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A variety of analytical and intuitive conceptual models have been used to describe the CDM process focusing on critical thinking skills, reflection, clinical judgment, and problem solving (Tiffen, Corbridgen, Slimer, 2014). CDM skills are developed in new nursing graduates as they face challenges in responding to challenging patient health problems, new technologies, and complex health care environments (AL-Dossary, 2013). Wieland, Altmiller, Dorr & Wolf, (2010) suggested that the transition to professional practice is characterized by complex changes.
It has been suggested that novice nurses tend to use analytical models in their decision-making processes, which are characterized as being more structured, slow, and often based on only a partial view of the total situation. In contrast, more experienced expert nurses with more experience use more intuitive models, recognizing patterns and generating quick actions to solve complex problems. (Benner & Tanner, 1987; Bjørk & Hamilton, 2011).
Lauri and Salanterä (2002) proposed four CDM models based on cognitive continuum theory (Hammond, 2000), and Benner’s model outlining the stages of clinical competence (1984). The CDM models proposed by Lauri and Salanterä include a fully analytical model, a fully intuitive model, an analytical-intuitive model, and an intuitive-analytical model. In addition, Lauri and Salanterä identified four stages of the CDM process that correspond with the stages of the nursing process: (a) collecting information for defining the patient's condition (Collecting), (b) handling information and defining nursing problems (Defining), (c) planning, and (d) implementing nursing and monitoring and evaluating patient's condition (Implementing and evaluating).
In Mexico, nurses spend the first year after graduation from their nursing programs providing social service in underserved health institutions in order to strengthen the theoretical and practical knowledge acquired during their training, while giving back a benefit to society. Unlike internships or residencies for new nursing graduates that are provided in other countries, the year of social service does not include structured orientation and mentorship to help the new graduate develop CDM skills.
Purpose:
The purpose of this study was to describe the cognitive models and skills used by new graduates in their year of social service, to guide their clinical decision-making during the four stages of the CDM process.
Methods:
A descriptive cross-sectional design was used, and the sample included 119 new nursing graduates who were engaged in their one year of social service work in different levels of health services. The graduates completed the "Nursing Decision-making Instrument" (Lauri & Salanterä, 2002), which includes 56 items ranked on a Likert scale to describe the predominant cognitive models used during the four stages of the CDM process, and to provide a measure of CDM skills (ranging from 0-224).Descriptive and inferential statistical analyses were used for the data analysis.
Results:
The results indicated that the predominant model used by 67% of the new graduates was analytical-intuitive. A total of 97% used the analytical-intuitive model during the Defining stage. The intuitive-analytical model was used by 69% during Implementing stage, 55% during the Collecting and Planning stages.
The mean score on CDM skills was 110 (± 4.76). The lowest score on the CDM subscales was for the Defining subscale (with a mean of 23.7 out of a possible total score of 56).
Conclusion:
The findings from this study suggest that the primary analytical model used by the new graduates was the analytical-intuitive model, consistent with the stages of clinical competence proposed by Benner (1984). The finding of low CDM skills in identifying patient problems suggests that basic and continuing nursing education programs should focus on helping students and new graduates learn to use clinical data to identify priority problems and plan patient care. New graduates also need guidance to help them to progress to using more intuitive models so that they can better recognize patterns and initiate nursing actions to solve complex patient problems.
Teaching strategies such as problem-based learning, case studies and clinical simulation can help students and new graduates develop more effective CDM skills and cognitive models. Such strategies could be incorporated into the year of social service for graduates of Mexican nursing programs, to support their professional development as critical thinkers who incorporate effective CDM models in their professional practice.