Frameworks for

decision- making &

problem solving

Debra Sprague
Debra.sprague@uce.ac.uk
0121 331 7171
Nursing Diagnosis
…is a problem solving
activity…depends on accurate,
comprehensive assessment

‘Assessment is … critical
analysis and evaluation or
judgment of the status or
quality of a particular
condition and situation of
the object of appraisal’
 Hypothetico-Deductive
Model
 What is your hypothesis?

 How would you test for your

hypothesis?

 How do you confirm your hypothesis?

 How would you refute your

hypothesis?
 Key Components
of a Diagnosis
• Statement of a client problem
• Refers to a health problem
• Based on objective and subjective assessment data
• Statement of a nursing judgement
• Short, concise 2-part statement (difficulty
with...due/related to...)
• A condition a nurse can prescribe care/treat
independently
• Can be validated with the client
Bellack and Edlund (1992), Shoemaker (1984), Iyer, Taptich & Losey (1995)
 Defining a disease
1. Dividing line between normal and abnormal is not
always clear cut
2. Many diseases, at least at the time they are
diagnosed, do not by themselves cause pain,
suffering, disability, or threat to life
3. The difficulty of defining a disease is compounded by
the fact that many of the signs and symptoms,
findings and condition that might suggest disease are
extremely common
 Making a Diagnosis
Two stages to making a diagnosis
 Surveillance
 Hypothesis driven search for information
 Menu driven inquiry

 Synthesis
 Information
 Prior knowledge retrieved from memory
 Hypothesis becomes more defined
 Inquiry becomes more focused

Final diagnosis reached
 Clinical Decision-Making

Rationale
Intuition
 Problem Solving is…

"the generation of possible solutions to an

issue of concern and therefore needs to
be an inherent part of the practice of all
professional"
(Eisenhauser and Gendrop 1990).
 Problem Solving.…
Wanting to achieve something but not knowing
immediately what series of actions to perform to
do so.
Newell and Simons 1972

Trial and Error
 Intuition
 Experimentation
 Scientific method
 Clinical Problem-solving

4 major cognitive activities in clinical problem

solving:

• Attention to available cues (signs, symptoms &

other data about the patient and environment)
• Generation of tentative hypotheses
• Gathering data about hypotheses to rule them out
• Evaluating hypotheses to refine diagnosis
 Decision Analysis
Consider a situation in which you had to make a
decision which involved choosing between options.

Dilemmas due to
 Complexity
 Uncertainty
 Conflict
 The Expert Decision-Maker

 Works through complexity

 Resolves dilemmas – pragmatic
 Flexible, timely, reflective
 Uses both breadth and depth of
knowledge
 Understands the ‘normal’
 Considers ethical & cultural issues
 Considers wider resources and policy
 Reasoning Cycle
Information

Critical
Thinking/Reflection
Consideratio
n or Reasoned
Generation Judgement
of
Alternatives
Recognition of
Problem
 Hypothetico-Deductive
Approach
 June Masters is of white European origin,
aged 35 years states she has back pain.
She has noticed that every time she has
passed urine this week it is painful and
has a red colour
 Using the headings below consider;
 What is your hypothesis
 How would you test for the hypothesis
 How would you confirm the hypothesis
 How would you refute the diagnosis
 What would you do- treatment /care