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British Journal of Anaesthetic & Recovery Nursing

Vol. 13(3-4), 65–71


doi:10.1017/S1742645612000435
Reflection r British Association of Anaesthetic and Recovery Nursing, 2012

Comparative Theories in Clinical Decision


Making and their Application to Practice:
a Reflective Case Study
Nicholas Gladstone
The South West London Elective Orthopaedic Centre, Epsom, Surrey, UK

INCIDENT
ABSTRACT

Within this article the author critically reviews Although walking through the post-operative care ward,
the theories surrounding clinical decision mak- the author noticed a patient lying in bed who appeared
ing and judgement while discussing a clinical unwell with shallow ‘disorganised’ breathing. On closer
incident, and his experiences of decision mak- examination the gentleman appeared cold and clammy
ing within his own practice setting. Exploring with a grey pallor and a blue cyanotic tinge to his lips. The
the works of Elstein and Schwarz, Benner, author attempted to speak to the gentleman; however, he
Hammond and Hamm, the author discusses was confused and anxious and talking incoherently. The
how aspects from each of their theories relate to author immediately undertook an Airway, Breathing and
his practice and clinical reasoning before con- Circulation (ABC) assessment, checked his airway, placed
cluding on the clinical decision-making process him on 15 L of oxygen via a Hudson non-rebreathe mask
and factors that can influence their successful and checked his vital signs. The gentleman’s pulse rate was
application. 120 beats per minute and regular; he had unrecordable
oxygen saturations and his systolic blood pressure was
Key words: reflection; decision making; 89 mmHg. The author immediately tilted the base of the
intuition; reasoning; heuristics; judgement patient’s bed and set up an IV infusion of plasma expander
(colloid) to raise his blood pressure.
Working in post-operative rehabilitation it is often
common to encounter patients who suffer with ortho-
static hypotension and syncope secondary to hypovo-
INTRODUCTION laemic shock. However, the author was concerned that
the patient was not responding to the usual treatment
The author’s experience of clinical decision making
provided and contacted the duty doctor on call. He was
details the diagnosis of an acute myocardial infarction
informed that the gentleman had been reviewed some
and the decision-making process taken to reach this. To
10 min earlier and there was no cause for concern as the
maintain confidentiality, the identity of the patient,
patient appeared comfortable and was sleeping. It was
hospital and other healthcare professionals have been
explained that the patient was acutely unwell and the
anonymised in accordance with the Nursing and
doctor responded that he would re-review the patient
Midwifery Council’s (NMC) Guidelines on confidentiality
shortly. As the author was convinced that the gentle-
[NMC, 2008].
man’s condition was deteriorating, he undertook an
electrocardiogram (ECG), which upon examination
Correspondence to: N. Gladstone, Senior Practice Development indicated a myocardial infarction.
Nurse, The South West London Elective Orthopaedic Centre, Epsom,
Surrey, KT18 7EG, UK. Tel: 01372 735813, Fax: 01372 735854; Concerned that he was not getting the appropriate
E-mail: nicholas.gladstone@eoc.nhs.uk. response from the duty doctor the author called the

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Comparative Theories in Clinical Decision Making

clinical lead down from the Post-Anaesthetic Care Unit 2. Hypothesis generation – development of a provi-
to help assess the patient again. On examination of the sional and differential diagnosis based on cues and
ECG, a posterior myocardial infarction was identified baseline data.
and the gentleman was immediately transferred to a 3. Interpretation of Cues – re-exploration and inter-
High Dependency Care bed in her unit. The gentleman pretation of cues to support or dismiss hypothesis
was promptly started on the Acute Coronary Syndrome with further data collection to aid interpretation.
protocol of care and further diagnostic tests revealed an 4. Evaluation of Hypothesis – the cues are then eval-
extensive myocardial infarction. uated and applied to an overall hypothesis that
directs the decision made and subsequent interven-
tion/action taken.
LITERATURE REVIEW
Relating the author’s clinical experience to the
Decision making forms the foundation of all nursing care
hypothetico-deductive approach, cue acquisition
and associated interventions from the administration
involved the collation of information from previous
of medicines to assistance with activities of living and
baseline observations and past medical history with
rehabilitation. Over the past 40 years considerable
new data that included visual cues and vital signs. From
emphasis has been placed on the need for knowledge
this information an initial hypothesis was formed that
and evidence to support practice and guide the decisions
suggested the patient was having a heart attack. Further
healthcare professionals make. Policies and directives
interpretation of cues included the use of electrocardio-
issued by the Government and Department of Health
graphy that revealed a posterior myocardial infarction
[Department of Health, 2010; House of Commons, 2011]
leading the author to evaluate and determine his
stipulate a need for high quality care underpinned by
hypothesis as correct.
research and clear evidence.
As detailed above, the hypothetico-deductive model
The phrase ‘Clinical Decision Making’ is used
of clinical problem solving relates to the way a nurse or
synonymously with terms such as ‘Clinical Judgement’,
healthcare professional processes patient-relevant infor-
‘Problem Solving’ and ‘Critical Thinking’ implying that
mation [Norman, 2005]. This scientific method to
it is a cognitive process concerned with problem
problem solving and analysis is considered beneficial
recognition through the identification of cues and
due to the linear approach and prescriptive manner in
clinical features, data gathering, integration, analysis,
which practitioners address a given situation; hypoth-
evaluation and choice to produce an informed decision
esis generation is considered rational and structured,
[Clack, 2009]. Standing [2010] suggests that decision
and related to the directionality of interpretation
making is a complex process that involves observation,
[Banning, 2007]. This assertion is supported by Botti
information processing, critical thinking and clinical
and Reeve [2003] who define the generation of a
judgement to select the best course of action in
hypothesis through data acquisition and interpretation
promoting and maintaining a patient’s health. While
as ‘forward reasoning’, and claim that clinical experts
Elstein and Schwarz [2002] assert that clinical decision
use such an approach in clinical decision making
making involves a rational process of ‘hypothetico-
and diagnosis.
deductive reasoning’ based on information processing.
However, this mode of decision making is not
Within clinical decision-making theory, ‘hypothetico-
infallible and a number of researchers have questioned
deductive reasoning’ is considered the most dominant
whether such a simplistic approach to assessment can
approach in health care with practice based on rationality
facilitate safe, accurate diagnosis and subsequent treat-
and empirical precision [Jefford et al, 2011]. A hermeneutic
ment [Patel and Groen, 1986; Kennedy, 2002; Priddy,
examination of figures, text, verbal and non-verbal cues
2004; Banning, 2007].
forms the foundation from which a hypothesis is generated
Hypothetico-deductive reasoning is dependent on
and subsequent treatment is based. This diagnostic
the hypothesis generated. That is, application of an
‘paradigm’ is formed of four stages that assist the assessor
inaccurate hypothesis can lead to a misdiagnosis and an
in identifying and interpreting cues and constructing and
inaccurate result. An example of this is the hypothesis
evaluating a hypothesis (primary diagnosis).
generated in the author’s scenario in which he
These four stages are:
diagnosed a heart attack based on the symptoms
1. Cue acquisition – primary data and sensory stimuli presented and associated cues. Symptoms of extreme
that steers the nurse towards a particular thought anxiety, cold clammy pallor, a positive ‘Portsmouth
process through specific cues. Sign’, unrecordable oxygen saturations and peripheral

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Comparative Theories in Clinical Decision Making

shutdown are also associated with late signs of septic experience in clinical decision making and critical
shock [Woodrow, 2000]. Thus, it can be suggested that analysis and rely on guidelines and rules for direction.
the author could have erroneously interpreted the cues Decision making and associated actions are often based
leading to misdiagnosis and ineffective treatment. This on rudimentary ‘primary’ concept formation influenced
assertion is supported by Rozeboom [1990] who is by fear, mistakes and the need for acceptance from
particularly scathing in his criticism of this approach, one’s peers [Daley, 1999]. As the nurse moves through
claiming that the ‘epistemic fecklessness’ of hypothetico- the stages of skill acquisition and gains experience,
deductive reasoning wrongly implies a simple rational ‘secondary’ concept formation occurs and new and pre-
process to decision making without acknowledging existing knowledge is assimilated in a process referred
context, affect, emotions and intuition. to as ‘subsumption’ [Vacek, 2009]. The expert is able to
While hypothetico-deductivism provides a linear and make decisions based on both abstract and concrete
scientific structure to the decision-making process, it information, which has been obtained through indivi-
fails to acknowledge intuition and experiential learning, dual experience and skill acquisition. This notion is
both of which influence the approach taken. This supported by Benner, who states that ‘at the heart of
notion is supported by Cioffi [1997] who claims that good clinical judgement and clinical wisdom lies
intuition is a legitimate and essential component of experiential learning from particular cases’, before
clinical judgement and decision making. Yet up until going on to state that nursing practice requires both
the past 25 years, and until the seminal work of Dreyfus techné (craftsmanship) and phronesis (wisdom) [Benner
and Dreyfus and Benner, the notion of experience and et al, 2009, p. XV (introduction)].
intuition in decision making was not considered What is clear from the work of both Dreyfus and
legitimate due to ambiguity and a lack of ‘hard-data’ Dreyfus and Benner is that practice is guided by
[Mallick, 1981]. experiential knowledge and that intuition can only
In a study of decision-making behaviour among US take place in the presence of this. However, one
Air Force pilots, brothers Stuart and Hubert Dreyfus significant criticism of the notion of novice to expert
developed a model of skill acquisition based on situated is the lack of any clear definition as to what an ‘expert’
performance and experiential knowledge [Dreyfus and actually is [Peña, 2010]. Lyneham et al [2008] asserted
Dreyfus, 1980]. Developing previous research under- that Benner’s theory fails to explicate the final stage of
taken by Johnson-Laird and Wason (1977, cited in the expert practitioner and it therefore remains open to
Dreyfus and Dreyfus, 1980, pp. 4–5), the authors debate. The authors go on to provide their own
determined a subject’s task performance improved definition based on Benner’s principles suggesting that
significantly if related to previous experience. Further the expert practitioner uses ‘embodied intuition; taking
research identified a direct correlation between the what action is appropriate at the time, doing so freely,
levels of skill acquisition in relation to concrete without conscious thought and practising within both
experience. As professionals gain experience in their cognitive and embodied intuitive paradigms’ [Lyneham
specific line of work, they move through a develop- et al, 2008, p. 384].
mental continuum progressing from a novice to an Referring to the author’s scenario it is hard to
expert. Dreyfus and Dreyfus, [1980] assert that workers consider his actions as that of an ‘expert’. What
move through five stages of career development that occurred with the identified patient was not part of the
they categorized as: novice, advanced beginner, compe- author’s usual working practice and was a predominantly
tent, proficient and expert. With each stage of ‘skill’ medical (cardiac) problem. Yet despite this, the author
acquisition comes an increase in knowledge and ability. instinctively undertook what he considered was the most
At the beginning, the ‘novice’ acts according to rules that appropriate action based on a pre-existing knowledge
determine a specific action; in the later stages of this and experience of cardiac arrest and resuscitation. The use
paradigm, the ‘expert’ is able to make intuitive decisions of ‘heuristics’ based on previous experience provided
based on previous experience, operating outside guide- a ‘cognitive shortcut’ in the decision-making process
lines and scientific principles [Blum, 2010]. and allowed the author to develop a rapid response to a
In her book ‘From Novice to Expert’, Benner [2001] difficult situation.
applies the principles of Dreyfus and Dreyfus’ model Based on Simon’s theory of bounded rationality
to nursing practice and clinical decision making. [1991], Tversky and Kahneman [1974] transformed
Employing the five stages of novice to expert, Benner academic research and theories on judgement with their
suggests that novices undertake clinical decision mak- ideas on ‘heuristics’ and rationality. The authors assert
ing guided by rules and policies. Novices have little that when faced with complex decisions individuals

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Comparative Theories in Clinical Decision Making

often make use of experience-based problem solving at opposing ends of the continuum [Dunwoody et al,
techniques using a three-tier process: 2000]:
1. Availability – assessing probability of actions based 1. Physical science experiment
on previous phenomena and recalling previous 2. Control group experiment
occurrences. 3. Quasi-experiment
2. Representativeness – comparing representation of 4. Computer modelling
data with that from previous experiences. Estimat- 5. Expert judgement
ing the probability that patient A is having the same 6. Unrestricted judgement.
problems as patient B through the comparison of
In his theory, Hammond argues that different
cues and data.
decision-making tasks require different approaches accord-
3. Anchoring/adjustment – Developing an initial
ing to the situation and task complexity [Hammond,
hypothesis (anchor) based on availability and
1996]. The cognitive continuum places tasks along a
representativeness, and then adjusting this based on
vertical axis in accordance with the decision-making
additional information.
approach taken. Along the horizontal axis, is the
This heuristic framework was employed when the cognitive approach taken with the decision-making
author undertook his decision making in the incident process beginning with ‘pure intuition’ and moving
detailed above, with the recollection of previous across to ‘pure analysis’. In addition to the two axis,
incidents involving a cardiac arrest guiding the author’s Hammond subdivides the cognitive continuum into six
actions. The patient presented with symptoms com- modes that detail the divergent intuitive and analytical
mensurate with previous experience and the author was methods associated with different tasks and the
able to undertake a representative comparison of the structure of the decision-making process [Thompson
cues presented in both. Having developed a hypothesis et al, 2004]. The scientific/analytical modes of 1–3
based on ‘rough pattern recognition’ the author then enable the decision maker to apply explicit theoretical
‘anchored’ this with the use of additional diagnostics knowledge supported with evidence-based practice
that confirmed this. and associated research. The intuitive/experimental
However, despite this cognitive approach being modes of 4–6 allows the decision maker to undertake
successful it can be suggested that the author’s actions tasks supported by tacit knowledge and trial and error
were based on ‘trial and error’ rather than structured [Standing, 2010]. Thus, the CCT focuses on the
assessment. Thompson and Dowding [2009] claim that relationship between the concepts of tasks and modes
the use of heuristics generates predictable systematic of cognition with Hammond asserting that the more
biases and errors due to the subjective nature of structured a task is, the more analytically induced the
the decision-making process. Tversky and Kahneman decision-making process will be. In contrast, an ill-
suggest that when recalling previous experience, indi- structured decision-making task is likely to be intuition-
viduals will often only recall those incidents where induced with little analysis involved [Cader et al, 2004].
interventions or decisions were positive and had Hamm [1988] later revised Hammond’s theory to
‘favourable’ outcomes; thus rendering the decision- explore doctors’ understanding of decision making and
making process biased and unrealistic. Reflecting on the clinical judgement; amending the terminology used in the
two approaches detailed above, it is apparent that six modes of inquiry to allow for better association of tasks:
intuition and analysis are at separate ends of the
1. Scientific experiment
decision-making spectrum. Yet, it can be asserted that
2. Controlled trial
decision making is seldom entirely intuitive or analy-
3. Quasi-experiment
tical but a combination of both.
4. System-aided judgement
Based on Brunswik’s Lens Model [see Thompson
5. Peer-aided judgement
et al, 2004], Hammond’s Cognitive Continuum Theory
6. Intuitive judgement.
(CCT) focuses not only on the decision maker, but also
on the environmental factors that influence cognition Hamm also determined that the quality of the task
and the decision-making process, taking into account structure was in direct proportion to the amount of
both analytical and intuitive strategies [Hammond, time taken along with the potential for judgement bias
1996]. Hammond’s theory rejects a dichotomous view and visibility of the task process.
of intuition and analysis, instead detailing six modes In his study, Hamm identified that decision making
of cognitive inquiry that places intuition and analysis among doctors fell between the 5th and 6th modes of

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Comparative Theories in Clinical Decision Making

the cognitive continuum, whereby mainly intuitive and need for ‘professional identity’ coupled with the fact
peer-aided judgement was used [Standing, 2010]. that decision making in nursing is fundamentally
Thompson [1999] asserts that employing the cognitive different from the technical/rational approach taken
continuum in nursing practice can help provide the in medicine.
‘middle ground’ in decision making that allows for the Furthermore, Standing’s revised theory removes the
use of both analytical and intuitive cognition. By sitting numerical sequencing from 1–6 as she asserts that
firmly between Elstein’s hypothetico-deductive model decision making should not be seen as a ‘linear’ activity,
[Elstein and Schwarz, 2002] and the notion of intuition but a ‘flexible continuum oscillating in either direction
and tacit knowledge derived from the work of Dreyfus along the continuum in response to continually chan-
and Dreyfus [1980] and Benner [2001], the cognitive ging judgement tasks’ [Standing, 2008, p. 130].
continuum allows for the synthesis of both theories Standing’s revised continuum provides a rational and
allowing for more comprehensive decision making. structured approach that promotes the ethical and
Reviewing Thompson’s work, Harbison [2001] endorses professional aspects of decision making in nursing.
his notion of the usefulness of the cognitive continuum in Recognising that the modes of practice are not sequential,
nursing asserting that Hammond’s paradigm helps to by removing the didactic numerical scale to each mode
instill quality in the decision-making process and sub- signifies the personal nature of decision making and the
sequent care provision by supporting the need for need for an objective multi-modal approach.
evidence-based practice and a sound knowledge base. Referring to the author’s clinical incident, it can be
However, Harbison is keen to point out that there needs suggested that his actions and the approach taken were
to be further investigation to determine what constitutes positioned across a number of modes in Standing’s
‘quality’ in nursing judgement and decision making. It can revised continuum, encompassing elements of intuitive,
be suggested that like Benner’s theory of expertise, the reflective and peer-aided judgement. Furthermore,
notion of quality is enigmatic and subjective, which is having made a clinical decision and undertaken the
open to mixed interpretation and a multitude of associated actions, the author returned to the con-
conflicting descriptions. tinuum to review this with the use of reflective
Like Hamm [1988], Standing [2008] further revised judgement and critical reflection to evaluate the patient
Hammond’s Cognitive Continuum in an attempt to outcome.
make it more applicable to the nursing profession.
Standing asserts that the definitions used in both
Hammond and Hamm’s versions of the continuum CONCLUSION
are ambiguous with the typology used for task structure
confusing. Moreover, Standing states that decision In conclusion, it can be suggested that the theoretical
making in nursing not only involves peer-aided judge- principles of the CCT and associated paradigms
ment, but involvement from the patient too. In revising developed by Hammond [1996], Standing [2008],
Hammond’s theory, Standing changes the terminology Dreyfus and Dreyfus [1980] and Benner [2001] all
used and adds a further three ‘modes of practice’ within provide the conceptual framework and insight from
the cognitive continuum that she feels underpins which clinical decisions are formed. The ideas and
decision making in nursing. Standing’s ‘revised cogni- methods identified are well supported by research that
tive continuum’ [Standing, 2008] identifies the benefits identifies the many different approaches the nurse can
of reflective practice and replaces the quasi-rational and take in clinical judgement and decision making.
experimental modes of cognition with more specific However, it can be suggested that in reality, as patients’
categories that include action, experiential, qualitative, needs change and care provision constantly evolves,
survey and experimental research. these theoretical models will soon become obsolete,
In removing quasi-rationality from the cognitive forcing the nursing profession to reassess their
modes, Standing acknowledges that, unlike the medical approach to clinical decision-making theory and
model of care, decision making in nursing does not take practice. Moreover, as demonstrated by Benner [2001]
a predominantly ‘scientific’ stance. The nursing profes- and Elstein et al [1978], no decision-making model is
sion prefers a ‘holistic’ approach that encompasses completely infallible; environmental factors associated
reflection on and in action, patient involvement and with socio-economic instability and changes to the way
evidence-based practice. This notion is supported by in which care is provided have the potential to ‘shift the
Harbison [2001] who claims that nurses are reluctant goalposts’ and make the decision-making process more
to adopt medical frameworks and theories due to a difficult even for the ‘experts’.

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Comparative Theories in Clinical Decision Making

It is appreciated that the theories discussed within theory and practice is evident. Although the author
this article have not been explored as fully as the author takes a more pragmatic approach to the issues raised in
would have liked due to the constraints of this this assignment, it is evident that the theories have
assignment. However, it is hoped that the link between applications.

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