Essay on decision making in nursing practice in preparation for PEP

Decision making in healthcare has significant and far reaching implications as it involves patient safety, treatment and recovery. Today’s healthcare industry allows nurses to become active decision makers in the healthcare when it comes to the welfare of their patients. Healthcare industry has also undergone tremendous transformation in the last few years and like any other industries which places importance on consumerism, healthcare is not exception and has become customer-focused, that is, in other words patient focused and provides improved outcomes for patients at a lower cost (Sanderson and Tieman, 2010). This entails for every individual working in the healthcare sector to be more empowered, and strive to become autonomous. Clinical decision making by nurses is one such outcome of today’s global healthcare industry. Clinical decision making specifically requires critical thinking and a high quality judgement. This critical thinking stems from the nurses’ cognitive skills and knowledge of analyzing, discriminating, applying various standards, information processing, logical reasoning and conscious and knowledgeable prediction and transformation of knowledge (Dowding and Thompson, 2003) . 
The autonomy in the decision making by the nurses is a unique process and consists of the interaction of the knowledge of the patient’s condition, information pertaining to the patients’ present condition and history of ailments, experiential learning and nursing care (Cioffi, 2012). Today, there exist a number of decision making models, which the nurses and other healthcare workers can apply in real life critical patient care (Traynor, Boland and Buus, 2010). For the purpose of this paper, three models will be analyzed critically and their applications in today’s healthcare industry would be commented upon. These models chosen for this paper are – Information Processing Theory, Social Judgement Theory and Cognitive Continuum Theory. The utility of all the three models, and their application in provision to nursing care as well as other care related outcomes will be presented in this paper. 

The three theories to be analyzed are Information Processing Theory, Social Judgement Theory and Cognitive Continuum Theory. Each of the theories advantages and limitations would be presented, and finally a brief account would be provided which showcases the most relevant theory as per personal experience and knowledge. 

The “Information processing” theory is based on a psychological principle which is very popular in undertaking decision making in medical and research fields. It is characterized by a systematic scientific approach and helps the user to make knowledgeable informed decisions. This theory is also known as the “hypothetico-deductive” model and is one of the most dominant approaches to the process of clinical decision making (Oppenheimer and Kelso, 2015). 
Hamers et al, in 1994, identified the different stages of this decision making procedure. The stages are as follows – gathering of the early information pertaining to the patient, her present condition, information about her present and past medical conditions; secondly, generating a preliminary and tentative hypothesis regarding the condition of the patient; thirdly, interpreting and analyzing the primary registered flags or markers about the patient’s condition in terms of the generated hypothesis and finally, identifying different decision paths and alternatives, and choosing the one which as per to the nurse/ decision maker to be the most effective one (Hamers, Huijer Abu-Saad and Halfens, 1994). 
This information processing theory is a popular choice in determining how actually the medical practitioners think and reach upon the decisions. The theory focuses on the understanding as well as the explanation of the behaviour rather than focusing on the prediction and the control. The core advantage of this theory lies in the fact that, the scope for plausible reasons plaguing a patient is narrowed and hence, the problem space is also made restricted helping the decision makers choose a specific reason and reach upon a decision and this model reduces the chances of uncertainty to a great extent. The hypothesis which is generated in this specific theory, helps the decision makers to look for specific alternative conditions, namely, the complaint of what is the illness of the patient turns to, is the patient suffering from X, Y or Z? Therefore, for nurses using this theory or method, it is more probable that they undertake decisions which are more accurate to the diagnosis. This IPT (Information Processing Theory) is very influential in the decision making process for the nurses’ and has been effectively used to explore and depict the different aspects of the decision making procedure of nurses (Jefford, Fahy and Sundin, 2011). 
Though this theory is popular, it has its own share of critique as well. The primary critique is that, this theory is more applied and used in simulated situations rather than in actual clinical practices. Greenwood highlighted three reasons, for the problem of IPT in using in real life – they were, in realistic clinical situations, the information might not be available in a serial and systematic fashion, there might be limitations in the volume of information present and the goals and motivations of the nurse/ patient might not be simple and singular. Again, even if the patients provide information serially and systematic, it depends on the skill levels of the nurses and doctors to interpret such effectively, if the patient is inarticulate. Therefore, success of this theory depends on the skill levels of the decision makers (Offredy, Meerabeau and Elizabeth, 2005).

The social judgement theory is specifically applicable for undertaking medical decisions and judgements. Medical judgements in realistic scenarios involve in undertaking decisions, under tremendous uncertainties with chances of inevitable errors and a number of frail indications. SJT or Social Judgement Theory has received its own accolades and critique from various schools of thoughts. Examining the different judgements in nursing and healthcare is of critical importance, as the effect of such judgements lie on the patient’s outcome. As per Harvey in 2001, if the judgements are not considered accurately and specifically then the decisions pertaining from such judgements will be inaccurate and the patients might suffer from such wrong judgements undertaken. There can be two reasons which might lead to such inaccuracy – the nurse or the healthcare worker may use the information that has no role or effectiveness in the final judgement to be taken and therefore, the end judgement becomes ineffective and secondly, the nurse can place undue importance on specific information which might not have any effectiveness (Harries and Harries, 2001). 
The “lens model” proposed by Brunswik, is a representation of the relationship which exists between an individual and her/his social environment. The scholar depicted that in order to arrive at a specific judgement, the researchers or nurses in this case, should consider exhaustively the unpredictable nature of the external and internal social environment in which they operate and in which the patient exists (Harries and Harries, 2001). Then the range of judgements, specific to a range of situations can be identified and explored upon. 
In the lens model of SJT, one side represents the environment in which the patient exists and depicts her/his state of health, and consist of a host of cues related probabilistically to the environment. The other side consists of the nurse or decision maker, who undertakes the judgement by using the information cues associated with the environment. Namely, whether a nurse should call a doctor is a simple example of taking a judgement call by analyzing the information cues pertaining to the patient. By conducting a comparison with the information cues related to the environment and the importance associated an individual can understand whether the judgement is accurate, and whether the decision maker is using appropriate information. 
This model indicates the scenarios where disagreements occur between the decisions makers. The decision makers can be using different cues to place their importance on and such would lead to the creation of different judgements. In studies where social judgement has been observed, the number of scenarios has been typically very large to undertake realistic judgements. The decision makers, in the study conducted by Harries and Harries in 2001, were asked to undertake a judgement for each of the scenario and then it was modelled using statistical quantification and then it was identified each of the importance the decision makers placed on the different cues available (Harries and Harries, 2001). 

As per a study by Thompson et al, in 2005, it was identified that the information use of nurses using the Social Judgement Theory is not linear, and the utilities associated for final decision making interpreted from the patient’s clinical information is not even properly and equally distributed. This study highlighted that in scenarios like “Glasgow Coma Score” certain clinical patient based information are not effectively understood and therefore are not incorporated in making the clinical judgement. Therefore, this can be a major restraint for this model, if the decision makers, that is the nurses, do not even place equal importance to all the clinical information, and therefore the judgements which arise from such improper distribution of clinical information can lead to ineffective and wrong decisions (Thompson et al., 2005). 

The Cognitive Continuum Theory was proposed by Hammond in the late nineteenth century, and this theory has now gained widespread dominance in decision making in the healthcare and medical industry. As per the theory, different cognition forms, namely, analytical, intuitive, common sense etc exists in relation to one another in a range or continuum which provides intuitive or subjective processing of information at one end, and the other end consists of analytical objective processing. The very properties of reasoning, namely, cognitive ability and control, awareness of such, speed of such control etc varies from one another in several aspects, and the structure of the tasks which require the reasoning also vary as along the range, as per the degree of ability in which they are predicted to be induced (Dhami and Thomson, 2012). 
As per the paper by Hammond, the decision making and judgement is situated in the middle of the entire field of cognition. As per Hammond, five aspects or premises are presented which together make up the entire basis for CCT (Cognitive Continuum Theory). These are – primarily, the different forms of cognition which can be placed in relation to one on a range effectively marked by analytical cognition at one end and intuitive cognition on the other end; secondly, the different forms of cognition which exists in the range between the intuition and the analysis consist of elements of both such intuition and analysis and are associated with the term “quasi-rationality”, which is the most common cognition form, and is known by the readers as the “common sense”; thirdly, the very properties of such cognitive tasks let them to be placed on the range in relation to their capacity to induce the intuition, common sense and analysis, hence, a specific relation can be identified between the different properties of such cognitive tasks and the different modes of their induced cognition; fourthly, such cognitive activities with time move along the analysis-intuitive range and during such, the relative contributions in association to the quasi-rationality changes- failed cognition stimulates it and the successful cognition prohibits it and lastly, the intuition, analysis and the common sense act as cognitive functions which have structural complementary counterparts in the brains of the decision makers (Cader, Campbell and Watson, 2005). 
Offredy et al, in 2008 conducted a study in which the CCT Model was utilized in checking the nurse practitioner’s decision making procedure and knowledge when choosing the final medications for the patients. The researchers’ utilized interviews which were semi structured and created four different patient scenarios. The number of nurses who participated in the study was 25 and it was found from the results that, the majority of the nurses undertook decisions on the range of intuitive-common sense spectrum of the range or the intuitive-quasi-rational spectrum while deciding for the final medications. However, it was identified that it is very important to be analytical and use pharmacological knowledge while prescribing, as the chances of failure when only depending on intuitive-quasirational aspect of the continuum lead to wrong decision making. This study highlighted that CCT can be used as a valid model for decision making and this also identified the importance of experience and knowledge of the nurses or the healthcare workers as such knowledge and experience influence the cognitive processes used by the decision takers in prescribing the most accurate and effective strategy (Offredy, Kendall and Goodman, 2008). 
As per the CCT, the major implications of whether a nurse would utilize the intuitive approach or the analytical/ rational approach are determined by the task position on the continuum or range, which itself has three principles. These are- complexities involved in the task structure; the ambiguity of the task and lastly, the nature of the presentation of the related task. The complexity of specific task depends on the number of cues, the redundancies of the cues and the nature of the organizing principle. Namely, when a large number of cues are present, the decision maker is more likely to utilize the intuitive approach. Similarly when a number of cues result in the prediction of the presence of further cues, again intuitive approach is selected. Again if it is considered by the decision makers, that when combined with evidence, the accurate decision can be taken, then analytical approach will be preferred.  The ambiguity of the assisted task depends on the potential for accuracy, the familiarity of the task and whether an existing organizational principle is in place or not. Unfamiliarity leads to a heightened chance of intuitive approach whereas, analytical approach is preferred when a specific organizing standard exists or when a specific approach is associated with known more accuracy. Lastly, the nature in which a task is presented depends upon the decomposition of the task, the manner in which the information is presented and the available time to undertake such a decision. If a specific task can be broken down into subtasks, then nurses do take a more analytical approach. When the information is presented in a visual form, it leads to intuitive decision making and when the information is presented in a quantitative and objective format the analytical approach is taken. Also how much time is available to the nurse decision maker also leaves an impact on whether she or he will take an analytical decision making or an intuitive decision making. The shorter the time, more intuitive based approach is undertaken and the opposite rings true as well (Thompson, 1999). 
Hence, whether a nurse will utilize intuitive cognition or analytical cognition not only depends on her/his knowledge but also depends on the apparent complexity of the task, the time available and the manner in which the task is represented. But this can be safely claimed that, of all the models discussed in this paper starting from Information Processing Theory, Social Judgement Theory and Cognitive Continuum Theory, it is found that whichever theory be made to use while undertaking the decision, the decision maker needs to be rational, knowledgeable, aware of the organizational policies and procedures, be experienced and be objective in her/his approach. In typical healthcare settings, hierarchical authority figures can accept analytical decision making from individuals who are perceived as competent, and analytical and objective and at the same time, can reject intuitive decision making from junior staff members who apparently lack the expertise. Hence, Thompson opined that an individual decision maker’s position in the organization hierarchy, her/his apparent perceived expertise will provide some sway on the principles of cognition available to her/him for deploying. Also, decision maker’s knowledge with that of cognitive modes is of critical importance, as the ability of an individual to engage a specific cognitive mode depends on the knowledge and expertise (Standing, 2008). For example, when a nurse is faced with a decision of taking care of a horrific would, then unless such nurse has clear idea and knowledge about scientific principles on choosing the right wound care ingredients and equipments, then such would not encourage an analytical cognitive action or decision. 
Therefore, knowledge and expertise are two most critical aspects which can aid a nurse in decision making. Along with knowledge and expertise, the task at hand, and the different implications of such task, will help in choosing the right solution or decision for the nurse. After careful consideration of all the theories chosen, the most suitable one was felt to be Cognitive Continuum Theory, as it practically considers both the aspects of any event which needs sudden decision making. 

The importance of quick and accurate decision making in the healthcare profession, cannot be enough stressed upon. Not always, doctors and surgeons are available when the condition of a patient suddenly takes the wrong turn, and majority of the times, it is up to the nurses to take quick decisions seeing the condition of the patient, and provide intermediate treatment options, to help the patients cope up till the specialists arrive. Therefore, decision making for the nurses is of critical importance. This decision making, does not occur automatically and randomly and even if sub-consciously, the manner in which nurses take decisions can be modelled into specific theories. Some of these decision making theories were identified and analyzed in this paper. Information Processing Theory (IPT), Social Judgement Theory (SJT) and the Cognitive Continuum Theory (CCT) were chosen and explained in this paper. 
IPT is concerned with analyzing all the information present to the nurses, analyzing such information, creation of plausible hypotheses and final choosing the right decision. The limitation of this theory is that, it is more suitable for simulated situations where information is readily available, and nurses can create effective hypotheses, but lack practicality in real world situations. The second theory, SJT is based upon a Lens Model, whereby the social cues and the environmental cues associated to the condition of the patient helps a nurse undertake the right decision. But the limitation of this model also exists in the fact that, in cases where the nurse or health care decision maker does not understand the implications of the environmental cues taken, then accurate judgement cannot be made, and correct decision cannot be taken. Hence, for the success of SJT, thorough knowledge, thorough interpretive power and expertise is required on behalf of the nurses. The last theory to analyze was the Cognitive Continuum Theory (CCT) which depicted those decisions taken by nurses on a specific situation ranged from cognitive analysis in one end and intuitive analysis in another with a quasi-rational cognitive thinking in the middle. However, though this was felt to be the most logical, and practical and realistic decision making theory, it was found that, this model will only be successful if the decision maker has thorough expertise, analytical knowledge, and experience and has strong interpretive skills. 

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