluations were seldom recorded in surgical
chartç. However, it is not surprising that few problem situations were recorded
in the surgical charts given that most surgical patients have an unevenfful
recovery following surgical procedures.
There were also differences between the medical and surgical nursing
units in the utilization of the structured SOAP charting format in the narrative
notes. The surgical nurses used the SOAP charting format in the rnajority of
clinical notes, whereas the majority of medical notes used an unstructured
format. The structure of the SOAP format used by the surgical nurses seemed
to encourage the use of selection and inference thinking skills. On the surgical
unit, specific flowsheets were used to record clinical data such as post-
operative patient assessment. Consequently, it was not necessary for the
surgical nurses to document narrative notes as frequently as the medical
nurses who lacked specific flowsheets to record changes in the patient's
health status. In addition, medical nurses encountered patient problem
situations more frequently than surgical nurses. The problerns encountered
with medical patients necessitated the documentation of several narrative
notes over one shift, sometimes in inteivals of less than hivo minutes apart.
Thus, the variations in the proportions of thinking skills docurnented by medical
and surgical nurses can be explained by the type of patient problern situations
encountered, and the differential use of the SOAP charüng format. Differences
in the utilization of specific thinking skills and operations rnay not reflect
differences in the thinking processes used in clinical decision making, but may
result f ~ o m contextual factors specific to a particular nursing sub-group.
The chart data represented a sumrnary of the nurse's thinking and the
communication of selected information about the clinical situation. Thus, al1 the
thinking processes that occurred prior to the documentation of the clinical
situation may not be captured in the chart data. In addition, the hospital work
environment limited the opportunities for thoughtful reflection about clinical
situations prior to documentation in the chart. The nurses were frequently
observed recording in the chartç while standing in the hallway so as to be able
to monitor il1 patients, and were frequently interrupted by requests from
patients, visitors, and other health Gare workers. Thus, the thinking skills
evidenced in the chart data may have been limited by the effect of the work
environment on the nurse's ability to tthoughffully reflect on the clinical situation.
and the methodological limitations in capturing the thinking processes that
occurred prior to documentation. The limitations of the chart data were partially
addressed by the inclusion of interview data about the thinking processes that
nurses used in clinical decision making.
Althoug h the literature supports primary nursing as a professional
practice mode1 that encourages independent thinking and increased autonomy
(Manthey, 1980; Prescott et al. 1987), no significant changes occurred in the
documentation of nursing diagnoses, and thinking processes utilized by the
medical nurses after the introduction of primary nursing. Investigation into the
differences between the designated primary nurse and other nuning staff in
the nursing diagnosis documentation, and thinking processes uülized in
specific patient charts was not possible, because the designated primary
- nurse was not recorded on any chart documents. The lack of significant
differences following primary nursing implementation rnay not be surprising,
given the paucity of research evidence supporting the implernentation of
primary nursing (Giovannetti, 1986). The lack of research based support is
thought to be related to the difficulty in the operaüonalization of primary nursing
(Giovannetti, 1986).
Task Variables
There were significant differences in the utilization of thinking skills and
operations in the three types of clinical situations. In type 1 clinical situations
nurses documented only description and selection thinking skills. This finding
.is to be expected, since in type 1 situations, such as patient transfers, there is a
, legal requirement to document complete. and accurate information. Type 2 and
type 3 cliriical situations reflected more complex clinical situations and
contained evidence of five categories of thinking skills (description, selection;
inference, synthesiç, and verification) and up to 14 different operations.
Most of the type 2 clinical situations on the surgical units were post-
operative assessments and. used a structured SOAP format similar to the
example provided in the charting procedure manual. Surgical nurses used
description and selection thinking skills when they docurnented patient cues
and clinical data as subjective (S) and objective (0) data. Description was used
when nurses recorded general information about the clinical situation,
whereas selection was used when the nurses documented specific patient
data that provided important cues as to the nature of the clinical situation.
Inference was used when the nurses recorded a conclusion regarding the
patient's status in the assessment (A) statement. Description was used when
the nurses recorded a general statement about future plans (P) for nursing
care since usually there was no problem identified post-operatively.
The medical nurses, on the other hand, tended to use the SOAP format
more frequently when they recorded identified problem situations (type 3). As
on the surgical unit, description and selection was used when the nurses
recorded subjective and objective clinical data, and inference was used in the
assessrnent statement. In the planning section, however, the medical nurses
tended to use synthesis when they recorded specific interventions to address
the identified clinical problern. Evidence of verification was found more often in
the medical notes when the nurses evaluated previous interventions and
recorded additional clinical notes Iater in the shift. Thus, the findings indicate
that different categories of thinking processes were used by each nursing sub-
group in the three types of clinical situations. Further, the use of a structured
charting format encouraged the use of a wider range of operations in the SOAP
formatted type 2 and 3 clinical notes.
. Clinician Characteristics
If experienced nurses are to act as mentors for novice students, an
important aspect of this role is the ability to communicate the critical features
and steps utilized in the identification and resolution of clinical problem
situations. The nursing literature suggests that there are differences between
ptoficient and expert nurses in the level of understanding of cornplex clinical
situations (Benner, 1 984). Although proficient nurses are able to identify
important aspects of a patient situation so that clinical decision making is
efficient and accurate, the literature further suggests that proficient nurses lack
the deep understanding and intuitive grasp of the situation characteristic of
expert nurses (Benner, 1 984). The literature, however, does not suggest
whet her differences between the two experienced nursing levels are reflected
in or driven by the documentation of clinical decisions and the underlying
thinking processes utilized by proficient and expert nurses.
This study, however, revealed that the expert medical nurses used a
greater nurnber of thinking skill categaries within individual clinical notes and
documented more type 3 clinical notes with identified problems than the
proficient medical nurses. The greater number of type 3 situations recorded by
the expert medical nurses may be partly explained by the increased ability of
expert nurses to recognize the subtle patient cues that occur frequently in
problem situations. The greater number of typs 3 situations documented by the
expert medical nurses would then encourage the uüiization of a greater range
of thinking skills.
There were no significant differences between the expert and proficient
nurses in this study in their ability to discuss the thinking skills they utilize in
clinical decision making. Nurses Rom both groups experienced difficulty
describing how and what thinking skills are used in clinical practice. One
explanation for this finding is the nurses' unfamiliarity with the vocabulary
. associated with clinical decision making. Another explanation is that experts
have an intuitive grasp of a given situation, and are unable to explain their
rationale for many decisions (Benner, 1984; Dreyfus & Dreyfus, 1986). The
nursing exemplars and illustrations of the model of thinking processes
however, could offer a tool to use in further investigations to delineate the
thinking processes utilized by expert nurses in actual clinical situations.
Thin king Skills Utilized in Clinical Decision Makinq
The model of thinking skills (Donald, 1992) provided a framework to
describe the underlying thin king processes utilized in clinical decision making.
Nurses used five different categories of thinking skills (description, selection,
inference, synthesis, and verification) as evidenced in the chart data. Although
there was no evidence of specific representation operations in the documented - narrative notes, other chart documents such as the vital signs graph can be
viewed as representations of the patient's health status. More than three
quarters of the medical and surgical clinical notes contained evidence that
nurses used two or more categories of thinking skills when documenting
clinical decisions. This is an important finding, given that other health care
professionals generally attribute little value to chart documentation (Howse & - Bailey, 1992), yet important decisions are being made and recorded by nurses.
In addition, at least half the nurses agreed that description, selection,
inference, synthesis, and verification were important thinking skills that they
utilized in clinical decision making. The results suggest that clinical decision
making in nursing practice is a complex cognitive process requiring numerous
thinking skills and operations. How the thinking skills are used in clinical
decision making is shown in the following section.
Description. The nurses' extensive utilkation of description in the
narrative notes can be explained by the fact that there is a legal requirement for
nurses to record information such as complete descri'ptions of the patients'
responses to clinical situations (CNO, 1996a). The nurses used the operation
list facts when they recorded descriptions of past events and routine nursing
actions. Nurses used the operation state goal when tbey recorded general
statements about future nursing care plans. The hospital charting protocol
required the nurses to document post-operative patient assessments. Since
usually there were no problems post-operatively, the nurses tended to record a
general plan of 'care such as "fllow standard Gare plan" in the "P" section of
the SOAP notes, modelling the example provided in the charting procedure
manual. The nurses used the operation identiv context when they included a
brief surnmary statement of the clinical notes in the form of a title. Entitling each
chart entry was also a POR charting procedure requirement. The operation
state assumptions was used when the nurses recorded their rationale for
routine nursing procedutes, such as the administration of night time sedatives.
The operation list conditions was used when nurses described features of the
clinical environment that were relevant to. patient safety. Thus, the legal
requirements to record data regarding the patient's progress, and the need to
communicate clinical information to other health care professionals, resulted in
nurses using description in the majority of docurnented clinical notes.
Selection. The chart data and the nurses' intewiews confimied that
selection was an important thinking skill in clinical decision making. The
operation choose relevant infomaüon was the predominant operation in
selection when nurses documented information relevant to a specific clinical
situation. Choosing relevant information is an underlying thin king process
utilized in the search for supporting characteristics or cues to confirm the
patient's cornplaints (Gordon, 1994). Nurses used the operation idenl;fy critical
etements in the majorKy of type 3 clinical notes when they recorded patient
cues and clinical data relevant to the identified problem situation. The ability to
select crucial information in problern situations is one of the defining
characteristics of expertise in nursing (Benner, 1984; Tanner et al., 1987).
When a nurse makes a diagnosis based on the critical characteristics of a
particular diagnostic category (Gordon, 1994) the process of identifying cdfical
elements has occurred. Ordering information in importance is used in the
selection of cue clusters that have the greatest urgency or importance
(Carnevali & Thomas, 1993). During the inteiview, seven out of the eight
nurses-acknowledged that they used the operation ordering information in
importance when they prioritized clinical or patient data during consultations
with other health professionals. Although there was no specific evidence of the
operation ordering information in the narrative notes, it is likely that ordering
informafion occurs prior to documentation, and thus would not be found in the
chart data. Likewise, evidence of identifying cntical reiafions was not found in . the chart data, but half the nurses acknowledged using this operation. Again, It
is likely that identifying critical relations also occurs intemally, and evidence of
this process would not be found in the narrative notes. Further research is
required to confirm the circumstances under which nurses use the selection - operations not evidenced in the narrative notes.
Representation. No specific evidence of any representation operations
were found in the documented narrative notes, but other components of the
hospital record such as graphic sheets and flowsheets, can be viewed as
representations of the patient's prior and current status. Although
representation is an important component in the problem solving process, and
is indeed basic to knowledge acquisition and utilization (Donald, 1989), few
nurses acknowledged the importance of this skill. Half the nurses expressed
difficulty understanding the vocabulary associated with representation
- processes, and thus would be hampered in their consideration of whether
representation was used in clinical decision rnaking. Yet, the emerging roles of
nurses require higher order thinking skills to manage complex and ill-defined
problem situations (Bramadat, Chalmers, & Andrusyszyn, 1996; Baumgart &
Larsen. 1992; Hamric & Spross, 1989). Nurses must have well developed
representations of nursing knowledge to be able to develop clinical expertise.
How then is representation utilized in the practice setting? If representation is
considered an internalized thinking process not readily evident in formalized
chart documentation, would methodological approaches such as think aloud
protocols capture these thinking processes?
Inference. The results indicate that inference is also an important
thinking skill in clinical decision making. Three operations were found in the
narrative notes: categofie, hypothesize, and discover new relations between
elements. Crow and Spicer (1995) suggest that the ability to categorize patient
conditions is a requirernent for skilled nursing judgement. Nurses used the
operation categorize when they made a judgement about the patient's overall
condition or status under the assessment (A) component of the SOAP
fomatted notes. A significant finding was that there was no evidence of
inference skills in non-SOAP formatted type 2 surgical notes. The operations
hypothesize and discover new relations between elements were only found in
type 3 clinical notes when nurses documented their conclusions as to the
patient's condition in problem situations, as part of the assessment
component of the SOAP formatted notes. Thus, the results indicate that the
problem oriented system, and specifically the SOAP charting format,
encouraged the use of inference thinking skills by requiring nurses to
document a nursing judgement under the assessment section. These findings
lend support to the results of a previous study by Mitchell and Atwood (1975) in
which nursing students were able to more clearly document patient.probiems
when they used the POR charting system.
Although there was no evidence of hnro other inference operations (order,
and change perspective) in the narrative notes, at least half the nurses
acknowledged during the interviews that they used these operations in clinical
decision making. Further investigation is needed to determine how these
operations are used in actual clinical decision making situations.
Synthesis. The ability to intuitively grasp a situation as a whole is one of
the characteristics of nursing expertise (Benner, 1984; Benner & Tanner, 1987).
Thus, synthesis is an important thinking skill in expert nursing practice. During
the interview, one of the nurses discussed how many years of experience have
allowed her to intuitively sense when the patient cues present a disconcerting
pattern, especially in life threatening situations.
I know decisions I have made have saved people. Sometimes you know
that something is wrong. I don't know what you would cal1 it, whether it's
a sixth sense or whether it's just a feeling you get. But often you just get
a feeling. The vital signs are OK, there's nothing. You've gone through it
in your mind and there's nothing you can put your finger on definitely. But
you just know there is something wrong. They're doing something.
Whether it's the way they look, the colour's not right, but nothing else
matches up to give you a clear picture. And I've caught 2 Ml's [heart
attacks] that way. (Nurse H)
ln the chart data, the nurses' use of jargon for recording nursing actions
initially made it difficult to establish differential criteria between routine nursing
actions and procedures that were evidence of the nurse's use of description or
synthesis. Nursing actions classified at the descriptive level were routine
nursing protocols, whereas nursing actions coded as eviden ce of synthesis
reflected an understanding of the individual patient situation, and required the
nurse to modify existing procedures, or devise new strategies. On the medical
unit, nurses used the operation developing course of action when they
recorded information such as the amount and type of medications
adrninistered in response to a paüent's discomfort. However, on the surgical
unit, medication administration in response to post-operative pain was
documented on flow sheets, as some posl-operative pain was considered an
"expected occurrencen after surgery. Consequently, the chart documentation
reflected that on the medical unit, patient complaints such as chest pain would
be considered a problem situation, whereas on the surgical unit, post-
operative pain was an expected occurrence. However, one could postulate that
the thinking processes required to select the appropriate interventions for both
usual and unusual problem situations would be similar.
Nurses infrequently used the operation combining parfs to form a whole
in the chart data, although half the nurses acknowledged using this operation
in clinical practice. Likewise, at least half the nurses agreed that the remaining
syn thesis operations elaborate and generate missing links, were used in
clinical decision rnaking. Further research is required to detemine how nurses
use the other synthesis operations in clinical decision making situations.
Verifkation. The deliberate evaluation of nursing actions is an important
phase in the nursing process, and recognized as an essential component of
nursing practice. In fact, an important nursing practice expectation is the
documentation of evaluations of nursing interventions and patients' responses
to nursing actions (CNO, 1996). The results indicate that nurses are fulfilling
this responsibility, as medical nurses recorded specific clinical evidence as to
the effectiveness of previous nursing actions in almost half the identified
problem situations (type 3). The verification operation, judge validity was used
when the nurses docurnented specific patient cues that indicated the
effecüveness or ineffectiveness of specific nursing interventions. Nurses used
the operation confirm resulis when they recorded general statements of the
patient's response to nursing actions.
Evidence of verification was found more frequently in the rnedical clinical
notes. The limited utilization of verification thinking skills and operations by the
surgical nurses may be explained by the fact that there were only six identified
problem situations (type 3 clinical notes) recorded in the surgical charts. Thus'
there were few documented situations that required the surgical nurses to
evaluate specific nursing actions. The limited nurnber of identified problem
situations documented in the surgical charts is not surpn'sing, given that most
surgical patients undergo an uneventfid recovery following surgical procedures.
Although there was no evidence of the other verification operations in the
narrative notes, the majority of nurses acknowledged that verification was an
important thinking skill, and at least half the nurses indicated Chat they used al1
the verification operations in clinical decision making. For example, nurses
reported that receiving feedback from colleagues helped to confirm that their
assessrnent of a problem situation was correct. It appears, then, that
verification is also important in clinical practice, but further investigation is
required to confirm how nurses use the other verification processes in clinical
decision making.
To synthesize the discussion of thinking skills, the results reveal that
description, selection, inference, synthesis and verification thinking skills are
important in clinical decision making, and thus, nursing practice. There is a
legal requirement to record accurate and complete clinical data, and
consequently the ability to describe is important. The ability to select critical
information is necessary to be able to communicate essential data to other
health- professionals and to distinguish the essential features in a problem
situation. The ability to make inferences is required to be able to make sound
clinical judgements. The expert nurse is one who is able to grasp the rneaning
of a corn plex whole or to synthesize information. Finally, verification is an
important process that is used to measure the effectiueness of nursing actions.
Although there was no specific evidence of any representation operations in the
documented narrative notes, nurses must have well developed
representations of nursing knowledge to be able to develop clinical expertise.
Further investigation is required to detemine how nurses use representation
in actual clinical decision making situations.
Implications for Professional Nursing Education
Clinical decision making is a cornplex cognitive process and nursing
instnictors are challenged to implement instructional approaches that will
promote effective learning. An instructional approach that focuses on the
acquisition of knowledge and thinking skills utilized by experts in realistic and
complex problem situations, known as "cognitive apprenticeshipu (Collins, -
Brown, & Newman, 1989) is receiving increasing attention by educatorç.
Currently, there is a paucity of nursing education Iiterature that supports this
approach to learning the skills necessary for expert clinical practice. An
instructional approach that focuses on the acquisition of cognitive skills used in
realistic and complex problems however, would be of benefit in professional
nursing education, given that the major goal of clinical nursing education is the
acquisition of knowledge and skills to manage complex clinical situations
(Cavanaugh, 1993; Dinham & Stritter, 1986; Reilly & Oermann, 1992; Schon,
1987). To be able to rnodel the thinking skills involved in clinical decision
making, nursing instructors must have knowledge of the underlying cognitive
processes used by expert nurses in realistic clinical situations. The nursing
exemplars and illustrations of the mode1 of thinking processes in this study
provides nursing educators with a working vocabulary and an instructional
resource to describe the underlying thinking processes used in clinical
practice.
Although half the nurses experienced some difficulty in understanding
the vocabulary in the model of thinking processes, it is encouraging that the
nurses were able to recognize and acknowledge the thinking processes that
they use in clinical decision making. Nursing students could use this rnodel to
gain insight into the thinking processes that they rnust learn to be effective
decision makers. For example, the model of thinking processes could be used
to elucidate the underlying thinking skills and operations in each step of the
nursing process.
Nursing educators acknowledge that the step-wise, linear nursing
process mode1 of clinical decision making does not always reflect expert
practice (Grobe et al., 1991). However, the nursing process continues to be an
effective model for introducing novice students to clinical decision making
(Oermann, 1991). The nursing process is used extensively in nursing
education, as evidenced by the number of curricular resources that employ the
nursing process as content organizers (Clemen-Stone et al., 1995; Kuhn,
1991; Oermann, 1991). Although the nursing process is used to structure
nursing roles such as the identification of family and patient outcomes
following assessment, there is minimal focus on the underlying thinking
processes required to complete the tasks (Clemen-Stone et al., 1995).
Consequently, nursing students have minimal guidance in developing the
necessary thinking processes to achieve the nursing iasks associated with
assessmen t, diagnosis, planning, implemen tation, and evaiuation.
The nursing exemplars and illustrations of the mode1 of thinking
processes could be used to elucidate the underlying thinking skills and
operations in each step of the nursing process. Appendix T reveals the tiinking
skill operations wnfirmed by the results of the chart data analysis, as well as
the additional thinking skills confirmed through the interview data analysis that
are utilized in each step of the nursing process. The assessment phase
requires several operations in description, selection, represen tation, synthesis,
and verification, in order to collect and interpret the clinical data and patient
cues. Assignment of the diagnostic category or nursing diagnosis requires
inference and verification. Description, inference, synthesis, and verification are
used in the planning phase. The outcomes of previous thinking processes
become evident du ring the implemen tation phase, which consists mainly of
psychomotor activities. In the evaluation phase, verification thinking skills are
used.
Nursing instructors can guide students through simulated decision
making situations by "modelling" or explicitly describing the underlying thinking
processes (Collins et al., 1989). Novice students can benefit from the structure
provided by the nursing process as they initially work through clinical problern
solving situations. Instructional frameworks such as the nursing process,
permit the instnictor to "scaffold" (Collins et al., 1989) the learning experience
by providing cognitive assistance to the students as they resolve actual clinical
problem situations.
Realistic clinical situations can be introduced dumg small group
discussions of actual clinical situations experienced by students, or case
studies derived from intewiews with nurses. Essential clinical data and
descriptions of patient cues can be presented in written or video format. As
students work through the clinical situations, the nursing instructor guides the
students to reflect not only on the steps involved, but also the thinking
processes required in each step. For example, nursing students frequently
have difficulty discriminating between important and superfiuous clinical data
(Thiele et al., 1991) during the assessrnent phase. To assist novice students
in identifying important clinical data, the nursing instructor would explicitly
identify the underlying thinking processes, such as the selection operations
-choose relevant information and identify citical elements that are used in the
selection of clinical data that are important verçus crucial in a given clinical
situation. Although this instructional approach would need to be tesied in actual -
'professional nursing educational prograrns, the increased insight into the
cognitive demands of clinical practice reported by the nurses in the study is
encouraging.
Implications for Nursing Practice
Nurses must acknowledge that expert clinical practice requires not only - psychomotor and affective skills, but also complex thinking skills. To enhance
their role as a member of the professional health care team, nurses must be .
able to clearly describe their practice. The interview task for the participants of
analyzing the thinking skills used in clinical practice increased the nurses'
awareness of the cognitive demands of clinical practice. Several nurses
comrnented on an increased sense of self worth and respect for their
colleagues' expertise as a result of participating in the interviews. One nurse
commented:
Your "mode1 of thinking skills" and sheet of "definitions of thinking skills"
were interesthg for me to read and understand more about my thought
processes than before ... You taught me to appreciate my nursing
colleagues more for their great expertise.
During the interviews sorne of the nurses began to reflect on the
cognitive demands of clinical decision making for the first time. During a
discussion about whether nurses use the inference operation hypothesize in
clinical decision making, one nurse commented:
Why are they vomiting? Because she's got a PCA morphine pump
going? 1 wouldn't have thought of doing hypothesizing. I would be
dealing with the problem that she [the patient] has. Or trying to find a
reason for it. But I never thought of it in quite that term.
Although the literature suggests that individuals experience difficulty
describing their thinking processes in problem situations, (Nisbett & Wilson,
1977),. nurses in this study were able to gain an understanding into the
cognitive aspects of clinical practice. The model of thinking processes was an
effective resource to assist nurses to refiect on the thinking processes used in
clinical decision making. If nurses in the clinical setting are to be effective role
models for nursing students and new graduates, they must be able to describe
and communicate their tacit knowledge so that less experienced nurses can
benefit from their expertise (Barnett, Becher, 8 Cork, 1987) through the
modelling of expert clinical decision rnaking. More formal educational
programs, such as presentations and discussions of the model of thinking
processes, and the nursing exemplars used in specific clinical situations,
could be useful in improving nurses' clinicai decision rnaking skills, as well as
enhancing their ability to mode1 professional thinking processes.
Another approach to enhancing the clinical decision making skills of
nurses is the adoption of structured charting formats such as POR. This study
revealed that the structure of the SOAP narrative notes promoted greater
uülization of a broader range of thinking processes, particularfy higher order
thinking skills such as inference. Although it is acknowledged that the cognitive
processes used in clinical decision making are more readily evident when
nurses use the POR system (Gordon, 1994; Mitchell & Atwood, 1975), there is
liWe empirical evidence to support the use of POR as a means of encouraging -
greater utilization of higher order thinking skills in the pracüce seffing. This
study however, provided empirical support for the utilization of POR in nursing
practice as an approach to promoting greater utilization of higher order thinking
skills, such as inference. The assessrnent component of the SOAP notes
requires nurses to document a nursing judgement, and consequently
encourages nurses to use inferential thinking skiil operations. Nurses must be
encouraged to record clinical decisions in patient chartç, as the documentation
of their nursing decisions is a reflection of their level of professional
corn petency.
Contribution to Knowledge
The six research questions that guided this study provide the framework
for the commentary on the knowledge contribution of this study. First, the
results revealed that numerous thinking skills and operations are used in
clinical decision making. Nurses used five different categories of thinking skills
(description, selection, inference, synthesis, and verification) as evidenced by
the clinical situations that were documented in the patient charts. Nurses from
both units used two or more categories of thinking skills when documenting
clinical decisions in more than 75% of the narrative notes. These findings are
noteworthy given that little value is generally attributed to the chart
documentation by nurses, yet the results suggest that nurses are using
numerous thinking skills in clinical decision making situations. An important
outcome of this study was the development of nursing exemplars and
illustrations of thinking processes that can provide a working vocabulary to
describe the underlying thinking processes used in clinical decision making.
Nurse educators can use the nursing exemplars and illustrations of thinking -
processes as an instructional resource to enhance the developrnent of clinical
decision making skills in students. In addition, the methodology used to
analyze the thinking processes evidenced in the chart data could be used to
invesügate the underlying thinking processes used by other health care
professionals in actual clinical problern situations.
Second, this study revealed that differences exist between the two
nursing sub-groups within adult acute care, surgical and medical nursing, in
the documentation of clinical decisions, the type of clinical decisions
encountered, and the thinking skills utilized in clinical decision making
situations. These findings are important given that there is a paucity of literature
that informs nursing educators as to the differences in the types of clinical
decision making situations encountered in different nursing specializations.
Nu rsin g educators have g enerally regarded clinical leaming experiences in
surgical and medical practice seffings to be equivalent, but this study suggests
that there are differences in the clinical decision making situations
* encountered in the two sub-groups. This knowledge can assist nursing
educators in the examination of clinical learning experiences and the
underlying thinking processes that should be developed though clinical
courses in specific nursing specializations.
Third, although the literature supports primary nursing as a professional
practice mode1 that encourages independent thinking and increased
autonomy, no significant changes occurred in the documentation of patient
problems as nursing diagnoses, or the thinking processes utilized by the
medical nurses aft er the introduction of prirnary nursing. The differences in
clinical decision making as a result of primary nursing have received Iittle
attention in the literature. This study however, provided em pirical evidence that
the introduction of primary nursing did not result in signifcant changes in the
documentation of clinical decisions. Therefore this study has contributed to the
understanding of primary nursing as a professional pracüce model and its
effect on clinical decision making.
Fourth, the results also revealed that different thinking processes were
utilized in each of the three types of clinical situations identified in the chart
data. Nurses from both hospital units documented a wider range of thinking
skills and operations in situations of greater cornplexity. These findings
contribute to our understanding of the thinking skills involved in ackial clinical
decision making situations. Nurse educators can use this system of
categorizing clinical situations to structure actual clinical situations
encountered by students in the practice setong and to teach the underlying
thinkiny processes involved in tealistic clinical decision making situations.
Fifth, there is little empirical evidence to support the preference of one
charting system over another in terms of the development of certain thinking
processes. This study however, provided empirical evidence that the use of a
structured charting format (POR) encouraged the use of a wider range of
thin king processes, as evidenced in the SOAP formatted clinical notes. The
results also suggest that structured charting formats such as the SOAP
narrative notes encouraged the use of higher order thinking processes such as
inference. These findings can be used to enhance the understanding of
nursing educators so they can develop higher order thinking skills in nursing
students though the use of structured charüng formats in the documentation of
clinical decisions.
Finally, there were significant differences in the documentation of clinical
decisions between the expert venus proficient nurses on the medical unit. The
expert medical nurses docurnented more type 3 clinical notes with identified
problems and used a greater number of thinking skill categories than the
proficient medical nurses. On the other hand, there were no significant
differences between the expert versus proficient surgical nurses. There were
no significant differences between the expert and proficient nurses in this study
in their ability to discuss the thinking skills they utilize in clinical decision
making. These findings provide additional insights into the nature of clinical
expertise in nursing pracüce.
Recommendations
This study has provided insight into the cognitive processes utilized in
nursing practice though an investigation into the clinical decisions documented
by experienced, diploma prepared hospital nurses. Although the majority of
nurses are diploma prepared and work in institutional settings, there is a
movement to baccalaureate prepared pracütioners. To be able to describe the
cognitive processes utilized across the discipline, the thinking skills utilized by
nurses in other practice settings such as the home and community
environments need to be investigated. For example, would the thinking
processes utilized by nurses who work in non-institutional settings, be different
than those of nurses who work in traditional hospital environments? How do
the thinking processes change as nurses acquire increased decision making
responsibilities? How do advanced levels of education change the thinking
processes used in clinical practice?
The structured format of narrative SOAP notes in the problem oriented
charting system appears to encourage the nurses' use of higher order thinking
processes such as inference and synthesis. How does the use of other .
documentation systems influence the thinking processes used by nurses?
To improve the quality of education in professional programs the
following questions should be addressed. Are there differences in the thinking
processes utilized by novice nursing students and more experienced nurses?
Are there aspects of the decision making process that pose greater diffwlty for
students, and what underlying processes are involved?
Conclusions
Clinical decision making is essential to clinical nursing practice, yet
research into the cognitive processes underlying clinical decision making is
limited. The purpose of this study was to investigate the cagnitive processes
utilized by nurses in actual clinical decision making situations. Using a criterion
sampling technique, eight experienced medical and surgical nurses from an
acu te care community hospi ta1 were selected as participants for in-depth
interviews about clinical decision rnaking in nursing practice. Actual clinical
data documented by the eight nurses was obtained from a review of 100
randomly selected hospital records of patients discharged over a one year
period. The study examined the influence of contextual factors (nursing sub-
group, primary nursing patient assignment system, and Problem Oriented
Recording [PORI charting system), task variables (complexity of clinical
pro blems), and clinician characteristics (nursing expertise) on clinical decision
making. The dependent variables included the accuracy of nursing diagnosis
documentation and the utilization of specific thinking processes. Donald's
(1992) model of thinking processes provided a framework for the analysis of
the data.
The results suggest that clinical decision making is a complex cognitive
process requiring numerous thinking skills and operations. Evidence of five
different categories of thinking skills (description, selection, inference,
synthesis, and verification) and 14 different operations were found in the
narrative notes. The nurses used description when they recorded information
such as the transfer of patients from one hospital unit tu another, as required
by hospital protocol. Selection was used when the nurses recorded clinical
data concerning the patient's health status following surg ery or admission.
lnference was used when nurses documented a conclusion regarding the
patient's current health status. Nurses used synthesis when they recorded
specific nursing actions based on an analysis of multiple clinical data.
Verification was used when the nurses documented clinical data that gave
evidence as to the effectiveness of previous nursing interventions.
This study revealed that differences exist between the hivo nursing sub-
groups within adult care, rnedical -and surgical nursing, in the documentation of
clinical decisions, the types of clinical situations encountered, and the thinking
skills utilized in clinical decision making situations. Overall, more clinical notes
and clinical elements were documented in the charts from the rnedical unit.
This finding can be explained partly by the dRerences in the patient population,
and partly by differences in charthg procedures. On the medical unit the
patients were older and had longer hospital admissions, resulting in more
opportunities for the nurses to document clinical problems in the chart. The
charting procedure on the surgical unit utilized specific flowsheets for patient
assessment resulting in the documentation of fewer clinical notes.
Another difference between the h o nursing sub-groups was the
proportion of clinical notes that contained specific thinking skills. The majority
of surgical clinical notes contained evidence of description, selection, and
inference, whereas the majority of medical notes contained evidence of
description, selection, synthesis, and greater utilization of verificaüon. These
findings can be explained partly by differences in the clinical situations
encountered on each unit, and partly by differences in charting procedures. The
rnajority of surgical narrative notes were post-operative or admission notes.
The nurses used description when they recorded information such as the
transfer of patients from one hospital unit ta another as required by hospital
protocol. Selecüon was used when the nurses recorded clinical data
concerning the patient's health status following surgery or admission. The
structured SOAP format used more frequently by the surgical nurses
encouraged the use of inference when the nurses recorded an assessment
staternent regarding the patient's health status.
There were many more identified problem situations in the medical
clinical notes than the surgical notes. The medical nurses used synthesis
more frequently when they recorded specific nursing actions, and venfication
when they recorded data to indicate the effectiveness of their nursing
interventions. On the surgical unit, few identified pro blem situations were
documented. Thus, specific nursing interventions to address the clinical
problems and the ensuing evaluations were seldom recorded in surgical
charts.
Clinical situations were categorked into three types, based on the
cornplexity of clinical problems. Type 1 clinical situations included hospital
protocol situations, such as patient transfers to and from the hospital unit that
contained evidence of description and selection thinking skills. Type 2 clinical
situations included patient assessment situations without a documented
problem statement. The majority of type 2 surgical clinical situations were post-
operative assessments or condition reports in which the nurses utilized a
structured SOAP format modelling the example found in the charh'ng procedure
manual. The type 2 medical situations tended to be less structured and
represented a range of clinical situations. Evidence of description, selection,
inference, synthesis, and verification was found in type 2 notes from both units.
In type 3 clinical situations there were identified problem situations with
documented clinical data. The majority of the type 3 situations on the medical
unit continued over several hours, and necessitated the documentation of up to
six clinical notes over an eight hour shift. There were very few type 3 clinical
situations documented in the surgical charts, which was not unexpected, given
that most surgical patients have an uneventful recovery following surgical
procedures. There was evidence of description, selection, inference, synthesis,
and verification in the type 3 clinical situations. Three operations were found
only in type 3 clinical situations: the selection operation idenfi@ critical
elements, and the inference operations discover relations between elernents,
and hypofhesize. Nurses from both hospital units documented a wider range
of thinking skills and operations in situations of greater complexity.
The findings also suggest that stnictured charting formats such as
SOAP narrative notes encouraged the use of higher order thinking processes
such as inference. Introduction of the primary nursing patient assignment
system did not result in significant changes in the documentation of nursing
diagnoses or thinking processes utilized by nurses.
Nurses in this study were grouped acçording to two levels of nursing
expertise; proficient and expert (Benner, 1984). This study revealed that the
medical expert nurses used a greater number of thinking skill categories in the
clinical notes, documented more type 3 clinical notes with identified problems,
and had a greater tendency to use a structured SOAP format Vian the proficient
nurses. On the other hand, there were no statistically significant differences in
the documentation of clinical decisions between the expert and proficient
surgical nurses, which can be partly explained by the greater utilization of a
structured SOAP format by al1 surgical nurses, and the limited number of type 3
clinical situations.
An important outcome of this study was the development of nursing
exemplars and illustrations of thinking processes that can provide a working
vocabulary to describe the underlying thinking processes used in clinical
decision making. The model of thinking processes (Donald, 1992) was useful
in elucidating the thinking processes used in clinical decision making, and
thus, the cognitive processes that should be taught in professional nursing
education.
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Appendices
Appendk A
Definitions of Operaüons of lntellectual Skills in Higher Educaüon
DESCRIPTION
ldentify Context
List Conditions
List Facts
List Functions
State Assumptions
State Goal
SELECTION
Choose Relevant lnformation
Order Information in Importance
ldentify Critical Elements
ldentify Critical Relations
The delineaüon or definition of a situation or the f o n of a thing.
Esta blis h surrounding environment or circurnstances through objective environmental or mental scanning to create a total picture.
List essential parts, stipulations, indispensable circumstances, prerequisites or req uirements, that on which something is contingent. .
List known information, events that have occurred, observations.
List the normal or proper activity of a thing or the specific duties.
State suppositions, postulates or propositions assumed. premises.
State the ends, aims, objectives.
Choice in preference to another or others.
Select information that is pertinent, to the purpose, applicable, bearing on the issue in question.
Rank, sequence, arrange methodically in terms of importance or according to its significance, consequence, effect.
Detemine units, parts, components, constituents which are essential, decisive, or important as regards consequences.
Determine connections between things which are essential, decisive, or important as regards consequences.
REPRESENTATION Depiction or portrayal through enactive, iconic or symbolic means.
Recognize Organizing ldentify laws, methods, rules, basic tenets Principles which arrange, form, or combine into a
systernaüc whole.
Organize Elements & Arrange, form, combine into a systematic Relations whole, units, parts, components and
connections between things.
Illustrate Elements & Make clear by examples, the units, parts, Relations components and connections between things..
Modify Elements & Reletions Partially change, Vary, alter in some respect, moderate or qualiw in the units, parts, cornponents and connections between things.
INFERENCE Act or process of drawing conclusions from premises or evidence.
Discover New Relations Detect or expose new connections between Between Elements parts, units and components.
Discover Relations Between Detect or expose connections between Relations connections of things.
Discover Equivalences Detect or expose equality in value, force or sig nificance.
Categ orize Classify, arrange into parts.
Order Rank, sequence, arrange methodically.
Change Perspective Alter view, vista, appearance, interrelations or significance of facts or information.
Hypothesize Suppose or form a proposition as a basis for reasoning .
SYNTHESIS
Combine Parts to Forrn a. Whole
Ela borate
Generate Missing Links
Develop Course of Action
VERIFICATION
Compare Alternative Outcomes
Compare Outcome to . Standard
Judge Validity
Use Feedback
Confirm Results
Composition of parts or elements into a cornplex whole.
Join, unite or associate elements, components into a complete entire system or pattern.
Work out or complete with great detail, exactness or complexity.
Produce or create whatever is lacking for the completion of a series or sequence; fi11 in the W P *
Work out or expand, the path, route or direction , to be taken.
Confirmation of accuracy, coherence, consistency or correspondence.
Examine or note similarities and differences of possible results, consequences or conclusions.
Examine or note similarities and differences of results, consequences, or conclusions to the criterion, greater level of excellence or quality.
Crîtically examine or estimate the soundness, effectiveness or support actual fact of a thing.
Employ results to regulate, adjust or adapt.
Establish or ratify conclusions, effects, outcomes or products.
Appendix B I
Description of Chart Documents
Chart Recording Information Remrded _ Document Frequency Cardiac Teaching Educational plan for heart attack Record
Diabetic Teaching Record
Fluid Balance Record
Graphic Chart
Medication Administration Record
Neuro Vital Sign Record
Nursing Data Base
Nursing Kardex
Palliative Care Pain Assessment Record
Patient Care Log
Progress Notes
Treatrnent Record
Stat and First Dose
q shift, prn
q shift, prn
q shift, prn
once
Pm
qshift,prn
q shift -
q shift, prn
q shift, prn
patients.
Educational plan for new diabetic patients.
Detailed list of type and amount of fiuid intake and output
Monitoring of temperature, pulse, blood pressure, weig ht
Regularly scheduled medications -
Monitoring of neurological status or frequent monitoring of pulse, blood pressure
Patient assessrnent data collected on admission
Sumrnary of critical patient information and most current nursing care plan
Monitoring of pain levels and response to therapies
List of nurses responsible for patient care each shift
Narrative reports of patient problem situations
lndividualized list of specific regularly scheduled nursing procedures (e.g. wound care)
List of medications administered Medication Remrd urgently or once only
Appendk C
Professional Nursing Education: Cognitive Processes Utilized in Clinical Decision Making
Proposa1 for Ph.D. dissertation by
Kathryn Higuchi Faculty of Education, McGill University
Request for support from Queensway-Carleton Hospital
Involvement of Nursing Department
Assist with arrangements for meetings with nursing staff on Level 3, Section B and Level 4, Section B to explain purpose of the study and to recruit volunteers.
Assist with the scheduling of obsewation shifts and interview times for nursing staff. Assist with the booking of office space suitable for conducting interviews with individual nurses.
Assist with the identification of nursing employees (full and part tirne versus casual) from selected units for coding purposes.
Involvernent of medical records department
1. Retrieve a total of 100 medical records of patients discharged from 2 units during the following tirne periods:
Level 3, Section B Level4, Section B December 1993 10 records ? O records February 1994 10 records 10 records July 1994 1 O records I O records September 1994 10 records I O records November 1994 1 O records 10 records
2. Assist with the location of suitable working space to review data from patient records.
Appendix D i
Professional Nursing Education: Cognitive Processes Utilized in Clinical Decision Making
Researcher: Kathryn Smith Higuchi, R.N. Ph.D. Candidate, Faculty of Education, McGill University
Thesis advisor: Dr. Janet Donald, Centre for University Teaching and Learning, McGill University
Consent Forrn
I have voluntarily agreed to participate in this study and understand that 1 may withdraw at my discretion and for any reason. I understand that my participation or withdrawal will have no adverse consequences to my employment at the Queensway-Carleton Hospital.
I understand that this study is an investigation into the clinical decision making skills utilized by nurses. The main purpose of this study is to gain a better understanding of the thinking processes used in clinical decision making.
I understand that I may be observed in the hospitai setting as 1 conduct nursing activities. I may also be involved in interviews to solicit more information about how I make clinical decisions.
I understand that my identify will be protected and that all records will be coded to guarantee anonymity. I understand that al1 data will be collected by the researcher and reviewed only by the tesearcher, research assistants, and her thesis advisory comrnittee.
Name:
Signature:
Date:
Telephone number:
Appendix 02
May 10,1995
Ms. Lynne Taylor, Vice President Patient Sewices Queensway-Carleton Hospital 3045 F3aseline Road Nepean, Ontario K2H 8P4
Dear Lynne:
At its meeting on May 3,1995 the Consents & Research Comrnltteeapproved the research proposal tMed 'Cognitive Processes Utilized in Clnical Decislon Making'.
At its meeting On May 9,1995 the Medical Advisory Committee appmved the recommendation of the
a Consents & Research Committee.
This wiU permit Ms. Higuchie to proceed with her project
D.G. Gray, M.D. Chair Consents & Research Committee
Appendix D3
CERTIFICATE OF ETHICAL ACCEPTABILiTY FOR RESEARCH INVOLVING HUMAN SUBJECTS
A review cornmittee consisting of three of the following members:
1. Prof. J. Derevensky 1. Prof. M. Maguire
2. Prof. M. Downey 2, Prof. N. Jackson
3. Prof. S. Nemiroff 3. Prof. H. Perreault
has examined the application for certification of the ethical acceptability of the project titled:
as proposed by:
Applicant8s Name &+h~q tî H i q ~h r
Appticant's Signature
Supervisor's Name J d k / ~ T iJAC
1 .
Supervisai's Signature LJ ,
Granting Agency
The review cornmittee considers the research procedures. as explained by the applicant application, ta be acceptable on ethical grounds.
(Sig ned)
C; - Dean (Acadernic) ; L-,J
Appendix E
Participants
Number of Years Nurse Status yearssince worked Patients Shifts Shifts Charts
graduation on unit assigned worked per chart with notes A Fr 24 15 15 44 2.9 8
Note: FT = full-tirne, PT = part-tirne - D & E = works day and evening shifts D 8 N = works day and night shifts
Appendix F1
Average Admission Days by Patient Chart
Medical Unit M SD n
Medical Cases M SD n
0 s 9.8 7.8 I O TOTAL 9.3 11.8 50
11.1 8.0 8 13.8 15.0 25
Surgical Unit M SD n
Surgical Cases M SD n
0 5 3.2 4 .O 1 O TOTAL 4.1 3.7 50
2.3 2.4 7 4.2 3.9 25
Appendix F2
Average Age of Patients During Hospital Admission
Medical Unit M SD n
01 67.4 26 .7 10
Medical Cases M SD n
66.0 23.6 5 4 69.9 21 -3 I O 0 3 61.4 22.4 1 O O4 66.3 20 .6 1 O 0 5 77.8 11.7 I O
TOTAL 68.6 21 .O 50
58.0 31 .l 2 71 .O 19.0 4 73.3 10.9 6 77.8 7.9 8 71.7 16.0 25
. Surgical Unit M SD n
Surgical Cases M SD n
0 s 47.4 22.6 1 O TOTAL 54.4 20 -4 50
46.9 23 .O 7 55.1 19.7 25
Appendix G
Example of Coded Narrative Note
Chart # 446 DX Pulmonary edema, Angina, Myocardial lnfarction DOB 1923 (M) Admission Date 24-12-93
DATE TIME NURSE INFORMATION 28-12 0706 415 Rechest pain (1 .i)
S. "1 need-a nitro. (2.3) My chest pain is back." (2.3)
O. Pt up to BIR 8 returned to bed. (2.3) C/O anterior chest pain local @ first. (2.3) BP 142190 P-84. (2.3) Nitro given XI @ 0704 hrs. (5.4) One min later pt stated pain iç going down to his arms. (2.3) Nitro repeated. (5.4) O2 put on. (5.4) HOB T (5.4) Then pt stated chest pain is going away. (6.3) A. Chest pain R/T activity. (4.7) P. Monitor chest pain. (1.6) & notify Dr. in am re pt chest pain. (5.4)
Type 3 situation (with identified patient problem)
Code Thinking skill
Description Description Selection lnference Synthesis Verification
Operation
identiw context state goal identify critical elements h ypothesize develop course of action judge validity
Appendix H l
Clinical Episodes Documented by Nurses in Each Observation Period
Medical Unit 0 7 4 O3 O4 0 s TOTAL
Nurse
Su b-total 17 11 13 1 O 17 68
Surgical Unit E 1 O O O 3 4 F 3 2 2 4 3 14 G 1 O 5 1 1 8 H O 1 1 2 2 6
Su b-to ta1 5 3 8 7 9 32 TOTAL 22 14 21 17 26 100
Note: Chi square test was not statistically significant (3 (4, N = 100) = 2.69, - p =.61)
Appendix H2
Clinical Notes Documented by Nurses in Each Observation Period
Medicat Unit 01 02 4 O4 0 5 TOTAL
Nurse A 5 5 4 3 O 17 8 9 12 O 1 O 8 39 C 6 O 'l 1 6 14
Surgical Unit E 1 O O O 4 5
Sub-total 5 4 1 O 10 11 40 Total 35 22 25 27 33 142
Note: Chi square test was not statistically significant (2 (4, N = 142) = 8.0, - p =.09)
Appendix I
Interview Schedule
Background information First, could you tell me about your nursing background?
When did you graduate frorn nursing school? How would you describe your basic nursing education in terms of teaching thin king skills? What experiences in nursing school helped to prepare you for your first n ursin g job? What types of nursing positions have you had since graduation? Have you taken any additional courses since graduation? Could you describe thern?
Current nursing position How long have you been employed in this hospital? On this unit? How would you describe your role as a nurse on this unit? How have your nursing education and previous job experiences helped you in your current nurçing position? . Clinical decision makinq Could you give me some examples of decisions that you make every day in nursing? Are some decisions more diffÎcult or easier to rnake Vian others? Why? Could you describe for me an incident that stands out in your mind in which your interventions or decisions made a difference €0 a patient? What did you do? Why did you do that? What knowledge did you use to make those decisions? What past experiences helped you to understand this situation?
Cornmunica tion of clinical decisions How do you decide what patient information should be shared with the patient, other nursing colleagues, and other health professionals? How do you communicate patient information? Are you ever uncertain about your clinical decisions? If so, what do you do? Are there resources in the hospital or on your unit that help you in making decisions? How do you use these resources? Are there aspects of the hospital environment or documentation system that hinders the communication of patient information and clinical decisions? Could you explain in more detaii how this is a problern for you?
Clinical decision making: cognitive skills '
5.1 Take a few minutes to look at this list of thinking skills. This list represents thinking skills that are used in variaus disciplines. Which skills are more important in nursing? Could you give me examples of how you use these skills in clinical practice?
5.2 Are there any skills that are more important than others in clinical decision making?
Prirnary nursing and clinical decision making 6.1 Could you describe for me how primary nursing is used on your unit? 6.2 How has pnmafy nurçing affected your how you assess your patients and
make decisions?
Clinical Assessment: Importance in nursing 7.1 How important is clinical decision making in nursing? Why? 7.2 How important is it that nurses communkate .their decisions to others?
Could you explain why? -7.3 If you could make any changes to the decision making process .on this . *
unit, what would they be?
Appendix I (continued)
Definitions of Thinking Processes in Higher Education (Donald, 1992)
DESCRIPTION
ldentify Context
List Conditions
List Facts
List Functions
State Assumptions
State Goal
SELECTION -
Choose Relevant Info
Order lnfo in Importance
ldentify Critical Elements
ldentify Critical Relations
REf RESENTATION
Delineation or definition of a situation or form of a thing Establish surrounding environment to create a total picture List essential parts, prerequisites or requirements List known information, events that have occurred List normal or proper activity of a thing or specific duties State suppositions, postulates or propositions assumed State the ends, aims, objectives
Choice in preference to another or others Select information that is pertinent to the issue in question Rank, arrange in importance or according to its significance Determine units, parts, components which are important Determine connections between things which are important
Depiction or portrayal throug h enactive, iconic or sym bolic means
Recogn ize Organizing Principles ldentify laws, methods, rules which arrange in systematic whole
Organize Elements & Relations Arrange parts, connections between things into systematic whole
lliustrate Elemen ts & Relations Make clear by examples. the parts, connection between things
Modify Elements & Relations Change, alter or qualify the parts, connections between things
INFERENCE --
Discover Rel'ns Between Elements
Discover .Rel'ns Between Relations
Discover Equivalences
Categ orize
Order
Change Perspective
Hypothesize
SYNTH ESI S
Combine Parts to Form a Whole
Ela borate
Generate Missing Links
Develop Course of Action
VERIFICATION
Compare Alternative Outcornes
Compare Outcorne to Standard
Judge Validity
Use Feedback
Confirrn Results
Act or process of drawing conclusions from premises or evidence Detect or expose connections between parts, units, cornponents Detect or expose connections between connections of things Detect or expose equality in value, force or significance Classify, arrange into parts
Rank, sequence. arrange rnethodically
Alter view, vista, interrelations, significance of facts or info Suppose or form a proposition as a basis for reasoning
Composition of parts or elements into a complex whole Join, associate elements, components into a system or pattern Work out, complete with great detail, exactness or wmplexity Produce or create what is lacking in a sequence; fiIl the gap Work out or expand the path, route or direction to be taken
Confirmation of accuracy, coherence, consistency, correspondence Examine sirnilarities or differences of results, consequences Examine similarities, differences of results to a criterion Critically examine the soundness, effectiveness by actual fact Employ results to regulate, adjust, adapt Establish or ratify conclusions, effects, outcornes or products
Appendix J 4
Coding of Labelling Accuracy of Nursing Diagnoses
Evaluation code Criteria Accurate label Nursing diagnostic statemen t correctly worded
according to currently accepted NANDA taxonomy.
Atternpted label Nursing diagnostic statement worded differentiy from currently accepted NANDA taxonomy.
Accurate etiology Etiology relevant to specific nursing diagnostic statement.
Atternpted etiology Etiology not related to nursing diagnosp'c staternent.
Coding of Diagnostic Accuracy of Nursing Diagnoses
Evaluation code Criteria Accurate diagnosis Patient data present supports nursing
diagnosis selected. Incorrect diagnosis Patient data does not tit with nursing
diagnosis selected. Unsupported diagnosis Patient data not present when nursing
diagnosis selected. Unspecific diagnosis General diagnosis selected when data exists
that indicates a specific nursing diagnosis. Omitted diagnosis Patient data exists, but no nursing diagnosis
selected or documented.
Frequency of Documentation of Nursing Diagnoses and Clinical Notes in Patient Charts
Nurse Patient Charts Nursing Diagnoses Clinical Notes A 1 2 4
Total 12 55 20
Appendix L
Hospital Charting Procedure
EFFECTIVE: Feb., 1 982 REVISEO: Sept., 1992
GENERAL POLlCY & PROCEDURE MANUAL (PROCEDURE)
Approved by: Head Nurses Cornmittee
CHARTING PROCEDURE - PROGRESS NOTES
PURPOSE:
To provide legal documentation of the events occurrïng during a patient's hospital stay.
PROCEDURE:
1. Progress notes rnust be written for the following:
a problern identified during the course of hospitalization. any positive or negative change in a patient's condition. a problern which becornes inactive. resolved or dropped. on admission when (i) the nursing data base cannot be
completed due to patientrs condition. (ii) problems are identified which require
immediate documentation andlor nursing intervention.
interdepartmental or inter-hospital transfer. when patient leaves the hospital for a test and upon the patient's return. on arrivai to the unit, post-operatively. after an invasive procedure. documentation of patient and/or family teaching. if there is no change in a patient's condition within 3 days of admission.
Appendix Ml
Diagnostic Statements and Etiologies with Accurate Labels
Medical Unit Suraical Unit Total Accu rate Accurate Accu rate
Statements n Statements n Statements n - - -
01 22 22 18 18 40 40 0 2 8 9 6 6 14 15 4 5 6 22 22 27 28 O4 3 3 18 18 21 21 O5 13 14 20 20 33 34
TOTAL 51 54 84 84 135 138
Appendix M2
Patient Charts with Documented Nursing Diagnoses
Medical Unit Surgical Unit Total Charts n Ch arts n Charts n
01 6 1 O 4 10 1 O 20 0 2 5 1 O 2 IO 7 20 4 3 10 4 10 7 20 O4 1 I O 4 1 O 5 20 0 5 5 1 O 6 I O 11 20
TOTAL 20 50 20 50 40 1 O0
Appendix M3
Medical and Surgical Charts that Omitted Diagnoses
Medical Unit Surgical Unit Total 01 4 6 IO 0 2 5 8 13 0 3 7 6 13 O4 9 6 15 0 5 5 4 9
TOTAL 30 30 60
Note: Chi square test was not statistically significant (2 (4, N = 60) = 1.88, - p = .76).
Appendix N I
Clinical Episodes and Clinical Notes Docurnented in Medical and Surgical Charts
Clinical e~isodes Clinicâl notes Medical unit Surgical unit Medical unit Surgical unit
01 17 5 30 5 O2 11 3 18 4 O3 13 8 15 1 O O4 1 O 7 17 1 O 0 5 17 9 22 II
TOTAL 68 32 102 40
Note: Chi square test was not statistically significant for clinical episodes (2 - (4, N = 100) = 2.69, p = .6l) anddinical notes 2 (4, N = 142) = 8.0,
p = .09).
Appendix N2
Thin king S kill Categories Evidenced in Clinical Notes
Number of Medical Surgical Cornbined
categories per clinical notes dinical notes
clinical note % n % n % n
1 25 25 15 6 22 31
2 22 22 25 1 O 23 32
3 26 26 40 16 30 43
4 21 21 16 7 19 27
5 8 8 3 1 6 9
Total 102 102 99 40 100 142
Note: Chi square test was not statistically significant (2 (4, N = 142) = 2.86, - p =.58). Total percentages do not always equal 100 because of rounding.
Appendix 01
Thinking Skills Evidenced in Clinical Episodes and Notes
Clinical episodes Clinical notes
Medicine Surgery Medicine Surgery
Thinking skills % n % n % n % n
Description 94 64 100 32 79 81 IO0 40
Selection 78 53 91 29 69 70 88 35
1 nference 46 31 72 23 33 34 58 23
Synthesis 53 36 25 8 48 48 20 8
Verification 46 31 9 3 36 37 8 3
Total 68 32 102 40
Note: Clinical episodes and clinical notes can contain more than one type of - thin king skill.
Appendix 0 2
Number of Operations Evidenced in Clinical No tes
Number of operations Medical notes Surgical notes Corn bined per note
% n % n % n
Total IO0 102 102 40 99.7 142
Note: Total percentages do not always equal 100 because of rounding. -
Appendix 0 3
Operations in Medical and Surgical Clinical Notes
Medical clinical Surgical clinical notes notes
% n % n Description
ldentify context List conditions List facts State assumptions State goal
Seleciion Relevant information Critical elements
ln fer en ce Relations bt elements Categorize Hypothesize
Syn the sis Combine parts Plan action
Verifica tion Judge validity Confirm results
Note: Most clinical notes contain more than one type of thinking skill operation.
Appendix 0 4
Distribution of Clinical Elements by Thinking Skill in Clinical Notes
Medical notes
Thinking skill n % minhote maxlnote M/note
Description 198 32 1 7 1.9 Selection 235 38 1 12 2.3 lnfe rence 36 6 1 2 0.35 Synthesis 87 14 1 5 0.85
Verification 57 9 1 3 0.56 Total 613 99 1 12 6
Surgical notes
Thin king skill n % minhote maxhote Mlnote
Description Selection lnference Syn thesis Verification 3 O -9 1 1 0.08
Total 321 99.9 1 14 8
Note: There is more than one category of thinking skill in most clinical notes. - Total percentages do not always equal 100 because of rounding.
Appendk P l
Distribution of Types of Clinical Situations
Nurse T e l Total A 2 4 II 17
Sub-Total 6 48 48 102 E O 4 1 5 F 6 9 2 17 G O 8 3 11 H 2 5 O 7
Sub-Total 8 26 6 40
Total 14 74 54 142
Appendix P2
Operations in Type 1 Clinical Situations
Medical Notes Suraical Notes % n % n
Description Identify context 17 1 13 1 List facts 1 O0 6 100 8 State goal 33 2 O O
Selection Relevant information O O 50 4
Note: Clinical notes contain more than one type of thinking skill operation.
Appendix P3
Number of Operations Evidenced in Type 2 Clinical Notes
Number of operations Medical notes Surgical notes Corn bined per note
% n % n % n . - - -
1 19 9 8 2 15 11 2 25 12 19 5 23 17 3 25 12 4 1 18 13 4 15 7 8 2 12 9 5 10 5 42 l? 22 16 6 4 2 12 3 7 5 7 O O 8 2 3 2 8 2 3 O O 1 1
Total 1 O0 48 101 26 101 74
Note: Total percentages do not always equal 100 because of rounding. -
Operaüons in Type 2 Clinical Situations
Medical Notes Surgical Notes . -
Description ldentify context 9 5 65 17 List conditions 2 1 O O List facts 75 36 96 25 State assumptions 19 10 12 3 State goal 13 6 62 16
Selection Relevant information. 73 35 92 24
ln ference Catego rize 17 8 69 18
Syn th esis Corn bine parts 6 3 8 2 Plan action 35 17 12 3
Verifica tion Judge validity 29 14 8 3 Confirrn results 8 4 O O
Note: Clinical notes contain more than one type of thinking skill operation. -
Appendix P5
Number of Operations Evidenced in Type 3 Clinical Notes
Number of operations Medical notes Surgical notes Corn bined Der note
Total 1 O0 48 1 O1 6 99 54
Note: Total percentageç do not always equal 100 because of rounding.
Appendix P6
Operations in Type 3 Clinical Situations
Medical Notes Suraical Notes
Description Identiw context List conditions List facts State assumptions State goal
~e lec tbn Relevant information Critical elements
In ference Relations bt elements Categorize Hypothesize
Syn thesis Corn bine parts Plan action
Verifica tion Judge validity Confirm results O O O O
Note. Clinical notes contain more than one type of thinking skill operation. -
Thinking Skills Evidenced in SOAP and Non-SOAP Fomatted Notes
Medical Notes SOAP formatted 1 Non-SOAP formatted
% n Description 1 O0 34
TOTAL 34 1 68
% n 69 47
Seiection 85 29 Inference 82 28 Synthesis 74 25 Verification 47 16
Surgisal Notes SOAP formatted 1 Non-SOAP formatted
60 41 9 6 35 24 31 21
Note: Chi square test was statistically significant (2 (1, N = 142 = 6.98, p = - .008)
% n Description 96 22 Selection 1 O0 23 lnference 1 O0 23 Syn thesis 35 8 Verification 9 2 TOTAL 23
% n 1 O0 17 65 II O O O O 6 1
17
Appendix Q2
Operations in Type 2Notes With and Without SOAP Format
Medical Notes SOAP Non-SOAP
% n % n Descrip tio n
Idenüfy conte* 38 3 5 2 List conditions O O 3 1 List facts 88 7 98 39 State assumptions 13 1 23 9 State goal 63 5 3 1
Selection Relevant information 88 . 7 95 38
ln fer ence Categorize
Syn the sis Combine parts Plan action
Verifica tion Judge validity Confirm results
Surgical Notes SOAP Non-SOAP
% n % n Description
Identify con text 89 16 O O List facts 1 O0 18 1 O0 8 State assumptions 1 7 3 State goal 83 15 13 1
Selection Relevant information 100 18 88 7
ln fer ence Categorize 100 18 O O
Syn th esis Combine parts 17 2 O O Plan action 17 3 O O
Veritica tion Judge validity 11 2 13 1
Appendix Q3
Number of Operations Evidenced in SOAP and Non-SOAP Formatted Notes in Type 2 Clinical Situations
Medical Notes Number of SOAP formatted o~erations % n
Non-SOAP formatted
Surgical Notes Number of SOAP formatted operations % n
1 O O
TOTAL 99 18
Non-SOAP formatted
Note: Total percentages do not always equal 100 because of rounding. -
Appendix Q4
Operations in Type 3 Notes With and Without SOAP Format
Medical Notes SOAP Non-SOAP
% n % n Description
ldentify context 54 14 9 2 List conditions 19 5 5 1 List facts 54 14 32 7 State assumptions 8 2 O O State goal 62 16 9 2
Selection Relevant information 23 6 36 8 Critical elements 85 22 23 5
ln ference Relations bt elernents 39 1 O O O Categorize 15 4 5 1 Hypothesize 46 12 O O
Syn th esis Plan action 77 20 50 11
Verifica tion Judge validity 42 II 46 1 O
Surgical Notes SOAP Non-SOAP
% n % n Description
Identify context 40 2 O O List facts 80 4 1 O0 1 State assumptions . 20 2 O O State goal 20 2 O O
Selectl'on Relevant information 80 4 1 O0 1 Critical elements 1 O0 5 O O
ln ference Relations bt eiements 20 2 O O Categorize 1 O 1 O O H ypothesize 20 2 O O
Syn th esis Plan action 60 3 O O
Appendix Q5
Nurnber of Operations Evidenced in SOAP and Non-SOAP Formatted Notes in Type 3 Clinical Situations
Medical Notes Number of SOAP formatted 1 Non-SOAP formatted
Surgical Notes Number of SOAP forrnatted. 1 Non-SOAP formatted
- -
operations % n 1 O O
% n 36 8
operations % n -l O O
Note: Total percentages do not always equal 100 because of rounding. -
% n O O
7 20 1 TOTAL 1 O0 5
O O A00 1
Appendk R I
Number of Clinical Notes Documented by Expert and Proficient Nurses
Medical Unit Surgical Unit Total
Expert Nurses 56 22 78
Proficient Nurses 46 18 64
Total 102 40 142
Note: Chi square test was not statistically significant (2 (1, N = 142 = .00, - p = -99)
Appendix R2
Distribution of Thinking Skill Elernents Docurnented by Expert and Proficient Nurses
Medical Unit (Nurses) - -
Expert Nurses Prof cient Nurses Total Description 111 87 198 Selection Inference Synthesis Verification 39 18 57 Total 359 254 61 3
Surgical Unit (Nurses) -
Description 64 71 135 Selection Inference Synthesis Verifkation 1 2 3 Total 173 148 321
Note: Chi square tests were not statistically significant for medical nurses (2 - (4, N = 613) = 5.01, p =.29) and surgical nurses (2 (4, N = 321) = 4.92, p =.30).
Appendk R3
Number of Thinking Skill Categories Documented by Expert and Proficient Nurses
Medical Unit Number of 1 2 3 4 5 Total Categories
Expert Nurses
Proficien t Nurses
- - -
Total 25 22 26 21 8 102
Surgical Unit Number of 1 2 3 4 5 To ta1 Cateaories
Proficien t Nurses
Total 6 1 O 16 7 1 40
Note: Chi square test was statisücally significant for the medical nurses (2 - (4, N = 102) = 11.49, p = .OZ), but not for the surgical nurses (2 (4, N =
40) = 3.29, p = -51)
Appendix R4
Distribution of Types of Clinical Situaüons Documented by Expert and Proficient Nurses
Medical Unit Type 1 Type 2 Type 3 Total
Expert Nurses 2 21 33 56
P roficien t Nurses
Total 6 48 48 102
Suraical Unit Type 1 Type 2 Type 3 Total
Expert Nurses 6 13 3 22
Proficien t Nurses
Note: - Chi square test was statistically significant for the medical nurses (2 (2, N = 102) = 7.26, p =.03), but not for the surgical nurses (3 (2, N =
40) = 1.39, p = .45)
Appendix R5
Distribution of SOAP and NonSOAP Fomatted Type 2 and 3 Notes Documented by Expert and Proficient Nurses
Medical Unit SOAP Notes Non-SOAP Notes Total
Expert Nurses 23 31 54
Proficien t Nurses 11 31 42
Total 34 62 96
Surgical Unit SOAP Notes Non-SOAP Notes Total
Expert Nurses 13 3 16
Proficien t Nurses 1 O 6 16
Total 23 9 32
Note: Type 1 clinical situations were not included in these analyses because - there were no SOAP fomatted type 1 clinical notes.
Chi square test was not statistically significant for the medical nurses
(2 (1, N = 96) = 2.78, p = . IO ) and the surgical nurses (3 (1, N = 32) =
Appendix S
Interview Data: Thinking Skills Utilized in Clinical Decision Making
A B C D E F G H DESCRIPTION + * + * + * * 3
ldentify context Conditions List facts List functlons State assurnptions State goal
SELECTION Choose relevant info Order information Critical elements Critical relations
REPRESENTA TION Recognize org an king principles Organize elements & relations Illustrate elements & relations Modify elements & relations
Note: + uses thinking skill, E elaborates or cites example, * important skill, - number 1-6 = ranking of thinking skill
Appendix S (Continued)
Interview Data: Thinking Skills Utilized in Clinical Decision Making
Discover relations between + elements Discover relations between + relations Discover equivalences Categorize Order Change perspective H ypothesize
SYNTHESIS Combine parts to form a whole Etaborate Generate missing links Develop a course of action
VERIF ICA 77ON Compare alternative ou tcomes Compare outcome to standard Judge validity Feed back + E Confirrn results + + E + + +
Appendix T
Thinking Processes Underlying the Nursing Process
Nursing process Operations confirmed by chart data Operations confirmed by interview data
Description - identify context, list conditions, Representation -recognizing organizing Assessrnent
list facts, state assumptions principles, illustrate elements and relations
Selection - choose relevant information, Verjflcation ~feedback, compare alternative
iden tify critical elernents outcomes
Synthesis -combine parts to forrn a whole
Nursing diagnosis
Planning
lnference - hypothesize, categorize, discover Verjfication - feedback
new relations between elernents
Description - state goal lnference - order
Synthesis - develop course of action Synthesis -generate missing links
Verification - feedback
Evaluation Verifbation - judge validity, confirm results Verification - compare alternative outcomes,
compare outcome to standard, feedback
