Journal of Advanced Nursing, 1996, 24, 24-30

Decision making in community nursing: an

analysis of the stages of decision making as they
relate to community nursing assessment practice
Alison Bryans MSc BA RHV RGN RNT
Research Fellow/Lecturer

and Jean Mclntosh PhD BSc(Soc) SRN

Professor of Community Nursmg Research, Glasgow Caledonian University,
Glasgow, Scotland

Accepted for publication 18 August 1995

BRYANS A & MclNTOSH J (1996) foumal of Advanced Nursing 24, 24-30

Decision making in community nursing, an analysis of the stages of
decision making as they relate to conmiunity nursing assessment practice
This paper considers the nature of decisions made in the context of commiinity
nursing practice, m the light of the stages of decision making distilled hy Carroll
& Johnson from the work of various theorists, and explores the relevance of each
stage to community nurses' decision making Illustrative examples of specific
theoretical perspectives are included throughout the paper The discussion forms
part of the literature review for research currently hemg undertaken hy the authors
into patient assessment hy community nurses As decision making IS a key
element of community nurses' assessment practice, the paper argues that decision
making theory forms a useful conceptual framework for investigating this aspect
of community nursing

TMTPnnTTPTinM Each of the stages will be discussed, along with

The body of decision research is large and complex, con-
ceptually difficult and has its share of controversial issues
Community nursing practice is equally complex, less re-
se^ched than hospital nursing and not generally well
understood Nurses working m the community often face
different decision-making challenges from those encoun-
tered by their hospital colleagues When examining this
aspect of community nursing, it is important to develop an
understandmg of theones of decision making m order to
establish which components of decision making models are
particularly important m the context of commumty nursmg
practice This paper will explore the stages of decision
making distilled by Carroll & Johnson (1990) from 'the
comments of several theonsts' m order to cleuify their
relevance for research into community nursing practice
Correspondence Alison Bryans Research Fellov^/Lecturer, Department of
Nursmg and Commumty Health, Glasgow Caledonian University City
Campus Cowcaddens Road, Glasgow G4 0BA Scotland
predomi-nant models and theories, and with specific
reference to the nature of nursmg decisions made m
commumty settings
^^^ CONCEPT OF A DECISION
Carroll & Johnson (1990) begin their comprehensive
over-view of decision research by considering the
nature of decision making They descnbe the concept
of a decision as 'a shorthand for mental activities that
recognise and stmcture decision situations and then
evaluate preferences to produce judgements and
choices' (present author's emphasis)
The preliminary stages of recognition and structuring of
decision situations included m Carroll & Johnson's (1990)
description tend to be neglected m discussions of decision
making ui nursing practice For example, Baumann &
D^ber (1989) define decision makmg BS 'SltuaUons m
whlch a choice IS made among a number of possibl
alternatives, often uivolvmg trade-off among the values

24 1996 Blackwell Science Ltd


given to different outcomes' This defimtion's mclusion of
'trade-off' among outcome values has special appeal to
those mterested in decision makmg by community nurses,
as its adoption by the authors of a recent study of decision
making by community nurses would suggest (Orme &
Maggs 1993) However, it does not draw attention to the
important preliminary stages of the decision-makmg
process
Models and theones of decision-making
It IS noteworthy that, although most decision-making
theory emanates fi"om the discipline of psychology,
decision research has also been undertaken m such diverse
fields as organizational behaviour (Emhom & Hogarth
1975), consumer research (Johnson & Russo 1984), econ-
omics (Crether & Plott 1979), nursing and medicine (Orme
& Maggs 1993), and it appears to be a burgeoning field
, (Arkes & Hammond 1986) It is therefore hardly surpnsmg
- that models and theones reflect this wide diversity of inter-
ests The components of the decision-making process f which
are included or emphasized in a model or theory
J depend largely on two related factors the perspective of a
theonst or mvestigator and the nature of the decisions
^ imder consideration The eclectic approach taken here has
been adopted m an attempt to cleeirly identify those com-"
ponents which will be most helpful m researching I decision
making by community nurses
The seven stages of decision makmg
Carroll & Johnson (1990) outline seven temporal stages of
decision making, acknowledging that these stages may not
simply be followed through m their given sequence, but I
may 'repeat and backtrack m a complex way ' The stages
I There are two important points to be made here Firstly,
1 recognition,
2 formulation,
3 alternative generation,
4 information search,
5 judgement or choice,
6 action,
7 feedback
THE STAGES OF DECISION MAKING
AND COMMUNITY NURSING PRACTICE
The first two stages, problem recognition and formulation,
can be descnbed as predecisional activity and involve
exploration and classification of the situation by the
decision maker The nature of a nurse's predecisional
activity will depend on vanous factors, mcludmg her state
of preparedness and her personal view of her role, as well
as the situation or task itself This important phase of
1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
Decision making m community nursing
decision making is generally less conscious and deliberate,
and more difficult to articulate, than subsequent phases It
therefore tends to be neglected m decision research Elstem
et al (1978), for example, proposed a four-stage model for
medical decision making which begms with data
collection, thus completely excluding the predecisional
phase
This exclusion of all but the rational aspects of the
decision maker fi^m the study of decision making is
closely related to the adoption of a behavioural model as
the theoretical basis for decision research According to
Simon (1986), the behavioural model of decision making
suggests that 'human rationality is very limited, very much
bounded by the situation and by human computationsd
powers' He argues that there is 'a great deal of empmcal
evidence supporting this kind of theory as a valid descnp-
tion of how human beings make decisions' This evidence
explains the appeal of such a model to empmcal research-
ers However, the behavioural model of decision making
appears limited by its failure to take into account the nature
of the decision maker and the lnfiuence of such factors as
his or her prior learning and personal goals withm the
decision-making process
The assumption that data collection or information gath-
ermg is the first step on a decision-making journey is also
reminiscent of nursing process approaches to patient care,
and of the use (or misuse) of nursing models merely as
frameworks for collecting and documenting information
about patients Systematic approaches to nursing care tend
not only to imply that each nurse will recognise and class-
ify patient problems or requirements in the same way as
his or her colleagues, but to suggest that this is desirable
emd vnW result m better patient care In other words, it is
implicitly assumed that all 'good' nurses will explore and
classify situations m the same way
It IS axiomatic that excellent nursing practice requires the
nurse to be highly flexible and responsive to the special
requirements of individual patients A predetermmed
approach is unlikely to encourage such flexibility Nursing
care provided m pabents' homes is even more idiosyn-
cratic than hospital care because of the sheer diversity to be
found m people's home environments, lifestyles, family
and neighbourhood support systems In such a changing
work context, the ability to be flexible is a key-stone of
effective practice
The second important point is that a nurse bnngs his or
her own unique collection of pnor knowledge and inter-
pretive frameworks (Schon 1987) to any decision-makmg
task He or she is not a tabula rasa, but a uniquely pro-
grammed and constantly self-programming individual The
nature of this mtnnsic personally-owned knowledge IS
elusive and community nurses have difficulty in descnbing
it (Luker & Kennck 1992) A more readily ident-ifiable
determinant of predecisional activity is extrinsic
25
A Bryans and f Mclntosh
knowledge, or mformation denved from external sources A
good example of this is the information which com-munity
nurses receive through a referral request, which has an
obvious bearmg on a nurse's potential decision making
Indeed, inadequate referral mformation is often a real
problem for community nurses, especially when deal-ing
with terminally ill patients It is important to acknowl-edge
the role of a practitioner's unique collection of knowledge,
both intrinsic and extnnsic, in a study of nurses' decision
making
It has been argued that mtuition has an important role to
play m expert nursing performance (e g Benner & Tanner
1987) and there appears to be a link between the use of
expenentially gained knowledge and the role of intuition in
predecisional activity Simon (1986) views intuitive theory
as a component of behavioural theory, which emphasizes
experts' recognition processes and the accessibility of prior
expenence stored in memory (present author's italics)
Insofar as recogmtion processes form the basis of effective
problem-recognition, they are at the heart of expert
decision making
The importance of the predecisionai phase has also been
highlighted by decision-making research m the sphere of
business management, which descnbes the avoidance of
definmg and/or making decisions (Corbm 1980, Isenberg
1984) These studies bring to mmd the saying 'To do
nothing IS to take sides' In some situations, failure or
refusal to either recognize a problem or define it as such
will have considerable repercussions
Withm the specific context of commumty nursing
assessment, failure to recognize a potential decision-
makuig task, or deliberate avoidance of a decision, may
limit subsequent nursmg mterventions Problem recog-
nition and formulation can thus be viewed as intimately
related to professional perceptions of health care need
Because a practitioner's predecisional activity will strongly
influence his or her subsequent view of a patient's 'actual
health state', and approach to 'settling the goal of health
care need' (Liss 1993), such activity is important for
research m this area
REAL WORLD CONSTRAINTS ON
DECISION MAKERS
While a community nurse's exploration and classification
of a patient's situation will depend to a considerable extent
on intrinsic factors outlined above, the potential influence
of external 'real world' constraints, such as the demands of
the caseload or the availability of local health care
resources, must also be acknowledged For example, a
nurse who is working under severe time constraints (per-
haps because of a larger than average number of termmally
ill patients on his or her caseload) may, understandably,
choose to postpone certain decisions about a patient who
IS less ill because he or she realizes the workload
26 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
imphcations of such decisions Conversely, it may be poss-
ible to offer extra help to a patient or carer if caseload
demands are lighter than usual
An mteresting study of caseload management by distnct
nurses draws attention to the increasing importance of
caseload muc (Badger et al 1989) A further example of the
influence of 'real world' factors on the decision-making
process is that of a nurse who happens to know of several
free places m a day hospital in the locality for elderly
people suffenng from dementia Armed with such knowl-
edge, this nurse may well be more likely to explore the
needs of someone canng for such a person The importance
of such factors is not unique to community nursmg prac-
tice Lawrence (1988), m a recent study of expertise m
judicial decision making, discusses the 'environmental
factors which constrain and interact with a magistrate's
processmg [of information]' She notes that these include
certain legal constraints, such as the law of evidence, and
heavy caseloads
The context of practice can thus be seen to influence
problem recognition and formulation m that it imposes real
life constraints, such as limited time and resources, on a
decision maker The practice context therefore forms a
legitimate focus for the study of decision makmg m
community nursmg practice
The 'common sense' view of decision making
Stages 3, 4 and 5, alternative generation, information
search and judgement or choice, form what Carroll &
Johnson (1990) refer to as the 'common sense' view of
decision making Alternative generation (stage 3) involves
creating hypotheses, information is then gathered about
these hypotheses (stage 4) in order to allow the decision
maker to rate the importance of vanous attnbutes (judge-
ment) and to choose from the alternatives (choice)
Judgement and choice are used with these specific mean-
mgs m decision-making research by cognitive psychol-
ogists Information search has been the focus of decision
research which employs search methods
The aim of such methods is to 'momtor the physical
behaviours used to acquire information as people make
decisions [m order to] infer the cognitive processes
underlying the decisions' (Carroll & Johnson 1990) Search
methods include the use of sophisticated equipment which
can detect eye movements, for example, and tend to be
intensive, time-consmmng and laboratory-based Because
these research techniques require short, one-off, problem-
solving decision tasks, they are of limited value in the study
of longer, complex verbal tasks such as patient assessment
Interestmgly, these three stages have been the focus of
most research mto clinical decision making, to the virtual
exclusion of other aspects of the decision-makmg process
and the decision maker The question of how relevant
 Decision making m community nursing

these particular stages are to the study of nurses' decision- are generated by doctors when they first encounter a
makmg must therefore be posed patient They explain that medical hypotheses 'are not
necessanly diagnostic entities, they can represent anatom-
Decision making and problem solving ical, physiological, patho-physiological or aetiological
explanations for the problem encountered As such, they
These three stages tend to be associated with problem- rcuige from non-specific ideas such as "a heart problem"
solvmg approaches and with the hypothetico-deductive to very specific diagnoses such as "aortic insufficiency
model which has been prevalent m the field of medical sec-ondary to rheumatic heart disease" Doctors often start
decision-makmg research A typical example of such an with non-specific hjrpotheses, and as the patient's problem
approach to decision making is an early study by Barrows becomes better defined through enquiry, will generate
& Bennett (1972) of 'the diagnostic (problem solving) skill more specific hypotheses to refine the enquiry'
of the neurologist', whose summary of 'what seems to be In this mibal, uncertain, phase the word hjrpothesis is
going on cognitively m the good neurologist' rests firmly not bemg used in the specific scientific sense but in the lay
withm the confines of these three stages of decision making sense of 'a possible explanation for something' A degree of
They delineate the process as 'the eeirly appear-ance of uncertainty and vagueness is permitted m the lay sense of
hypotheses almost before the interview begins, [asking] the term However, it is important to note the specific and
enquiry-oriented questions aimed at achiev-ing specific objective nature of the adjectives used by these authors
items of information and [asking] questions that are part of anatomical, physiological, patho-physiological and
his routine functional enquiry to assist in his mental their clear orientation towards physi-cal care The authors
ranking of hypotheses' descnbe this lmtial, non-specific hj^othesizmg as divergent
The aim of such studies is to provide an accurate picture or inductive thinking which takes place in order to
of the expert clinician's problem solvmg approach, which generate 'more specific hypotheses to refine the enquiry'
will serve to inform clinicians, educators and medical stu- The purpose, to reach a stage at which more specific
dents There is an underlying assumption that the hypo- hypotheses may be generated, is clear The medical
thetico-deductive model is the model of choice, and vnl\ decision-maker is already on course, heading towards the
provide a helpful structure for education and practice This diagnosis
assumption has been challenged more recently by Groen & Later, specific hypotheses perhaps bear a closer resem-
Patel (1985) They cite cognitive psychology research blance to scientific hypotheses, m that 'unsatisfactory
which compares expert-novice behaviour to sup-port their hypotheses are set aside and new ones generated as the
arguments that 'the use of the hypothetico-deductive enquiry progresses', thus guiding questioning and physical
method is characteristic of novices rather than experts' and exammation of the patient The second stage of the clinical
'experts use methods which are dependent on a highly reasoning process, in which such specific hypotheses are in
elaborated and structured knowledge base' use, IS descnbed by Barrows & Feltovich (1987) as rep-
Groen & Patel acknowledge that 'there must be some- resenting 'convergent, vertical or deductive reasoning that
thing effective about the h3fpothetico-deductive method' as instantiates to the particulars of the patient from a set of
a teaching technique, given its extensive current use, but generic explanations'
express strong reservations about its use m the process of
scientific investigation Their thinking stems in part from
the philosophy of Popper (1968) and of histonans of Structured and less structured problems
science such as Kuhn (1970) Popper pointed out a basic The nature and purpose of alternative generation, infor-
logical flaw m the hypothetico-deductive method, that a mation search and judgement m the clinical reasoning pro-
hjrpothesis can never be rejected, only confirmed Kuhn's cess descnbed by Barrows & Feltovich (1987) differs from
well-respected contribution to the history of knowledge the process of patient assessment m community contexts
views the process of scientific discovery as far from m certain important respects Even the most ill-structured
rational and suggests that the h5^othetico-deductive medical problem is likely to have a generally acceptable
method is 'a rhetorical device [which] is extremely useful solution and end-point, that is, diagnosis
in communicating the results of scientific research' (Croen Only some problems in nursmg practice have such end-
& Patel 1985) points For example, an interesting study by White et al
(1992) of decision making by gynaecological, obstetnc and
family nurse practitioners used interactive video and com-
THE NATURE OF HYPOTHESES
puter simulation to explore the process by which nurse
Barrows & Feltovich (1987) shed considerable light on practitioners diagnosed the cause of a patient's specific
Carroll & Johnson's (1990) stages of alternative generation, complamt and prescnbed the appropnate drugs They
mformation search and judgement or choice, m the course reported that 'nearly all data acquired was S3rmptom-
of their discussion of the nature of the hypotheses which dnven, directly related to the hypothesis formulated'

1996 Blackwell Science Ltd, Journal of Advanced Nursmg, 24, 24-30 27

A Bryans and f Mclntosh
Unfortunately, only 27 subjects were mvolved, tools do not
appear to have been tested and the study does not yet
appear to have been rephcated, so the importance of their
findmgs IS uncertain The context of this study also differs
from that of current community nursing practice m the UK
However, the point is that their decision-makmg task had a
nght answer, and a hypothetico-deductive, decision-
analysis or problem-solving approach would thus seem
appropnate
Some aspects of nurses' decision making in community
settings, such as the appropnate treatment of a leg ulcer,
could reasonably be exammed usmg such em approach
However, other aspects of assessment are much less clear-
cut and much more long-term For example, the promotion
of adequate nutntion of an elderly patient may involve other
agencies and raises complex issues regarding the
acceptability of vanous available strategies for the patient
Deciding how best to achieve the goal will be a slow pro-
cess, which IS dependent upon leammg ahout the patient,
rather than simply possessing knowledge about nutntion
Deductive reasoning will be of little value in such a situ-
ation There is no one, obviously correct, solution to this
problem Many of the decisions made in the course of
community nursing practice are of this nature
Voss & Post (1988) make a useful distinction between
'social science problem solving' which 'basically involves
planning' and problem-solving activity in the field of
medicine, which more often involves 'right answers' A large
number of commumty nursing problems fall into the
psychosocial bracket, rather than into the category of
physical care Because of the distinction between the two
types of problem solving, it is important not to import
models from medical decision-making research for use in
nursmg research, unless the nursing decisions bemg
investigated already have clear and unambiguous solu-tions
or 'right answers' However, perhaps because medi-cal and
nursing professions both work at the 'coal-face' of patient
care, and a substantial body of research mto medi-cal
problem solving and decision making already exists, it IS
tempting for nursmg researchers to import theories and
models from medical research
Decision analysis
One imported approach which also focuses on alternative
generation, information search and judgement is decision
analysis Here 'a model of the problem is constructed,
showing the avmlable options which are to be considered
and the consequences of following each' (Harbison 1991)
Outcomes are given a score related to the benefit of the
patient and the best option is thus rendered computable
Although it may be useful for certain 'diagnostic' aspects of
nursing, perhaps m relation to physical care and man-
agement of symptoms, the use of this technique has been
cnticized (Baumann & Deber 1989) as unsuitable for
28 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
nursmg's process-onentated approach to care It is cer-tainly
difficult to see the usefulness of this approach to the study
of decision makmg m the context of community nursmg,
where the sconng of outcomes, just like the rank-ing of
hypotheses, is likely to be problematic, if not impossible
The real world of patient care is made up of 'messy,
lndetermmate situations' (Creenwood 1993) where best
outcomes may be very much a matter of opinion, and
ranking hypotheses either difficult or meanmgless
THE CONTINUOUS NATURE OF
COMMUNITY NURSING ASSESSMENT
Medicine also shares some of the d5mamic, mteractive
aspects of patient assessment and decision making with
nursing, as can be illustrated by the following issues which
are bemg raised about information search Recent research
into medical decision-making (Barrows & Feltovich 1987)
draws attention to the mappropnate nature of problems
which have generally been used m medical decision
research Traditionally, such problems have been highly
structured and complete, unlike those which face medical
decision-makers m the real world of practice In a recent
paper about the climcal reasoning process m medicine, the
authors argue cogently that 'it is important to recognize that
clinical problems are lU-structured and that the doc-tor's
reasoning is built around a temporal unfolding of
information' (Barrows & Feltovich 1987 present author's
italics) They argue that studies which do not take account of
this reality are likely to be of limited value
The idea of a temporal unfolding of information will be
familiar to community nurses, who view patient assess-
ment very much as a continuous process, rather than as a
one-off event (Cowley et al 1994) It is crucially important
to acknowledge this when designmg research mto
community nurses' decision making
CHALLENGING DOMINANT MODELS
Challengmg traditionally accepted medical models of
decision making with a problem-solving focus is a pro-
ductive activity for reseeirchers mto decision making m
nursing It is of value because it helps to alert the nurse
researcher to the existence of predetermined views of the
nature of decision making in health care and to the notion
that less limited models than those used by researchers mto
climcal decision-making m medicme may be more useful
for nursing research
In the words of Rhodes (1985), 'theoretical models are
useful to the extent that they nurror or represent reahty' If
models are not to limit and constrain a researcher they must
be broad and mclusive of the realities of the area being
researched Models with a problem-solving slant, with their
charactenstic focus on alternative generation, mformation
search and judgement or choice, are not

sufficiently mclusive of the reahties of commumty nursu^
practice As well as excluding predecisional activity, they
fail to acknowledge the importance of action and feedback
m the decision-making process
Process approaches versus input/output
approaches to decision making
The last two stages described by Carroll & Johnson, action
and feedback, do not feature at all in some models of
decision making (for example, that used by Elstein et al
(1978), which finishes with hypothesis evaluation)
However, the influence of feedback in modifying decision
behaviour is mcreasingly recognized by those researchers
m the field of decision making who are interested in
mtervenmg processes m decision making (e g Nisbett &
Ross 1980), rather than merely m 'the relationship between
inputs and output' (Carroll & Johnson 1990)
THE DYNAMICS OF DECISION MAKING
The role of feedback forms a fascinatmg natural link
between the areas of decision research, adult learning
theory, practical reasoning, and theones of expertise
Unfortunately, discussion of these related areas is not
within the remit of this paper
Klemmuntz (1985) argues that success m decision
making depends on 'the availability of feedback and
opportunities for taking corrective action based on that
feedback' A recently-coined phrase 'decision taking'
(Carroll & Johnson 1990) usefully includes decision
making and subsequent action and feedback The mclusion
of action and feedback m models of decision making has
particular relevance to the study of community nursmg
assessment Because such assessment is djmamic and
continuous in nature (Cowley et al 1994), its relative
success and the effectiveness of subsequent patient care
depends to a considerable extent on a nurse's inter-
ventions, patient responses to these interventions, and the
nurse's appropriate utilization of information gained from
feedback
Although feedback has the potential to influence all
phases of the decision-making process, its impact on
guiding mformation gathering is of particular interest for
any study which aims to focus on the realities of com-
munity nursing practice Some decision tasks may be
rendered more difficult by lack of information For
example, m a study of judicial decision-making,
Lavirrence (1988) quotes a magistrate descnhmg his
efforts to maximize the quality and quantity of information
he uses 'AH you can do is push the sides out you are still
constncted at some stage' In the context of community
nursing assessment, too much mformation is perhaps a
more probable scenario Because the 'sides' can be pushed
out m vanous directions over a considerable
1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 24-30
Incision making m community nursing
penod of tune, an overwhelming amount of mformabon
may become available to the community nurse He or she
must therefore use feedback as one means of limiting and
directmg mformation-gathenng activities
In addition to gathenng important mformation from the
pabent and the external environment, information already
stored m his or her memory will influence the nurse's use
of feedback As well as possessing generalized knowledge,
more expenenced practitioners will be able to draw bom a
well of 'particularized' or 'craft-based' knowledge
(Mackenzie 1992) which they have accrued over time
Feedback is therefore likely to play a vital role m guiding
information search, and any study which is attempting to
understand assessment practice must necessanly take
cognisance of this
RELEVANCE TO COMMUNITY
NURSING PRACTICE
This paper has argued that the seven stages of decision
making outlined by Carroll & Johnson offer a promising
conceptual base from which to explore the decisions made
by community nurses In particular, the broad perspective
provided by the adoption of such a framework acknowl-
edges some key features of community nursing practice
These include the uncertain and ill-structured nature of
many problems encountered by community nurses, the
d3rnamic and interactive nature of practice, the associated
phenomenon of the temporal unfolding of information
about the patient and also the influence of the climate or
context of caring
While decision making is integrated mto community
nursing practice as a whole, a particularly fruitful aspect of
practice through which the authors have chosen to explore
all stages of the decision-malang process is the lmtial
assessment visit Dunng such a visit, the commumty nurse
may be confronted with a range of patient problems Some
of these are discrete and easily recognized, while others
are lmked to and dependent upon vanous circum-stances m
the patient's life which are likely to remain hidden unless
they are explored by the nurse In view of the fact that the
patient and nurse are strangers to each other, this
exploration must be skilfully negotiated by the community
nurse if he or she is to appropnately frame needs and thus
begin the process of addressing these needs and planning
smtable care
The community nurse's pnor knowledge, the recog-
mtion processes which this knowledge informs and the
context of practice will together influence the assessment
and subsequent care offered to the patient Key elements of
pnor knowledge include the technical, rationed aspects of
knowledge, such as pathology and physiology, as well as
know-how or professional artistry (Schon 1987) The
community nurse must know how to engage in the process
of assessment in such a way as to gain and utilize relevant
20
 A Bryans and f Mclntosh
information while at the same time securing the patient's
trust uid confidence
Conclusion
The research study on which the authors are engaged has
shown that the breadth of conceptual base provided by
Carroll & Johnson's (1990) distillation of decision-making
theones facilitates examination of the whole process of
assessment Carroll & Johnson have provided a framework
for the examination of important issues relating to the
nature of the decision maker, professional artistry, the
expenential knowledge base of commumty nursing and the
use of feedback, as well as the judgements and nursing
actions which are the product of an assessment visit It is
hoped that m exploring the utility of such a framework, a
significant contribution to understanding the professional
expertise of the community nurse will be made
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