Journal of Nursing Education

An Investigation of Decision Theory: What are the Effects of Teaching Cue Recognition?

Joan E Thiele, PhD, RN; Joan H Baldwin, MA, MSN, RN; Roberta S Hyde, MS, RN; Beth Sloan, MS, RN; Gloria A Strandquist, MS, RN

Abstract

ABSTRACT

As currently formulated, decision theory assumes that care givers learn cue recognition primarily by experience. However, it seems probable that the ability to receive and recognize cues can be taught. To investigate cue recognition abilities of junior and senior baccalaureate nursing students, five computer simulations were developed. The specific question investigated was: What are the effects upon students' cue recognition and clinical decision-making abilities of teaching cue recognition?

Following teaching of cue recognition and decision making, a statistically significant difference was noted in both junior and senior students in relation to accuracy of cue recognition and clinical decision making. The conclusions were that cue recognition and cue sorting can be taught. Also, linking or grouping of related cues can be taught. In this study, the teaching of cue recognition and linking of cues improved the accuracy of clinical decisions made by students who were presented computer simulations of a variety of clinical situations.

Abstract

ABSTRACT

As currently formulated, decision theory assumes that care givers learn cue recognition primarily by experience. However, it seems probable that the ability to receive and recognize cues can be taught. To investigate cue recognition abilities of junior and senior baccalaureate nursing students, five computer simulations were developed. The specific question investigated was: What are the effects upon students' cue recognition and clinical decision-making abilities of teaching cue recognition?

Following teaching of cue recognition and decision making, a statistically significant difference was noted in both junior and senior students in relation to accuracy of cue recognition and clinical decision making. The conclusions were that cue recognition and cue sorting can be taught. Also, linking or grouping of related cues can be taught. In this study, the teaching of cue recognition and linking of cues improved the accuracy of clinical decisions made by students who were presented computer simulations of a variety of clinical situations.

Introduction

To a large extent, the quality, completeness, and appropriateness of care provided to clients is dependent upon the ability of the care giver to determine the needs of the client. Assessment of cues and interpretation of these findings form the basis for making judgments regarding client care needs. Critical factors in the development of the ability to make decisions are the detection, grouping, or chunking of cues and assigning meaning to these grouped cues which have been obtained from clients (Carnevali, 1983). Cues are facts or pieces of information which can be connected together to form patterns. Within nursing, clinical situations often evolve as a series of pieces, or cues, much as the pieces of a puzzle. Each separate piece is a cue; the fitting together of these cues to form a total picture is termed linking, while predicting the outcome before the puzzle is complete is the making of inferences. The processes of recognizing cues, formulating patterns and interpreting these into appropriate clinical actions form the basis for clinical decisions. Each step in the total process requires learning and the assimilation of knowledge. In general, experience has been utilized as the universal teacher of these processes.

How then, do nursing students who are lacking professional experience learn to make clinical decisions regarding the health care needs of clients? Students are taught a variety of nursing actions which include observation, interview techniques, physical and mental assessment procedures, and a vast number of psychomotor skills. Armed with specific nursing skills and some degree of basic nursing knowledge, the students are expected to attain the ability to make appropriate clinical decisions with a high degree of accuracy.

Prior to any clinical practicum, the novice student practices skill development on the well known "Mrs. Chase" and a host of other manikins. The missing ingrethents in this approach are the verbal responses and feedback regarding the approaches selected by the student. Just as psychomotor skills must be practiced, students must practice decision making and use of a systematic approach to gathering data upon which to make decisions. Novice students are able to make rudimentary clinical decisions based upon their previous life experiences. The problem that arises from this approach is that the majority of the decisions are inappropriate, superficial, or lack the establishment of priorities. The decisions at this level are usually a "stab in the dark" approach.

Review of Literature

As presently formulated, decision theory assumes that care givers have the ability to recognize and utilize cues. While this may be so for the expert, the novice must learn to identify and interpret cues. Accurate and appropriate clinical decisions are functions of knowledge and experience (Balla, 1982; Baumann & Baubonnais, 1983; Feltovich, Chase & Simon, 1973; Larkin, 1973). The dilemma arises in the acquisition of this experience; beginners simply do not have an experience base upon which to draw. How then, does the novice learn to make decisions? What information does the novice consider when making a decision?

For the novice, each situation is viewed as a new event. Carnevali (Carnevali, Mitchell, Woods, & Tanner, 1984) describes the nursing domain as "daily living (with its environment) and health status and a relationship between them" (p. 12). This approach provides a means for the novice student to use life experiences as a starting point for learning clinical decision making. Using this approach, the novice student is able to analyze daily living, health status, and the effects of one upon another based upon individual experience. In the absence of previous experience, decision making may be delayed, be inappropriate, or, at the very least, result in decisions which are only partially correct.

del Bueno (1983) found that inexperienced nurses respond to patient cues with "less precision and accuracy than do experienced nurses" (p. 10), if they respond to the cues at all. Failure to recognize cues and inability to group, or link cues, are major explanations for the making of inaccurate clinical decisions. Compounding these inaccuracies is the realization that in actual clinical situations, corrective feedback is often not present. Therefore, the inaccuracies may persist uncorrected, and result in subsequent erroneous clinical decisions.

Decision theory has evolved from studies of problem solving, cognitive psychology and artificial intelligence. Problem solving is viewed as a function of the reception of information within a given context, and the processing of this information by the receiver. Diagnostic reasoning, the process by which clinical decisions are made, has received considerable research attention (Carnevali, 1983; 1984).

The analysis resulting in a clinical decision has wellidentified steps. These steps are the recognition of cues, sorting of cues, linking, or grouping of related cues, developing hypotheses or inferences regarding the clinical interpretation of the cues and activation of the indicated action (Carnevali, 1984). While it is known that intellectual and environmental factors contribute to the ability to make decisions, the total scope of abilities needed to make decisions is not known.

To date, the studies of clinical decisions and diagnostic reasoning abilities of nurses have focused upon the correctness of the decisions, once they have been made. The purposes of this study were to determine the effects upon decision making of deliberately and systematically teaching cue recognition and interpretation in a variety of clinical situations.

Methodology

To achieve these purposes, a series of five clinical simulations was developed and programmed for use on Apple II microcomputers. The first of these computer-assisted instruction (CAI) programs "Cues, Chunks, and Clinical Inferences," presented the steps in the diagnostic reasoning process, with major emphasis upon the recognition of relevant and irrelevant cues, and linking of cues in clinical situations. Subsequent simulations each presented a brief review of this content, but focused upon applications of diagnostic reasoning in a variety of clinical environments and situations. Linking of cues and developing inferences based upon these cues were the primary emphases of the subsequent simulations, although cue recognition and cue sorting were inherent in each program. All situations were consistent with the level of student and the course in which the presentations were made. Also, each program utilized a similar format in that the goals of the program were first specified, then followed by one or more situations from which students selected applicable cues. Corrective feedback was provided for each incorrect response; scoring routines were incorporated into each program to inform the student of the accuracy of their choices. Content questions were interspersed throughout each program, also.

Prior to viewing a program, each student completed a pre-test which consisted of situations from which the student identified and sorted cues. Following each presentation, a posttest was administered. The posttest contained new situations and asked for cue recognition and sorting, and utilized the information from the CAI programs. Scores on these tests were obtained to determine the change in students abilities to recognize and to sort cues based upon knowledge and practice of these activities.

Brief Description of the Computer Programs

The initial program, "Cues, Chunks, and Clinical Inferences," was presented to all students. The program content utilized noncomplicated nursing situations designed for development of the process of diagnostic reasoning. Students were presented definitions, examples, and then asked to identify cues within a new situation. For example, if a patient reported the presence of a "frequent cough," this piece of data would be a relevant cue, as it indicated the need for obtaining additional information. Irrelevant cues were defined as those facts or pieces of information which are noncontributory to a situation, at least at the present time. Nonsignificant cues may be superfluous or trivial information, or of future, rather than immediate concern. For instance, determining that the individual sometimes wears white socks when "coughing frequently" would be a nonrelevant cue, as it does not contribute to the situation.

In addition to the initial program, junior students viewed programs entitled "Interpreting Vital Signs of the Elderly" and "Vital Signs Interpretation in the Well Child." Each of these programs was focused upon typical situations with individuals in the two age groups.

In the program 'Vital Signs Interpretation in the Elderly," students selected relevant cues from a menu of information given in the situation. In the first situation, the student was given the definition of relevant cues. If a student selected a non-relevant cue, the response would reiterate the definition and explain why the choice was incorrect. For example, the student would receive a response such as "Remember, nonrelevant cues do not contribute to a situation." Content questions relating to normal values of vital signs in elderly individuals were also included in each situation.

The content of the program, "Interpreting Vital Signs of the Child," consisted of two simulated episodes which involved an elevated pulse in one child and an elevated temperature in the other. The students selected cues from listings of information given in the situations. In one situation, the cues listed were "age, sex, other family members, 103.0 F. temperature, listlessness, and left shoulder pain." The identified relevant cues were the 103.0 F. temperature, left shoulder pain and listlessness. After determining the relevant cues, the students were asked to connect, or link the cues, and develop clinical inferences. Following this step, the students were to make decisions about the indicated nursing care.

The CAI programs developed for use by senior students presented complex nursing situations. Half of the seniors viewed a program entitled "Community Health Nursing: That First Home Visit," while the seniors in the leadership course viewed a program entitled "Decision Making in Leadership Situations." Linking of cues and developing inferences based upon these cues were the primary emphases of the simulations, although cue recognition and cue sorting were inherent in each program.

The computer program entitled "Community Health Nursing: That First Home Visit" incorporated utilization of cues, linking, and formulating clinical inferences into a community health nursing situation. The simulations progressed as though the students were actually in the home, conducting the first home visit. Periodically, the visits were interrupted by a built-in computer preceptor who asked the students questions about particular observations. For example, one situation described a "female patient who paused to breathe very rapidly for several seconds after shuffling a few feet across the floor and then lowering herself into a slipcovered sofa." The students were to identify the rapid breathing after taking a few steps, and to link these relevant cues together to provide a data base indicating some degree of compromise of her lung capacity. The slipcovered sofa was a nonrelevant cue in the scenario. Cumulative scores in the content areas of nursing assessment, nursing diagnosis, interventions, nutrition, pathophysiology, and pharmacology were also displayed.

The CAI simulation presented to the senior students in leadership incorporated cue theory and diagnostic reasoning in relation to planning care for several clients. In the program "Decision Making in Leadership Situations," the students were provided with baseline data for each of several patients. Both relevant and nonrelevant cues were provided, as well as information which required additional assessments on the part of the student. The program presented the student with multiple opportunities to seek additional information. For instance, one situation involved a patient who had emergency surgery at 4:30 in the morning. The situation began at 7:00 a.m. the same morning, with the student receiving information in report. A variety of cues and additional information were presented which enabled the student to select "ineffective airway clearance" as the nursing problem with the highest priority at the moment. However, new information soon altered the situation and forced the student to reprioritize the nursing care needs of the simulated patients. As with the other programs, the students were required to identify relevant cues and then to link these cues to make clinical decisions. Following an incorrect choice, the student would be presented additional information and then be asked to make appropriate clinical decisions. As the simulation progressed, decisions were required in the areas of clinical inferences, priority of care, and plan of nursing action.

Data Analysis

For this investigation, all of the junior and senior students in the baccalaureate nursing program at Idaho State University were included. A total of 43 juniors and 37 seniors were tested; however, as the research was conducted on several different days, the number of students who completed each separate portion of the study varied.

As is shown in Table 1, the junior students obtained mean scores of 76 on the cue recognition pretest and a mean score of 67 on the posttest. The decline in scores on the posttest was attributed to three factors: 1) a high rate of guessing on the pretest which resulted in identifying many pieces of data as cues, regardless of the degree of relevancy; 2) the lack of correcting for guessing; and 3) to differences in difficulty level of the pre- and posttests. Equivalent forms of the instruments were utilized for all measurements, however, the reliability and discrimination indices of the instruments were not known. Prior to being used, all instruments were evaluated by experts for content validity. On subsequent measures, the junior students obtained cue recognition mean scores of 59.9 on the pretest relating to the program "Interpreting Vital Signs of Children" and 62.5 in relation to the pretest for the program "Interpreting Vital Signs in the Elderly." The posttest scores for these two programs were 58.4 and 93.5 respectively.

Table

TABLE 1CUE IDENTIFICATION- JRS

TABLE 1

CUE IDENTIFICATION- JRS

Table

TABLE 2CUE IDENTIFICATION - JUNIOR STUDENTS

TABLE 2

CUE IDENTIFICATION - JUNIOR STUDENTS

Table

TABLE 3CUE IDENTIFICATION- SRS

TABLE 3

CUE IDENTIFICATION- SRS

Table

TABLE 4CUE IDENTIFICATION - SENIOR STUDENTS

TABLE 4

CUE IDENTIFICATION - SENIOR STUDENTS

Paired t-tests were utilized to analyze these data. As is shown in Table 2, statistically significant results (p<.05) were obtained on the pretest and posttest differences in relation to two of the three programs. Both the differences between scores obtained on individual programs and the effects of repeated teaching of cue recognition must be noted, however.

The senior students obtained a mean pretest score of 83.1 and 64.0 on the posttest on the program "Cues, Chunks, and Clinical Inferences." The senior students who viewed "Community Health Nursing: That First Home Visit" obtained a mean score of 9.3 on the pretest and 70.9 on the posttest. The senior students who viewed the simulation "Decision Making in Leadership Situations" obtained mean scores of 39.6 on the pretest and 87.0 on the posttest. These data are graphically displayed in Table 3.

The results of analyses by t-tests are shown in Table 4. Statistically significant results (p<.05) were obtained on each of the cue recognition measures. As was seen with the junior students, cue recognition in relation to familiar situations resulted in higher pretest scores than were obtained in relation to new, unfamiliar events. These data are shown in Table 4.

Table

TABLE 5DECISION MAKING - JUNIORS

TABLE 5

DECISION MAKING - JUNIORS

Table

TABLE 6DECISION MAKING - JUNIOR STUDENTS

TABLE 6

DECISION MAKING - JUNIOR STUDENTS

Table

TABLE 7DECISION MAKING - SENIORS

TABLE 7

DECISION MAKING - SENIORS

Table

TABLE 8DECISION MAKING - SENIOR STUDENTS

TABLE 8

DECISION MAKING - SENIOR STUDENTS

Pre- and posttest results were also obtained in relation to clinical decision-making by the students. On the initial program, "Cues, Chunks, and Clinical Inferences," junior students obtained mean scores of 68.7 on the pretest and 62.9 on the posttest. On the subsequent instructional programs, the junior students mean pretest scores were 51.4 and 23.8, while the posttest scores were 75.5 and 70.9, respectively. These scores are graphically displayed in Table 5.

T-test results obtained on the scores were statistically significant (p<.05) for the last two measures. Again, scores were highest in relation to familiar situations and much lower when new, unfamiliar situations were presented in the instructional materials. These results are displayed in Table 6.

The results from the senior students on the measures of decision-making are shown in Table 7. These data indicate mean scores of 68.1 and 71.3 on the measures relating to the program "Cues, Chunks, and Clinical Inferences." Scores of 25.0 and 46.4 were obtained on the measures for the program "Community Health Nursing: That First Home Visit." The scores obtained in relation to the program "Decision Making in Leadership Situations" were 53.5 on the pretest and 65.6 on the posttest. These data are displayed in Table 7.

As is shown in Table 8, statistically significant results (p<.05) were obtained in relation to the community health and leadership situations. Both of these programs introduced new situations to the students, while the initial program ("Cues, Chunks and Clinical Inferences" ) applied decision making to non-complex and relatively familiar events.

Interpretation and Conclusions

Teaching the identification of relevant cues, sorting and linking of cues, and decision making was achieved in this study. While students have a base of previous life experiences, what was noted in this study was that, when confronted with a new subject or new environment, such as a complex nursing situation, the students did not have prior experience upon which to establish priorities.

Frequently, the students leapt to incorrect conclusions based on an inadequate data base. Perhaps, students learned that right or wrong, they must quickly arrive at conclusions. The making of accurate and efficient decisions is essential to nursing practice, especially in rural settings where resources are limited. As shown in this investigation, the use of CAI simulations provides a relatively riskfree environment for learning and testing decision-making processes.

These findings indicate that the subjects in this study displayed the characteristics of the novice. That is, when presented with cues within clinical situations, each cue was viewed as an independent, and equally meaningful, piece of data. This approach results in the necessity to learn a fantastically large number of separate responses. As a result, incorrect clinical judgments were made, as each item was viewed as having equal priority.

The findings also indicate that the novice, or student, must have multiple opportunities to develop astute cue recognition and accurate decision-making abilities. The fact that mean scores on each of the posttests for the final program in each sequence were considerably higher than the initial results supports the need for multiple learning opportunities to be provided. One might wonder what the results would be in relation to increasing accurate clinical judgment abilities if all students had multiple situations such as those in this study which required the development of decision-making abilities. Theoretically, teaching may be found to be more effective than experience for developing clinical judgment.

Following the teaching from the CAI, however, both junior and senior students began to utilize the concepts of sorting of cues, and linking, or chunking of cues. The sorting means that some items are viewed as being relevant while others do not pertain to a situation at the moment. The linking of cues enabled students to view cues as groups, rather than single items. The posttest scores indicated that in this study, accuracy of cue identification in relation to selecting relevant cues increased. Rather than choosing every option, the students selected more of the pertinent cues. The linking of cues indicated changes in the manner in which information was utilized in making inferences or clinical decisions.

Several conclusions were drawn from this investigation. Based on these findings, cue sorting and recognition can be taught, rather than relying solely upon experience as the teacher of clinical judgment abilities. Experience, or trialand-error learning, is based upon the assumption that the learner knows how to recognize cues. This basic precept is very likely to be totally fallacious! The results of this study indicate that linking, or chunking of cues, can also be taught. The effects of these teachings are improvement in the ability to make decisions and the accuracy of the clinical decisions.

Another conclusion which was drawn from this study was that learning from carefully and systematically designed CAI occurred readily. The subjective responses of the students were very supportive of this mode of instruction and of this approach to presenting clinical situations and the accompanying clinical teaching.

In consideration of these findings, educators need to develop, validate, and utilize clinical situations which are designed to deliberately and systematically teach cue recognition, sorting, and clinical decision-making abilities. As shown in this study, clinical judgment and clinical decision making can be taught. Improvement in nursing practice results from teaching cue identification and the steps in decision making.

References

  • Balla, J.I. (1982). Use of critical cues and prior probability in decision-making. Methods of Information in Medicine, 21, 9-14.
  • Baumann, A. & Bourbonnais, F. (1983). Decision-making in a crisis situation. Canadian Nurse, 79, 23-25.
  • Carnevali, D.L. (1983). Nursing care planning: Diagnosis and management (3rd ed.). Philadelphia: J.B. Lippincott.
  • Carnevali, D.L., Mitchell, P.H., Woods, NF. & CA. Tanner. (1984). Diagnostic Reasoning in Nursing. Philadelphia: J.B. Lippincott.
  • Chase, W.G. & Simon, H.R. (1973). Perception in chess. Cognitive Psychology, 4, 55-81.
  • del Bueno, D.J. (1983). Doing the right thing: Nurses' ability to make clinical decisions. Nurse Educator, 8, 7-11. A
  • Feltovich, P.J. (1983). Expertise: Reorganizing and refining knowledge for use. Professions Education Research Notes, 4, 5-9.
  • Larkin, JH. (1983). A general knowledge structure for learning or teaching science. In A.C. Wilkinson (Ed. ), Classroom computers and cognitive science, (pp. 51-69). New York: Academic Press.

TABLE 1

CUE IDENTIFICATION- JRS

TABLE 2

CUE IDENTIFICATION - JUNIOR STUDENTS

TABLE 3

CUE IDENTIFICATION- SRS

TABLE 4

CUE IDENTIFICATION - SENIOR STUDENTS

TABLE 5

DECISION MAKING - JUNIORS

TABLE 6

DECISION MAKING - JUNIOR STUDENTS

TABLE 7

DECISION MAKING - SENIORS

TABLE 8

DECISION MAKING - SENIOR STUDENTS

10.3928/0148-4834-19861001-05

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