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A model of clinical judgment processes in psychiatric nursing
A Model of ClinicalJudgment Processes in Psychiatric Nursing Mary Jo Regan-Kubinski
This study addressed judgment processes in psychiatric nursing by analyzing reported use of clinical cues cited as being relevant in the process of making a nursing judgment. Using an exploratory, qualitative approach. data were collected by interviewing 15 subjects who provided 36 in-depth interviews upon completion of an intake interview. Comparative content analysis was used to determine the underlying structure in subject reports. A model depicting judgment processes is presented and discussed. Results suggest that although judgments were highly context-dependent, all subjects assessed data labeled as universals in the psychiatric nursing assessment: suicidality, depression, drug and alcohol use, and patient functional abilities. Similarities among subjects were noted in that presenting behaviors were most salient, a categorization process occurs within the judgment process, and patients are included in the judgment process. Finally, nursing judgments uncovered an action orientation rather than a labeling function.
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0 1991 by W.B. Saunders
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LINICAL JUDGMENT and diagnosis present a particular challenge in most nursing situations. Indices of patient responses and states are not well delineated and data available to the nurse are often inconclusive. Yet, on the basis of this uncertain data, nurses come to conclusions regarding the health status of their patients and these judgments form the basis for their choice of nursing intervention. Despite the pivotal role of clinical judgment in the delivery of nursing care, the factors that influence the diagnostic process in nursing, the nature of nursing judgment tasks, and the characteristics that influence nursing judgment strategies have not been explicated (Hammond, 1966; Tanner, 1987). In the practice of psychiatric nursing, clinical judgments are complicated by an abstract data base without the advantage of laboratory or objective data to validate one’s conclusions. The challenge posed is to document how
From the School of Nursing, University of Pittsburgh, Pittsburgh, PA Address reprint requests to May Jo Regan-Kubinski, Ph.D., R.N., 3201 Momingside Dr., Allison Park, PA 15101. Copyright 0 1991 by W.B. Saunders Company 0883~9417/91/0505-0004$3.00/O
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nurses make sense of what has been called the fuzzy data available in a psychiatric setting (Cantor, Smith, French, & Mezzich, 1980) and come to conclusions upon which nursing interventions are based. BACKGROUND OF THE STUDY
Studies of nursing judgments indicate that nurses as decision makers generally do not make use of optimal (e.g., rational or mathematical) strategies when drawing diagnostic conclusions (Aspinall, 1979; Baumann & Deber, 1989; Corcoran, 1986; Hammond, 1966; Tanner, 1987). Judgments are cited as being compromised by mental shortcuts, or heuristics (Tversky 8z Kahneman, 1974). In nursing, it has been suggested that approaches to nursing diagnosis are characterized by random selection processes, leading to a lack of consistency (Coler & Vincent, 1987a). These findings are of particular concern since the outcomes of nursing judgments influence patients’ lives and future health states. Studies of nursing judgment indicate that cue grouping, or the combining of information into clinically meaningful categories, is used by nurses as
Archives of Psychiatric Nursing, Vol. V, No. 5 (October), 1991:
pp. 262-270
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a means of dealing with complex clinical situations (Gas& 1979; Gordon, 1980; Kelly, 1966). Similarly, it is generally suggested that the cognitive basis for judgments and clinical decisions is the nurse clinician’s ability to capture important relationships among clinical cues (Corcoran, 1986; Matthews & Gaul, 1979; Westfall, Tanner, Putzier, & Padrick, 1986). However, these same investigators report that nurses use highly individualistic categorization schemes that are not readily identifiable. In a similar vein, intuition, characterized by an understanding without a rationale (Benner & Tanner, 1987) or without the conscious use of reason (Rew, 1988; Schraeder & Fischer, 1987) is noted to play a prominent role in nursing judgments, particularly in expert practice. Even so, it is claimed that nursing knowledge does include rules that nurses use to combine facts to make clinical nursing judgments (Graves dz Corcoran, 1989). The identification and subsequent testing of the generalizability and utility of these rules in clinical practice remains a challenge for nurse researchers and practitioners. The nature of the relationships in cognitive knowledge structures that capture the rules and patterns that are observed and noted by clinicians cannot be validated without bringing this knowledge into conscious awareness and subsequently documenting it. Further study is needed to identify how nurses synthesize objective and subjective data in order to arrive at and act on decisions (Rew, 1988), as well as to document the knowledge base for nursing practice. Documentation of the knowledge base for practice is of particular importance in psychiatric mental health nursing since the overlap between nursing care and the services provided by other mental health professionals (Coler & Vincent, 1987b) may blur the distinct contributions made by nurses. In addition, the current emphasis on biological models in psychiatric practice and changes in reimbursement (e.g., health maintenance organizations’ policies aimed at reducing length of hospitalization) may lead to reorganization of caregiving models. SPECIFIC AIMS
The specific aim of this study was to describe how psychiatric nurses select, assemble, and use signs and symptoms and other information in making a judgment about the health status of a patient. The following research questions were addressed:
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(1) What specific aspects of a clinical judgment process can be distinguished? (2) What cues and categories of cues emerge as the bases for clinical judgment? (3) What underlying theme or themes characterize the nature and focus of clinical judgments in psychiatric nursing? METHODS
Design
Grounded theory provided the specific design framework for this study. Grounded theory is particularly applicable for exploring phenomena that are embedded in nursing practice and, as a result, are not easily quantifiable (Corbin, 1986; Leininger, 1985). Briefly, this approach focuses on the responses of people who are involved in a defined situation with the intent of discovering the focus of that particular situation. Of particular interest to this study was the identification of the categories that emerge from the data and that help explain the cognitive processes involved in the phenomenon of concern, clinical judgment. Subjects and Settings
Sampling was purposive in regard to the usual or typical sites of psychiatric nursing practice as well as representative of the nurse clinicians who practice in these settings. Fifteen subjects provided 36 in-depth interviews; six subjects were interviewed more than once. Subjects were all practicing psychiatric mental health nurses. Included in the sample were four clinical specialists in psychiatric nursing, one nurse with a Bachelor of Science in Nursing degree, and 10 nurses with Associate degrees in nursing. They ranged in age from 24 years to 60 years. One subject was a man; all of the others were women. The number of years in nursing ranged from 2 years to 33 years; years in psychiatric nursing practice ranged from 1 year to 25 years. In general, the clinical specialists tended to have more years of experience exclusively in psychiatric nursing. Procedures
Subjects were recruited by the directors of nursing at each site, who presented the study to head nurses. The head nurses solicited participation from the nurses working on their units. Participation was invited from any nurse working on the units for which permission for participation was
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obtained. Each nurse who agreed to participate was asked to call the investigator when an assessment interview was scheduled on the unit. The scheduling of interviews was done on an on-call basis. The goal was to interview subjects as soon as possible after they had completed their nursing admission interview. The data collection interviews were audiotaped so that all of the information reported by subjects, as well as the sequence in which it was reported, were recorded. The interview itself was open and unstructured, based on the requirements of grounded-theory methods, and was modified as the study progressed to validate the theory being generated. The investigator began each interview by saying to the subject, “Think back over the assessment interview you have just completed. In your own words, what were the pieces of information that you used about the patient in order to come to your nursing judgment regarding that patient?” An interview guide was developed; however, questions were posed to subjects only for purposes of clarification and/or to distinguish possible specific aspects of the judgment process. Questions were framed at the time of the interview and were dependent on both the subjects’ responses and information the investigator had noted in previous interviews. Immediately after the interview, the tapes were transcribed for analysis, which occurred simultaneously with further data collection. The investigator also wrote memos throughout data collection and analysis. Memos essentially are ideas that occurred to the investigator regarding connections noted in the data. These notes were used in later interpretation of data and in theory generation. Data Analysis
Data were analyzed using a comparative content analysis (Corbin, 1986; Glaser & Strauss, 1967). The investigator read each interview and highlighted each reported cue. A cue was defined as a descriptor of the patient or the patient’s situation. A list of cues without any interpretation was generated. Next, the investigator searched for patterns in the cues and began the categorization process. Cue lists were inspected, cue by cue, and cues were categorized on the basis of the kind of information that they contained. For example, “70 years old” and “woman” were labeled as demo-
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graphic cues; “her breathing was not regular” was labeled as a physical cue. “She had delusions, nihilistic delusions that she was rotting away” was called a delusion and was categorized as a psychiatric cue. Attempts were made to validate the themes by using an iterative approach, going back and forth among the descriptive data to see if and when cues and combinations of cues were elicited from the data. Preceding interviews were reread for the presence or absence of newly identified categories. Data then were analyzed for identifiable strategies in the judgmental processes. Each interview was read again and each time a subject statement indicated that an inference was made or a conclusion was reached about the patient, that statement was highlighted. When a subject stated that a plan had been formulated, this was distinguished from a conclusion or an inference. Reports of intended nursing actions were noted. Each interview was reviewed for indicators of each emergent component of the judgment process and its presence or absence in the particular interview was recorded. All of the preceding interviews then were reviewed for presence or absence of the newly identified component. RESULTS
Theoretical Model of Cue Selection and Cue Use Strategies
The model (Fig 1) derived from the data summarizes the hypothesized cue selection and cue use strategies in psychiatric nursing judgments that emerged from the data in the present study. The components of this theoretical model are proposed as descriptors of the content and processes involved in making these judgments. The first model component, setting up, depicts the initial phase of the judgment process as composed of multiple, overlapping cues descriptive of the patient’s presenting behavior and symptomatology (supplemented by historical data, particularly psychiatric history). The subjects attended to both the content and the process of what the patient told them, and what and how it was said. For example, “I just let the patient tell his story. Then I had to divert him to do some problem solving”; and “I just let the patient take the lead.” At this point, data were reported in a loosely organized format. Subjects did not neatly report their find-
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judgment
frame
nursing action
Fig 1.
Model of cue use and cue selection strategies.
ings about patients and, as a result, their reports did not follow any particular format. This unstructured reporting process can be contrasted with the complete head-to-toe format that is typical of a physical examination report, and can likewise be contrasted with the highly organized assessment forms used by most subjects at the time they interviewed the patients. Cues related to many aspects of patient functioning. When cue lists were reviewed, it was evident that cues indicative of patient presenting behavior, as observed by the subject, were most frequently reported. There was clearly a focus on the hereand-now, that is, what the subject witnessed the patient saying and doing. Data referring to past behavior were used as a context in which present behavior was interpreted, as well as to corroborate present behavior and predict future behavior. All subjects began their reports with a few sentences that set up a context or established a framework for the data that was to follow. The consistency of this finding is striking, as is its consistent placement early in the report. A large part of that context was information regarding where the patient had come from, who accompanied him or her, and what his or her behavior was like at the time of the intake assessment. A focus on action was evident in the attention directed toward reporting data indicative of the patient’s functional abilities. Cues were reported regarding multiple aspects of the patient’s life, including family and job, suggesting that judgments were reached on multiple levels. The reports of clinicians with Masters of Science degrees tended to be more elaborate and detailed; however, similarities in the process of coming to a conclusion were noted across subjects and settings. Psychiatric history, past levels of functioning, and psychiatric diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Revised (American Psychiatric Association, 1987)
also were reported as contextual data. Subjects often indicated that importance was attached to psychiatric diagnosis as a adjunct to nursing judgment. In contrast, physical signs and symptoms were reported with much less regularity. The findings suggest that subjects had a preference for, or perhaps more confidence in, observable data. It is hypothesized that what subjects themselves saw and heard during the intake interview session was given the strongest weight. Present behavior is then theorized to be the most salient dimension in the judgment process since nurses are in constant interaction with patients and respond to patients on an ongoing basis. In the second component, it is hypothesized that subjects viewed the patient in a particular framework, dependent upon context and presenting patient behavior. Rather than assigning individual cues particular salience, certain aggregates of cues were designated as having significant meaning. Meaning was based on the interpretation of the cues within their reported context. For example, in describing a patient, a subject reported that “his flat affect, sad face, and look of hopelessness” stood out. This was followed by, “There’s a lot going on with his family . . . well, if I didn’t know about the family . . . well, my thinking is different because I do know. ” Included in the framing process was a patient categorization, evidenced in the subjects’ reference to general psychiatric descriptors such as depressed, schizophrenic, alcoholic, and addicted. Some examples: “I admitted a patient, 24 years old, this morning. He came in as a schizophrenic. ” “I was just following what I thought were the typical behaviors of the manic-depressive patient. ” “That’s a very common thing for addictive people to do.” This categorization is hypothesized as being based on past experience and knowledge about global patterns of patient functioning and to reflect noted associations between
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the patient’s behavior and diagnostic information stored in memory. These descriptors often were accompanied by expectations for certain behavior from the patient, suggesting that these categories contained an ability-to-function component. In further analysis of categories, it was noted that subjects relied most heavily on behavior indicative of patient functional abilities and that these behavioral indices were clustered around central problems or areas of concern. These categories were subsequently identified as universals in the assessment process. Specifically, presenting behavior, past psychiatric history, alcohol and drug use patterns of the patient and his or her family, depression, dangerousness to self or others, and patient functional ability were reported by every nurse in each interview. The universals in the psychiatric nursing assessment that emerged from the data are hypothesized as being core categories for the organization (grouping) of data, and evidence of categorization as a component of the clinical judgment process. These categories suggest that there are basic level data that are central to the psychiatric nursing judgment process. In the third component of the model, subjects reached a pivotal cue. A cue was labeled a pivot if its presence clearly altered the line of questioning pursued by the subject. The pivot acted as a link between what was going on in the mind of the subject (e.g., a hypothesis regarding the patient’s functioning) and the cues, or patient behavior. The pivot is hypothesized to sensitize the clinician to pursue one line of questioning over another, directing her or him in a particular direction. For example, a subject asked a patient, “What do you look forward to?” and the patient replied, “Dead people don’t look forward to things.” The subject reported that she altered her approach since she was cued to assess for delusional thinking. Indeed, the patient exhibited paranoid delusions later in the intake interview, and this behavior was later corroborated by the patient’s history. However, until this response, the subject reported that she had not recognized that the patient had a thought disorder. A pivot began a context-dependent exploration of aspects of patient behavior or functioning judged to be salient. This suggests that the pivot allowed the clinician to circumvent data collection as information determined to be salient was pursued in greater depth. It is hypothesized that a
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discriminatory process occurs, and the clinician pursues that information judged to be the most salient. After reporting the pivotal cue, subjects typically went on to list further signs or symptoms or a patient behavior, further verifying their conclusions reached about the patient. The use of pivotal cues also suggests that subjects attended to and incorporated feedback from the patient into the judgment process. The fourth proposed model component is hypothesis testing. At this point, further data collection is directed toward seeking evidence to corroborate or refute the inferences of the clinician regarding the patient’s status. Data search is narrowed to seek indicators that provide corroborating evidence, or less often, to seek absence of certain findings. Data collection continued in the direction suggested by the pivotal cues, as exemplified by: “And I found out she had just recently been discharged from a hospital about a month ago. She had been in about 2 weeks and she told me her diagnosis was depression. So, that gave me a clue. I started asking her about signs of depression.” A judgment or conclusion is the fifth model component. At this point, it is hypothesized that the subject’s interpretive work has been completed and conclusions reached. The clinician has substantiated, at least in her or his own way of thinking, the conclusions about the patient: “In her speech, there was that paucity that you see and feel in somebody who is depressed, when you feel like you have to pull every word out of them. So we knew we were able to make a case for depression. ” Or, in some cases, it was determined that the situation contained too much uncertainty to reach a definite conclusion. “So, you can’tliterally, can’t-separate out the psychoses from whether it’s functional or organic and induced by alcohol. At least, not when he’s obviously drunk.” Or, “If she had walked away from us, then I would have felt very uncomfortable because of not knowing if there was something seriously physically wrong with her. ” It is hypothesized that feelings, time constraints, and the system (the particular health care delivery context in which the clinician functions) are all factors involved in both cue interpretation and the conclusions reached, and hence, become data in the judgment process. Aspects of the health care delivery system are hypothesized to act as a pragmatic means of limiting the
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range of data collection by limiting the range of possible or available alternatives. Finally, a nursing diagnosis is reached. It is suggested that this component of the judgment process is characterized by action. A choice is made regarding what the nurse will do for and/or with the patient, often supplemented by expectations for what the patient will do. It is hypothesized that the subject has determined that the patient exemplifies characteristics requiring a particular intervention strategy or treatment approach to meet goals in relation to desired patient outcomes. This diagnosis represents the clinician’s judgment of the patient’s functional capacities, interpreted in light of a contextual background. The summary of patient functional level becomes the starting point for nursing action. For example, regarding a patient that the subject described by saying, “Well, I’ll tell you, the first thing that struck me was his flat affect, sad face, and his look of hopelessness. And sure enough, he’s very depressed,” she went on to say, “So I told him that even if nobody in this world liked him, he was still responsible for himself. ’ ’ And later in the interview, “Well, I would say, number one, he needs as much one-toone as he can get. And he has to learn how to ventilate his feelings in a positive way.” Another subject describes a depressed, suicidal patient who was abused by her husband, who didn’t sleep all night, slept in the morning, didn’t do the housework and adds, “It’s going to be hard helping her. The last time that she was here, she went home because of the children; she doesn’t trust anyone to watch them. She needs the program here, but 1 think she’s going to be hard to work with because of the situation she’s in.” A subject reported, “Just how they dealt with things in the past helps [to know what to plan]. Patterns of dealing with things help predict what they’re going to do and how they’re going to deal with things, and how they’re going to react to new situations here, on the unit _’ ’ DISCUSSION
The findings of this investigation suggest that the nurses who were the subjects in this study based data collection, interpretation of data, and their nursing judgments primarily upon present patient behavior, embedded in a context of past psychiatric history, previous functioning, and psychi-
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atric diagnosis. The data further suggest that subjects used behavioral data to establish current patient functional status and that the goal of nursing assessment and diagnosis has an action orientation, as opposed to a labeling function. Elstein (1976) suggested that clinical reasoning is reasoning about a specific set of problems, governed by principles common to all reasoning processes. Subsequently, greater variability is expected across tasks than across the reasoning processes of clinicians (Payne, 1980). Graves and Corcoran (1989, p. 227) state that the structure of nursing knowledge is substantially different from that of at least one other health discipline, medicine, and cite evidence suggesting that these differences are reflected in differences in decision strategies. The determination of the specific set of problems that is the focus of a particular clinical discipline differentiates the scope of practice of that discipline. The results of this study suggest that the focus of nursing as a discipline, and specifically, of psychiatric nursing, is on assessment and intervention related to the functional abilities of patients. These findings support the conclusions of McBride (1990, p. 26) that “nursing is committed to examining what facilitates or limits individuals in their activities of daily living” and of Benner (1984) that “to be effective, psychiatric nurses have to assess the patient’s potential for wellness. A sense of what is possible for the individual is the guide for treatment strategies and goals” (p. 106). The earliest reported studies of judgmental processes in nursing by Kelly (1964, 1966) concluded that individual nurses had their own unique inference systems and were highly consistent in their use of those systems. Unlike Kelly’s work, the goal of the present study was not to quantify the cues and categories used by subjects in the judgment process. Rather, this investigation sought to identify the underlying themes in the cues reported by nurses as being the data that they used in coming to their conclusions about the patient. The findings suggested that the subjects in this study used a core of categories, labeled as universals, as the basis for their nursing judgments and that they expanded the data base with the addition of contextual data. Psychiatric history was sought as an indicator and a predictor of patient functioning. Past functioning was considered a strong, if not the
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strongest, predictor of future patient functioning. The reported cues varied markedly according to the individual patient situation, yet all cues could be categorized. This study did not address whether subjects assessed the correct or most reliable cues, but rather, described what information subjects did select. The results suggest that despite a wide variety of nursing judgmental tasks, there is an element of similarity in what is assessed. The goal in most instances was to establish a baseline description of the patient’s ability to function in everyday life, resulting in reports that indicated a primary focus on behavioral cues. Behavioral cues were most frequently reported, indicating that they were regarded as having great utility for making psychiatric nursing judgments. Past history, commitment criteria (dangerousness to self or others), depression, and patient and family functioning acted as the background against which behavioral cues were interpreted. Thus, a cue in and of itself contained little information value until it was embedded in the entire constellation of cues that were indicative of patient functioning. An inherent danger in this selective attention to behavioral cues is that it increased the potential for the subject to overlook pertinent variables when a particular behavioral cue was deemed salient. Also, the potential exists that the selected cues were weighed too highly and given undue importance in the judgment process. This is of particular concern when a behavioral cue was competing with a physical cue for the attention of the psychiatric nurse. Subjects in this study reported and evaluated physical cues early in the assessment process, and physical cues typically were dismissed unless identified as having direct influence on the presenting situation. Potentially, assessment was less than complete if these physical cues were not detected early. The emphasis on observable presenting behavior illustrated a preference for specific level data upon which to base one’s judgments, as suggested by Holland, Holyoak, Nisbett, and Thagard (1986). That is, subjects looked for behavior that they themselves could observe and relied most heavily on those cues. Even though the cues were interpreted in light of information not in the present situation, the tendency was to focus on presenting behavior as a means of determining what could be
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done for and/or with the patient. These findings are similar to those of Baumann and Bourbonnais (1982), who found that nursing decisions in a critical care setting were based primarily on a constellation of presenting patient problems, not the medical diagnosis. As in the present study, the nurse’s personal observation, not the medical diagnosis, was the basis for the nursing judgment. Next, attention is directed toward the universals identified in the judgment processes of the subjects in this study. That is, judgments were reached regarding the degree of depression, alcohol and drug use patterns, and dangerousness to self and others, interpreted within a context of the patient’s family/ support system and functional abilities. The identification of the universals in the judgment process indicates that there is a common underlying core that directs the assessment process, and that although cues were specific to the individual patient situations, the cues used by subjects were not idiosyncratic to the individual nurse. Whether the underlying pattern is the result of training, of experientially derived models/categories of patients, or other factors cannot be determined from the results of this study and suggests an area for further research. A need also exists to document the process of categorization in psychiatric mental health nursing, and to describe more explicitly what constitutes category membership versus nonmembership, with attention paid to the utility of these categories for planning subsequent nursing interventions. The finding that subjects used pivotal cues in their search for further patient data is important because it demonstrated that judgments were based, at least in part, on selectively sought information. Likewise, the finding that conclusions were reached early in the report suggested that the initial conceptualization provided direction for the following data collection process. As reported by Hunt and MacLeod (1979) and Turk and Salovey (1985), the frame of reference of the clinician guided the information-gathering process, directing what information was sought and how it was interpreted. The pivotal cues are markers of decision points, places where the clinician decided to pursue one line of questioning rather than another. This narrowing of the field of information sought suggests that rules were used that determined which variables were the most important. Identifi-
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cation of the possible rules that subjects may have used to guide their information-seeking processes is beyond the scope of this study, offering another suggestion for further investigation. Additionally, study of the processes involved in narrowing the data search offers the potential for studying sources of bias and/or error in the judgment process. CONCLUSIONS
Hypotheses or theoretical statements are the conclusions of a study based on grounded theory methods. The data from the study, as summarized in the model of psychiatric nursing judgment processes, depict the theorized cue selection and use strategies that underlie these judgments. In addition, it is hypothesized that: (1) Presenting behavior is the most salient dimension in the psychiatric nursing judgment process. Nurses are in constant interaction with patients and respond to patient behavior on an ongoing basis, emphasizing the need for giving the highest weight to presenting behavior. (2) A categorization process takes place within the judgment process. This categorization is based on past experience and knowledge regarding global patterns of patient functioning. It reflects noted associations between present patient behavior, as observed by the nurse, and diagnostic information stored in memory. Expectations for future behavior are embedded in the categories. (3) There are core categories of behavior, called universals in this study, that underlie the knowledge base for psychiatric nursing practice. (4) A narrowing of the search process, as evidenced by the pivotal cues identified in the present study, suggest that a discriminatory weighting takes place within the judgment process. The nurse pursues the information judged to be most salient. (5) Conclusions reached by nurse clinicians are influenced by factors such as time constraints, the personal feelings of the nurse, and the system within which the nurse practices. (6) The nursing diagnosis is characterized by action; it is the starting point for nursing actions, which primarily address patient functional abilities. In summary, it is hypothesized that the core component of psychiatric nursing judgment process is the assessment of patient functional ability. The findings of this study suggest the need to further study and test issues related to the consistency
of approaches and intervention strategies across nurses and across cases, the accuracy of nursing judgments, and the relation between interventions and patient outcomes. Finally, it is suggested that assessment protocols in psychiatric mental health nursing focus particular attention on documentation of levels of patient functioning. As noted by Graves and Corcoran (1989), the processing of information must deal with meaning. The meaning of clinical cues in psychiatric mental health nursing suggested by this investigation is the information the cues convey about patient functional levels and capacities. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, revised (3rd ed.). Washington, DC: Author. Aspinall, M.J. (1979). Use of a decision tree to improve accuracy of diagnosis. Nursing Research. 28, 182-185. Baumann, A., & Bourbonnais, F. (1982). Nursing decision making in critical care. Journal of Advanced Nursing, 7, 435-446. Baumann, A., & Deber, R. (1989). The limits of decision analysis for rapid decision making in ICU nursing. Image. The Journal of Nursing Scholarship, 21, 69-71. Benner, P. (1982). From novice to expert. American Journal of Nursing, 82, 402-407. Benner, P. (1984). From novice to expert: Power and excellence in nursing practice. Palo Alto, CA: AddisonWesley. Benner, P., & Tanner, C. (1987). How expert nurses use intuition. American Journal of Nursing, 87, 23-31. Cantor. N., Smith, E., French, R., & Mezzich, I. (1980). Psychiatric diagnosis as prototype categorization. Journal of Abnormal Psychology, 80, 181-193. Corbin, J. (1986). Qualitative data analysis for grounded theory. In W.C. Chenitz & J.M. Swanson (Eds.), From practice to grounded theory: Qualitative research in nursing. Menlo Park, CA: Addison-Wesley. Coler, M.S.. & Vincent, K.G. (1987a). Nursing diagnosis along axes: A clinical interview study of prioritizing nursing diagnoses in psychiatric-mental health settings. In McLane, A.M. (Ed.), Classification of nursing diagnoses. Proceedings of the 7th conference. St. Louis, MO: Mosby. Coler, M.S., & Vincent, K.G. (1987b). Psychiatric-mental health assessment: A new look at the concept. Arrhives of Psychiatric Nursing, I 1 258-263. Corbin, J. (1986). Qualitative data analysis for grounded theory. In W.C. Chenitz & J.M. Swanson (Eds.), From practice to grounded theory: Qualitative research in nursing. Menlo Park, CA: Addison-Wesley. Corcoran, S. (1986). Task complexity and nursing expertise as factors in decision making. Nursing Research, 35, 107112.
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A.S., & Bordage, G. (1979). Psychology of clinical reasoning. In G.C. Stone, F. Cohen, & N.E. Adler (Eds.), Healrhpsychology: A handbook. San Francisco, CA: Jossey-Bass. Gast, H.L. (1979). A review of some recent studies of nursing diagnosis. Monographs of Texas Women’s University College of Nursing. Denton, TX: Texas Women’s University. Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine. Gordon, M. (1980). Predictive strategies in diagnostic tasks. Nursing Research, 29, 39-45. Graves, J., & Corcoran, S. (1989). The study of nursing informatics. Image: The Journal of Nursing Scholarship, 21, 227-231. Hammond, K.R. (1966). Clinical inference in nursing: A psychologist’s viewpoint. Nursing Research, 15. 27-38. Holland, J.H., Holyoak, K. J., Nisbett, R.E., & Thagard, P.R. (1986). Induction: Processes of inference, learning, ana’ discovery. Cambridge, MA: MIT Press. Hunt, E.B., & MacLeod, C.M. (1979). Cognitive and information processes in patient and physician. In G.S. Stone, F. Cohen, & N.E. Adler, (Eds.), Health psychology. San Francisco, CA: Jossey-Bass. Kelly, K.J. (1964). An approach to the study of clinical inference in nursing. Nursing Research, 13. 314-315. Kelly, K.J. (1966). Clinical inference in nursing: A nurse’s viewpoint. Nursing Research, 15, 19-27.
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Leininger, M. (1985). Qualitative research methods in nursing. Orlando, FL: Grune & Stratton. Matthews, C.A., &Gaul, A.L. (1979). Nursing diagnosis from the perspective of concept attainment. Advances in Nursing Science, 2, 17-26. McBride, A.B. (1990). Psychiatric nursing in the 1990s. Archives of Psychiatric Nursing, 4, 21-28. Payne, J.W. (1980). Information processing theory: Some concepts and methods applied to decision research. In T.S. Wallsten (Ed.), Cognitive processes in choice and decision research. Hillsdale, NJ: Erlbaum. Rew, L. (1988). Intuition in decision making. Image: The Journal of Nursing Scholarship, 20. 250-254. Schraeder, B.D., & Fischer, D.K. (1987). Using intuitive knowledge in the neonatal intensive care nursery. Holistic Nursing Practice, I, 45-5 1. Tanner, C. (1987). Teaching clinical judgment. In J.J. Fitzpatrick & R.L. Tauton (Eds.), Annual review of nursing research. New York, NY: Springer. Turk, D.C., & Salovey, P. (1985). Cognitive structure, cognitive processes, and cognitive-behavioral modification. Judgments and inferences of the clinician. Cognitive Therapy and Research, 9, 19-33. Tversky , A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185, 1124- 113 1. Westfall, U.E., Tanner, C.A., Putzier, D., & Padrick, K.P. (1986). Activating clinical inferences: A component of diagnostic reasoning in nursing. Research in Nursing and Health, 9, 269-277.
This study addressed judgment processes in psychiatric nursing by analyzing reported use of clinical cues cited as being relevant in the process of making a nursing judgment. Using an exploratory, qualitative approach. data were collected by interviewing 15 subjects who provided 36 in-depth interviews upon completion of an intake interview. Comparative content analysis was used to determine the underlying structure in subject reports. A model depicting judgment processes is presented and discussed. Results suggest that although judgments were highly context-dependent, all subjects assessed data labeled as universals in the psychiatric nursing assessment: suicidality, depression, drug and alcohol use, and patient functional abilities. Similarities among subjects were noted in that presenting behaviors were most salient, a categorization process occurs within the judgment process, and patients are included in the judgment process. Finally, nursing judgments uncovered an action orientation rather than a labeling function.
Copyright
0 1991 by W.B. Saunders
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LINICAL JUDGMENT and diagnosis present a particular challenge in most nursing situations. Indices of patient responses and states are not well delineated and data available to the nurse are often inconclusive. Yet, on the basis of this uncertain data, nurses come to conclusions regarding the health status of their patients and these judgments form the basis for their choice of nursing intervention. Despite the pivotal role of clinical judgment in the delivery of nursing care, the factors that influence the diagnostic process in nursing, the nature of nursing judgment tasks, and the characteristics that influence nursing judgment strategies have not been explicated (Hammond, 1966; Tanner, 1987). In the practice of psychiatric nursing, clinical judgments are complicated by an abstract data base without the advantage of laboratory or objective data to validate one’s conclusions. The challenge posed is to document how
From the School of Nursing, University of Pittsburgh, Pittsburgh, PA Address reprint requests to May Jo Regan-Kubinski, Ph.D., R.N., 3201 Momingside Dr., Allison Park, PA 15101. Copyright 0 1991 by W.B. Saunders Company 0883~9417/91/0505-0004$3.00/O
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nurses make sense of what has been called the fuzzy data available in a psychiatric setting (Cantor, Smith, French, & Mezzich, 1980) and come to conclusions upon which nursing interventions are based. BACKGROUND OF THE STUDY
Studies of nursing judgments indicate that nurses as decision makers generally do not make use of optimal (e.g., rational or mathematical) strategies when drawing diagnostic conclusions (Aspinall, 1979; Baumann & Deber, 1989; Corcoran, 1986; Hammond, 1966; Tanner, 1987). Judgments are cited as being compromised by mental shortcuts, or heuristics (Tversky 8z Kahneman, 1974). In nursing, it has been suggested that approaches to nursing diagnosis are characterized by random selection processes, leading to a lack of consistency (Coler & Vincent, 1987a). These findings are of particular concern since the outcomes of nursing judgments influence patients’ lives and future health states. Studies of nursing judgment indicate that cue grouping, or the combining of information into clinically meaningful categories, is used by nurses as
Archives of Psychiatric Nursing, Vol. V, No. 5 (October), 1991:
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a means of dealing with complex clinical situations (Gas& 1979; Gordon, 1980; Kelly, 1966). Similarly, it is generally suggested that the cognitive basis for judgments and clinical decisions is the nurse clinician’s ability to capture important relationships among clinical cues (Corcoran, 1986; Matthews & Gaul, 1979; Westfall, Tanner, Putzier, & Padrick, 1986). However, these same investigators report that nurses use highly individualistic categorization schemes that are not readily identifiable. In a similar vein, intuition, characterized by an understanding without a rationale (Benner & Tanner, 1987) or without the conscious use of reason (Rew, 1988; Schraeder & Fischer, 1987) is noted to play a prominent role in nursing judgments, particularly in expert practice. Even so, it is claimed that nursing knowledge does include rules that nurses use to combine facts to make clinical nursing judgments (Graves dz Corcoran, 1989). The identification and subsequent testing of the generalizability and utility of these rules in clinical practice remains a challenge for nurse researchers and practitioners. The nature of the relationships in cognitive knowledge structures that capture the rules and patterns that are observed and noted by clinicians cannot be validated without bringing this knowledge into conscious awareness and subsequently documenting it. Further study is needed to identify how nurses synthesize objective and subjective data in order to arrive at and act on decisions (Rew, 1988), as well as to document the knowledge base for nursing practice. Documentation of the knowledge base for practice is of particular importance in psychiatric mental health nursing since the overlap between nursing care and the services provided by other mental health professionals (Coler & Vincent, 1987b) may blur the distinct contributions made by nurses. In addition, the current emphasis on biological models in psychiatric practice and changes in reimbursement (e.g., health maintenance organizations’ policies aimed at reducing length of hospitalization) may lead to reorganization of caregiving models. SPECIFIC AIMS
The specific aim of this study was to describe how psychiatric nurses select, assemble, and use signs and symptoms and other information in making a judgment about the health status of a patient. The following research questions were addressed:
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(1) What specific aspects of a clinical judgment process can be distinguished? (2) What cues and categories of cues emerge as the bases for clinical judgment? (3) What underlying theme or themes characterize the nature and focus of clinical judgments in psychiatric nursing? METHODS
Design
Grounded theory provided the specific design framework for this study. Grounded theory is particularly applicable for exploring phenomena that are embedded in nursing practice and, as a result, are not easily quantifiable (Corbin, 1986; Leininger, 1985). Briefly, this approach focuses on the responses of people who are involved in a defined situation with the intent of discovering the focus of that particular situation. Of particular interest to this study was the identification of the categories that emerge from the data and that help explain the cognitive processes involved in the phenomenon of concern, clinical judgment. Subjects and Settings
Sampling was purposive in regard to the usual or typical sites of psychiatric nursing practice as well as representative of the nurse clinicians who practice in these settings. Fifteen subjects provided 36 in-depth interviews; six subjects were interviewed more than once. Subjects were all practicing psychiatric mental health nurses. Included in the sample were four clinical specialists in psychiatric nursing, one nurse with a Bachelor of Science in Nursing degree, and 10 nurses with Associate degrees in nursing. They ranged in age from 24 years to 60 years. One subject was a man; all of the others were women. The number of years in nursing ranged from 2 years to 33 years; years in psychiatric nursing practice ranged from 1 year to 25 years. In general, the clinical specialists tended to have more years of experience exclusively in psychiatric nursing. Procedures
Subjects were recruited by the directors of nursing at each site, who presented the study to head nurses. The head nurses solicited participation from the nurses working on their units. Participation was invited from any nurse working on the units for which permission for participation was
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obtained. Each nurse who agreed to participate was asked to call the investigator when an assessment interview was scheduled on the unit. The scheduling of interviews was done on an on-call basis. The goal was to interview subjects as soon as possible after they had completed their nursing admission interview. The data collection interviews were audiotaped so that all of the information reported by subjects, as well as the sequence in which it was reported, were recorded. The interview itself was open and unstructured, based on the requirements of grounded-theory methods, and was modified as the study progressed to validate the theory being generated. The investigator began each interview by saying to the subject, “Think back over the assessment interview you have just completed. In your own words, what were the pieces of information that you used about the patient in order to come to your nursing judgment regarding that patient?” An interview guide was developed; however, questions were posed to subjects only for purposes of clarification and/or to distinguish possible specific aspects of the judgment process. Questions were framed at the time of the interview and were dependent on both the subjects’ responses and information the investigator had noted in previous interviews. Immediately after the interview, the tapes were transcribed for analysis, which occurred simultaneously with further data collection. The investigator also wrote memos throughout data collection and analysis. Memos essentially are ideas that occurred to the investigator regarding connections noted in the data. These notes were used in later interpretation of data and in theory generation. Data Analysis
Data were analyzed using a comparative content analysis (Corbin, 1986; Glaser & Strauss, 1967). The investigator read each interview and highlighted each reported cue. A cue was defined as a descriptor of the patient or the patient’s situation. A list of cues without any interpretation was generated. Next, the investigator searched for patterns in the cues and began the categorization process. Cue lists were inspected, cue by cue, and cues were categorized on the basis of the kind of information that they contained. For example, “70 years old” and “woman” were labeled as demo-
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graphic cues; “her breathing was not regular” was labeled as a physical cue. “She had delusions, nihilistic delusions that she was rotting away” was called a delusion and was categorized as a psychiatric cue. Attempts were made to validate the themes by using an iterative approach, going back and forth among the descriptive data to see if and when cues and combinations of cues were elicited from the data. Preceding interviews were reread for the presence or absence of newly identified categories. Data then were analyzed for identifiable strategies in the judgmental processes. Each interview was read again and each time a subject statement indicated that an inference was made or a conclusion was reached about the patient, that statement was highlighted. When a subject stated that a plan had been formulated, this was distinguished from a conclusion or an inference. Reports of intended nursing actions were noted. Each interview was reviewed for indicators of each emergent component of the judgment process and its presence or absence in the particular interview was recorded. All of the preceding interviews then were reviewed for presence or absence of the newly identified component. RESULTS
Theoretical Model of Cue Selection and Cue Use Strategies
The model (Fig 1) derived from the data summarizes the hypothesized cue selection and cue use strategies in psychiatric nursing judgments that emerged from the data in the present study. The components of this theoretical model are proposed as descriptors of the content and processes involved in making these judgments. The first model component, setting up, depicts the initial phase of the judgment process as composed of multiple, overlapping cues descriptive of the patient’s presenting behavior and symptomatology (supplemented by historical data, particularly psychiatric history). The subjects attended to both the content and the process of what the patient told them, and what and how it was said. For example, “I just let the patient tell his story. Then I had to divert him to do some problem solving”; and “I just let the patient take the lead.” At this point, data were reported in a loosely organized format. Subjects did not neatly report their find-
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judgment
frame
nursing action
Fig 1.
Model of cue use and cue selection strategies.
ings about patients and, as a result, their reports did not follow any particular format. This unstructured reporting process can be contrasted with the complete head-to-toe format that is typical of a physical examination report, and can likewise be contrasted with the highly organized assessment forms used by most subjects at the time they interviewed the patients. Cues related to many aspects of patient functioning. When cue lists were reviewed, it was evident that cues indicative of patient presenting behavior, as observed by the subject, were most frequently reported. There was clearly a focus on the hereand-now, that is, what the subject witnessed the patient saying and doing. Data referring to past behavior were used as a context in which present behavior was interpreted, as well as to corroborate present behavior and predict future behavior. All subjects began their reports with a few sentences that set up a context or established a framework for the data that was to follow. The consistency of this finding is striking, as is its consistent placement early in the report. A large part of that context was information regarding where the patient had come from, who accompanied him or her, and what his or her behavior was like at the time of the intake assessment. A focus on action was evident in the attention directed toward reporting data indicative of the patient’s functional abilities. Cues were reported regarding multiple aspects of the patient’s life, including family and job, suggesting that judgments were reached on multiple levels. The reports of clinicians with Masters of Science degrees tended to be more elaborate and detailed; however, similarities in the process of coming to a conclusion were noted across subjects and settings. Psychiatric history, past levels of functioning, and psychiatric diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Revised (American Psychiatric Association, 1987)
also were reported as contextual data. Subjects often indicated that importance was attached to psychiatric diagnosis as a adjunct to nursing judgment. In contrast, physical signs and symptoms were reported with much less regularity. The findings suggest that subjects had a preference for, or perhaps more confidence in, observable data. It is hypothesized that what subjects themselves saw and heard during the intake interview session was given the strongest weight. Present behavior is then theorized to be the most salient dimension in the judgment process since nurses are in constant interaction with patients and respond to patients on an ongoing basis. In the second component, it is hypothesized that subjects viewed the patient in a particular framework, dependent upon context and presenting patient behavior. Rather than assigning individual cues particular salience, certain aggregates of cues were designated as having significant meaning. Meaning was based on the interpretation of the cues within their reported context. For example, in describing a patient, a subject reported that “his flat affect, sad face, and look of hopelessness” stood out. This was followed by, “There’s a lot going on with his family . . . well, if I didn’t know about the family . . . well, my thinking is different because I do know. ” Included in the framing process was a patient categorization, evidenced in the subjects’ reference to general psychiatric descriptors such as depressed, schizophrenic, alcoholic, and addicted. Some examples: “I admitted a patient, 24 years old, this morning. He came in as a schizophrenic. ” “I was just following what I thought were the typical behaviors of the manic-depressive patient. ” “That’s a very common thing for addictive people to do.” This categorization is hypothesized as being based on past experience and knowledge about global patterns of patient functioning and to reflect noted associations between
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the patient’s behavior and diagnostic information stored in memory. These descriptors often were accompanied by expectations for certain behavior from the patient, suggesting that these categories contained an ability-to-function component. In further analysis of categories, it was noted that subjects relied most heavily on behavior indicative of patient functional abilities and that these behavioral indices were clustered around central problems or areas of concern. These categories were subsequently identified as universals in the assessment process. Specifically, presenting behavior, past psychiatric history, alcohol and drug use patterns of the patient and his or her family, depression, dangerousness to self or others, and patient functional ability were reported by every nurse in each interview. The universals in the psychiatric nursing assessment that emerged from the data are hypothesized as being core categories for the organization (grouping) of data, and evidence of categorization as a component of the clinical judgment process. These categories suggest that there are basic level data that are central to the psychiatric nursing judgment process. In the third component of the model, subjects reached a pivotal cue. A cue was labeled a pivot if its presence clearly altered the line of questioning pursued by the subject. The pivot acted as a link between what was going on in the mind of the subject (e.g., a hypothesis regarding the patient’s functioning) and the cues, or patient behavior. The pivot is hypothesized to sensitize the clinician to pursue one line of questioning over another, directing her or him in a particular direction. For example, a subject asked a patient, “What do you look forward to?” and the patient replied, “Dead people don’t look forward to things.” The subject reported that she altered her approach since she was cued to assess for delusional thinking. Indeed, the patient exhibited paranoid delusions later in the intake interview, and this behavior was later corroborated by the patient’s history. However, until this response, the subject reported that she had not recognized that the patient had a thought disorder. A pivot began a context-dependent exploration of aspects of patient behavior or functioning judged to be salient. This suggests that the pivot allowed the clinician to circumvent data collection as information determined to be salient was pursued in greater depth. It is hypothesized that a
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discriminatory process occurs, and the clinician pursues that information judged to be the most salient. After reporting the pivotal cue, subjects typically went on to list further signs or symptoms or a patient behavior, further verifying their conclusions reached about the patient. The use of pivotal cues also suggests that subjects attended to and incorporated feedback from the patient into the judgment process. The fourth proposed model component is hypothesis testing. At this point, further data collection is directed toward seeking evidence to corroborate or refute the inferences of the clinician regarding the patient’s status. Data search is narrowed to seek indicators that provide corroborating evidence, or less often, to seek absence of certain findings. Data collection continued in the direction suggested by the pivotal cues, as exemplified by: “And I found out she had just recently been discharged from a hospital about a month ago. She had been in about 2 weeks and she told me her diagnosis was depression. So, that gave me a clue. I started asking her about signs of depression.” A judgment or conclusion is the fifth model component. At this point, it is hypothesized that the subject’s interpretive work has been completed and conclusions reached. The clinician has substantiated, at least in her or his own way of thinking, the conclusions about the patient: “In her speech, there was that paucity that you see and feel in somebody who is depressed, when you feel like you have to pull every word out of them. So we knew we were able to make a case for depression. ” Or, in some cases, it was determined that the situation contained too much uncertainty to reach a definite conclusion. “So, you can’tliterally, can’t-separate out the psychoses from whether it’s functional or organic and induced by alcohol. At least, not when he’s obviously drunk.” Or, “If she had walked away from us, then I would have felt very uncomfortable because of not knowing if there was something seriously physically wrong with her. ” It is hypothesized that feelings, time constraints, and the system (the particular health care delivery context in which the clinician functions) are all factors involved in both cue interpretation and the conclusions reached, and hence, become data in the judgment process. Aspects of the health care delivery system are hypothesized to act as a pragmatic means of limiting the
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range of data collection by limiting the range of possible or available alternatives. Finally, a nursing diagnosis is reached. It is suggested that this component of the judgment process is characterized by action. A choice is made regarding what the nurse will do for and/or with the patient, often supplemented by expectations for what the patient will do. It is hypothesized that the subject has determined that the patient exemplifies characteristics requiring a particular intervention strategy or treatment approach to meet goals in relation to desired patient outcomes. This diagnosis represents the clinician’s judgment of the patient’s functional capacities, interpreted in light of a contextual background. The summary of patient functional level becomes the starting point for nursing action. For example, regarding a patient that the subject described by saying, “Well, I’ll tell you, the first thing that struck me was his flat affect, sad face, and his look of hopelessness. And sure enough, he’s very depressed,” she went on to say, “So I told him that even if nobody in this world liked him, he was still responsible for himself. ’ ’ And later in the interview, “Well, I would say, number one, he needs as much one-toone as he can get. And he has to learn how to ventilate his feelings in a positive way.” Another subject describes a depressed, suicidal patient who was abused by her husband, who didn’t sleep all night, slept in the morning, didn’t do the housework and adds, “It’s going to be hard helping her. The last time that she was here, she went home because of the children; she doesn’t trust anyone to watch them. She needs the program here, but 1 think she’s going to be hard to work with because of the situation she’s in.” A subject reported, “Just how they dealt with things in the past helps [to know what to plan]. Patterns of dealing with things help predict what they’re going to do and how they’re going to deal with things, and how they’re going to react to new situations here, on the unit _’ ’ DISCUSSION
The findings of this investigation suggest that the nurses who were the subjects in this study based data collection, interpretation of data, and their nursing judgments primarily upon present patient behavior, embedded in a context of past psychiatric history, previous functioning, and psychi-
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atric diagnosis. The data further suggest that subjects used behavioral data to establish current patient functional status and that the goal of nursing assessment and diagnosis has an action orientation, as opposed to a labeling function. Elstein (1976) suggested that clinical reasoning is reasoning about a specific set of problems, governed by principles common to all reasoning processes. Subsequently, greater variability is expected across tasks than across the reasoning processes of clinicians (Payne, 1980). Graves and Corcoran (1989, p. 227) state that the structure of nursing knowledge is substantially different from that of at least one other health discipline, medicine, and cite evidence suggesting that these differences are reflected in differences in decision strategies. The determination of the specific set of problems that is the focus of a particular clinical discipline differentiates the scope of practice of that discipline. The results of this study suggest that the focus of nursing as a discipline, and specifically, of psychiatric nursing, is on assessment and intervention related to the functional abilities of patients. These findings support the conclusions of McBride (1990, p. 26) that “nursing is committed to examining what facilitates or limits individuals in their activities of daily living” and of Benner (1984) that “to be effective, psychiatric nurses have to assess the patient’s potential for wellness. A sense of what is possible for the individual is the guide for treatment strategies and goals” (p. 106). The earliest reported studies of judgmental processes in nursing by Kelly (1964, 1966) concluded that individual nurses had their own unique inference systems and were highly consistent in their use of those systems. Unlike Kelly’s work, the goal of the present study was not to quantify the cues and categories used by subjects in the judgment process. Rather, this investigation sought to identify the underlying themes in the cues reported by nurses as being the data that they used in coming to their conclusions about the patient. The findings suggested that the subjects in this study used a core of categories, labeled as universals, as the basis for their nursing judgments and that they expanded the data base with the addition of contextual data. Psychiatric history was sought as an indicator and a predictor of patient functioning. Past functioning was considered a strong, if not the
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strongest, predictor of future patient functioning. The reported cues varied markedly according to the individual patient situation, yet all cues could be categorized. This study did not address whether subjects assessed the correct or most reliable cues, but rather, described what information subjects did select. The results suggest that despite a wide variety of nursing judgmental tasks, there is an element of similarity in what is assessed. The goal in most instances was to establish a baseline description of the patient’s ability to function in everyday life, resulting in reports that indicated a primary focus on behavioral cues. Behavioral cues were most frequently reported, indicating that they were regarded as having great utility for making psychiatric nursing judgments. Past history, commitment criteria (dangerousness to self or others), depression, and patient and family functioning acted as the background against which behavioral cues were interpreted. Thus, a cue in and of itself contained little information value until it was embedded in the entire constellation of cues that were indicative of patient functioning. An inherent danger in this selective attention to behavioral cues is that it increased the potential for the subject to overlook pertinent variables when a particular behavioral cue was deemed salient. Also, the potential exists that the selected cues were weighed too highly and given undue importance in the judgment process. This is of particular concern when a behavioral cue was competing with a physical cue for the attention of the psychiatric nurse. Subjects in this study reported and evaluated physical cues early in the assessment process, and physical cues typically were dismissed unless identified as having direct influence on the presenting situation. Potentially, assessment was less than complete if these physical cues were not detected early. The emphasis on observable presenting behavior illustrated a preference for specific level data upon which to base one’s judgments, as suggested by Holland, Holyoak, Nisbett, and Thagard (1986). That is, subjects looked for behavior that they themselves could observe and relied most heavily on those cues. Even though the cues were interpreted in light of information not in the present situation, the tendency was to focus on presenting behavior as a means of determining what could be
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done for and/or with the patient. These findings are similar to those of Baumann and Bourbonnais (1982), who found that nursing decisions in a critical care setting were based primarily on a constellation of presenting patient problems, not the medical diagnosis. As in the present study, the nurse’s personal observation, not the medical diagnosis, was the basis for the nursing judgment. Next, attention is directed toward the universals identified in the judgment processes of the subjects in this study. That is, judgments were reached regarding the degree of depression, alcohol and drug use patterns, and dangerousness to self and others, interpreted within a context of the patient’s family/ support system and functional abilities. The identification of the universals in the judgment process indicates that there is a common underlying core that directs the assessment process, and that although cues were specific to the individual patient situations, the cues used by subjects were not idiosyncratic to the individual nurse. Whether the underlying pattern is the result of training, of experientially derived models/categories of patients, or other factors cannot be determined from the results of this study and suggests an area for further research. A need also exists to document the process of categorization in psychiatric mental health nursing, and to describe more explicitly what constitutes category membership versus nonmembership, with attention paid to the utility of these categories for planning subsequent nursing interventions. The finding that subjects used pivotal cues in their search for further patient data is important because it demonstrated that judgments were based, at least in part, on selectively sought information. Likewise, the finding that conclusions were reached early in the report suggested that the initial conceptualization provided direction for the following data collection process. As reported by Hunt and MacLeod (1979) and Turk and Salovey (1985), the frame of reference of the clinician guided the information-gathering process, directing what information was sought and how it was interpreted. The pivotal cues are markers of decision points, places where the clinician decided to pursue one line of questioning rather than another. This narrowing of the field of information sought suggests that rules were used that determined which variables were the most important. Identifi-
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cation of the possible rules that subjects may have used to guide their information-seeking processes is beyond the scope of this study, offering another suggestion for further investigation. Additionally, study of the processes involved in narrowing the data search offers the potential for studying sources of bias and/or error in the judgment process. CONCLUSIONS
Hypotheses or theoretical statements are the conclusions of a study based on grounded theory methods. The data from the study, as summarized in the model of psychiatric nursing judgment processes, depict the theorized cue selection and use strategies that underlie these judgments. In addition, it is hypothesized that: (1) Presenting behavior is the most salient dimension in the psychiatric nursing judgment process. Nurses are in constant interaction with patients and respond to patient behavior on an ongoing basis, emphasizing the need for giving the highest weight to presenting behavior. (2) A categorization process takes place within the judgment process. This categorization is based on past experience and knowledge regarding global patterns of patient functioning. It reflects noted associations between present patient behavior, as observed by the nurse, and diagnostic information stored in memory. Expectations for future behavior are embedded in the categories. (3) There are core categories of behavior, called universals in this study, that underlie the knowledge base for psychiatric nursing practice. (4) A narrowing of the search process, as evidenced by the pivotal cues identified in the present study, suggest that a discriminatory weighting takes place within the judgment process. The nurse pursues the information judged to be most salient. (5) Conclusions reached by nurse clinicians are influenced by factors such as time constraints, the personal feelings of the nurse, and the system within which the nurse practices. (6) The nursing diagnosis is characterized by action; it is the starting point for nursing actions, which primarily address patient functional abilities. In summary, it is hypothesized that the core component of psychiatric nursing judgment process is the assessment of patient functional ability. The findings of this study suggest the need to further study and test issues related to the consistency
of approaches and intervention strategies across nurses and across cases, the accuracy of nursing judgments, and the relation between interventions and patient outcomes. Finally, it is suggested that assessment protocols in psychiatric mental health nursing focus particular attention on documentation of levels of patient functioning. As noted by Graves and Corcoran (1989), the processing of information must deal with meaning. The meaning of clinical cues in psychiatric mental health nursing suggested by this investigation is the information the cues convey about patient functional levels and capacities. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, revised (3rd ed.). Washington, DC: Author. Aspinall, M.J. (1979). Use of a decision tree to improve accuracy of diagnosis. Nursing Research. 28, 182-185. Baumann, A., & Bourbonnais, F. (1982). Nursing decision making in critical care. Journal of Advanced Nursing, 7, 435-446. Baumann, A., & Deber, R. (1989). The limits of decision analysis for rapid decision making in ICU nursing. Image. The Journal of Nursing Scholarship, 21, 69-71. Benner, P. (1982). From novice to expert. American Journal of Nursing, 82, 402-407. Benner, P. (1984). From novice to expert: Power and excellence in nursing practice. Palo Alto, CA: AddisonWesley. Benner, P., & Tanner, C. (1987). How expert nurses use intuition. American Journal of Nursing, 87, 23-31. Cantor. N., Smith, E., French, R., & Mezzich, I. (1980). Psychiatric diagnosis as prototype categorization. Journal of Abnormal Psychology, 80, 181-193. Corbin, J. (1986). Qualitative data analysis for grounded theory. In W.C. Chenitz & J.M. Swanson (Eds.), From practice to grounded theory: Qualitative research in nursing. Menlo Park, CA: Addison-Wesley. Coler, M.S.. & Vincent, K.G. (1987a). Nursing diagnosis along axes: A clinical interview study of prioritizing nursing diagnoses in psychiatric-mental health settings. In McLane, A.M. (Ed.), Classification of nursing diagnoses. Proceedings of the 7th conference. St. Louis, MO: Mosby. Coler, M.S., & Vincent, K.G. (1987b). Psychiatric-mental health assessment: A new look at the concept. Arrhives of Psychiatric Nursing, I 1 258-263. Corbin, J. (1986). Qualitative data analysis for grounded theory. In W.C. Chenitz & J.M. Swanson (Eds.), From practice to grounded theory: Qualitative research in nursing. Menlo Park, CA: Addison-Wesley. Corcoran, S. (1986). Task complexity and nursing expertise as factors in decision making. Nursing Research, 35, 107112.
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A.S., & Bordage, G. (1979). Psychology of clinical reasoning. In G.C. Stone, F. Cohen, & N.E. Adler (Eds.), Healrhpsychology: A handbook. San Francisco, CA: Jossey-Bass. Gast, H.L. (1979). A review of some recent studies of nursing diagnosis. Monographs of Texas Women’s University College of Nursing. Denton, TX: Texas Women’s University. Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine. Gordon, M. (1980). Predictive strategies in diagnostic tasks. Nursing Research, 29, 39-45. Graves, J., & Corcoran, S. (1989). The study of nursing informatics. Image: The Journal of Nursing Scholarship, 21, 227-231. Hammond, K.R. (1966). Clinical inference in nursing: A psychologist’s viewpoint. Nursing Research, 15. 27-38. Holland, J.H., Holyoak, K. J., Nisbett, R.E., & Thagard, P.R. (1986). Induction: Processes of inference, learning, ana’ discovery. Cambridge, MA: MIT Press. Hunt, E.B., & MacLeod, C.M. (1979). Cognitive and information processes in patient and physician. In G.S. Stone, F. Cohen, & N.E. Adler, (Eds.), Health psychology. San Francisco, CA: Jossey-Bass. Kelly, K.J. (1964). An approach to the study of clinical inference in nursing. Nursing Research, 13. 314-315. Kelly, K.J. (1966). Clinical inference in nursing: A nurse’s viewpoint. Nursing Research, 15, 19-27.
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Leininger, M. (1985). Qualitative research methods in nursing. Orlando, FL: Grune & Stratton. Matthews, C.A., &Gaul, A.L. (1979). Nursing diagnosis from the perspective of concept attainment. Advances in Nursing Science, 2, 17-26. McBride, A.B. (1990). Psychiatric nursing in the 1990s. Archives of Psychiatric Nursing, 4, 21-28. Payne, J.W. (1980). Information processing theory: Some concepts and methods applied to decision research. In T.S. Wallsten (Ed.), Cognitive processes in choice and decision research. Hillsdale, NJ: Erlbaum. Rew, L. (1988). Intuition in decision making. Image: The Journal of Nursing Scholarship, 20. 250-254. Schraeder, B.D., & Fischer, D.K. (1987). Using intuitive knowledge in the neonatal intensive care nursery. Holistic Nursing Practice, I, 45-5 1. Tanner, C. (1987). Teaching clinical judgment. In J.J. Fitzpatrick & R.L. Tauton (Eds.), Annual review of nursing research. New York, NY: Springer. Turk, D.C., & Salovey, P. (1985). Cognitive structure, cognitive processes, and cognitive-behavioral modification. Judgments and inferences of the clinician. Cognitive Therapy and Research, 9, 19-33. Tversky , A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185, 1124- 113 1. Westfall, U.E., Tanner, C.A., Putzier, D., & Padrick, K.P. (1986). Activating clinical inferences: A component of diagnostic reasoning in nursing. Research in Nursing and Health, 9, 269-277.