040601using judgement to improve accuracy in decision making

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AUTHORSDawn Dowding, PhD, RN,is senior lecturer,

Hull York Medical School, University of York; Carl

Thompson, DPhil, RN, is senior research fellow,

Department of Health Sciences, University of York.

ABSTRACT Dowding, D., Thompson, C. (2004) Using

judgement to improve accuracy in decision-making.

Nursing Times;100: 22, 4244.

Nursing judgements are complex, often involving the

need to process a large number of information cues. Key

issues include how accurate they are and how we can

improve levels of accuracy. Traditional approaches to thestudy of nursing judgement, characterised by qualitative

and descriptive research, have provided valuable insights

into the nature of expert nursing practice and the com-

plexity of practice. However, they have largely failed to

provide the data needed to address judgement accuracy.

Social judgement analysis approaches are one way of

overcoming these limitations. This paper argues that as

nurses take on more roles requiring accurate judgement,

it is time to increase our knowledge of judgement and

ways to improve it.

This is the third of four papers discussing judgement and

decision-making in nursing. The first paper in this series

(Thompson et al, 2004) highlighted the importance of

judgement and decision-making to nursing practice. The

second (Dowding and Thompson, 2004) discussed how

complexity associated with decision problems could be

made sense of by using an approach to structuring deci-

sions known as decision analysis. The aim of this article

is to discuss the issue of judgement in nursing. In par-

ticular, it examines the way nurses may use information

to inform their judgements, and ways in which this proc-

ess can be assisted to improve the accuracy of judge-

ments.

Judgement in nursingThe process of judgement involves integrating different

aspects of information (which may be about a person,

object or situation) to arrive at an overall evaluation(Maule, 2001). In nursing this could be considered as the

process of using different types of clinical information

about the patient (such as appearance, vital signs, and

behaviour) to make an assessment of her or his current

health status (Dowding and Thompson, 2003).

Judgements feed into decision-making (Box 1) in that

the evaluations or assessments an individual makes can

be used as the basis of choice between alternatives. For

example a nurse may assess a patient as being at risk

of developing a pressure ulcer (judgement) and then

choose a particular intervention to reduce that risk

(decision) on the basis of the assessment.

Examining judgements in nursing is important, as they

have an effect on decisions taken about patient care.

Harvey (2001) suggests decisions may be poor because

the judgements on which they depend are inaccurate or

because individuals combine different judgements inap-

propriately. Therefore, a key issue for nurses and patients

is ensuring judgements are as accurate as possible.

There are two main reasons for inaccuracy:

The nurse may be using information that has no utility

for the judgement in question (Cioffi 2002);

The nurse may be placing too much importance on

particular information (Dowding, 2002).

Therefore, the type of information individuals use to

inform their judgements, some knowledge of the infor-

mation they should be using to inform their judgements,

and how that information is (or should be) combined is

required to investigate and improve accuracy. The two

main ways these issues have been investigated are

descriptive research and social judgement analysis.

Descriptive research into judgementMost of the research examining judgement in nursing is

qualitative and descriptive in nature an appropriate

design for the research questions being addressed. The

aim of many of the studies is to describe the nature of

judgements through the analysis of how nurses manage

clinical situations, including the information they use toinform their judgements and decisions.

The use of intuition and rules

Perhaps the most well known research in this area is that

carried out by Benner et al (Benner, et al 1999; 1992;

Benner, 1982). This research highlighted characteristics

of expert nursing practice and judgement and how that

expertise develops. Benner (1982) suggests expert

nurses mainly use intuition, which is defined as knowing

without necessarily having a specific rationale or making

explicit all that goes into ones sense of a situation

42

Using judgement to improve

accuracy in decision-making

NT 1 June 2004 Vol 100 No 22 www.nursingtimes.net

REFERENCES

Benner, P.(1982) From Novice to

Expert.American Journal of Nursing;

82: 402407.

Benner, P. et al(1999) Clinical Wisdom

and Interventions in Critical Care.

Philadelphia, PA: WB Saunders.

Benner, P. et al(1992) From beginner

to expert: gaining a differentiated

clinical world in critical care nursing.

Advances in Nursing Science;14: 3,

1328.

Cioffi, J.(1997) Heuristics, servants

to intuition, in clinical decision-making.

Journal of Advanced Nursing;

1997: 26, 203208.

Cioffi, J.(2002) What are clinical

judgements? In: Thompson, C.,

Dowding, D. (eds) Clinical decision-

making and judgement in nursing.

Edinburgh: Churchill Livingstone.

Corcoran, S.A.(1986) Task Complexity

and nursing expertise as factors

in decision-making. Nursing Research;

35: 2, 107112.

Dowding, D.(2002) Interpretation of

risk and social judgement theory. In:

Thompson, C., Dowding, D. (eds)

Clinical decision-making and

judgement in nursing.Edinburgh:

Churchill Livingstone.

Dowding, D., Thompson, C.(2004)

Using decision trees to aid decision-

making in nursing. Nursing Times;

100: 21, 3639.

CLINICAL ADVANCED

BOX 1. DEFINING JUDGEMENT AND DECISION

Generally considered

to be assessments,

estimates or

predictions of an entity

(Harvey, 2001)

Generally considered to

be opposed to decisions,

which are considered

to be a choice

between alternatives

(Dowie, 1993).

JUDGEMENTS DECISIONS


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(Benner, 1999).

This is in direct contrast to less experienced individuals

who may use rules to combine common attributes such

as a patients vital signs (Benner, 1982). This combina-

tion may eventually be combined into some form of

global pattern that guides action.

Although Benners work has provided insight into the

nature of expert nursing practice, it fails to give details of

how information is processed to inform accurate judge-

ments. This is due in part to the research methods used

predominantly observation of practice and interviews.

However, observation cannot provide insight into all

the information used in reaching a judgement, and self-

reporting has been shown to be an unreliable method of

investigating judgement and decision-making as indi-

viduals often have little insight into how they make

judgements and decisions (Harries et al, 1996). Also, the

critical incident method used by Benner et al (1999) may

mean individuals only examine situations where theirreasoning processes have been successful (Lamond and

Thompson, 2000), meaning a full exploration of issues of

judgement accuracy is not possible.

Information processing

Another set of studies used the psychological theory of

information processing (Newell and Simon, 1972) as the

basis for exploring the reasoning processes nurses use

when making judgements and decisions. This theory

suggests humans have limited capacity for processing

information, meaning a variety of strategies is employed

to assist the process. Examples of this type of study have

been carried out by Cioffi (1997), Tanner et al (1987),

and Corcoran (1986). These studies have suggested that

nurses use a process of hypothetico-deductive reasoning

when making judgements, together with mental short

cuts or heuristics.

Hypothetico-deductive reasoning involves using avail-

able information to formulate hypotheses, which are

then tested and reformulated until a conclusion is

reached (Thompson and Dowding, 2002). The types of

information that appear to be used vary considerably. For

instance in a very early study examining the information

nurses use to make a judgement about patient pain,

Hammond et al (1966) found they used 165 different

information cues. Hypothetico-deductive reasoning

appears to be used by individuals in situations where

they have no experience of the task in question. In situ-

ations where people have more experience, they aremore likely to use a process of pattern matching, which

involves the recognition of similarities between the

patient case being considered and ones that have been

encountered in the past (Elstein et al, 1990). These short

cuts are the focus of the fourth paper in this series.

The main strategies used to examine reasoning and

information use in information processing studies are

variations of a think aloud technique and retrospective

interviewing (Tanner et al, 1987; Corcoran, 1986).

Simulations are typically used to compare individuals

across cases. The process of thinking aloud involves the

subject of the study verbalising everything they think of

while carrying out the judgement task. They may be

interviewed after the task to discuss any other informa-

tion they think they used and their rationale.

There are a number of problems with this type of

study: the use of simulations may mean the judgements

made by the subject do not reflect what they would do

with a patient. Also, thinking aloud relies on the partici-

pants ability to make their judgement policies explicit

(Harries and Harries, 2001), and retrospective interview-

ing suffers from the same problems as highlighted above.

Limitations of descriptive research

In summary, if we are interested in the accuracy of

judgements, much of the descriptive research into nurs-

ing practice fails to provide the evidence that is needed

to inform practice. These types of study are a useful rep-

resentation of practice but it is difficult to observe a suf-

ficient range of scenarios for a given judgement in orderto determine how information is used to make that

judgement (Harries and Harries, 2001).

Many of the studies look at a broad range of practice,

which means detail about the information cues is often

lacking. Also, a reliance on self-report methods (such as

interviews and thinking aloud) means the research is

dependent on a participants insight into her or his judge-

ment processes and ability to verbalise these processes.

By definition expert judgement usually involves the

use of automatic, unconscious thought processes (often

referred to as intuition). Such experts often will not be

able to verbalise their thoughts a characteristic that

limits the analysis of their judgements (Lamond and

Thompson, 2000).

Social judgement analysisThe lens model

The theoretical basis of social judgement analysis is the

lens model of cognition proposed by Brunswik. This is a

representation of the relationship between a person and

her or his environment (Harries and Harries, 2001).

Brunswik suggested that to investigate judgement,

researchers should take into account the unpredictable

nature of the environment in which they operate, and

that a range of judgements, in a range of situations,

needs to be investigated (Harries and Harries, 2001).

The lens model can be represented diagrammatically

(Fig 1). In this diagram the left-hand side represents the

environment (such as a patients state of health). Anumber of different information cues will be related

probabilistically to this environment. The right-hand side

represents the individual making the judgement. This

person uses information cues to make her or his judge-

ment on the environment (for example, do I need to call

a doctor?) and in doing so will attach more weight to

some cues than others. By comparing the way the infor-

mation cues are related to the state in the environment

and the weighting assigned to information cues by the

judge, one can identify:

If the persons judgement is accurate (is there a corre-

KEYWORDSEducation Decision-making Judgement

REFERENCES

Dowding, D., Thompson, C.(2003)

Measuring the quality of judgement a

decision-making in nursing.Journal o

Advanced Nursing;44: 1, 4957.

Dowie, J.(1993) Clinical decision

analysis: Background and introduction

In: Llewelyn, H., Hopkins, A. (eds)

Analysing How we Reach Clinical

Decisions. London: Royal College of

Physicians.

Elstein, A.S. et al(1990) Medical

problem solving: a ten-year

retrospective. Evaluation and the

Health Professions;13: 1, 536.

Hammond, K.R. et al(1966) Clinical

inference in nursing: use of informatio

seeking strategies by nurses. Nursing

Research;15: 4, 330336.

Harries, C. et al(1996) A clinical

judgement analysis of prescribing

decisions in general practice. Le Trava

Humain;59: 1, 87111.

Harries, P.A., Harries, C.(2001)

Studying clinical reasoning. Part 2:

Applying social judgement theory.

British Journal of Occupational

Therapy;64: 6, 285292.

Harvey, N.(2001) Studying judgemen

general issues. Thinking andReasoning; 7: 1, 103118.

Lamond, D., Thompson, C.(2000)

Intuition and analysis in decision-

making and choice.Journal of Nursin

Scholarship;32: 3, 411414.

Maule, A.J.(2001) Studying judgeme

some comments and suggestions for

future research. Thinking and

Reasoning; 7: 1, 91102.


For related articles on this subjectand links to relevant websites see wwwnursingtimes.net

This article has been double-blindpeer-reviewed.


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spondence between patient state and the judgement?);

Whether the judge uses appropriate information, and ifso, does she or he put appropriate importance or weight-

ing on different pieces of information (Dowding, 2002).

Disagreement between judges

Using this model highlights where disagreements occur

between judges: they could be using different informa-

tion or be placing different importance on certain cues,

which would lead to differences in judgements.

In order to model the environment statistical tech-

niques are used to identify possible relationships

between information and a patient state. For instance, in

a study examining doctors diagnoses of heart failure,

Skanr et al (2000) used information from patient cases

to model how different cues were related to the diagno-

sis. This optimal strategy suggested cardiac enlarge-

ment was the most important cue to determine if a

patient had heart failure. To model the clinicians judge-

ment, a number of scenarios of patient cases are con-

structed containing information considered important for

the judgement under investigation, and designed to

represent the range of situations in the environment.

Judging scenarios

In social judgement analysis studies, the number of sce-

narios is often very large to make the judgements as real

as possible (Harries and Harries, 2001). The judge(s) are

then asked to make a judgement about each of the sce-

narios, and this is then also modelled using statistical

techniques (usually of linear multiple regression). Thisprovides a statistical analysis of the information the

judge uses to make judgements, and the importance she

or he attaches to each of the cues.

For instance, Skanr et al (2000) studied the diagnostic

judgements of GPs, cardiologists, and medical students.

Through their modelling of how individuals used infor-

mation to make a diagnosis, they highlighted the varia-

tion in the use of information cues. One-third of

participants used relative heart volume as the most

important cue as opposed to cardiac enlargement,

which was identified in the optimal strategy.

Cognitive feedback

As well as being able to identify possible sources of error

in judgement which may affect judgement accuracy

the results of social judgement analysis studies can be

used to provide cognitive feedback to participants as a

way of improving their accuracy. Cognitive feedback is

different to outcome feedback, which provides partici-

pants with the outcome of each case, in that it contains

information about the optimal strategy (how information

is related to the patient state in the environment) and

the individuals own policy (how she or he uses the

information). With this knowledge they can identify dis-

parities and be aware of how to improve their use of

information (Wigton, 1996). Various studies that used

cognitive feedback have shown it can improve diagnostic

accuracy and prognostic predictions (Wigton, 1996).

Social judgement analysis requires individuals to make

judgements as they normally would, and then uses sta-

tistical techniques to describe the relationship betweenthe information available to the judge and the judge-

ment or decision made (Harries and Harries, 2001). The

focus of these studies is not the process of judgement,

rather an analysis of how information use is linked to

judgement accuracy, so in this way studies are able to

analyse in detail how and why judgements may differ

among individuals, as well as offering a way of improv-

ing accuracy through the use of cognitive feedback.

Another strength of social judgement analysis is that it

is not reliant on the ability of participants to self-report

their judgement processes, and can identify policies that

judges are unaware of (Harries and Harries, 2001).

However, social judgement analysis studies are often

reliant on the construction of scenarios, frequently with

limited sets of information presented in a way not found

in reality. So, as with all other types of study, they do

have limitations.

ConclusionAs highlighted by Hammond et al (1966) nursing judge-

ments are complex, often involving the need to process

a large number of information cues. Key issues in the

study of such judgements are the analysis of judgement

accuracy and ways of improving accuracy.

More traditional approaches to the study of nursing

judgement have provided valuable insights into the

nature of expert nursing practice and the complexity of

practice. However, they have limitations in terms of

being able to provide the specific data needed to addressjudgement accuracy.

Social judgement analysis approaches may be a way of

overcoming these limitations. However, as yet these

approaches have been more common in medicine,

examining the nature of medical diagnosis and prescrib-

ing (Skanr et al 2000; Harries et al 1996), than in nurs-

ing practice.

With nurses taking on roles requiring accurate judge-

ment, it is time for clinicians and researchers to grapple

with this thorny issue in ways that will reveal possible

routes forward rather than offering just description.

X1

X2

X3

X4

FIG1. THE LENS MODEL


ADVANCED

REFERENCES

Newell, A., Simon, H.A.(1972)

Human Problem Solving. Englewood

Cliffs, NJ: Prentice Hall.

Skanr, Y. et al(2000) The use of

clinical information in diagnosing

chronic heart failure: a comparison

between general practitioners,

cardiologists, and students.

Journal of Clinical Epidemiology;

53: 10811088.

Tanner, C.A. et al(1987) Diagnostic

reasoning strategies of nurses and

nursing students. Nursing Research;

36: 6, 358363.

Thompson, C. et al(2004) Strategies for

avoiding pitfalls in clinical decision-

making. Nursing Times;100: 20, 4042.

Thompson, C., Dowding, D.(2002)

Decision-making and judgement in

nursing an introduction. In: Thompson,

C., Dowding, D. (eds) Clinical Decision-

Making and Judgement in Nursing.

Edinburgh: Churchill Livingstone.

Wigton, R.S.(1996) Social judgement

theory and medical judgement.

Thinking and Reasoning;

2: 2 175190.

44

Accuracy

Cues

True state Judged

Judgesweights

Correctweights

This is the third in a four-partseries on decision-making:

1. Strategies for avoiding the pitfalls inclinical decision-making

2. Using decision trees tostructure clinical decisions

3. How to use information cuesaccurately when making clinical

decisions;4. Tools for handling information

in clinical decision-making.

SERIES ON CLINICAL DECISION-MAKING

040601using judgement to improve accuracy in decision making

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