clinical problem-solving in nursing: insights from the literature

Clinical problem-solving in nursing: insightsfrom the literature

Catherine Taylor RGN RCNT DipCNE BAppSc MEd PhD

Director, Act Now Services, Administration, Education and Research

Consultants, Melbourne, Australia

Accepted for publication 2 August 1999

TAYLORTAYLOR C. (2000)C. (2000) Journal of Advanced Nursing 31(4), 842±849

Clinical problem-solving in nursing: insights from the literature

This paper reviews the literature surrounding the research on how individuals

solve problems. The purpose of the review is to heighten awareness amongst

nurses in general, and nurse academics in particular about the theories

developed, approaches taken and conclusions reached on how clinicians

problem-solve. The nursing process, which is heavily used and frequently

described as a problem-solving approach to nursing care, requires a deductive

reasoning process which is not the problem-solving process in use during care-

giving activities. More knowledge is required on what process is in place as we

develop as a profession. The literature highlights the complexities involved in

attempting to uncover thinking processes. The main research approaches to

discovering problem-solving strategies in the past three decades have been from

a cognitive perspective, with two main theories, decision-theory and informa-

tion processing-theory, underpinning the majority of studies conducted.

None of the research approaches used to date has resulted in the identi®cation

of a general model of problem-solving that is consistent across tasks or

disciplines. However, early hypothesis activation with subsequent testing of the

hypothesis seems to be consistent in clinicians across disciplines.

Keywords: literature review, nurse education, clinical reasoning,

problem-solving theories, decision theory, information processing theory

INTRODUCTION

The impetus for this review was embedded in gaining an

understanding of how nurses think, that is the process of

problem-solving while providing nursing care. In nursing

practice, patient problems constantly arise. It is therefore

important that nurses are able to solve clinical problems.

The heavy emphasis upon the use of the nursing process

in both undergraduate education and in clinical practice

would lead one to expect that the process of clinical

problem-solving is well understood and applied.

However, although the nursing process is a valuable tool

in clinical nursing, it is essentially used to plan care-

giving activities and is therefore a different process from

the one in use during the provision of care.

Although the problem-solving process used by clini-

cians during care-giving activities is different from the

nursing process, little attention has been given to it in

undergraduate curricula. The ability of the nurse to

provide safe competent care depends on good clinical

problem-solving skills, and various nursing scholars,

including McCarthy (1981), Hurst et al. (1991), Jones

(1988), Harbison (1991a, 1991b), Benner (1984) and

Carnevali et al. (1984), all state that there is a need for a

better understanding of the cognitive problem-solving

strategies used by nurses in clinical practice.

For the purposes of this review the generic nature of the

term problem-solving is conveyed in the followingCorrespondence: Catherine Taylor, 82 Fulton Rd, Mt Eliza, Melbourne,

Victoria 3930, Australia. E-mail: [email protected]

Journal of Advanced Nursing, 2000, 31(4), 842±849 Integrative literature reviews and meta-analyses

842 Ó 2000 Blackwell Science Ltd

de®nition. Problem-solving according to Eisenhauer &

Gendrop (1990 p. 80) is the `generation of possible

solutions to an issue of concern and therefore needs to

be an inherent part of the practice of all professionals'.

This process begins when a patient problem is identi®ed

by a nurse and persists through to the point where a

decision is made that will alleviate or solve the problem.

A number of writers concerned with student learning

believe that if educators have an understanding of the

processes involved in clinical problem-solving then it will

be possible to teach those processes. As a result, student

problem-solving would develop more quickly and there

would be a ¯ow-on effect of improved care-giving

(Hammond et al. 1967, Broderick & Ammentorp 1979,

Gordon 1980, Pyles & Stern 1983, 1986b, Corcoran 1986a,

Westfall et al. 1986).

APPROACHES TO UNDERSTANDINGPROBLEM-SOLVING

The majority of research studies reported in the literature

on clinical problem-solving in nursing presents patient

situations through ®lm, written case notes, audio-tapes or

interactive computer programmes. Although a great deal

of energy is expended by many researchers in trying to

make the simulated tasks as close to the real life situation

as possible, one problem remains. It is that the simulation

inevitably lacks the contextual complexity of the clinical

environment, and as such should be taken into considera-

tion when interpreting results.

The use of computer modelling of cognitive processes

has become a major vehicle for examining problem-

solving strategies in individuals in recent years. Arti®cial

intelligence, according to Simon & Kaplan (1989 p. 29), is

concerned with `programming computers to perform in

ways that, if observed in human beings, would be consid-

ered intelligent'. This suggests that computer programmes

should succeed and fail in exactly the same ways that

humans do, thus indicating that computers can simulate

human behaviour. The `creator' of arti®cial intelligence,

according to Barwise & Etchemendy (1989 p. 211),

`constructs a computer programme to model a speci®c

cognitive process, one that gives rise to certain outputs,

when given certain inputs'. Arti®cial intelligence can be

used very effectively as a teaching aid; however, at the

current level of programming, computers should not be

regarded as having the capacity to think like a person.

Dreyfus (1993 p. 285) warns of the limits of arti®cial

intelligence and cognitive simulations. He argues that

`nonprogrammable human capacities are involved in all

forms of human behaviour'. He also acknowledges

(Dreyfus 1993 p. 3) that representing and organizing

`common sense knowledge is incredibly dif®cult' and that

facing up to this problem constitutes the `moment of truth

for arti®cial intelligence'. In other words, human learning

is not only context- or task-speci®c but is an ongoing

process of sense-making in which new items are incor-

porated into broad patterns, and in which there is

ongoing, normative and cultural shaping and re-shaping

of what is learned.

Acknowledging that tacit knowledge cannot be

programmed into a computer is important therefore

because many of the studies reported in the literature

use computers to identify instances of human problem-

solving. Results of research studies in this ®eld should

therefore be interpreted with caution, knowing that `real'

behaviour cannot be entirely emulated through computer

modelling.

WHAT IS KNOWN ABOUT PROBLEM-SOLVINGIN NURSING?

According to Tanner (1986a) the majority of research into

nurses' clinical judgement has been informed either by

decision theory or information processing theory.

Although both approaches facilitate the investigation of

problem-solving, different research methods are usually

employed in each case.

Typical decision theory approaches to the identi®cation

of clinical thinking in nursing have viewed the process as

a series of decision formulations that include: decisions

about what observations should be made in the patient

situation; decisions about deriving meaning from the data

observed (clinical inferences); and decisions regarding the

selection of action to be taken that will be of optimal

bene®t to the patient (Grant 1989).

A brief overview of the two major approaches to

understanding problem-solving and decision-making is

now presented.

Decision theory

Decision theory, according to McGuire (1985 p. 587),

involves `sophisticated calculation and manipulation of

complex probability and utility values in order to arrive at

optimal decisions that will maximize patient bene®ts'.

Applications of decision-theory to clinical judgements

have been conducted primarily to identify theoretically

how an individual should make a decision. This prescrip-

tive approach attempts to describe mathematically how an

individual should `(1) weigh cues to derive a diagnosis or

(2) choose an action which has the highest probability of

achieving the most highly valued outcome' (Tanner 1986a

p. 6).

Decision theory focuses on what decision is to be made

rather than the process used in making it. Experiments

using decision theory usually involve a subject being

asked to assign subjective probabilities to elements within

a simulated case study. If the study involves making a

diagnosis then the subject will be asked to assign

Integrative literature reviews and meta-analyses Clinical problem-solving

Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 842±849 843

probabilities to a diagnosis being accurate, and to identify

the cues related to the diagnosis. A mathematical model

using subjectively assigned values is used typically to

prescribe what the correct judgement might be. Decision

theory is then tested by the comparison of the judgement

made by a clinician with that derived from the mathe-

matical model.

The three general approaches most often employed in

mathematical modelling of clinical decisions are Bruns-

wiks' lens model, Bayes' theorem and utility theory.

Brunswiks' lens modelThe lens model represents the probabilistic interrelations

between the human and the environmental components

involved in a judgement situation. In this model the state

of the patient (SP) is unknown and can be inferred only by

the cues (signs and symptoms) that the patient displays.

The relationship between the cues and the state of the

patient is uncertain and probabilistic.

The lens model was used by Hammond and associates

in 1966 in a series of nursing studies which attempted to

apply the model to the study of: (1) the cognitive tasks

representative of nursing problems (Hammond et al.

1966a); (2) the information units used in making a

diagnostic inference (Hammond et al. 1966b); and (3) the

information seeking strategies used for making a diag-

nostic inference (Hammond et al. 1966c).

The ®rst study in this series attempted to discover the

cognitive tasks representative of nursing problems and the

frequency and cue characteristics involved in the more

frequently occurring tasks (Hammond et al. 1966a). Forty-

seven nurses working in a hospital were asked to record

during a 24-hour period, instances where a clinical

inference or decision was required. The study identi®ed

a large number of decision situations, which could not be

grouped together and analysed in terms of clusters.

The second study, which focused on a single type of

patient situation, dealt with complaints of abdominal pain

after surgery. Nurses working in 30 hospitals were

surveyed and the actions taken by them in response to

each patient's complaint were analysed. Fifteen action

categories were identi®ed from 212 cases. The results

showed that no signi®cant relationship existed between

any one cue and the selection of any of the action

categories. It was concluded from this result that no

single cue provided enough information for nurses to

make an informed decision.

Another study conducted by Hammond et al. (1966b)

involved an intensive study of six nurses. The major

purpose of the study was to identify what basic units of

information were associated with the selection of certain

actions. Cues were treated individually or were grouped

according to textbook descriptions or categories selected

by the nurses. Again, no single cue provided enough

information for the nurses to select certain action categ-

ories. It was found also that the nurses did not make

conscious distinctions about the usefulness of particular

cues but seemed to make inferences, almost intuitively,

from a sense of the patient situation in which the cues

were embedded.

As a result of these studies Hammond and associates

introduced two theoretical perspectives to the study of

clinical judgement in nursing: concept attainment theory

and statistical decision theory (Hammond et al. 1966c,

Hammond et al. 1967). A limited number of studies have

been conducted in nursing since that time using these

theories as a basis. Concept attainment theory is derived

from the work of Bruner et al. (1956). The theory describes

human cognitive strategies used to form categories or

concepts when a person is presented with a set of

descriptors. It suggests that humans attend selectively to

information, formulate hypotheses about possible ways to

categorize the information, and select strategies to test the

hypotheses. The theory also suggests that the strategy

selected depends upon the amount and relevance of

information available. Tanner (1986a) identi®ed three

investigators (Matthews & Gaul 19791 , Gordon 1980, Cianf-

rani 1984) who prior to 1986 used this theory as a basis for

their studies, although none of them indicated that they

were testing the theory per se. These three studies provide

little information as to whether the process of diagnosis in

general can be described using the concept attainment

model. Matthews & Gaul (1979) found that there was a

positive relationship between scores on a concept

metering test and diagnostic scores on a case study for

undergraduate students but not for graduate students.

Gordon (1980) found that nurses used hypothesis testing

strategies similar to those described in the concept attain-

ment literature. Cianfrani (1984) found that the number of

health problems identi®ed and the accuracy of diagnosis

varied as a function of the amount and relevance of the

information available to the nurse.

This series of studies highlighted the complexity of the

judgement process in nursing and, as such, has made an

important contribution to the study of clinical judgement.

The relevance of acknowledging cues is very important

during problem-solving activities, as this process appears

to be the basis for clinical actions.

Bayes's theorem

The second general approach used in decision-theory is

Bayes's theorem. This is a statistical model that describes

the way in which judgements are revised in the light of

new information. This model of decision-making has been

used extensively to compare clinician's decisions with

those produced by the model. Bayes's theorem describes

the process of revising the probability of a diagnostic

hypothesis, and is based on three factors (Tanner 1986a

p. 10):

C. Taylor

844 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing 31(4), 842±849

· The prior probability of the hypothesis without refer-

ence to a cue, or the unconditional probability.

· The probability of a cue given a certain diagnostic

hypothesis.

· The probability of a cue without reference to a diag-

nostic hypothesis.

Hammond et al. (1967) used Bayes's theorem to review

the performance of nurses in relation to probability

revision and the accuracy of that revision, compared to

the model. Six nurses were involved in the study and were

asked to judge 12 nursing inferential tasks. The nurses

were given a brief description of a patient and a statement

of the patient's possible condition. They were asked to

state the probability that the patient's condition was

correct. They were then given more information and asked

to revise the probability in light of the new information.

Subjective probability estimates were used, the subjects'

performance in probability revision was then compared

with the product of the model. The results showed that the

nurses tended to revise the probabilities in the same

direction as that prescribed by Bayes's theorem.

A similar study conducted by Hayes (1989) required

medical students to read case histories of patients and

form a diagnosis. After an initial review, new information

was introduced at several different points in the history.

On the second reading the students incorporated the new

information and revised the probability of their diagnoses,

even when the information incorporated was irrelevant.

This result was consistent with other studies (Tversky &

Kahneman 1974).

On the evidence provided by these studies, it would

seem that the application of Bayes's theorem to clinical

judgement improves students' abilities to incorporate new

information, but unfortunately there seems to be no

corresponding improvement in the accuracy of the diag-

noses made.

Utility theory

The third general approach to decision theory is utility

theory, which describes the selection of an action or set of

actions according to a subjective assignment of a value to

the probable outcomes of those actions. Utility theory is

used to improve decision-making under conditions of risk.

The explicit incorporation of anticipated outcomes into

decision-making is seen as important to some researchers

as a number of clinical decisions may involve a risk either

to the patient or to the clinician. Utility theory involves

the clinician choosing an action (management strategy)

when confronted with a problem. Each action is associ-

ated with an outcome and each outcome is associated with

a probability of occurrence and has a value assigned

(Tanner 1986a).

Grier (1976) tested this theory in a study of clinical

judgement in nursing. She attempted to determine if

intuitive decisions of nurses were in agreement with those

prescribed by utility theory. Fifty nurses took part in the

study. Each was presented with four patient situations.

They were asked to rank three possible courses of action.

They were then asked to estimate the probability of each of

seven outcomes occurring in light of the three actions (this

gave 21 probabilities). They were also asked to assign a

value (totalling 100) for each of the outcomes. A total of

185 decisions were analysed. The intuitive judgements of

the nurses agreed with the quantitatively derived

preferred action prescribed by utility theory in 109

(58á9%) cases. Grier (1976 p. 109) concluded from this

study that `decision-theory is applicable to nursing'.

Utility theory has not been used widely in nursing and,

although it may be of value in improving decision-making

under conditions of risk, it requires more research to help

improve its acceptance.

Comments on decision theoryDecision theory, according to Grant (1989), can tell us a

great deal about what is wrong with a clinical decision, it

can also help make utility assessment explicit. However,

the processes involved are very time consuming. Grant

(1989 p. 114) also suggests that `clinicians will need to

have a better understanding of the reliability of data,

obtain the necessary epidemiological information essen-

tial for decision-making and learn fully to appreciate the

impact of probabilistic concepts on clinical decisions. In

particular, they will need to understand how people

commonly handle these issues contrary to theory.'

The limitations of the application of decision theory to

nursing decisions relate to the fact that nursing treatment

options are frequently not `either-or' but often need to be

taken together. In addition, nursing care outcomes can be

dif®cult to quantify and are not always stable or ®nal.

Information processing theory

An extensive theory of human problem-solving, namely

information processing theory, has evolved through the

work of Newell and Simon in arti®cial intelligence

(Newell et al. 1958, Newell & Simon 1972, Simon 1978).

Information processing theory describes problem-

solving as an interaction between the information proces-

sing system (the problem-solver) and a task environment.

The theory postulates that there are limits to human

information processing capacity and that effective prob-

lem-solving relies on the individual's ability to adapt to

these limitations.

According to this theory the overall problem-solving

process can be analysed as two simultaneously occurring

sub-processes of `understanding' and `search' (Van Lehn

1989 p. 530). The understanding process is responsible for

assimilating the stimulus that poses the problem, and then

for producing mental information structures that



constitute a person's understanding of that problem. In

this way, a person is able to convert problem stimuli into

the initial information needed for the search process. The

search process is driven by the products of understanding,

rather than by the problem stimulus itself, and the search

process enables a person to ®nd or calculate a solution to

the problem.

According to Newell & Simon (1972) problem-solving

occurs when the solver translates a problem into their own

internal representation of the problem and then searches

for a pathway to reach the desired goal. Meyer (1992

p. 180) refers to the problem-solver's internal representa-

tion of a problem as having three separate states:

· Initial state, where the starting conditions are repre-

sented.

· Goal state, where the ®nal goal state is represented.

· Intermediate problem states, consisting of states where

operators are applied.

Applied to nursing, Meyer's approach would imply

that, in problem-solving situations, the nurse must recog-

nize the prevailing conditions, have an outcome or goal

identi®ed and have some strategies that can be applied in

order to achieve that goal. During care-giving activities the

nurse has a starting point. For example, a patient may

require a dressing to be changed. Although the beginning

and end points are easy to identify in the dressing

procedure, the process involved in actually performing

the task requires the nurse to have multiple cognitive

strategies in place. Problem-solving related to the patient's

needs involves the nurse's exercise of memory processes

in order to draw on accumulated knowledge and experi-

ence to carry out the dressing change. Observing the

nurse's behaviour during the dressing change does not

give any explicit indication of the mental processes

involved. Questioning the nurse about the thought

processes involved during the dressing procedure may

provide access to the cognitive strategies involved. This

approach to gaining cognitive insight is known in infor-

mation processing theory as verbal protocol.

Verbal protocolIn attempting to identify cognitive problem-solving strat-

egies, investigators, according to Ericsson & Simon (1993),

have recognized the limitations of relying wholly on

external observation in studying mental processes.

Ericsson and Simon questioned subjects about their

experiences, thought processes and the strategies they

employed during problem-solving exercises. This process

of using verbal reports has produced a level of under-

standing of human cognitive performance which,

according to Ericsson & Simon (1993 p. xii), `represents

the same cognitive processes that were discovered in more

traditional cognitive tests reporting on speed of button

presses and sequences of eye ®xations'. This outcome was

an important breakthrough, as it implied that individuals'

verbal accounts of what they were thinking could be

accepted as representative of their actual cognitive

processes.

Eliciting the required information from the problem-

solver regarding the actual cognitive process requires a

`think aloud' protocol in which the problem-solver is

asked to comment on what was in his/her mind while

performing the task. Newell & Simon (1972), who devised

this theory, argue that such concurrent reporting offers

accurate insight into the problem-solving processes of

individuals. Because the problem-solver acknowledges

cues and thinks aloud as the cues enter his or her short-

term memory, Newell & Simon (1972) believe that it is

possible to record and to identify the problem-solving

strategies in use. When subjects verbalize directly the

thoughts entering their attention as part of performing

the task, `the sequence of thoughts is not changed by the

added instruction to think aloud. However, if subjects are

also instructed to describe or explain their thoughts,

additional thoughts and information have to be accessed

to produce these auxiliary descriptions and explanations.

As a result, the sequence of thoughts is changed, because

the subjects must attend to information not normally

needed to perform the task' (Ericsson & Simon 1993

p. xiii).

According to Ericsson & Simon (1993 p. xvi), a subset of

the sequence of thoughts occurs during the performance of

a task and is stored in the performers' long-term memory.

Immediately after a task is completed, `there remain

retrieval cues in short-term memory that allow effective

retrieval of the sequence of thoughts'. Retrospective

reporting, however, although considered of less value

than concurrent reporting, can reveal valuable information

regarding the problem-solving strategies used by individ-

uals. It must be noted, however, that because retrospective

reporting relies on long-term memory it may not always be

accurate.

Think-aloud protocols, both concurrent and retrospect-

ive, were used extensively during the 1980s to give

valuable insight into students' thinking patterns. Newell

& Simon (1972) and Ericsson & Simon (1980, 1993)

recommended that, when using retrospective inter-

viewing, probing of the individual's answers should use

cued recall and should occur as soon as possible after the

observed situation.

Comments on verbal protocolsThere are some shortcomings in the use of verbal proto-

cols. First, protocol analysis relies on subjects verbally

reporting their thoughts and it is still not known whether

higher level mental processes are accessible (Nisbett &

de Camp-Wilson 1977). Supporters of the verbal protocol

method argue that reports of thinking do provide indirect

evidence of the underlying processes, which produce

C. Taylor


them. With regard to retrospective reporting, Ericsson &

Simon (1993 p. 16) believe it is of considerable value in

providing cognitive insights because `a durable (if partial)

memory trace is laid down of the information heeded

successively while completing a task. Just after the task is

®nished, this trace can be accessed from short-term

memory, at least in part, or retrieved from long-term

memory and verbalised'. Ericsson and Simon (1993 p. 16)

claim that both concurrent and retrospective reporting `are

direct verbalizations of speci®c cognitive processes'.

However, the extent to which the process of thinking

aloud alters the process and content of thought is not yet

known.

A second limitation of verbal protocols is that they

produce a large amount of data, so the method is generally

used with a small number of simulations and subjects.

The ability to generalize from ®ndings is therefore

constrained.

The third limitation is related to validity and is a problem

inherent in the use of simulations. Many of the cues

individuals use in problem-solving are on the fringe of

consciousness and their importance to the task in hand may

be unrecognized by both the individual constructing the

simulation and the subjects responding to it (Dreyfus 1979).

A number of studies in clinical decision-making have

used verbal protocol as a strategy to describe the diag-

nostic reasoning and planning process of nurses and

physicians (Elstein et al. 1978, 1986b, Corcoran 1986a,

Tanner et al. 1987). Critics of this methodology have

suggested that being instructed to describe cognitive

processes affects performance (Dreyfus & Dreyfus 1986)

and that the verbal reports of individuals do not represent

accurately their underlying cognitive processes (Nisbett &

de Camp-Wilson 1977, Lichtenstein 1982). Verbal protocol

remains, however, a major component of information

processing theory.

Comments on information processingInformation processing theory has particular relevance to

descriptive, as opposed to prescriptive, theory develop-

ment. The work of Newell & Simon (1972) on problem-

solving has advanced theory development through its

recognition of the computer's potential for building

models of judgement.

The focus of virtually all investigations in the nursing

literature based on information processing theory was to

identify the cognitive strategies employed by expert and

novice clinicians in deriving a diagnosis. The use of

simulated patients in actor, videotape or written form,

gave the researchers control over the cues presented as

well as providing a comparison of performance across

subjects. Both concurrent and retrospective verbal proto-

cols have been used.

The principal assumption underlying information

processing theory is that there are limits to human

information processing capacity and that effective prob-

lem-solving depends on the individual's ability to adapt to

these limitations. The two major factors which impact on

human information processing capacity are: (a) the

amount of information to which an individual can attend

at one time; and (b) factors which determine the clarity

and accessibility of the information, either in the task

environment or internal to the problem-solver.

Central to information processing-theory is the notion of

bounded rationality which emphasizes the limits of

human information processing as a result of the relatively

small size of short-term working memory (Newell & Simon

1972).

Although the information processing approach to prob-

lem-solving has not produced a general model of problem-

solving across tasks or disciplines, it nevertheless

continues to be used by researchers to gain cognitive

insights into individual problem-solving.

GENERAL MODEL OF PROBLEM-SOLVING

In order to determine if there is a general approach to

clinical problem-solving Elstein et al. (1972, 1978)

conducted a series of studies with expert and non-expert

physicians. The only consistent general strategies found

between the groups studied were those related to the

generation of early hypotheses and subsequent data gath-

ering to test the activated hypotheses. These ®ndings on

early hypotheses activation have been corroborated in

similar studies by Barrows & Bennett (1972), Ekwo (1977)

and Neufeld et al. (1981). Studies of registered nurses and

nursing students by Westfall et al. (1986), Corcoran

(1986a, 1986b) and Taylor (1997) produced similar results.

DISCUSSION

In the majority of the studies conducted into problem-

solving, researchers also attempted to discover if there

were any consistent approaches taken by clinicians in

seeking out information from patients. The results suggest

that clinicians do tend to use similar strategies in seeking

out information from patients in order to form a diagnosis.

They appear to do this most commonly by asking patients

routine general questions until the patient says something

that seems signi®cant to the clinician. When something

signi®cant is noted, information sought from the patient

from this point on becomes more speci®c, and is usually

related to a newly activated hypothesis. The results of the

research conducted into questioning techniques of clini-

cians also suggest that the use of general questions

prevents the clinician±patient interview from coming to

an end too quickly (Barrows & Bennett 1972). Theoret-

ically, the longer the interaction, the more information

is gathered and the more accurate the diagnosis is likely

to be.



CONCLUSION

The literature reviewed in this paper highlights to some

degree the different research approaches taken to identify

problem-solving strategies in spite of the complexity that

exists. The studies report that no single general model of

diagnostic reasoning exists. However, a small number of

strategies appear to be used consistently. The strategies

identi®ed indicate that the nurse as a problem-solver

activates a hypothesis/hypotheses early in the nurse/

patient encounter. Subsequent to activating a hypothesis/

hypotheses, there seems to be agreement among many

researchers that data then collected relates to the hypo-

thesis/hypotheses. Finally, the use of routine general

questions to seek out information from patients before

probing for more speci®c information is also consistent

across disciplines.

It is evident from what is known about clinical problem-

solving, that the process involved in decision making is

one of inductive reasoning (which stems from the clinician

activating a hypothesis), and not one involving deductive

reasoning, as in the nursing process. This is important for

nurse academics who develop undergraduate curricula.

Education units should be developed for students to

highlight differences in the cognitive strategies required

between the nursing process and the clinical reasoning

process in an attempt to improve care-giving.

With so many changes in health care today, nurses must

be good problem-solvers in order to deliver safe, profes-

sional care. Unfortunately, as yet, there are a large number

of clinicians and educators unaware of the clinical

reasoning process. Further research into how nurses

problem-solve in different clinical settings needs to be

conducted to redress the balance.

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