fournal of Advanced Nursing, 2000, 32(4), 981-989

Nursing theory and concept development or analysis

Classifying clinical decision making: a unifying approach

Christopher D, Buckingham PbD MSc BSc Lecturer in Gognitive Science, European Institute of Health and Medical Sciences, University of Surrey and Ann Adams PbD MSc BA RGN Research Fellow, European Institute of Health and Medical Sciences, University of Surrey, Guildford, England

Accepted for publication 17 April 2000

BUGKINGHAM G,D. & ADAMS A. (2000) Journal of Advanced 981-989

Nursing 32(4),

Classifying clinical decision making: a unifying approach This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their ov\^n decision-making processes as unique. Identifying good nursing decisions and where improvements can he made is therefore prohlematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decisionmaking theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification hehaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism. Keywords: decision making, classification, clinical reasoning, judgement, nursing health care, multidisciplinary collaboration, medicine
Correspondence: Christopher D. Buckingham, Computer Science, University of Aston, Aston Triangle, Birmingham B4 7ET, England. E-mail: c.d.buckingham@aston.ac.uk

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CD. Buckingham and A. Adams

INTRODUCTION
Gaining a better understanding of their decision-making processes has important benefits for nurses and their employing organizations. Clinical effectiveness will be enhanced where nurses can consolidate those elements that lead correctly to predicted outcomes and re-evaluate those which do not. Greater self-knowledge in this respect will enahle nurses to give better explanations to patients, thereby facilitating both professional and health service policy aspirations to achieve patient partnership in care decisions (Ersser & Tutton 1991, National Health Service Executive, NHSE 1996). At an organizational level, improved understanding of decision-making processes will afford greater protection against litigation and support quality management through enhancing managers' ability to implement clinical governance (Department of Health, DoH 1998). More transparency in decision making will also assist multidisciplinary working. A long history of research into the psychology of thinking and reasoning (Dominowski & Bourne Jr 1994) has resulted in a morass of different clinical decision-making theories and confusing terminology (see Higgs & Jones 1995 and Dowie & Elstein 1988 for reviews). The danger is that each clinical discipline considers its decision-making processes in isolation without drawing adequately on the general research base. Separate disciplines therefore tend to think that their approach to making decisions is unique: a hard notion to disabuse because of the difficulty of comparing theories. A good example of this problem is in Grow et al. (1995 p. 207) who suggest that the purpose of nursing assessments is 'to form an evaluation or judgement about a condition, not a diagnosis of a problem', the latter supposedly being the province of doctors. Furthermore, it is deemed that the distinction hetween types of decision 'raises the question of whether the cognitive component of assessment might include different cognitive strategies from those involved in diagnosis' (Crow et al. 1995 p. 207). In other words, nurses' decision-making processes are given a different name to those of doctors, with the speculation that they are likewise different in nature. Such beliefs represent potential barriers to change in health service environments increasingly characterized by fluidity in professional w^ork role boundaries, and where the remit of nurses in particular is expanding. As a result of organizational restructuring, multiskilling initiatives, and professional projects creating growing diversity among specialist and advanced practitioners (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, UKGG 1992, NHSE 1995, Adams et al. 2000), nurses' work is acknowledged to include transferred elements of managerial, medical and therapeutic work. These trends are evident in both Europe and North America, hut are particularly marked in the United Kingdom (UK) where, in the context of financial
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constraints and National Health Service (NHS) staffing problems, the move towards expanding nurses' work roles looks set to continue. Indeed, expanding the roles of nurses, midwives and health visitors to make better use of their knowledge and skills is a stated aim in recent government policy (DoH 1999), and is reflected in professional activity (UKGG 1999). It is therefore imperative that inter-disciplinary barriers are re-examined and, where possible, removed. How much this can be achieved through an academic channel is open to question and Allen (1997) discovered that boundary transgressions between physicians and nurses were more contentious in theory than in practice. Nevertheless, a common frame of reference for decisions will contribute to multidisciplinary collaborations. A better understanding of their decisions will also benefit nurses as a profession. Nurses have struggled continually to articulate the nature of their expertise and scope of practice: essential components of any claim to professional status (Ereidson 1970, Witz 1992, Macdonald 1995). Part of the prohlem is that much nursing work is believed to be hidden from objective, lay scrutiny because of the subtle, interpersonal nature of many interventions. Blindness to these aspects has led to nursing work being viewed as a series of tasks which can easily be delegated to less qualified personnel. Recent research priorities identified by Nursing's Research and Development Priority Setting Initiative (Royal Gollege of Nursing 1999) emphasize the need to uncover hidden aspects of nursing work. Research efforts may, however, be hampered by the magnitude of change affecting nursing, making it increasingly difficult to define nurses' work, both visible and hidden. By focusing on decisionmaking processes across disciplines, this paper has the potential to make nurses' expertise more apparent. Another persistent problem undermining the professional status of nurses is that their decision making has been viewed traditionally as intuitive rather than rational. Nurses themselves have promulgated this view (see King & Appleton 1997 for a review), which may have helped to reinforce the gendered nature of ingrained perceptions about nurses and their work. Nursing knowledge and decision making is predominantly viewed as tacit, feminine and emotional, whereas medical knowledge and decision making is thought empirical and rational, and is therefore accorded greater societal value (Davies 1995). Davies (1995) further argues that the predominantly masculine nature of health care organizations and health policy is responsible for the systematic devaluing and under-development of nursing. This paper and the one to which it is linked aim to explode the myth that there are differences in how nurses and other professionals make decisions, by demonstrating how these processes can be re-conceptualized as classification activities common to all clinicians.

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Nursing theory and concept development or analysis

Classifying clinical decision making operational terms depending upon the model of decision making used. Referring to Offredy's (1998) four cited decision models, a decision tree might point to the wrong probabilities attached to choice points, or the tree having an incorrect structure. The hypothetico-deductive model might suggest that initial patient cues (such as hlood pressure, location of pain, etc.) are not generating the correct hypotheses. This leads to faulty deduction of expected cues, thereby exacerbating the problem of wrong, or inaccurately weighted, hypotheses. Pattern matching may propose that cues are connected to the wrong decision categories with the wrong weights, and intuition might propose that 'hunches' were based on faulty memory of previous cases [these decision-making approaches are introduced below, but fuller descriptions are provided in 'Classifying clinical decision making: interpreting nursing intuition, heuristics, and medical diagnosis' (Buckingham & Adams 2000)]. The question is whether these models are elucidating the same phenomena. If so, how can clinicians relate their different explanations when evaluating decisions? These questions are addressed by proposing a unifying framework based on psychological classification, capahle of describing all types of clinical decision. By formulating decisions in terms of classification behaviour, a coherent single approach is provided for integrating research evidence across disciplines. This enables clarification of terminology and formalizes concepts, many of which have been loosely applied. It discourages clinical elitism by demonstrating that underlying decision processes are not distinct: doctors may diagnose and nurses assess, but both classify patients. Outcome categories may be different diseases compared with conditions or states and category structures (i.e. the particular clinical knowledge) will be domain specific, but the underlying classification processes are the same. This was apparent when creating computer programs for simulating expert clinical decisions: large amounts of specialist domain knowledge were required, but processing methods were transferable across domains (Waterman 1986). Similarly, although domainspecific knowledge is important for clinical decision making (Boshuizen & Schmidt 1992), it will be seen that knowledge can be represented by a generic classification model applicable to any clinical discipline. This paper gives a brief overview of various theories of clinical decision making and shows how their apparent differences have failed to distinguish types of nursing decisions. A general model of classification is described which provides the unifying framework subsequently used to clarify and compare other theories. It removes the need for separating nursing decisions by eliminating the arbitrary categories supposedly dividing them. The overall aim is to formalize theories, link them to current psychological ideas, and create a research agenda that is not confined to any particular clinical discipline.
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APPLYING DECISION-MAKING THEORY IN NURSING PRACTICE

Distinctions between assessing conditions and diagnosing problems, as proposed above by Crow et al. (1995), are not supported by all nurse researchers (e.g. Gordon 1987, Jones 1988, Hogston 1997). Fonteyn (1995 p. 60) summarizes the purpose of nurses' clinical reasoning as to 'identify and diagnose actual or potential patient problems' which places diagnosis within nurses' remit and militates against attempts to inculcate it with special properties. Nevertheless, there is clearly some doubt over labelling the domain of nurses' decisions, refiected in the current interest in classifying nursing diagnoses (McCloskey & Buluchek 1994, Hogston 1997). Whether the type of clinical task changes the way in which decisions are made is a moot point, but there are plenty of theories from which to choose. Offredy (1998 p. 994) suggests her research into nurse practitioners demonstrated that 'different models such as hypothetico-deductive method, decision analysis theory, pattern matching and intuition could be applied to the information according to the presenting problem'. The proliferation of theories with different explanatory language and terms of reference obscures commonalities among clinical decisions, and obstructs clinicians' ability to evaluate their performance. Defining a decision as good or bad is not easy because most clinical decisions operate within stochastic domains. Hence the right decision made using information available at the time may still result in an undesirable outcome purely due to probabilistic factors: e.g. patients with classical symptoms of cardiac pain may occasionally be found to have a stomach ailment. However, as clinicians' experience of decision-making increases over time, one can see whether the probabilities of desirable outcomes are being maximized. Clinicians need to know what factors may be marshalling for or against this objective. The problem is that sources of potential error are couched differently within the terms of various theories of decision-making. Error explanations within each model are therefore different, even if error sources are the same, and determining the equivalence of errors and explanations is a labyrinthine task. An example may help to illustrate this point. Suppose a coronary-care nurse titrates the dosage of an infusion of drugs for relieving cardiac pain and limiting ischaemic damage. There are a numher of possible outcomes depending upon the 'real' patient state and the drug regime being administered: (i) the patient's pain may turn out not to be cardiac in origin, or (ii) not indicative of myocardial infarction, or (iii) the drugs may compromise the patient's vital signs, or, hopefully (iv) the intervention has the desired effect. An ostensibly poor decision may have several explanations, all described in different

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CD. Buckingham and A. Adams

BRIEF OVERVIEW OF CLINICAL DECISION MAKING APPROACHES

is that generating hypotheses, deducing, and manipulating probabilities, is entirely conscious, open to scrutiny, and scientific compared witb the mysticism of One of the most influential theories of clinical decision- pattern recognition and intuition. Traditional emphasis making is the hypothetico-deductive one that originated on the latter in nursing may be a significant root cause of in medicine (Elstein et al. 1978, Kassirer & Gorry 1978), nurses' weak professional status. Cioffi (1997) argued that heuristic reasoning is an but has subsequently been applied to nursing (e.g. Padrick et al. 1987, Tanner et al 1987, Jones 1988, Carnevali & important element of intuition. Heuristics wfere postulated Thomas 1993, Taylor 1997). It embraces two types of by Tversky & Kahneman (1974) as methods for simplifying reasoning: induction, where data collection leads to the complicated likelihood judgements about different generation of hypotheses, and deduction, where hypothe- outcomes. Rather than learning the multiple probabilities ses are used to predict the presence or absence of data connecting cues with outcomes, people use short cuts or which clinicians then search for to confirm or deny the 'rules of thumb', which still lead to reasonably accurate hypotheses. Higgs & Jones (1995 p. 6) proposed a variant, probability estimates. For example, nurses using the incorporating a spiral process of clinical reasoning where representativeness heuristic would estimate the likeli'each loop of the spiral incorporates data input, data hood that patients have a particular condition on the basis interpretation (re-interpretation) and problem formulation of how good an example or how 'representative' of the (re-formulation) to achieve a progressively broader and condition they are. Alternatively, the 'availability' heuristic (Tversky & Kahneman 1974) judges the most probable deeper understanding of the clinical problem'. The most common probabilistic representation of clin- condition of a patient to be that bringing to mind the ical decision making uses a decision tree to structure the highest number of previously experienced patients with progression of choices and consequences (see Corcoran similar or the same cues. Cioffi & Markham (1997) cited 1986, Lilford et al. 1998, for worked examples). Some tree both types of heuristic as explanations of nurses' intubranches represent alternative paths (decision points), and ition, but we argue in our related paper (Buckingham & other branches are possible events. Probabilities for the Adams 2000) that the precise definition of heuristics and events are estimated and final outcomes are given values their relationship to other theories is confused. This short summary of clinical decision making theories representing patient preference for that outcome. The has demonstrated a proliferation of terminology and approach attempts to mix subjective benefits (utilities) conceptual distinctions. When applied to nursing deciswith objective probabilities. However, it is more a method ions, the tangled web becomes evident. A couple of for rationalizing clinicians' behaviour rather than one for examples will illustrate this point. Offredy (1998 pp. 995, explaining how they actually behave. 997) quoted the following extracts to illustrate two types Models where only probabilities are used, not utilities, of reasoning: are based on Bayes theorem. The prior probability of an outcome (condition or disease) is its probability if there is Patients will tell you what's wrong with them if you let them. So no diagnostic evidence for it. For example, a nurse you let the patient tell you as much as possihle and by now you entering a new ward has a rough estimate of the likelihood are getting some idea of what might he wrong, but lots of things that any one patient might have a myocardial infarction. come into your head and you ask questions to see if what you are This estimate, or prior probability, is based on previous thinking fits with what the signs and symptoms the patient is experience of similar wards and the frequencies of telling you. If not, you cross off that in your head and then you myocardial infarctions within them. The probability for move on to the next thing you might think the problem is... a particular patient is altered as soon as relevant information is known, such as pain location. The new 'posterior' ... a child with his mother came in to see me. I noticed he had probability is the adjusted prior probability conditional on watery eyes and nose. His mother said he's heen coughing and the cue of pain location. In other words, judgements about sneezing and is a little hoarse sometimes... and he's also patient outcomes adjust with accumulating evidence, and miserable and off his foods. It sounded very much like the early Bayes theorem models the adjustment by the laws of stages of measles so I had a look in his mouth and sure enough the typical Koplik's spots were there... probability. In nursing, pattern recognition is a popular term for Is there any fundamental difference between the behadescribing judgements (Benner et al. 1996, Fonteyn 1999). viours underlying the two descriptions? Why is one It is usually cited in connection with intuition (Easen & pattern recognition and the other hypothetico-deductive Wilcockson 1996) where a pattern of cues seems to reasoning? Which is which? generate outcomes without conscious awareness of the A study by Fonteyn (1997) of 10 experienced nurses process. The language of pattern recognition is less wellrevealed 12 thinking strategies. Some were overall approadefined compared with other models, using terms such as ches to decision making (e.g. pattern recognition) and 'gut feeling', salience, gestalt, hunch, etc. The implication
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Nursing theory and concept development or analysis others were sub-tasks that might be included within any or all of the strategies (e.g. making choices). The definitions of each strategy illustrate the difficulty of identifying real differences: 'looking at his dehydration and his high serum osmolality, it looks like he probably has cirrhosis' and 'her platelets are low, so I think she's at risk to bleed' (Fonteyn 1997 p. 308). Fonteyn uses these presumably apposite quotes for drawing distinctions between pattern recognition and hypothesis generation. But which is which? The thesis of this paper 'is not to condemn valuable research about clinical and, in particular, nurses' decision making. Neither does it intend to banish different theoretical interpretations of such decision making. Its aim is to show how an overarching, general framework for describing clinical decisions relates the data and their interpretations. This framework is constructed by considering judgements and decisions as a classification task. CLASSIFICATION AS A MODEL FOR CLINICAL DECISION MAKING Classification is a fundamental activity without which one cannot make sense of the world (Bruner et al. 1956, Mechelen et al. 1993). It involves organizing categories and methods of assigning objects to them. In medicine, categories are diseases and diagnosis is the term used for classification. In nursing, categories are more to do with assessments of patient conditions (Jones 1988, Hogston 1997), but there is no reason to suppose that assigning patients to conditions is fundamentally different from assigning them to diseases. In the probabilistic domains mostly encountered by clinicians, decisions are based on predicting the likelihood of particular patient outcomes. Outcomes are defined by the scope of the decision, and may relate to patient diseases, pain levels, body conditions or states of mind. The important point is that the exact patient state is unknown and clinicians attempt to

Glassifying clinical decision making judge the probability that each outcome accords with the patient's true state. Each potential outcome, then, can be seen as a class or category to which patients are assigned on the basis of their presenting cues. For any particular decision, there will be a set of plausible alternatives which Rosch & Mervis (1975) called the contrast concepts. The set can be generated by asking the question 'If it is not this concept, what is it?'. For example, if there is concern about a patient's heart, one intervention might be to recommend referral of the patient to a coronary-care unit (CCU). Alternatives can be identified by considering what other strategies nurses might use in this situation such as monitoring the patient closely or seeking immediate medical attention. The medical term for contrast concepts is differential diagnoses, but the idea is the same: they are the complete set of possible outcomes suggested by current information. Figure 1 illustrates the general classification tasks that can be applied to any domain. The pattern vector can be visualized as a line of labelled pigeonholes. Each label is a descriptive attribute of the entity being classified and the box contains its specific value. In clinical decision making, patients are the entities and their attributes are often referred to as clinical cues (e.g. 'temperature' which might have a value of 37C). In the parlance of patternrecognition theory (e.g. Fu 1980), the pattern vector is a hypothetical structure representing the infinite variety of patient attributes, many of which are irrelevant to the decision. The subset of relevant cues makes up a patient's feature vector. Hence, a patient's pattern vector will include the variable 'eye colour' which is not relevant to cardiac pain. On the other hand, shortness of breath does help predict the outcome of cardiac as opposed to, say, stomach pain, and would therefore be included in the feature vector. Deciding which attributes are relevant to particular decision domains is one of the most important tasks in clinical decision making, and distinguishes experienced

Pattern Vector
Hair colour Age Shortness of breath Height Pain location "^Immediate medicai attention Temperature Feet size Pulse Eye colour Classifier 1

Feature Vector

Psychological Representation

Decision Classes (levels of support)

^Watchful waiting

* " Recommend transfer

Figure 1 General modei of classiiication. 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(4), 981-989

What form? " Linear multiple regression? Bayesian statistics? Simitariry to a prototype? Decision tree? Rules? Probabilities? Exemplar-based similarity? Neural net?

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CD. Buckingham and A. Adams nurses from novices (Fonteyn & Grobe 1993). Equally important is measurement of attributes, which has given rise to the field of study known as clinimetrics (Feinstein 1983, Wright & Feinstein 1992). Clearly all decisions operate on data and clinimetrics relates to any decisionmaking theory. However, Figure 1 also highlights the critical transformation from physical data (patient cues) to the decision maker's psychological equivalent. For example, temperature has a precise decimal value but its psychological representation might be in terms of low, normal, moderately high, or dangerously high. Errors can occur if the psychological value does not appropriately represent the physical value. Having identified a patient's relevant cues, measured them, and generated a suitable internal (psychological) value for them, the time has come to assess their combined influences. This is the classification process itself whereby the clinician integrates multiple cues to generate a single likelihood judgement for each output class. It is shown as the 'classifier' circle in Figure 1, the output of which is a judgement for each potential decision class. For the cardiac example, the possible outcomes might be: continue watchful waiting, recommend patient transfer to e c u , or seek immediate medical attention. Decision-making theories differ in how they interpret the integration task, but they all produce a single value for each potential outcome, thereby encapsulating the probability of that patient outcome occurring. In classification terminology, outcomes are classes or sets, and because clinicians are not certain which sets patients helong to, the sets are called 'fuzzy'. Fuzzy sets (Zadeh 1965) allow objects to have partial membership of more than one set, where the degree of membership in a set is called the object's 'membership grade'. Membership grades can vary from 0 (definitely not in the set) to 1 (certainly in the set), but they sum to 1 across all the sets of which an object may be a member. The classification model, then, uses membership grades as the currency for clinical judgements. According to the clinician, the higher the membership grade for an outcome (class or set), the more likely it is to be true. Applying Figure 1 to our example, membership grades will be distributed between three outcomes: watchful waiting, seeking medical help, and transfer to CCU, with different cues generating different distributions of membership grades. The membership grade can be considered an umbrella term for class supports encapsulating many different approaches. For example, a membership grade might represent probabilities, expected utilities, similarities, discriminant values from linear equations, or even be a membership grade in its own right (e.g. Buckingham & Birtle's (1997) classification model of psychotherapy assessment). Whatever the currency, the final support for a class is a single value based on multiple information sources which represents the clinician's likelihood judgement of a patient being in that class.
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Judgements and decisions

Confusion can surround the distinction between judgements and decisions. In this paper, the two terms have been used interchangeably on the grounds that assigning patients and membership grades to a class are both types of decision. However, a difference can be drawn if one argues that the assignation of membership grades is a judgement of an amount, i.e. what value should each decision class or outcome have? The judgement becomes a decision when clinicians compare membership grades and assign the patient to a particular class, thereby deciding to treat the patient for the condition represented by that class. In the cardiac-pain example, a patient's cues will lead to a judgement about membership grades in the three possible decision classes. Classification (and therefore treatment) will depend upon both the membership grades and, crucially, the consequences of providing the wrong intervention. For example, nurses may recommend transferring a patient to CCU if the membership grade is only 0 3, compared with 0 6 in watchful waiting. In a different decision domain, nurses might implement the intervention attached to a class with the highest membership grade on the grounds that it is the most likely outcome but that if they are wrong, there will be no serious harm in delaying interventions associated with an alternative class. In effect, membership grade judgements provide raw decision material and the decision itself draws boundary lines between classes: patients are treated according to the classes defining the range within which their membership grades fall. Boundaries depend upon the consequences of wrong treatment or failure to treat. If the consequences of not treating are serious, then the membership grade threshold for belonging to that class will be relatively low, i.e. it will take less evidence for clinicians to decide that the patient ought to be treated as a class member. For example, nurses in Jacavone & Dostal's (1992) study assessed sources of patients' pain. If pain is cardiac in origin, it can result in ischaemia and possible infarction. Hence nurses were keen to treat pain as if it was cardiac, despite greater evidence for alternative causes. Experts can therefore have a very low membership threshold for the cardiac pain class, so that even small membership grades (i.e. limited evidence of cardiac pain) will cause patients to be treated as class members. In short, patient cues are used to assign a membership grade to each outcome class; the membership grade represents the nurse's judgement that each outcome turns out to be the real one, and the decision is taken on the relative amounts of membership grade in each class. Hence judgements provide strengths of evidence, decisions determine in which class patients are placed, and classes indicate action to be taken.

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Nursing theory and concept development or analysis

Classifying clinical decision making represent a statistical equation. Clearly both representations are important, as advocated by Hammond (1996), who stated that they should not be envisaged as separate research agendas. It is not enough to determine the rationality of an approach if its accuracy of application is unknown. Neither does it improve clinicians' understanding of their own behaviour if their psychological processes are not part of the analysis. To know why clinicians may be making errors necessitates recording their empirical accuracy, studying the effect of cues on their behaviour (the correspondence approach), and investigating how their reasoning processes are transforming cues into outcome judgements (the coherence approach). Our linked paper 'Classifying clinical decision making: interpreting nursing intuition, heuristics, and medical diagnosis' (Buckingham & Adams 2000) will attempt to elucidate the coherence issue by reinterpreting theories of clinical decision making as psychological classification. CONCLUSION

Integrating multiple cues

The big question in clinical decision making is how the many different, individual patient cues combine to produce a single value of support (membership grade) for each possible decision class. Two influential approaches, sometimes referred to as the coherence and correspondence approaches (Hammond 1996), are neatly juxtaposed within Figure 1. The coherence approach has its roots in the infiuential heuristics and biases research programme (Kahneman et al. 1982) which studied the rationality of diagnostic processes. It would consider the circle in Figure 1 as the clinician's cognitive apparatus and would want to know how integration is effected. The emphasis is on the psychology of probability judgements and where this process might cause inaccuracies: did the judgements conform to normative (that is, mathematically correct) calculations? The correspondence approach, based on Brunswick's social judgement theory (see Hammond et al. 1975, Cooksey 1996), changes the focus from the decisionmaker's mind to the cues themselves. Empirical evidence for a particular condition is gathered by examining the cues of patients subsequently known to have that condition. The aim is to determine which cues are relevant and how they combine to predict the condition in reality taXhet than in the clinician's head. Hence the interest is in evidence for determining which cues are in the feature rather than the pattern vector, and what statistical model can process those cues to produce the most accurate prediction of a patient's state. In other words, the main concern is the correspondence between patients' attributes (signs and symptoms) and their actual state (the 'true' diagnosis).

It has been argued that it is important for nurses to have a better understanding of their decision-making processes in order to identify when good decisions have been made, and where there is room for improvement. This will enhance the care of patients, and nurses' ability to work in partnership with them. At an organizational level, more transparent decision making will aid quality management, multidisciplinary working and provide better protection against litigation. The proliferation of different decision-making theories for understanding nurses' decisions was seen to impede nurses' ability to evaluate their practice. This is because each theoretical approach has its own distinctive termiMany researchers following this tradition aim to deter- nology and concepts, often loosely applied, making it mine the best linear discriminant equation relating cues to difficult to compare the outcomes of decisions conceptuknown outcomes (i.e. the weightings of cues which alized in different ways. A brief overview of commonly provide the most accurate patient classification) and then used approaches was provided to illustrate this diversity obtaining the linear discriminant equation modelling how and a model of psychological classification proposed to clinicians actually classify patients. Differences in cue provide a unifying framework. This model was used to weightings bet^veen the two models highlight areas where clarify and formalize terms and concepts scattered across clinicians' performances may be open to improvement. a range of theories that demonstrate a high degree of Studies have shown that a simple linear classification similarity, despite the diversity in nomenclature. The model can often outperform experts (e.g. Lovie & Lovie model is equally applicable to nursing and medical 1989, Dawes & Corrigan 1974, Brehmer 1987) and the key decision domains. Hence, nurses can use this cohesive question for clinical decision making is whether the most approach to integrate research evidence about decision important attributes (those with the highest weightings) making within their own profession with evidence from are actually accorded the most influence by clinicians. other disciplines. The main difference between the correspondence and The classification model demonstrates that different coherence approaches is that the former is interested in clinical domains do not necessitate different decision the statistical behaviour of cues and the latter in how cues processes. Recognition of this situation may enhance are used in clinicians' reasoning processes. nurses' status by undermining clinical elitism, thereby Using the coherence approach, the classifier in Figure 1 improving nurses' ability to participate as equal partners would represent the clinician's psychological processes, in multidisciplinary decision making. Secondly, having a whereas with the correspondence approach it would clear, universal framework within which to analyse their
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CD. Buckingham and A. Adams decisions will render nurses' expertise and hidden elements of their work more visible. This paper described the unifying classification model and introduced its terminology. The second paper, 'Classifying clinical decision making: interpreting nursing intuition, heuristics, and medical diagnosis' (Buckingham & Adams 2000) details how the classification model can be applied to reinterpret and integrate the decision-making theories described above, removing artificial distinctions. Together, the two papers lead to the overall conclusions that interpreting decision making as classification can dissolve communication barriers and provide a coherent analysis of nursing decisions.
Grow R.A., Ghase J. & Lamond D. (1995) The cognitive component of nursing assessment: an analysis. Joumal of Advanced Nursing 22, 206-212. Davies G. (1995) Gender and the Professional Predicament in Nursing. Open University Press, Buckingham. Dawes R.M. & Gorrigan B. (1974) Linear models in decision making. Psychological Bulletin 81, 95-106. Department of Health (1998) A First Class Service. Her Majesty's Stationery Office, London. Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. Her Majesty's Stationery Office, London. Dominowski R.L. & Bourne L.E. Jr (1994) History of research on thinking and problem solving. In Thinking and Problem Solving 2nd edn (Sternberg R.J. ed.). Academic Press, London, pp. 1-35. Dowie J. & Elstein A. (1988) Professional fudgment: A Reader in Clinical Decision Making. Gambridge University Press, Gambridge. Easen P. & Wilcockson B.A. (1996) Intuition and rational decision-making in professional thinking: a false dichotomy? fournal of Advanced Nursing 24, 667-673. Elstein A.S., Shulman L.S. & Sprafka S.A. (1978) Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press, Gambridge. Ersser S. & Tutton E. (1991) Primary Nursing in Perspective. Scutari Press, London. Feinstein A.R. (1983) An additional basic science for clinical medicine: IV. The development of clinimetrics. Annals of Internal Medicine 99, 843-848. Fonteyn M.E. (1999) Thinking Strategies for Nursing Practice. Lippincott, New York. Fonteyn M.E. (1997) Thinking in nursing practice. In Nursing Informatics '97 (Gerdin J., Talberg M. & Wainvwight P. eds), IOS Press, Amsterdam. Fonteyn M. (1995) Glinical reasoning in nursing. In Clinical Reasoning in the Health Professions (Higgs J. & Jones M. eds), Butterworth-Heinemann, Oxford, pp. 60-71. Fonteyn M. & Grobe S. (1993) Expert critical care nurses' clinical reasoning under uncertainty: representation, structure and process. In Sixteenth Annual Symposium on Computer Applications in Medical Care (Frisse M. ed.), McGraw-Hill, New York, pp. 405-409. Freidson E. (1970) Profession of Medicine: A Study of the Sociology of Applied Knowledge. Harper & Row, New York. Fu K.S. (1980) Digital Pattern Recognition. Springer-Verlag, New York. Gordon M. (1987) Nursing Diagnosis: Process and Application 2nd edn. McGraw-Hill, New York. Hammond K.R. (1996) How convergence of research paradigms can improve research on diagnostic judgment. Medical Decision Making 16, 281-287. Hammond K.R., Stewart T.R., Brehmer B. & Steinmann D.O. (1975) Social judgment theory. In Human Judgment and Decision Processes (Kaplan M. & Schwartz S. eds). Academic Press, New York, pp. 271-312. Higgs J. & Jones M. (1995) Clinical Reasoning in the Health Professions. Butterworth-Heinemann, Oxford.

Acknowledgements
We would like to thank Margaret Coulter for her help in reading and commenting on drafts of this paper.

References
Adams A., Lugsden E., Chase J., Arber S. & Bond S. (2000) Skillmix changes and work intensification in nursing. Work, Employment and Society 14, 541-555. Allen D. (1997) The nursing-medical boundary: a negotiated order? Sociology of Health and Illness 19, 498-520. Benner P.E., Tanner CA. & Chesla CA. (1996) Expertise in Nursing Practice: Caring, Clinical fudgment and Ethics. Springer, New York. Boshuizen H.P.A. & Schmidt H.G. (1992) On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cognitive Science 16, 153-184. Brehmer B. (1987) Note on subjects' hypotheses in multiple-cue probability learning. Organisational Behavior and Human Decision Processes 40, 323-329. Bruner I.S., Goodnow J. & Austin G. (1956) A Study of Thinking. Wiley, New York. Buckingham G.D. & Adams A. (2000) Glassifying clinical decision making: interpreting nursing intuition, heuristics, and medical diagnosis. Journal of Advanced Nursing 32, 990-998. Buckingham G.D. & Birtle J. (1997) Representing the assessment process for psychodynamic psychotherapy within a computerized model of human classification. British Journal of Medical Psychology 70, 1-16. Garnevali D.L. & Thomas M.D. (1993) Diagnostic Reasoning and Treatment Decision Making in Nursing. Lippincott, Philadelphia. Gioffi J. (1997) Heuristics, servants to intuition, in clinical decision-making. Journal of Advanced Nursing 26, 203-208. Gioffi J. & Markham R. (1997) Glinical decision-making by midwives: managing case complexity, foumal of Advanced Nursing 25, 265-272. Cooksey R.W. (1996) Judgment Analysis: Theory, Methods, and Application. Academic Press, New York. Gorcoran S. (1986) Decision analysis: a step-by-step guide for making clinical decisions. Nursing and Health Care 7,144-154.

988

' 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(4), 981-989

Nursing theory and concept development or analysis

Hogston R. (1997) Nursing diagnosis and classification systems: a position paper. Joumal of Advanced Nursing 26, 496-500. Jacavone J. & Dostal M. (1992) A descriptive study of nursing judgment in the assessment and management of cardiac pain. Advances in Nursing Science 15(1), 54-63. Jones J.A. (1988) Glinical reasoning in nursing. Journal of Advanced Nursing 13, 185-192. Kahneman D., Slovic P. & Tversky A. (1982) fudgement Under Uncertainty: Heuristics and Biases. Gambridge University Press, Gambridge. Kassirer J.P. & Gorry G.A. (1978) Glinical problem solving: a behavioral analysis. Annals of Internal Medicine 89, 245-255. King L. & Appleton J.V. (1997) Intuition: a critical review of the research and rhetoric. Joumal of Advanced Nursing 26, 194-202. Lilford R.J., Pauker S.G., Braunholtz D.A. & Ghard J. (1998) Decision analysis and the implementation of research findings. British Medical Journal 317, 405-409. Lovie A.D. & Lovie P. (1989) Linear scoring models: lessons for experts and cognitive scientists. In Expert Knowledge and Explanation (Ellis G. ed.), Ellis Horwood, Ghichester, pp. 58-75. Macdonald K. (1995) The Sociology of the Professions. Sage, London. McGloskey J.G. & Buluchek G.M. (1994) Standardizing the language for nursing treatments: an overview of the issues. Nursing Outlook 42(2), 56-63. Mechelen I.V., Hampton J., Michalski R.S. & Theuns P. (1993) Categories and Concepts - Theoretical Views and Inductive Data Analysis. Academic Press, London. National Health Service Executive (1995) Progress with PatientFocused Care in the United Kingdom. NHSE, Leeds. National Health Service Executive (1996) Consumers and
Research in the NHS: An R&D Contribution Involvement in the NHS. NHSE, Leeds. to Consumer

Classifying clinical decision making

Offredy M. (1998) The application of decision making concepts by nurse practitioners in general practice. Journal of Advanced Nursing 28(5), 988-1000. Padrick K., Tanner G., Putzier D. & Westfall U. (1987) Hypothesis evaluation: a component of diagnostic reasoning. In Classification of Nursing Diagnosis: Proceedings of the Seventh Conference (McGlane A. ed.), G. V. Mosby, Toronto, pp. 299-305. Rosch E. & Mervis G.B. (1975) Family resemblance: studies in the internal structure of categories. Cognitive Psychology 7, 573-605. Royal Gollege of Nursing (1999) The Nursing Profession's R&D Priority Setting Initiative. Live newsletter, 7 October 1999, RGN, http://www.man.ac.uk/rcn/policy/priorities.htm. Tanner G.A., Padrick K.P., Westfall U.E. & Putzier D.J. (1987) Diagnostic reasoning strategies of nurses and nursing students. Nursing Research 36(6), 358-363. Taylor G. (1997) Problem solving in clinical nursing practice. Journal of Advanced Nursing 26, 329-336. Tversky A. & Kahneman D. (1974) Judgment under uncertainty: heuristics and biases. Science 185, 11241131. United Kingdom Gentral Gouncil for Nursing, Midwifery and Health Visiting (1992) Scope for Professional Nursing Practice. UKGG, London. United Kingdom Gentral Gouncil for Nursing, Midwifery and Health Visiting (1999) A Higher Level of Practice. UKGG, London. Waterman D.A. (1986) A Guide to Expert Systems. AddisonWesley, Reading, Massachusetts. Witz A. (1992) Professions and Patriarchy. Routledge, London. Wright J.G. & Feinstein A.R. (1992) A comparative contrast of clinimetric and psychometric methods for constructing indexes and rating scales. Journal of Clinical Epidemiology 45(11), 1201-1218. Zadeh L.A. (1965) Fuzzy sets. Information Control 8, 338-353.

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