dm theories
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dm theories

Course Number: 107 603, Fall 2008

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N U R SI N G T H E O R Y A N D C O N C E PT D E V E L O P M E N T O R A N A L Y SI S Cognitive Continuum Theory in nursing decision-making Rafk Cader BA MSc DN CertEd RGN RMN Senior Lecturer, School of Health, Community and Education Studies, Northumbria University, Newcastle Upon Tyne, UK Steve Campbell BNurs PhD RGN RSCN RHV NDNCert FRSH Head of Research and Development, Education and Training Centre, City...

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U N R SI N G T H E O R Y A N D C O N C E PT D E V E L O P M E N T O R A N A L Y SI S Cognitive Continuum Theory in nursing decision-making Rafk Cader BA MSc DN CertEd RGN RMN Senior Lecturer, School of Health, Community and Education Studies, Northumbria University, Newcastle Upon Tyne, UK Steve Campbell BNurs PhD RGN RSCN RHV NDNCert FRSH Head of Research and Development, Education and Training Centre, City Hospitals Sunderland, Sunderland, UK Don Watson BA MPhil PhD CPsychol AFBPsS Emeritus Professor of Applied Psychology, School of Health, Community and Education Studies, Northumbria University, Newcastle Upon Tyne, UK Accepted for publication 21 June 2004 Correspondence: Rafk Cader, School of Health, Community and Education Studies, Northumbria University, Manor House, Coach Lane West, Newcastle Upon Tyne NE7 7XA, UK. E-mail: C A D E R R . , C A M P B E L L S . & W A T S O N D . ( 2 0 0 5 ) Journal of Advanced Nursing 49(4), 397405 Cognitive Continuum Theory in nursing decision-making Aim. The purpose of this paper is to analyse and evaluate Cognitive Continuum Theory and to provide evidence for its relevance to nurses decision-making. Background. It is critical that theories used in nursing are evaluated to provide an understanding of their aims, concepts and usefulness. With the advent of evidencebased care, theories on decision-making have acquired increased signicance. Method. The criteria identied by Fawcetts framework has been used to analyse and evaluate Hammonds Cognitive Continuum Theory. Findings. There is empirical evidence to support many of the concepts and propositions of Cognitive Continuum Theory. The theory has been applied to the decision-making process of many professionals, including medical practitioners and nurses. Existing evidence suggests that Cognitive Continuum Theory can provide the framework to explain decision-making in nursing. Conclusion. Cognitive Continuum Theory has the potential to make major contributions towards understanding the decision-making process of nurses in the clinical environment. Knowledge of the theory in nursing practice has become crucial. Keywords: decision-making, evaluation, nursing information, intuition, cognitive continuum, task continuum Introduction The implementation of evidence-based care in clinical practice has increased the need to understand decision-making in nursing. The purpose of this paper is to show how Cognitive Continuum Theory can contribute towards such an understanding. There is evidence of discussions on the Theory in the nursing literature (Luker et al. 1998; Thompson 1999; Harbison 2001; Lauri et al. 2001). Thompson (1999) argued for the appropriateness of Hammonds Cognitive Continuum 2005 Blackwell Publishing Ltd Theory in providing a middle ground for decision-making in nursing practice. The theory, being both prescriptive and descriptive, also prompted Harbison (2001) to endorse its application to nursing practice and research. Evaluating a theory is important to provide an understanding of its aims, concepts and usefulness. Fawcetts (1993) framework is useful for the purpose of analysing and evaluating Cognitive Continuum Theory as applied to nursing because it is both comprehensive and a suitable for middle-range theory. Many theoretical frameworks that are being used to 397 R. Cader et al. generate research questions and hypotheses in published research in nursing tend to be middle-range theories from other disciplines (Moody et al. 1988). McKenna (1993, p. 126) perceives borrowing knowledge from other disciplines as one of nursing greatest strengths. The literature, however, provides many examples of the need to advance the discipline of nursing by the development of theories unique to nursing (Crow 1982; Jennings 1987). It has been argued that nonnursing theories do not reect the uniqueness of nursing (Draper 1990), but the literature also includes evidence on the contributions of theories from other disciplines to nursing. One example is Banduras (1977) Self-Efcacy Theory, which has been used by practitioners to empower clients through education (Oetker-Black & Kauth 1995; Fleming et al. 2003). Another example is Ajzen and Fishbeins (1980) Theory of Reasoned Action, which has helped to inform studies on nurses attitudes and caring behaviour (McKinlay et al. 2001). In the eld of nurses decision-making, the need for increased quality (Harbison 2001) and for nurses to be accountable for their decisions (Dowding & Thompson 2002) point to an apparent knowledge decit. Cognitive Continuum Theory, as a middle-range theory, can help to bridge this knowledge gap. Focusing on middle-range theories is the appropriate stage for knowledge development in nursing (Blegen & Tripp-Reimer 1997), as middle-range theories have greater potential to guide research (Lenz et al. 1995). extends into evaluation so that value can be judged. Through analysis, a non-judgemental and detailed examination of the scope, context and content of the theory is carried out using the theorists published work. The result informs the evaluation process that is undertaken from interpretations and critiques by other scholars, from research reports and from reports of practical application. The evaluative criteria identied by Fawcett (1993) are: signicance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. The signicance criterion is achieved when the metaparadigmatic, philosophical and paradigmatic origins of the theory are made explicit. The criterion for internal consistency is fullled when all the elements of the theorists work are congruent and when there is semantic clarity, semantic consistency and structural consistency. To meet the parsimoniousness criterion, the theory has to be stated clearly and concisely. The testability criterion considers whether the concepts and propositions of the theory can be measured. The criterion of empirical adequacy evaluates empirical evidence for its theoretical claims. Finally, the pragmatic adequacy of the theory is judged by the educational requirements for its application and usefulness in practice. These criteria constituting Fawcetts (1993) framework are general enough to be used in the analysis and evaluation of Cognitive Continuum Theory. Cognitive Continuum Theory The Cognitive Continuum Theory (Hammond 1981) is a descriptive theory that illustrates how judgement situations or tasks relate to cognition. Hammond (2000, p. 83) asserts that judgement is a joint function of task properties and cognitive processes. The theory suggests six broad modes of decision-making based on two continua: cognition and judgement task structure. The cognitive continuum ranges from intuition to analysis, and the judgement task structure ranges from ill-structured to well-structured. The volume and nature of information cues associated with judgement tasks are crucial in Hammonds theory. The more structured a task is, the more analytically induced will be the decision-making mode. Conversely, with an ill-structured task decisionmaking is likely to be intuition-induced. Analysis of Cognitive Continuum Theory Scope of the theory Cognitive Continuum Theory focuses exclusively on judgement and decision-making. It can be appropriately classied as a middle-range, descriptive theory as Hammond offers explanations about general and specic relationships between the concepts of tasks and cognition and also about the precise relationships between the nature of tasks and modes of cognition. These have been tested by Hammond et al. (1997), Hamm (1988b) and Dunwoody et al. (2000). Context of the theory Originating from cognitive psychology, Cognitive Continuum Theory offers researchers of judgement and decision-making a framework in which the concepts of task and cognition are linked together. Hammond (2000) stresses the necessity to have a theory of task properties to parallel a theory of cognitive properties. To exemplify the concept of two parallel continua task and cognition Cognitive Continuum Theory includes the concept of task properties Fawcetts framework Fawcetts (1993) framework has two components analysis and evaluation with separate criteria for each component. Identifying a theorys strengths and weaknesses to make it more understandable is undertaken through analysis, which 398 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 Nursing theory and concept development or analysis Cognitive Continuum Theory in nursing decision-making from Social Judgement Theory, which describes the weighing and combining of information by decision-makers to make judgements (Hammond et al. 1975). Social Judgement Theory asserts that the accuracy of an individuals judgement in a situation depends on the weighting the individual attaches to the different information cues emanating from that situation. If information cues are weighted to reect the real situation, then the judgement will be accurate (Dowding 2002); otherwise an inaccuracy in judgement is likely. Fawcetts (1993) widely cited metaparadigm concepts of nursing, which are person, environment, health, and nursing and associated propositions, are not explicit as the theory was not specically designed for a nursing environment. However, as nurses are constantly in the process of making decisions that have implications for their clients health, the metaparadigm concepts of person and environment can be said to be implicit in the theory. Similarly, it can be argued that the theory clearly supports the interaction in nursing between person and environment and its linking of person, environment and health. This is because in the clinical environment nurses are constantly interacting with clients to take decisions that have a direct effect on the health of clients. The main philosophical claim made by Hammond (1996) is based on a person being capable of both modes of cognition intuition and analysis. He claims that, although these two modes of cognition have made positive contributions to modern existence, they have also suffered from imperfections. From an ontological perspective, he dismisses the view that intuition and analysis are rival forms of knowing, and questions the belief that judgement and decision-making can be either intuitive or analytical. In addition, he has argued at length that coherent and correspondence theories of truth provide the epistemological basis for Cognitive Continuum Theory: both types of inducement frequently occur in human ecologies (p. 104). He maintains that the notion of rationality (coherent theory) and the achievement of empirical accuracy (correspondence theory) are essential in making sound judgement and decisions. Reconciling these two approaches strengthens research endeavours by understanding judgement and decision-making. Modes of cognition The concept modes of cognition are not clearly dened by Hammond; however, the three dimensions associated with this concept have been clearly dened: analysis, intuition and quasirationality. Analysis is dened as a process that is slow, conscious and consistent (Hamm 1988a), and is detailed by Hammond (1988) as high cognitive control, slow data processing, high conscious awareness, task-specic organizing principle and high condence in method. Intuition involves rapid and unconscious data processing (Hamm 1988a). Its properties are detailed by Hammond (1988) as involving low cognitive control, rapid data processing, low conscious awareness, averaging organizing principle and low condence in method. Quasirationality occupies the central region on the cognitive continuum and relates to modes of cognition that include elements or properties of both intuition and analysis (Hammond 1996). The term quasirationality originates from Brunswiks (1956) extensive work in cognitive psychology. Task properties Task properties concern (i) the task complexity (number of information cues, redundancy of cues and the principle for combining information), (ii) the level of ambiguity of its content (existence of a principle to organize information, familiarity with content, potential for accuracy in judgement) and (iii) its presentation (potential for decomposition into subtasks, visual or quantitative presentation and time available to undertake the task). The two identied dimensions for task properties are: well-structured and ill-structured tasks. Well-structured tasks have properties that induce analysis. According to Hammond (1988), these tasks have a high level of decomposition, to have a high degree of certainty, and to take time to resolve. An example of a well-structured task is a nurse deciding on the signicance of the tracing from an electrocardiograph, and needs time to compare it with a normal electrocardiograph. To increase certainty in the outcome of this task, the nurse can potentially divide (decompose) the electrocardiograph into sections to facilitate analysis. Ill-structured tasks have task properties that induce intuition. According to Hammond (1988), they have a low level of decomposition and certainty, and need to be resolved quickly. For example, when a nurse attempts to support a falling patient, the speed of such an incident makes it impossible to break up (decompose) the task into its potential subtasks, with the consequence that the certainty of the outcome is low. 399 Content of the theory Central to the Cognitive Continuum Theory are the concepts of modes of cognition and task properties. Additional concepts are modes of inquiry, pattern recognition, functional relations, oscillation, and alternation (Hammond 1996). The denitions of these concepts are included for clarity and understanding. 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 R. Cader et al. Modes of inquiry Borrowed from Churchman (1971), modes of inquiry represent the different reasoning strategies needed to ensure epistemological safeguarding in decision-making (Hamm 1988a). This is justied by Hammond (1996), who states that different modes of inquiry make different demands on human judgement (p. 233). He identies the six dimensions to modes of inquiry as modes 16, with modes 13 being biased towards analysis and modes 46 biased towards intuition. Mode 1 exemplies pure analytical cognition requiring true experiments to support the evidence for decision-making. Mode 2, based on statistical inference, is seen as less analytical than mode 1 and is referred to as control-group experiments. Mode 3 is the weakest of the three analytical modes and is labelled quasi-experiments with relaxed controls because strict random assignment and double-blind experiments are not feasible. Mode 4 is labelled computer modelling and relates to thought experiments, making it less analytical than mode 3. Mode 5 is referred to as data-based expert judgement and decisions are based on expert judgement, making this mode less intuitive than mode 6. Mode 6, called unrestricted judgement, is based purely on intuitive thought. Pattern recognition refers to inference drawn from patterns of information recognized from experience. Functional relations refers to inferences made from observations of statistical data. Oscillation describes the process by which modes of cognition can change from analysis to intuition, and vice versa. Alternation occurs when there is a complete shift from pattern recognition to functional relations, or vice versa. The main propositions of Cognitive Continuum Theory are both relational and non-relational in nature and assert that: Modes of cognition can be on a continuum, depending on whether they are analytical or intuitive, with quasirationality providing the link between the intuition and analysis endpoints on the cognitive continuum. Tasks can be placed on a continuum depending on their properties, with well-structured tasks and ill-structured tasks forming the end-points of the continuum and tasks exhibiting the properties of both situated in the middle of the continuum. Properties of a task could inuence the modes of cognition on the continuum. Whilst undertaking a task, there can be oscillation between intuition and quasirational modes of cognition and also between quasirational modes and analysis. There can be alternation as modes of cognition change. Evaluating Cognitive Continuum Theory Signicance The metaparadigm concepts and propositions addressed by the theory and the philosophical claims on which Cognitive Continuum Theory is based are explicit. The conceptual model from which the theory is derived is the Social Judgement Theory and this provides the basis for some of the key propositions of Hammonds Theory, in particular the inuence of task properties on judgement and modes of cognition. Hammond (1996) claims that both intuition and analysis have properties and merits in the different contexts where they are applied. He acknowledges Egon Brunswiks concept of quasirationality when he states that Brunswick made clear the relative value of each mode of cognition (Hammond 1996, p. 90). Hammond has borrowed the concept of modes of inquiry from Churchman (1971) to set up his six modes of inquiry. He also acknowledges the psychologist Edwards (1954) for introducing the coherence approach in judgement and decision-making (Hammond 1996). The special signicance of this Theory is that it counteracts the traditional view that judgement and decision-making can be either intuitive or analytical. Instead it presents a unifying theory for these two modes of cognition, with quasirationality establishing the link between them. Internal consistency The Cognitive Continuum Theory is congruent with the philosophical claims and conceptual model on which it is based. Semantic clarity is evident, in particular, in providing comparable denitions for both intuition and analysis. This has an important implication for the four middle range modes of cognition relating to quasirationality, because two of these are biased towards intuition and the other two are biased towards analysis. Semantic consistency is evident in Hammonds published work in the consistent use of terms, with the same denition attached to each of them. There are no concept redundancies, as each concept contributes something unique to the theory. Analysis of the Theory indicates that it is structurally consistent. Parsimony Hammond offers a detailed explanation of his concepts and propositions, with many illustrative examples (Hammond 1981, 1996, 2000). Whilst the use of such examples from many situations justies the relevance of the theory in many 400 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 Nursing theory and concept development or analysis Cognitive Continuum Theory in nursing decision-making areas of decision-making, it also serves to ensure clarity. The analysis reveals that the Theory is made up of seven major concepts, some of which have two or more dimensions. To achieve a parsimonious presentation of the theory, some terms have been grouped as dimensions of others. For example, the explanation Hammond offers for intuition, analysis and quasirationality clearly identies them as dimensions of the concept of modes of cognition. Similarly, well-structured and ill-structured tasks have been identied as the dimensions of the concept of task properties. It is also clear that the modes of inquiry concept has six dimensions in the form of modes 16. Extensive explanations of the concepts and propositions (Hammond 1996, 2000) have served to clarify the complexity of the Cognitive Continuum Theory without oversimplication. On the whole, the arrangement of the concepts, as shown in the analysis section, provides a parsimonious structure for the theory. Empirical adequacy Hammond et al. (1997) undertook the rst application of Cognitive Continuum Theory with highway engineers. The engineers were asked to undertake nine judgement tasks relating to aesthetic, safety and capacity of highways. It was found that the closer the engineers were on the cognitive mode predicted by the task structure, the better was their overall judgement performance. The relationship between tasks and modes of cognition was also demonstrated by Dunwoody et al. (2000) in their study with undergraduates. Hamm (1988b) also showed that the cognitive activity of highway engineers does move back and forth between intuition and analysis as they undertook sub-tasks to complete their overall tasks. All these studies have shown the interaction between cognitive modes and task structure. Lauri et al. (2001) conducted an investigation on the process of decision-making used by Registered Nurses working in elder care and medicalsurgical wards in Canada, Finland, Sweden, Switzerland and the United States of America (USA). They used a structured based questionnaire on the Theory, and found that nurses used ve models of decision-making represented by analytical, intuitive, and quasirational modes of cognition. Hence, on a worldwide basis, nurses from short-term and long-term care environments have been shown to use cognitive processes that are reected in the Theory. A secondary analysis of the data in a study with postregistration nurses undertaken by Cader et al. (2003) on evaluating nursing information on the WWW gives support to the Cognitive Continuum Theory by demonstrating that nurses use a range of sub-tasks with different levels of complexities and structure in the evaluative process. The sub-tasks identied are: Evaluating research evidence, Assessing the nature of WWW information, Evaluating publication source, Assessing application to practice, Assessing the cultural origin of WWW information, and Assessing user-friendliness of websites. Using Hammonds (1988) denition of ill-structured tasks, the sub-tasks of Assessing the cultural origin of WWW information, and Assessing user-friendliness of websites are labelled as illstructured. With these sub-tasks multiple cues have to be processed almost instantaneously, pointing to low conscious awareness and low cognitive control, indicating that these tasks induce intuition. Similarly, according to Hammonds (1988) denition of well-structured tasks, Evaluating research evidence is classed as well-structured. Processing this task involves analysis, as it demands a high level of cognitive control, requiring a step-by-step, conscious and logical process as stated by Hammond (1996). 401 Testability The dynamic interaction of the parallel concepts of task and cognition has been identied by Cooksey (2000) as an important focus for researchers investigating the Cognitive Continuum Theory. This proposition and some others have been tested using quantitative methodology. Eleven criteria to measure task properties have been identied by Hammond (1988). These are: the number of cues associated with the task, the degree of certainty associated with the task, the measurement of cues (objective or perceptual), the level of redundancy of cues, the availability of an organizing principle for the cues, the weighting of cues, the degree of non-linearity in the organizing principle for the cues, the distribution of cues, the level of task decomposition, the way cues are displayed and the time available to do the task. The task properties are important as they help to determine its location on the task continuum. Data collection methods used to test Cognitive Continuum Theory include: a task continuum index (TCI), constructed using the above mentioned criteria to locate a task on the task continuum; a cognitive continuum index (CCI) derived from the cognitive properties of analysis and intuition to locate a cognitive activity on the cognitive continuum; the Think Aloud method to allow participants to verbalize their thoughts; and a questionnaire (Hammond et al. 1997; Hamm 1988b; Dunwoody et al. 2000). A range of methods have proved useful for data analysis, and these include correlational analysis to examine the covariation between TCI and CCI, coding scheme and a one-way analysis of variance to show whether participants shift from intuition to analysis, and vice versa. 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 R. Cader et al. The empirical evidence discussed above supports the Cognitive Continuum Theory to a large extent. As the empirical data conform to the theoretical assertions of the Theory they can be accepted as reasonable and valid. The secondary analysis of the data from Cader et al.s (2003) study with postregistration nurses also offers support to the Theory, albeit in a non-clinical environment. In addition, Lauri et al. (2001) provided support for its use in nursing practice. Although there is conclusive evidence to support many of the propositions of the Theory, there has been no empirical evidence to show alternation of cognitive activity between pattern recognition and functional relations. There is a need for further investigations to clarify this issue. Pragmatic adequacy The Cognitive Continuum Theory has been applied to the decision-making process of many professionals in the eld of engineering, social policy-making, medicine and nursing. In engineering, to reduce the many design failures attributed to over-reliance on an analytical mode of inquiry, Cognitive Continuum Theory is proving useful (Hammond et al. 1997). For the formulation of social policies, Hammond (1996) recommends the inclusion of social values as well as probability factors to increase their feasibility and effectiveness. In medicine, Hamm (1988a) has shown that the Theory can assist with improvement in clinical judgement in an environment of uncertainty, where scientic medical knowledge has to be applied to specic patient complaints before reaching a decision. In his version of the cognitive continuum, he has replaced Hammonds modes of inquiry with modes of practice to emphasize their relevance to medical practice (Figure 1). The same rationale seems to have prompted Hamm (1988a) to introduce minor changes to some of the terms used for the six modes of practice. For example, intuitive judgement replaces unrestricted judgement; peer-aided judgement has replaced data-based expert judgement; computer modelling has been replaced with system-aided judgement; quasi-experiments with relaxed controls simply becomes quasi-experiment, controlled trial replaces control-group experiment and scientic experiment replaces true experiment. His work in medicine has been inuential in making these changes. Thompson (1999) has argued that Hamms analysis of the theory from a medical perspective can equally be applied to nursing practice. Cognitive Continuum Theory can be used in any context where decision-making is crucial, including nursing activities demanding that nurses constantly take decisions to assist clients. The application of Hamms version of the Theory to medicine has exemplied its relevance to the clinical environment where nurses practise. His use of terminology which is more familiar to nurses has helped to position the Theory closer to nursing. Fundamentally, in practice Cognitive Continuum Theory can help nurses in two ways. Firstly, it assists them to predict the modes of cognition most appropriate to making nursing decisions, depending on the number and nature of cues presented by clients. The implication of this approach is that Cognitive Continuum Theory provides the framework to assist nurses to aim for accuracy in their decisionmaking process. Adjusting modes of cognition to correspond to judgement tasks leads to accuracy in decisionmaking (Hamm 1988a). Not adhering to this basic premise of the Theory is likely to lead to judgement inaccuracies. Well structured Scientific experiment Mode 1 Controlled trials Mode 2 Quasiexperiment Task Mode 3 System-aided judgement Mode 4 Peer-aided judgement Mode 5 Intuitive judgement Mode 6 Intuition Cognitive mode Analysis III structured Figure 1 After Hamms (1988a) Cognitive Continuum. 402 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 Nursing theory and concept development or analysis Cognitive Continuum Theory in nursing decision-making Secondly, when practising within a multiprofessional environment, nurses should expect their decisions to be challenged by other professionals or clients or clients representatives. Cognitive Continuum Theory can help nurses explain the rationale underpinning their professional decisions to challengers because they will be cognisant of whether they have used tasks that induce intuition, analysis or a mixture of both to reach their decisions. Therefore, nurses judgement will manifest varying levels of rationality, depending on the activities being undertaken and the nature of the cues associated with these activities. With Hammonds (1981) support for equity in modes of cognition, nurses can also argue that, with the Theorys framework, analytical cognition is not always superior to intuitive or quasirational cognition as the choice of modes of cognition is task-dependent. The theory has the potential to help make nurses decision-making process in clinical practice more transparent, which is highly relevant to clinical governance. Although no specic skills are required to apply Cognitive Continuum Theory in clinical practice, it is important that it is included as part of the curriculum for nurse education. Providing student nurses with the appropriate learning experience will ensure that they have a sound knowledge base and understanding of the Theory in order to be able to apply it in practice. Preregistration nursing curricula could incorporate the Theory as part of a management module in which students are usually taught decision-making. For postregistration nursing curricula, the Theory could be included as part of a core module in continuous professional development, ensuring its importance as a decision-making theory. This will complement other approaches to decisionmaking currently included in nursing curricula, widening the scope for understanding and explaining decision-making in nursing. In addition, strategies associated with these different modes of cognition, for example decision analysis, will also need to be incorporated in nursing curricula. An appropriate method is problem-based learning, where students can be given video scenarios and other information representing a range of cues from which decisions can be taken within the Theorys framework. To operate within the framework, Harbison (2001, p. 132) has identied basic numeracy, logic and critical thinking as the skill requirements, and these important skills already form part of existing nursing curricula. Discussion In clinical environments, nurses are operating at modes 5 and 6 on the cognitive continuum framework (Harbison 2001), supporting Dowies (1996) empirical assumption. As anticipated, within the WWW environment too, many evaluative tasks are located at mode 6. In an investigation on how postregistration nurses evaluate WWW information (Cader et al. 2003), cross-checking with peers has also been identied as an option. This informal professional discussion to assist with the evaluative process can be said to be equivalent to mode 5 (not pure intuition), as Eraut et al. (1995) acknowledge that professional deliberations contain both intuition and analysis. The data in Cader et al.s (2003) study also indicate that, depending on the nature of the tasks, nurses use a mixture of intuition and analysis, thus providing evidence to demonstrate the dynamic interaction between the two continua within the cognitive continuum framework. Another study (Lauri et al. 2001) has indicated that the models of decision-making used by nurses, in clinical practice, mirror intuition, analysis and quasirationality. Cognitive Continuum Theory gives nurses a tool that can assist in making their decision-making process more transparent to peers, other professionals in the multidisciplinary team, and clients. With the advent of evidence-based practice, the nursing literature is encouraging nurses to adopt an analytical approach in decision-making (Luker et al. 1998). There is support for this view from Lamond and Thompson (2000), when they explain that the information on which decisions are based should be known, to allow for choices from related outcomes to be made explicit. The current dichotomous view that decisionmaking can be either intuitive or analytical does not clearly reect the level of analysis that nurses use. The quasirational modes within the Theory should offer nurses the required framework to exercise the appropriate level of analysis as demanded by their judgement tasks in clinical practice. For nurses to be able to use theory, it is crucial that they are given the necessary education (Levine 1995). Teaching decision-making in nursing has followed the traditional dichotomous approach. Cognitive Continuum Theory offers a compromise between analysis and intuition. Unless nurses are taught that accuracy in decision-making depends on the tasks they are undertaking, they will not exercise skills appropriate for analysis or intuition or a combination of both. The inclusion of Cognitive Continuum Theory in nurse education will not only increase the knowledge-base of nurses, but will also ensure that the level of analysis in their decision-making process becomes explicit. If the Theory assists them to achieve accuracy in their judgements, then its impact on nursing practice can only be positive. 403 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397405 R. Cader et al. What is already known about this topic A range of theoretical frameworks has been published to offer an understanding of the decision-making process. The majority of published nursing research has adopted either an analytical or intuitive approach to explaining decision-making in nursing. Hammonds Cognitive Continuum Theory can be applied to the decision-making process of many professionals, including those in health care. What this paper adds An analysis and evaluation of Cognitive Continuum Theory. Evidence that Cognitive Continuum Theory can be used to explain decision-making process in nursing practice. Cognitive Continuum Theory can contribute to achieving accuracy in nursing decision-making. Conclusion The process of applying Fawcetts (1993) framework to analyse and evaluate Cognitive Continuum Theory shows that it consists of concepts and propositions that are expressed clearly to ensure their understanding. There is evidence that the theory can be applied to the decision-making process of professionals, including medical decision-making. It also has the potential to offer an understanding of the decision-making process for all members of the multidisciplinary team, as other health care professionals have to face similar decision-making challenges in clinical practice. Modern health services demand that all professionals be accountable for their decision-making process. In this respect, Cognitive Continuum Theory could provide the much-needed understanding required by professionals to enhance their decision-making processes. Author contributions Study conception and design/Drafting of manuscript RC, SC, DW; Data collection/Data analysis/Admin RC; Critical revisions/Supervision SC, DW. References Ajzen I. & Fishbein M. (1980) Understanding Atitudes and Predicting Social Behavior. Prentice Hall, Englewood Cliffs. Bandura A. (1977) Self-efficacy: Toward a unifying theory of behavioural change. Psychological Review 84, 191215. 404 Blegen M.A. & Tripp-Reimer T. 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