CLINICAL

ADVANCED

Using judgement to improve

accuracy in decision-making

Benner, P. et al (1999) Clinical Wisdom

and Interventions in Critical Care.
Philadelphia, PA: WB Saunders.
Benner, P. et al (1992) From beginner
to expert: gaining a differentiated
clinical world in critical care nursing.
Advances in Nursing Science; 14: 3,
1328.
Cioffi, J. (1997) Heuristics, servants
to intuition, in clinical decision-making.
Journal of Advanced Nursing;
1997: 26, 203208.
Cioffi, J. (2002) What are clinical
judgements? In: Thompson, C.,
Dowding, D. (eds) Clinical decisionmaking and judgement in nursing.
Edinburgh: Churchill Livingstone.
Corcoran, S.A. (1986) Task Complexity
and nursing expertise as factors
in decision-making. Nursing Research;
35: 2, 107112.
Dowding, D. (2002) Interpretation of
risk and social judgement theory. In:
Thompson, C., Dowding, D. (eds)
Clinical decision-making and
judgement in nursing. Edinburgh:
Churchill Livingstone.
Dowding, D., Thompson, C. (2004)
Using decision trees to aid decisionmaking in nursing. Nursing Times;
100: 21, 3639.

42

This is the third of four papers discussing judgement and

decision-making in nursing. The first paper in this series
(Thompson et al, 2004) highlighted the importance of
judgement and decision-making to nursing practice. The
second (Dowding and Thompson, 2004) discussed how
complexity associated with decision problems could be
made sense of by using an approach to structuring decisions known as decision analysis. The aim of this article
is to discuss the issue of judgement in nursing. In particular, it examines the way nurses may use information
to inform their judgements, and ways in which this process can be assisted to improve the accuracy of judgements.

Judgement in nursing
The process of judgement involves integrating different
aspects of information (which may be about a person,
object or situation) to arrive at an overall evaluation
(Maule, 2001). In nursing this could be considered as the
process of using different types of clinical information
about the patient (such as appearance, vital signs, and
behaviour) to make an assessment of her or his current
health status (Dowding and Thompson, 2003).
Judgements feed into decision-making (Box 1) in that
the evaluations or assessments an individual makes can
be used as the basis of choice between alternatives. For
example a nurse may assess a patient as being at risk
of developing a pressure ulcer (judgement) and then
choose a particular intervention to reduce that risk

BOX 1. DEFINING JUDGEMENT AND DECISION

JUDGEMENTS

DECISIONS

Generally considered
to be assessments,
estimates or
predictions of an entity
(Harvey, 2001)

Generally considered to
be opposed to decisions,
which are considered
to be a choice
between alternatives
(Dowie, 1993).

(decision) on the basis of the assessment.

Examining judgements in nursing is important, as they
have an effect on decisions taken about patient care.
Harvey (2001) suggests decisions may be poor because
the judgements on which they depend are inaccurate or
because individuals combine different judgements inappropriately. Therefore, a key issue for nurses and patients
is ensuring judgements are as accurate as possible.
There are two main reasons for inaccuracy:
The nurse may be using information that has no utility
for the judgement in question (Cioffi 2002);
The nurse may be placing too much importance on
particular information (Dowding, 2002).
Therefore, the type of information individuals use to
inform their judgements, some knowledge of the information they should be using to inform their judgements,
and how that information is (or should be) combined is
required to investigate and improve accuracy. The two
main ways these issues have been investigated are
descriptive research and social judgement analysis.

Descriptive research into judgement

Most of the research examining judgement in nursing is
qualitative and descriptive in nature an appropriate
design for the research questions being addressed. The
aim of many of the studies is to describe the nature of
judgements through the analysis of how nurses manage
clinical situations, including the information they use to
inform their judgements and decisions.

The use of intuition and rules

Perhaps the most well known research in this area is that
carried out by Benner et al (Benner, et al 1999; 1992;
Benner, 1982). This research highlighted characteristics
of expert nursing practice and judgement and how that
expertise develops. Benner (1982) suggests expert
nurses mainly use intuition, which is defined as knowing
without necessarily having a specific rationale or making
explicit all that goes into ones sense of a situation

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Alamy

REFERENCES
Benner, P. (1982) From Novice to
Expert. American Journal of Nursing;
82: 402407.

AUTHORS Dawn Dowding, PhD, RN, is senior lecturer,

Hull York Medical School, University of York; Carl
Thompson, DPhil, RN, is senior research fellow,
Department of Health Sciences, University of York.
ABSTRACT Dowding, D., Thompson, C. (2004) Using
judgement to improve accuracy in decision-making.
Nursing Times; 100: 22, 4244.
Nursing judgements are complex, often involving the
need to process a large number of information cues. Key
issues include how accurate they are and how we can
improve levels of accuracy. Traditional approaches to the
study of nursing judgement, characterised by qualitative
and descriptive research, have provided valuable insights
into the nature of expert nursing practice and the complexity of practice. However, they have largely failed to
provide the data needed to address judgement accuracy.
Social judgement analysis approaches are one way of
overcoming these limitations. This paper argues that as
nurses take on more roles requiring accurate judgement,
it is time to increase our knowledge of judgement and
ways to improve it.

KEYWORDS

(Benner, 1999).
This is in direct contrast to less experienced individuals
who may use rules to combine common attributes such
as a patients vital signs (Benner, 1982). This combination may eventually be combined into some form of
global pattern that guides action.
Although Benners work has provided insight into the
nature of expert nursing practice, it fails to give details of
how information is processed to inform accurate judgements. This is due in part to the research methods used
predominantly observation of practice and interviews.
However, observation cannot provide insight into all
the information used in reaching a judgement, and selfreporting has been shown to be an unreliable method of
investigating judgement and decision-making as individuals often have little insight into how they make
judgements and decisions (Harries et al, 1996). Also, the
critical incident method used by Benner et al (1999) may
mean individuals only examine situations where their
reasoning processes have been successful (Lamond and
Thompson, 2000), meaning a full exploration of issues of
judgement accuracy is not possible.

Information processing
Another set of studies used the psychological theory of
information processing (Newell and Simon, 1972) as the
basis for exploring the reasoning processes nurses use
when making judgements and decisions. This theory
suggests humans have limited capacity for processing
information, meaning a variety of strategies is employed
to assist the process. Examples of this type of study have
been carried out by Cioffi (1997), Tanner et al (1987),
and Corcoran (1986). These studies have suggested that
nurses use a process of hypothetico-deductive reasoning
when making judgements, together with mental short
cuts or heuristics.
Hypothetico-deductive reasoning involves using available information to formulate hypotheses, which are
then tested and reformulated until a conclusion is
reached (Thompson and Dowding, 2002). The types of
information that appear to be used vary considerably. For
instance in a very early study examining the information
nurses use to make a judgement about patient pain,
Hammond et al (1966) found they used 165 different
information cues. Hypothetico-deductive reasoning
appears to be used by individuals in situations where
they have no experience of the task in question. In situations where people have more experience, they are
more likely to use a process of pattern matching, which
involves the recognition of similarities between the
patient case being considered and ones that have been
encountered in the past (Elstein et al, 1990). These short
cuts are the focus of the fourth paper in this series.
The main strategies used to examine reasoning and
information use in information processing studies are
variations of a think aloud technique and retrospective
interviewing (Tanner et al, 1987; Corcoran, 1986).
Simulations are typically used to compare individuals
across cases. The process of thinking aloud involves the

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Education Decision-making Judgement

subject of the study verbalising everything they think of

while carrying out the judgement task. They may be
interviewed after the task to discuss any other information they think they used and their rationale.
There are a number of problems with this type of
study: the use of simulations may mean the judgements
made by the subject do not reflect what they would do
with a patient. Also, thinking aloud relies on the participants ability to make their judgement policies explicit
(Harries and Harries, 2001), and retrospective interviewing suffers from the same problems as highlighted above.

Limitations of descriptive research

In summary, if we are interested in the accuracy of
judgements, much of the descriptive research into nursing practice fails to provide the evidence that is needed
to inform practice. These types of study are a useful representation of practice but it is difficult to observe a sufficient range of scenarios for a given judgement in order
to determine how information is used to make that
judgement (Harries and Harries, 2001).
Many of the studies look at a broad range of practice,
which means detail about the information cues is often
lacking. Also, a reliance on self-report methods (such as
interviews and thinking aloud) means the research is
dependent on a participants insight into her or his judgement processes and ability to verbalise these processes.
By definition expert judgement usually involves the
use of automatic, unconscious thought processes (often
referred to as intuition). Such experts often will not be
able to verbalise their thoughts a characteristic that
limits the analysis of their judgements (Lamond and
Thompson, 2000).

Social judgement analysis

The lens model
The theoretical basis of social judgement analysis is the
lens model of cognition proposed by Brunswik. This is a
representation of the relationship between a person and
her or his environment (Harries and Harries, 2001).
Brunswik suggested that to investigate judgement,
researchers should take into account the unpredictable
nature of the environment in which they operate, and
that a range of judgements, in a range of situations,
needs to be investigated (Harries and Harries, 2001).
The lens model can be represented diagrammatically
(Fig 1). In this diagram the left-hand side represents the
environment (such as a patients state of health). A
number of different information cues will be related
probabilistically to this environment. The right-hand side
represents the individual making the judgement. This
person uses information cues to make her or his judgement on the environment (for example, do I need to call
a doctor?) and in doing so will attach more weight to
some cues than others. By comparing the way the information cues are related to the state in the environment
and the weighting assigned to information cues by the
judge, one can identify:
If the persons judgement is accurate (is there a corre-

REFERENCES
Dowding, D., Thompson, C. (2003)
Measuring the quality of judgement and
decision-making in nursing. Journal of
Advanced Nursing; 44: 1, 4957.
Dowie, J. (1993) Clinical decision
analysis: Background and introduction.
In: Llewelyn, H., Hopkins, A. (eds)
Analysing How we Reach Clinical
Decisions. London: Royal College of
Physicians.
Elstein, A.S. et al (1990) Medical
problem solving: a ten-year
retrospective. Evaluation and the
Health Professions; 13: 1, 536.
Hammond, K.R. et al (1966) Clinical
inference in nursing: use of informationseeking strategies by nurses. Nursing
Research; 15: 4, 330336.
Harries, C. et al (1996) A clinical
judgement analysis of prescribing
decisions in general practice. Le Travail
Humain; 59: 1, 87111.
Harries, P.A., Harries, C. (2001)
Studying clinical reasoning. Part 2:
Applying social judgement theory.
British Journal of Occupational
Therapy; 64: 6, 285292.
Harvey, N. (2001) Studying judgement:
general issues. Thinking and
Reasoning; 7: 1, 103118.
Lamond, D., Thompson, C. (2000)
Intuition and analysis in decisionmaking and choice. Journal of Nursing
Scholarship; 32: 3, 411414.
Maule, A.J. (2001) Studying judgement:
some comments and suggestions for
future research. Thinking and
Reasoning; 7: 1, 91102.

This article has been double-blind

peer-reviewed.
For related articles on this subject
and links to relevant websites see www.
nursingtimes.net

43

ADVANCED

REFERENCES
Newell, A., Simon, H.A. (1972)
Human Problem Solving. Englewood
Cliffs, NJ: Prentice Hall.

Accuracy

X1

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

clinical information in diagnosing
chronic heart failure: a comparison
between general practitioners,
cardiologists, and students.
Journal of Clinical Epidemiology;
53: 10811088.
Tanner, C.A. et al (1987) Diagnostic
reasoning strategies of nurses and
nursing students. Nursing Research;
36: 6, 358363.
Thompson, C. et al (2004) Strategies for
avoiding pitfalls in clinical decisionmaking. Nursing Times; 100: 20, 4042.
Thompson, C., Dowding, D. (2002)
Decision-making and judgement in
nursing an introduction. In: Thompson,
C., Dowding, D. (eds) Clinical DecisionMaking and Judgement in Nursing.
Edinburgh: Churchill Livingstone.
Wigton, R.S. (1996) Social judgement
theory and medical judgement.
Thinking and Reasoning;
2: 2 175190.

SERIES ON CLINICAL DECISION-MAKING

This is the third in a four-part

series on decision-making:
1. Strategies for avoiding the pitfalls in
clinical decision-making
2. Using decision trees to
structure clinical decisions
3. How to use information cues
accurately when making clinical
decisions;
4. Tools for handling information
in clinical decision-making.
44

Cognitive feedback

FIG1. THE LENS MODEL

Cues

X2
X3
True state

Judged
Correct
weights

X4

Judges
weights

spondence between patient state and the judgement?);

Whether the judge uses appropriate information, and if
so, does she or he put appropriate importance or weighting on different pieces of information (Dowding, 2002).

Disagreement between judges

Using this model highlights where disagreements occur
between judges: they could be using different information or be placing different importance on certain cues,
which would lead to differences in judgements.
In order to model the environment statistical techniques are used to identify possible relationships
between information and a patient state. For instance, in
a study examining doctors diagnoses of heart failure,
Skanr et al (2000) used information from patient cases
to model how different cues were related to the diagnosis. This optimal strategy suggested cardiac enlargement was the most important cue to determine if a
patient had heart failure. To model the clinicians judgement, a number of scenarios of patient cases are constructed containing information considered important for
the judgement under investigation, and designed to
represent the range of situations in the environment.
Judging scenarios
In social judgement analysis studies, the number of scenarios is often very large to make the judgements as real
as possible (Harries and Harries, 2001). The judge(s) are
then asked to make a judgement about each of the scenarios, and this is then also modelled using statistical
techniques (usually of linear multiple regression). This
provides a statistical analysis of the information the
judge uses to make judgements, and the importance she
or he attaches to each of the cues.
For instance, Skanr et al (2000) studied the diagnostic
judgements of GPs, cardiologists, and medical students.
Through their modelling of how individuals used information to make a diagnosis, they highlighted the variation in the use of information cues. One-third of
participants used relative heart volume as the most
important cue as opposed to cardiac enlargement,
which was identified in the optimal strategy.

As well as being able to identify possible sources of error

in judgement which may affect judgement accuracy
the results of social judgement analysis studies can be
used to provide cognitive feedback to participants as a
way of improving their accuracy. Cognitive feedback is
different to outcome feedback, which provides participants with the outcome of each case, in that it contains
information about the optimal strategy (how information
is related to the patient state in the environment) and
the individuals own policy (how she or he uses the
information). With this knowledge they can identify disparities and be aware of how to improve their use of
information (Wigton, 1996). Various studies that used
cognitive feedback have shown it can improve diagnostic
accuracy and prognostic predictions (Wigton, 1996).
Social judgement analysis requires individuals to make
judgements as they normally would, and then uses statistical techniques to describe the relationship between
the information available to the judge and the judgement or decision made (Harries and Harries, 2001). The
focus of these studies is not the process of judgement,
rather an analysis of how information use is linked to
judgement accuracy, so in this way studies are able to
analyse in detail how and why judgements may differ
among individuals, as well as offering a way of improving accuracy through the use of cognitive feedback.
Another strength of social judgement analysis is that it
is not reliant on the ability of participants to self-report
their judgement processes, and can identify policies that
judges are unaware of (Harries and Harries, 2001).
However, social judgement analysis studies are often
reliant on the construction of scenarios, frequently with
limited sets of information presented in a way not found
in reality. So, as with all other types of study, they do
have limitations.

Conclusion
As highlighted by Hammond et al (1966) nursing judgements are complex, often involving the need to process
a large number of information cues. Key issues in the
study of such judgements are the analysis of judgement
accuracy and ways of improving accuracy.
More traditional approaches to the study of nursing
judgement have provided valuable insights into the
nature of expert nursing practice and the complexity of
practice. However, they have limitations in terms of
being able to provide the specific data needed to address
judgement accuracy.
Social judgement analysis approaches may be a way of
overcoming these limitations. However, as yet these
approaches have been more common in medicine,
examining the nature of medical diagnosis and prescribing (Skanr et al 2000; Harries et al 1996), than in nursing practice.
With nurses taking on roles requiring accurate judgement, it is time for clinicians and researchers to grapple
with this thorny issue in ways that will reveal possible
routes forward rather than offering just description.

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