Journal of Advanced Nursing, 1996, 24, 24-30

Decision making in community nursing: an

analysis of the stages of decision making as they
relate to community nursing assessment practice
Alison Bryans MSc BA RHV RGN RNT
Research Fellow/Lecturer

a n d Jean Mclntosh PhD BSc(Soc) SRN

Professor of Community Nursmg Research, Glasgow Caledonian University, Glasgow,
Scotland

Accepted for publication 18 August 1995

BRYANS A & MclNTOSH J (1996) foumal of Advanced Nursing 24, 24-30

Decision making in community nursing, an analysis of the stages of decision
making as they relate to conmiunity nursing assessment practice
This paper considers the nature of decisions made in the context of commiinity
nursing practice, m the light of the stages of decision making distilled hy Carroll
& Johnson from the work of various theorists, and explores the relevance of each
stage to community nurses' decision making Illustrative examples of specific
theoretical perspectives are included throughout the paper The discussion
forms part of the literature review for research currently hemg undertaken hy
the authors into patient assessment hy community nurses As decision making
IS a key element of community nurses' assessment practice, the paper argues
that decision making theory forms a useful conceptual framework for
investigating this aspect of community nursing

TMTPnnTTPTinM Each of the stages will be discussed, along with predomi-

The body of decision research is large and complex, con-
ceptually difficult and has its share of controversial issues
Community nursing practice is equally complex, less re-
se^ched than hospital nursing and not generally well
understood Nurses working m the community often face
different decision-making challenges from those encoun-
tered by their hospital colleagues When examining this
aspect of community nursing, it is important to develop
an understandmg of theones of decision making m order
to establish which components of decision making models
are particularly important m the context of commumty
nursmg practice This paper will explore the stages of
decision making distilled by Carroll & Johnson (1990) from
'the comments of several theonsts' m order to cleuify their
relevance for research into community nursing practice
Correspondence Alison Bryans Research Fellov^/Lecturer, Department of
Nursmg and Commumty Health, Glasgow Caledonian University City
Campus Cowcaddens Road, Glasgow G4 0BA Scotland
nant models and theories, and with specific reference to
the nature of nursmg decisions made m commumty
settings
^^^ CONCEPT OF A DECISION
Carroll & Johnson (1990) begin their comprehensive over-
view of decision research by considering the nature of
decision making They descnbe the concept of a decision
as 'a shorthand for mental activities that recognise and
stmcture decision situations and then evaluate preferences
to produce judgements and choices' (present author's
emphasis)
The preliminary stages of recognition and structuring of
decision situations included m Carroll & Johnson's (1990)
description tend to be neglected m discussions of decision
making ui nursing practice For example, Baumann &
D^ber (1989) define decision makmg BS 'SltuaUons m
whlch a choice IS made among a number of possible
alternatives, often uivolvmg trade-off among the values

24 © 1996 Blackwell Science Ltd


given to different outcomes' This defimtion's mclusion of
'trade-off' among outcome values has special appeal to
those mterested in decision makmg by community nurses,
as its adoption by the authors of a recent study of decision
making by community nurses would suggest (Orme &
Maggs 1993) However, it does not draw attention to the
important preliminary stages of the decision-makmg
process
Models and theones of decision-making
It IS noteworthy that, although most decision-making
theory emanates fi"om the discipline of psychology,
decision research has also been undertaken m such diverse
fields as organizational behaviour (Emhom & Hogarth
1975), consumer research (Johnson & Russo 1984), econ-
omics (Crether & Plott 1979), nursing and medicine (Orme
& Maggs 1993), and it appears to be a burgeoning field
, (Arkes & Hammond 1986) It is therefore hardly surpnsmg
- that models and theones reflect this wide diversity of inter-
ests The components of the decision-making process
f which are included or emphasized in a model or theory
J depend largely on two related factors the perspective of a
theonst or mvestigator and the nature of the decisions
^ imder consideration The eclectic approach taken here has
• been adopted m an attempt to cleeirly identify those com-
" ponents which will be most helpful m researching
I decision making by community nurses
The seven stages of decision makmg
Carroll & Johnson (1990) outline seven temporal stages of
decision making, acknowledging that these stages may not
simply be followed through m their given sequence, but
I may 'repeat and backtrack m a complex way ' The stages
I There are two important points to be made here Firstly,
1 recognition,
2 formulation,
3 alternative generation,
4 information search,
5 judgement or choice,
6 action,
7 feedback
THE STAGES OF DECISION MAKING AND
COMMUNITY NURSING PRACTICE
The first two stages, problem recognition and formulation,
can be descnbed as predecisional activity and involve
exploration and classification of the situation by the
decision maker The nature of a nurse's predecisional
activity will depend on vanous factors, mcludmg her state
of preparedness and her personal view of her role, as well
as the situation or task itself This important phase of
© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
Decision making m community nursing
decision making is generally less conscious and deliberate,
and more difficult to articulate, than subsequent phases
It therefore tends to be neglected m decision research
Elstem et al (1978), for example, proposed a four-stage
model for medical decision making which begms with data
collection, thus completely excluding the predecisional
phase
This exclusion of all but the rational aspects of the
decision maker fi^m the study of decision making is
closely related to the adoption of a behavioural model as
the theoretical basis for decision research According to
Simon (1986), the behavioural model of decision making
suggests that 'human rationality is very limited, very much
bounded by the situation and by human computationsd
powers' He argues that there is 'a great deal of empmcal
evidence supporting this kind of theory as a valid descnp-
tion of how human beings make decisions' This evidence
explains the appeal of such a model to empmcal research-
ers However, the behavioural model of decision making
appears limited by its failure to take into account the
nature of the decision maker and the lnfiuence of such
factors as his or her prior learning and personal goals
withm the decision-making process
The assumption that data collection or information gath-
ermg is the first step on a decision-making journey is also
reminiscent of nursing process approaches to patient care,
and of the use (or misuse) of nursing models merely as
frameworks for collecting and documenting information
about patients Systematic approaches to nursing care tend
not only to imply that each nurse will recognise and class-
ify patient problems or requirements in the same way as
his or her colleagues, but to suggest that this is desirable
emd vnW result m better patient care In other words, it is
implicitly assumed that all 'good' nurses will explore and
classify situations m the same way
It IS axiomatic that excellent nursing practice requires the
nurse to be highly flexible and responsive to the special
requirements of individual patients A predetermmed
approach is unlikely to encourage such flexibility Nursing
care provided m pabents' homes is even more idiosyn-
cratic than hospital care because of the sheer diversity to
be found m people's home environments, lifestyles, family
and neighbourhood support systems In such a changing
work context, the ability to be flexible is a key-stone of
effective practice
The second important point is that a nurse bnngs his or
her own unique collection of pnor knowledge and inter-
pretive frameworks (Schon 1987) to any decision-makmg
task He or she is not a tabula rasa, but a uniquely pro-
grammed and constantly self-programming individual
The nature of this mtnnsic personally-owned knowledge
IS elusive and community nurses have difficulty in
descnbing it (Luker & Kennck 1992) A more readily ident-
ifiable determinant of predecisional activity is extrinsic
25
A Bryans and f Mclntosh
knowledge, or mformation denved from external sources
A good example of this is the information which com-
munity nurses receive through a referral request, which
has an obvious bearmg on a nurse's potential decision
making Indeed, inadequate referral mformation is often a
real problem for community nurses, especially when deal-
ing with terminally ill patients It is important to acknowl-
edge the role of a practitioner's unique collection of
knowledge, both intrinsic and extnnsic, in a study of
nurses' decision making
It has been argued that mtuition has an important role
to play m expert nursing performance (e g Benner &
Tanner 1987) and there appears to be a link between the
use of expenentially gained knowledge and the role of
intuition in predecisional activity Simon (1986) views
intuitive theory as a component of behavioural theory,
which emphasizes experts' recognition processes and the
accessibility of prior expenence stored in memory (present
author's italics) Insofar as recogmtion processes form the
basis of effective problem-recognition, they are at the heart
of expert decision making
The importance of the predecisionai phase has also been
highlighted by decision-making research m the sphere of
business management, which descnbes the avoidance of
definmg and/or making decisions (Corbm 1980, Isenberg
1984) These studies bring to mmd the saying 'To do
nothing IS to take sides' In some situations, failure or
refusal to either recognize a problem or define it as such
will have considerable repercussions
Withm the specific context of commumty nursing
assessment, failure to recognize a potential decision-
makuig task, or deliberate avoidance of a decision, may
limit subsequent nursmg mterventions Problem recog-
nition and formulation can thus be viewed as intimately
related to professional perceptions of health care need
Because a practitioner's predecisional activity will
strongly influence his or her subsequent view of a patient's
'actual health state', and approach to 'settling the goal of
health care need' (Liss 1993), such activity is important
for research m this area
REAL WORLD CONSTRAINTS ON DECISION
MAKERS
While a community nurse's exploration and classification
of a patient's situation will depend to a considerable extent
on intrinsic factors outlined above, the potential influence
of external 'real world' constraints, such as the demands
of the caseload or the availability of local health care
resources, must also be acknowledged For example, a
nurse who is working under severe time constraints (per-
haps because of a larger than average number of termmally
ill patients on his or her caseload) may, understandably,
choose to postpone certain decisions about a patient
who IS less ill because he or she realizes the workload
26 © 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
imphcations of such decisions Conversely, it may be poss-
ible to offer extra help to a patient or carer if caseload
demands are lighter than usual
An mteresting study of caseload management by distnct
nurses draws attention to the increasing importance of
caseload muc (Badger et al 1989) A further example of
the influence of 'real world' factors on the decision-making
process is that of a nurse who happens to know of several
free places m a day hospital in the locality for elderly
people suffenng from dementia Armed with such knowl-
edge, this nurse may well be more likely to explore the
needs of someone canng for such a person The importance
of such factors is not unique to community nursmg prac-
tice Lawrence (1988), m a recent study of expertise m
judicial decision making, discusses the 'environmental
factors which constrain and interact with a magistrate's
processmg [of information]' She notes that these include
certain legal constraints, such as the law of evidence, and
heavy caseloads
The context of practice can thus be seen to influence
problem recognition and formulation m that it imposes
real life constraints, such as limited time and resources,
on a decision maker The practice context therefore forms
a legitimate focus for the study of decision makmg m
community nursmg practice
The 'common sense' view of decision making
Stages 3, 4 and 5, alternative generation, information
search and judgement or choice, form what Carroll &
Johnson (1990) refer to as the 'common sense' view of
decision making Alternative generation (stage 3) involves
creating hypotheses, information is then gathered about
these hypotheses (stage 4) in order to allow the decision
maker to rate the importance of vanous attnbutes (judge-
ment) and to choose from the alternatives (choice)
Judgement and choice are used with these specific mean-
mgs m decision-making research by cognitive psychol-
ogists Information search has been the focus of decision
research which employs search methods
The aim of such methods is to 'momtor the physical
behaviours used to acquire information as people make
decisions [m order to] infer the cognitive processes
underlying the decisions' (Carroll & Johnson 1990) Search
methods include the use of sophisticated equipment
which can detect eye movements, for example, and tend
to be intensive, time-consmmng and laboratory-based
Because these research techniques require short, one-off,
problem-solving decision tasks, they are of limited value
in the study of longer, complex verbal tasks such as patient
assessment
Interestmgly, these three stages have been the focus of
most research mto clinical decision making, to the virtual
exclusion of other aspects of the decision-makmg process
and the decision maker The question of how relevant
 Decision making m community nursing

these particular stages are to the study of nurses' decision- are generated by doctors when they first encounter a
makmg must therefore be posed patient They explain that medical hypotheses 'are not
necessanly diagnostic entities, they can represent anatom-
Decision making and problem solving ical, physiological, patho-physiological or aetiological
explanations for the problem encountered As such, they
These three stages tend to be associated with problem- rcuige from non-specific ideas such as "a heart problem"
solvmg approaches and with the hypothetico-deductive to very specific diagnoses such as "aortic insufficiency sec-
model which has been prevalent m the field of medical ondary to rheumatic heart disease" Doctors often start
decision-makmg research A typical example of such an with non-specific hjrpotheses, and as the patient's problem
approach to decision making is an early study by Barrows becomes better defined through enquiry, will generate
& Bennett (1972) of 'the diagnostic (problem solving) skill more specific hypotheses to refine the enquiry'
of the neurologist', whose summary of 'what seems to be In this mibal, uncertain, phase the word hjrpothesis is
going on cognitively m the good neurologist' rests firmly not bemg used in the specific scientific sense but in the
withm the confines of these three stages of decision lay sense of 'a possible explanation for something' A
making They delineate the process as 'the eeirly appear- degree of uncertainty and vagueness is permitted m the
ance of hypotheses almost before the interview begins, lay sense of the term However, it is important to note the
[asking] enquiry-oriented questions aimed at achiev- specific and objective nature of the adjectives used by
ing specific items of information and [asking] questions these authors — anatomical, physiological, patho-
that are part of his routine functional enquiry to assist physiological — and their clear orientation towards physi-
in his mental ranking of hypotheses' cal care The authors descnbe this lmtial, non-specific
The aim of such studies is to provide an accurate picture hj^othesizmg as divergent or inductive thinking which
of the expert clinician's problem solvmg approach, which takes place in order to generate 'more specific hypotheses
will serve to inform clinicians, educators and medical stu- to refine the enquiry' The purpose, to reach a stage at
dents There is an underlying assumption that the hypo- which more specific hypotheses may be generated, is clear
thetico-deductive model is the model of choice, and vnl\ The medical decision-maker is already on course, heading
provide a helpful structure for education and practice towards the diagnosis
This assumption has been challenged more recently by Later, specific hypotheses perhaps bear a closer resem-
Groen & Patel (1985) They cite cognitive psychology blance to scientific hypotheses, m that 'unsatisfactory
research which compares expert-novice behaviour to sup- hypotheses are set aside and new ones generated as the
port their arguments that 'the use of the hypothetico- enquiry progresses', thus guiding questioning and physical
deductive method is characteristic of novices rather than exammation of the patient The second stage of the clinical
experts' and 'experts use methods which are dependent reasoning process, in which such specific hypotheses are
on a highly elaborated and structured knowledge base' in use, IS descnbed by Barrows & Feltovich (1987) as rep-
Groen & Patel acknowledge that 'there must be some- resenting 'convergent, vertical or deductive reasoning that
thing effective about the h3fpothetico-deductive method' instantiates to the particulars of the patient from a set of
as a teaching technique, given its extensive current use, generic explanations'
but express strong reservations about its use m the process
of scientific investigation Their thinking stems in part
from the philosophy of Popper (1968) and of histonans of
Structured and less structured problems
science such as Kuhn (1970) Popper pointed out a basic The nature and purpose of alternative generation, infor-
logical flaw m the hypothetico-deductive method, that a mation search and judgement m the clinical reasoning pro-
hjrpothesis can never be rejected, only confirmed Kuhn's cess descnbed by Barrows & Feltovich (1987) differs from
well-respected contribution to the history of knowledge the process of patient assessment m community contexts
views the process of scientific discovery as far from m certain important respects Even the most ill-structured
rational and suggests that the h5^othetico-deductive medical problem is likely to have a generally acceptable
method is 'a rhetorical device [which] is extremely solution and end-point, that is, diagnosis
useful in communicating the results of scientific research' Only some problems in nursmg practice have such end-
(Croen & Patel 1985) points For example, an interesting study by White et al
(1992) of decision making by gynaecological, obstetnc and
family nurse practitioners used interactive video and com-
THE NATURE OF HYPOTHESES
puter simulation to explore the process by which nurse
Barrows & Feltovich (1987) shed considerable light on practitioners diagnosed the cause of a patient's specific
Carroll & Johnson's (1990) stages of alternative generation, complamt and prescnbed the appropnate drugs They
mformation search and judgement or choice, m the course reported that 'nearly all data acquired was S3rmptom-
of their discussion of the nature of the hypotheses which dnven, directly related to the hypothesis formulated'

© 1996 Blackwell Science Ltd, Journal of Advanced Nursmg, 24, 24-30 27

A Bryans and f Mclntosh
Unfortunately, only 27 subjects were mvolved, tools do
not appear to have been tested and the study does not yet
appear to have been rephcated, so the importance of their
findmgs IS uncertain The context of this study also differs
from that of current community nursing practice m the
UK However, the point is that their decision-makmg task
had a nght answer, and a hypothetico-deductive, decision-
analysis or problem-solving approach would thus seem
appropnate
Some aspects of nurses' decision making in community
settings, such as the appropnate treatment of a leg ulcer,
could reasonably be exammed usmg such em approach
However, other aspects of assessment are much less clear-
cut and much more long-term For example, the promotion
of adequate nutntion of an elderly patient may involve
other agencies and raises complex issues regarding the
acceptability of vanous available strategies for the patient
Deciding how best to achieve the goal will be a slow pro-
cess, which IS dependent upon leammg ahout the patient,
rather than simply possessing knowledge about nutntion
Deductive reasoning will be of little value in such a situ-
ation There is no one, obviously correct, solution to this
problem Many of the decisions made in the course of
community nursing practice are of this nature
Voss & Post (1988) make a useful distinction between
'social science problem solving' which 'basically involves
planning' and problem-solving activity in the field of
medicine, which more often involves 'right answers' A
large number of commumty nursing problems fall into the
psychosocial bracket, rather than into the category of
physical care Because of the distinction between the two
types of problem solving, it is important not to import
models from medical decision-making research for use in
nursmg research, unless the nursing decisions bemg
investigated already have clear and unambiguous solu-
tions or 'right answers' However, perhaps because medi-
cal and nursing professions both work at the 'coal-face' of
patient care, and a substantial body of research mto medi-
cal problem solving and decision making already exists, it
IS tempting for nursmg researchers to import theories and
models from medical research
Decision analysis
One imported approach which also focuses on alternative
generation, information search and judgement is decision
analysis Here 'a model of the problem is constructed,
showing the avmlable options which are to be considered
and the consequences of following each' (Harbison 1991)
Outcomes are given a score related to the benefit of the
patient and the best option is thus rendered computable
Although it may be useful for certain 'diagnostic' aspects
of nursing, perhaps m relation to physical care and man-
agement of symptoms, the use of this technique has been
cnticized (Baumann & Deber 1989) as unsuitable for
28 © 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
nursmg's process-onentated approach to care It is cer-
tainly difficult to see the usefulness of this approach to the
study of decision makmg m the context of community
nursmg, where the sconng of outcomes, just like the rank-
ing of hypotheses, is likely to be problematic, if not
impossible The real world of patient care is made up of
'messy, lndetermmate situations' (Creenwood 1993) where
best outcomes may be very much a matter of opinion, and
ranking hypotheses either difficult or meanmgless
THE CONTINUOUS NATURE OF
COMMUNITY NURSING ASSESSMENT
Medicine also shares some of the d5mamic, mteractive
aspects of patient assessment and decision making with
nursing, as can be illustrated by the following issues which
are bemg raised about information search Recent research
into medical decision-making (Barrows & Feltovich 1987)
draws attention to the mappropnate nature of problems
which have generally been used m medical decision
research Traditionally, such problems have been highly
structured and complete, unlike those which face medical
decision-makers m the real world of practice In a recent
paper about the climcal reasoning process m medicine,
the authors argue cogently that 'it is important to recognize
that clinical problems are lU-structured and that the doc-
tor's reasoning is built around a temporal unfolding of
information' (Barrows & Feltovich 1987 — present author's
italics) They argue that studies which do not take account
of this reality are likely to be of limited value
The idea of a temporal unfolding of information will be
familiar to community nurses, who view patient assess-
ment very much as a continuous process, rather than as a
one-off event (Cowley et al 1994) It is crucially important
to acknowledge this when designmg research mto
community nurses' decision making
CHALLENGING DOMINANT MODELS
Challengmg traditionally accepted medical models of
decision making with a problem-solving focus is a pro-
ductive activity for reseeirchers mto decision making m
nursing It is of value because it helps to alert the nurse
researcher to the existence of predetermined views of the
nature of decision making in health care and to the notion
that less limited models than those used by researchers
mto climcal decision-making m medicme may be more
useful for nursing research
In the words of Rhodes (1985), 'theoretical models are
useful to the extent that they nurror or represent reahty'
If models are not to limit and constrain a researcher they
must be broad and mclusive of the realities of the area
being researched Models with a problem-solving slant,
with their charactenstic focus on alternative generation,
mformation search and judgement or choice, are not
 Incision making m community nursing

sufficiently mclusive of the reahties of commumty nursu^ penod of tune, an overwhelming amount of mformabon
practice As well as excluding predecisional activity, theymay become available to the community nurse He or she
fail to acknowledge the importance of action and feedback must therefore use feedback as one means of limiting and
m the decision-making process directmg mformation-gathenng activities
In addition to gathenng important mformation from the
pabent and the external environment, information already
Process approaches versus input/output
stored m his or her memory will influence the nurse's use
approaches to decision making
of feedback As well as possessing generalized knowledge,
The last two stages described by Carroll & Johnson, action more expenenced practitioners will be able to draw bom
and feedback, do not feature at all in some models of a well of 'particularized' or 'craft-based' knowledge
decision making (for example, that used by Elstein et al (Mackenzie 1992) which they have accrued over time
(1978), which finishes with hypothesis evaluation) Feedback is therefore likely to play a vital role m guiding
However, the influence of feedback in modifying decision information search, and any study which is attempting to
behaviour is mcreasingly recognized by those researchers understand assessment practice must necessanly take
m the field of decision making who are interested in cognisance of this
mtervenmg processes m decision making (e g Nisbett &
Ross 1980), rather than merely m 'the relationship between
inputs and output' (Carroll & Johnson 1990) RELEVANCE TO COMMUNITY NURSING
PRACTICE
This paper has argued that the seven stages of decision
THE DYNAMICS OF DECISION MAKING
making outlined by Carroll & Johnson offer a promising
The role of feedback forms a fascinatmg natural link conceptual base from which to explore the decisions made
between the areas of decision research, adult learning by community nurses In particular, the broad perspective
theory, practical reasoning, and theones of expertise provided by the adoption of such a framework acknowl-
Unfortunately, discussion of these related areas is not edges some key features of community nursing practice
within the remit of this paper These include the uncertain and ill-structured nature of
Klemmuntz (1985) argues that success m decision many problems encountered by community nurses, the
making depends on 'the availability of feedback and d3rnamic and interactive nature of practice, the associated
opportunities for taking corrective action based on that phenomenon of the temporal unfolding of information
feedback' A recently-coined phrase 'decision taking' about the patient and also the influence of the climate or
(Carroll & Johnson 1990) usefully includes decision context of caring
making and subsequent action and feedback The While decision making is integrated mto community
mclusion of action and feedback m models of decision nursing practice as a whole, a particularly fruitful aspect
making has particular relevance to the study of community of practice through which the authors have chosen to
nursmg assessment Because such assessment is djmamic explore all stages of the decision-malang process is the
and continuous in nature (Cowley et al 1994), its relative lmtial assessment visit Dunng such a visit, the commumty
success and the effectiveness of subsequent patient care nurse may be confronted with a range of patient problems
depends to a considerable extent on a nurse's inter- Some of these are discrete and easily recognized, while
ventions, patient responses to these interventions, and the others are lmked to and dependent upon vanous circum-
nurse's appropriate utilization of information gained from stances m the patient's life which are likely to remain
feedback hidden unless they are explored by the nurse In view of
Although feedback has the potential to influence all the fact that the patient and nurse are strangers to each
phases of the decision-making process, its impact on other, this exploration must be skilfully negotiated by the
guiding mformation gathering is of particular interest for community nurse if he or she is to appropnately frame
any study which aims to focus on the realities of com- needs and thus begin the process of addressing these needs
munity nursing practice Some decision tasks may be and planning smtable care
rendered more difficult by lack of information For The community nurse's pnor knowledge, the recog-
example, m a study of judicial decision-making, mtion processes which this knowledge informs and the
Lavirrence (1988) quotes a magistrate descnhmg his efforts context of practice will together influence the assessment
to maximize the quality and quantity of information he and subsequent care offered to the patient Key elements
uses 'AH you can do is push the sides out you are still of pnor knowledge include the technical, rationed aspects
constncted at some stage' In the context of community of knowledge, such as pathology and physiology, as well
nursing assessment, too much mformation is perhaps a as know-how or professional artistry (Schon 1987) The
more probable scenario Because the 'sides' can be community nurse must know how to engage in the process
pushed out m vanous directions over a considerable of assessment in such a way as to gain and utilize relevant

© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30 20

 A Bryans and f Mclntosh
information while at the same time securing the patient's
trust £uid confidence
Conclusion
The research study on which the authors are engaged has
shown that the breadth of conceptual base provided by
Carroll & Johnson's (1990) distillation of decision-making
theones facilitates examination of the whole process of
assessment Carroll & Johnson have provided a framework
for the examination of important issues relating to the
nature of the decision maker, professional artistry, the
expenential knowledge base of commumty nursing and
the use of feedback, as well as the judgements and nursing
actions which are the product of an assessment visit It is
hoped that m exploring the utility of such a framework, a
significant contribution to understanding the professional
expertise of the community nurse will be made
References
Arkes HR & Hammond K {1986) Judgment and Decision Making
An Interdisciplinary Reader Gambndge University Press,
Gamhndge
Badger F , Cameron E & Evers H (1989) District nurses'
patients — issues of caseload management Journal of Advanced
Nursing 14, 518-527
Barrows H S & Bennett K (1972) The diagnostic (problem solv-
mg) skill of the neurologist Archives of Neurology 26, 272-278
Barrows H S & Feltovich P J (1987) The clinical reasoning pro-
cess Medical Education 21, 86-91
Baumann A & Deber R (1989) Decision Making and Problem
Solving in Nursmg — An Overview and Analysis of Relevant
Literature Literature Review Monograph University of
Toronto, Toronto
Benner P & Tanner G (1987) How expert nurses use intuition
Amencan Journal of Nursing 87(1), 23-31
Garroll JS & Johnson EJ (1990) Decision Research A Field
Guide Sage, Newbury Park, Galifomia
Gorbm R (1980) Decisions that might not get made In Cognitive
Processes m Choice and Decision Behaviour (Wallsten T S ed),
Lawrence Erlbaum, Hillsdale, New Jersey, pp 47-68
Cowley S , Bergen A , Young K & Kavanagh A (1994) The chang-
mg nature of needs assessment in pnmary health care Paper
presented at the Fourth International Primary Health Care
Conference, Kensington Town Hall, London, June
Einhom HJ & Hogarth RM (1975) Unit weighting schemes for
decision making Organisational Behaviour &• Human
Performance 13, 171-192
Elstem A S , Shulman L S & Sprafka S A (1978) Medical Problem
Solvmg An Analysis of Clinical Reasoning Harvard University
Press, Cambridge, Massachusetts
30 © 1996 Blackwell Science Ltd, Journal of Advanced Nursmg, 24, 24-30
Greenwood J (1993) Reflective practice a cntique of the work of
Argyns and Schtin Journal of Advanced Nursing 18,
1183-1187
Grether D M & Plott C (1979) Economic theory of choice and the
preference reversal phenomenon Amencan Economic Review
69, 623-638
Groen GJ & Patel VL (1985) Medical problem solving some
questionable assumptions Medical Education 19, 95-100
Harbison J (1991) Chnical decision makmg m nursmg Journal of
Advanced Nursing 16, 404-407
Isenberg D (1984) How senior managers think Harvard Business
Review (November-December), 80-90
Johnson E J & Russo J E (1984) Product familiarity and leammg
new information Journal of Consumer Research 11, 542-550
Klemmuntz D N (1985) Cogmtive heuristics and feedback m a
dynamic decision environment Management Science 31,
680-702
Kuhn T S (1970) The Structure of Scientific Revolutions 2nd edn
University of Chicago Press, Chicago
Lawrence J A (1988) Expertise on the bench modelling magis-
trates judicial decision-making In The Nature of Expertise (Chi
M T H , Glaser R & Farr M J eds ), Lawrence Erlbaum, New
Jersey, pp 229-259
Liss P E (1993) Health Care Need Meaning and Measurement
Avebury, Aldershot
Luker K A & Kenrick M (1992) An exploratory study of the
sources of influence on the climcal decisions of community
nnrses Journal of Advanced Nursing 17, 457-466
Mackenzie A E (1992) Learning from experience in the com-
munity an ethnographic study of district nurse students Jour-
nal of Advanced Nursing 17, 682-691
Nisbett RE & Ross L (1980) Human Inference Strategies and
Shortcomings of Social Judgment Prentice-Hall, Englewood
Cliffs, New Jersey
Orme L & Maggs C (1993) Decision-making m clinical practice
how do expert nurses, midwives and health visitors make
decisions'' Nurse Education Today 13, 270-276
Popper KR (1968) The Logic of Scientific Discovery 3rd edn
Hutchinson, London
Rhodes B (1985) Occupational ideology and clinical decision-
makmg in Bntish nursing International Journal of Nursing
Studies 22(3), 241-257
Schon D (1987) Educating the Reflective Practitioner Jossey Bass,
San Francisco
Simon HA (1986) Alternative visions of rationality In Judgment
and Decision Making An Interdisciplinary Reader (Arkes H R
& Hammond K eds), Cambndge University Press, Cambndge,
pp 97-113
Voss J F & Post T A (1988) On the solvmg of lU-structured prob-
lems In The Nature of Expertise (Chi M T H , Glaser R & Farr
M J eds), Lawrence Erlbaum, New Jersey, pp 261-285
White J E , Nativio D G , Kobert S N & Engberg S J (1992) Content
and process in clinical decision making by nurse practitioners
Image Journal of Nursing Scholarship 24(2), 153-158