in the clinical setting , nurses are continually faced with demands to make decisions of care . .    suggest that the complexity of clinical decision making ( cdm ) requires a broad knowledge base and access to reliable sources of information , as well as working in a supportive environment . the decisions nurses make while performing nursing care will influence their effectiveness in clinical practice and make an impact on patients ' lives and experiences with health care regardless of which setting or country the nurse is practicing in . understanding how nurses make decisions is also a prerequisite to facilitating learning and development of decision making skills in nursing education . historically , cdm in nursing has been discussed in light of systematic - positivist models and the intuitive - humanist model . two approaches dominate in nursing research within the systematic - positivist stance , analytical decision making theory , and information - processing theory . the analysis is a systematic step - by - step procedure with the use of logical rules that can be followed until a decision is made . the information - processing model is a psychological theory much used in research in medical decision making and characterized by a scientific approach to making decisions . it is also termed the hypothetico - deductive approach [ 1 , 4 ] . .    described four major stages of this process in nursing as , gathering preliminary clinical information about the patient , generating tentative hypotheses about the patients ' condition , interpreting the initially registered cues in light of the tentative hypotheses , and weighing the decision alternatives before choosing the one that fits best in light of the evidence collected . intuition has been defined in several ways , for example ,  understanding without a rationale  [ 10 , p.23 ] or  a perception of possibilities , meanings and relationships by way of insight  [ 11 , p.63 ] . according to benner this is an ability that develops with experience in managing patients in the nursing field . according to thompson [ 4 , p.1224 ] , the basic idea of the intuitive - humanist model is that ,  intuitive judgment distinguishes the expert from the novice , with the expert no longer relying on analytical principles to connect their understanding of the situation to appropriate action . the analytical and intuitive stance towards decision making have ardent followers and have often been viewed as two distinct types of cognitive activity sharply separated . however , since the late 1990s , a third approach to decision making has been discussed in the nursing literature , decision making based on the cognitive continuum theory ( cct ) by hammond . he offers instead the idea of a cognitive continuum where analysis and intuition are located at each end point . cognition often falls between the end points and thereby includes properties of both analysis and intuition , referred to as quasi - rational cognition , meaning that many judgment tasks present cues that induce an oscillation between analytical and intuitive cognition . a major tenet of the theory is that  judgment is a joint function of task properties and cognitive properties  [ 5 , p.83 ] , that is , different judgment tasks should be solved through different cognitive processes . in his theory , he therefore describes differences among judgment tasks and locates them in relation to cognitive properties along the cognitive continuum . a judgment task that involves uncertainty is difficult to break down into distinct components and may benefit from a more intuitive approach than a judgment task that is well structured with few and recognizable cues . dowding   in a commentary on banning 's article   seems to support hammond 's   idea of viewing decision making within one theoretical system . she suggests that hypothetico - deductive reasoning , intuition , pattern matching , heuristics , and so forth . the cct has been tested in nonnursing settings [ 1315 ] . since 1999 , several authors have suggested that hammond 's cct could be a possible alternative way of conceptualizing decision making in nursing [ 4 , 16 , 17 ] . in two qualitative studies , cct was used either as an explicit analytical tool   or as a theoretical perspective in the framing and discussion of the study . both studies concerned nurses ' decision making during pharmacological management . both studies also report a mismatch between the type of decision making nurses used and the characteristics of the situation , for example , that intuitive approaches were used when more analytic approaches should have been used , or that appropriate decision tools were missing to help nurses during their analytical approaches .        in collaboration with international colleagues , lauri and salanter   included hammond 's cct   in a theoretical framework for developing an instrument to explore nurses ' perception of their decision making at a general level , that is , the way in which nurses perceived to arrive at their decisions in practical nursing situations . the main purpose was to examine cognitive processes nurses thought they used in their decision making and correlate them with demographic and contextual factors . based on both cct and information processing theory , an extensive literature review , interviews with nurses , and former studies of decision making , a 56-item instrument was developed . according to the their content , the items in the questionnaire were organized to reflect four stages of cdm : ( a ) data collection , ( b ) data processing and identification of problems , ( c ) plans of action , and ( d ) implementation of plan , monitoring , and evaluation . the instrument was used in a study with 1460 nurses from seven countries after testing . their study showed that nurses ' use of cdm differed according to field of practice and country [ 2023 ] . in relation to different stages of the decision making process , lauri and salanter   claimed that pure intuitive decision making did not weight on any of the 4 stages . analytical decision making did weight in stage 2 , that is , data processing and identification of problems . the authors were cautious in drawing any general conclusions about factors underlying the differences in nurses ' perception of their decision making but suggested that it was fair to assume that  the instrument allows us to determine in general terms how nurses ' decision making occurs on the continuum from analytical to intuitive  [ 2 , p.98 ] . the present study was part of a larger study that had an overall purpose of exploring learning and professional development in hospital nurses . inspired by the work of lauri and salanter , the study aimed at exploring nurses ' perception of their clinical decision making ( cdm ) in a specified patient situation . what cdm models characterize the total sample of nurses ? what is the association between selected independent variables ( background and demographic variables ) and the dependent variable ( cdm ) ? is there any difference in cdm models across the four stages of the decision making process ? the study used a descriptive cross - sectional survey design in which nurses completed a questionnaire on one occasion . a convenience sample of registered nurses in clinical positions at four hospitals in the western and southern part of norway was recruited . two of the hospitals were affiliated with universities , the third was regional , and the fourth a local hospital . the inclusion criteria were nurses employed in clinical positions working half , or more than a half , of a full - time equivalent . respondents received an envelope at work including a cover letter explaining the purpose of the study and ensuring confidentiality , the questionnaire , and a preaddressed envelope for return of their response . the questionnaire included ( 1 ) demographic and background variables , ( 2 ) the 24-item nursing decision making instrument ( salanter , e - mail correspondence 2004 - 5 ) , ( 3 ) the index of work satisfaction , and ( 4 ) author - designed evaluative questions for participants in long - term in - house educational programs ( clinical ladder programs ) . results from the two latter sections are reported elsewhere [ 25 , 26 ] . the 24-item nursing decision making instrument is a shortened version of the original 56-item instrument presented in the background of this article . figure 1 shows how lauri and   salenter   related four decision making models to hammond 's cct . these four models are inserted in a continuum from analysis to intuition and defined by aspects of the patient 's health problem , knowledge structure , nursing task , and available time , corresponding to hammond 's [ 5 , p.235 ] concepts of task features and cognitive structures . based on the international sample , lauri and   salenter    developed a scoring system to allow for assessment of nurses ' decision making style . the scores were related to the decision making models presented in figure 1 : the intuitive - interpretive model , the intuitive - analytical model and the analytical - intuitive model constituting quasi - rational models of cognition , and the analytical - systematic model . in e - mail correspondence with salanter ( 2004 - 2005 ) , we were offered to use the 24-item nursing decision making instrument   ( sanna salanter , professor of clinical nursing science , department of nursing science , university of turku , 20014 turun yliopisto , finland , e - mail : sansala@utu.fi ) .   for the shortened version of the instrument , cut - off points in the scores relating to the four decision making models were defined on the basis of quartiles : 25% of the responses were intuitive - interpretive , 25% were analytical - systematic , and 50% in the two middle quartiles were analytical - intuitive or intuitive - analytical , that is , quasi - rational [ salanter , e - mail correspondence ] . equivalent to the original instrument , the 24-item instrument had four subscales , each with six items , corresponding to the four stages of the decision making process . even numbered items reflected decision making in unstable tasks or situations with short available time , for example ,  i make assumptions about forthcoming nursing problems during the first contact with the patient .  odd numbered items reflected decision making in structured tasks or situations with enough time to seek or handle information or plan actions , for example ,  on the basis of my advance iformation , i specify all the items i intend to monitor and ask the patient about . respondents answered each question on a 5-point likert - type scale with response options of  almost never ,   rarely ,   sometimes ,   often ,  and  almost always . these items were scored from 1 to 5 so the lowest scores measured analytical decision making and the highest scores intuitive decision making . on the even numbered items , the response option of  almost always  would then indicate a highly intuitive approach . the scores for responses to odd items were reversed ; thereby , the response option of  almost never  would be scored as 5 and also indicate a highly intuitive approach . a low total score described analytical decision making and a high - score intuitive decision making . the scores were added up , and the sum total was interpreted following instructions from salanter [ e - mail correspondence 2004 - 5 ] : 2467 indicate analytical - systematic decision making , 6877 indicate quasi - rational decision making , and 78120 indicate intuitive - interpretive decision making . an elective patient situation implies certain judgment tasks that differ from acute situations , that is , the difference in time at hand for colleting data about the patient , or discussing with colleagues the appropriateness of interventions . the idea was to set a scene that would prompt nurses to think of their decision making with the same type of judgment tasks in mind and thereby allow for comparison across hospitals and units .   according to norwegian law , permission was not needed from the regional committees for medical and health research ethics . permission to use name lists in order to supply enough questionnaires to each unit was granted by the director of nursing or director of research according to local regulations , and such lists were obtained from the personnel department of each hospital . in accordance with general statistical procedures , we addressed missing data in the present study in the following way . in relation to research questions 13 , the analysis aimed at matching each nurse 's total sum with cut - off points for different decision making models . respondents with more than 40% of the items missing were therefore taken out of the data set ( n = 75 , 3.6% of the total sample ) . an inspection of the data revealed that missing responses were often due to missing responses to all questions on the last page of the questionnaire . any missing items in other respondents data sets were substituted with the respondents own mean score . for question 4 , the purpose was to look more closely at decision making models within each stage of the decision making process . any stage with more than two out of six items missing was taken out of the analysis . where respondents had one or two missing items , these were substituted with the mean score within that stage of decision making . these procedures resulted in a final n = 2020 for total score analysis and a variation in n of 2061 , 2054 , 1974 , and 2009 for analysis within the four stages of cdm , respectively . data were analyzed with frequency distributions , and inferential statistics . when studying the association between potentially predictive variables and a dependent variable , linear regression analysis can be used . multicollinearity was controlled by the coefficients tolerance ( > 0.5 ) , and variance inflation factor ( vif , close to 1 < 2 ) cook 's d and mahalanobis d , and standard residuals were used to identify possible outliers that might distort the statistics [ 27 , p.128 ] . adjusted r square evaluated the variance that the independent variables contributed to explaining the association with the dependent variable , cdm . the statistical package for social sciences version 15.0 authors of the original 56-item instrument   developed the shortened version thru a factor analysis on the original instrument to ensure construct validity , reduction of items by keeping items that had a high impact in the factor analysis , and reformulation of items according to responses in the previous measurements . the shortened version of the instrument the questionnaire was translated back - and - forth from english to norwegian . a norwegian person fluent in english translated from english to norwegian , an english person translated the norwegian version back to english , and the study participants ranged in age from 21 to 68 ( mean 37.5 years ) , 7.9% were men , 8.3% of the nurses had worked more than 5 years in their unit , 66% had graduated before 1999 , and   average work experience in their present setting was 4.9 years . approximately 40% of the participants had formal continuing education between 1/2 and 1.5 years , and 25.8% of the nurses had completed or were enrolled in a 5-year in - house clinical ladder program . the possible range of scores in the cdm instrument was 24120 . in the whole sample , the distribution of cdm models as reported by the total sample of nurses is shown in the chart in figure 2 . figure 2 indicates that most nurses reported the use of quasi - rational models during cdm . few nurses fell within the score boundaries indicating the use of intuitive - interpretive models . background and demographic variables were computed with t - tests for nominal data and pearson 's r for interval level data . table 2 shows that nurses ' number of years in present job and further education had the largest associations with cdm . differences in nurses ' reported use of cdm models across the four subscales of the cdm instrument are illustrated in figure 3 . in general , nurses reported the use of quasi - rational models of cdm more often than either analytical - systematic or intuitive - interpretive models . however , the largest variations across the stages of decision making occurred in relation to reported use of the two latter models . 
 figure 3 shows that the percentage of nurses reporting the use of analytical - systematic models was highest during data collection and implementation and evaluation . correspondingly , interpretive - intuitive models were low in use during these stages , higher in use during data processing and used approximately as much as the analytical - systematic model during the stage of planning action . there were variations in the pattern illustrated in figure 3 when demographic and contextual variables were taken into account . it is clear that participation in clinical ladders had no significant impact on nurses ' reported use of cdm models across any of the stages of the decision making process . age and nurses ' field of practice was also variables that had little impact across the four subscales . the purpose of this study was to explore the cognitive processes used during cdm as reported by a large sample of norwegian nurses and to identify how demographic and contextual variables were associated with decision making . since no studies with the shortened cdm instrument have yet been reported , direct comparisons are not possible although results from the present study may be compared with trends in lauri and salanter 's research [ 20 , 22 , 28 ] . based on the scoring system developed for the shortened instrument , results from the present study show that in the whole sample of nurses the  window  for perceived quasi - rational approaches in cdm is large . 's study   and with hammond 's   suggestion that it is most common to oscillate between analytical and intuitive modes of cognition during decision making . also , the analytical - systematic model is perceived to be much more in use than the intuitive - interpretive model . one interpretation of this may relate to the character of the task outlined in the questionnaire . an elective patient situation affords a reasonable amount of time for decision making and is relatively well - structured . this situation therefore has properties that may induce analysis [ 16 , 29 ] . since the cdm instrument has a lower number for analytical - systematic cdm and a higher for intuitive- interpretive , with quasi - rational decision making modes in between , one can conclude that years in present job is significantly associated with intuitive - interpretive cdm , followed by further education , male gender , higher age , and surgical field of practice . in line with findings in benner and colleagues ' research [ 9 , 30 , 31 ] , there is a significant increase in the nurses ' reported use of intuitive - interpretive cdm models with increasing experience in their unit . . 's   report on cdm among nurses in geriatric and acute care settings in finland , sweden , switzerland , canada , and the usa . in other studies , however , experience does not significantly influence cdm [ 22 , 28 ] . further education was also associated with perceptions of more intuitive decision making among norwegian nurses . although earlier research into the association between educational level and decision making is inconclusive , lauri et al . ,   found that nurses with professional education used significantly more intuitive cdm than nurses with only 2.53 years of education . as age is also a significant factor associated with cdm models in the present study , and both further education and years of work experience often parallel increasing age , it is difficult to gauge the contributions of these demographic variables . male nurses ' cdm scores are similar to that of nurses who had more than 10 years experience in their unit . however , male nurses had fewer years of experience less further education and were younger . studies reporting on the association between gender and decision making are scarce . in the field of human relationships and management , burke and miller   found minimal support for a gender - based stereotype of women 's intuition . from 51 interviews with seasoned professionals , they found that men were believed to use intuitive skills at work as much or more than women . in contrast , in a study of 520 physicians , nurses and health managers , men preferred rational reasoning while women preferred intuitive reasoning . nurses ' perception of their cdm in this study is associated with field of practice , as nurses in predominantly surgical units are more intuitive interpretive than nurses in predominantly medical units . patients in surgical units may experience more sudden shifts in their health condition than patients in medical units . nurses in a surgical field of practice may therefore be faced with tasks characterized by uncertainty and many cues at the same time . variations in cdm models are also apparent across the different stages of the decision making process . as mentioned before , nurses in general use quasi - rational models of cdm the most . analytical - systematic models of cdm are perceived to be more in use than intuitive - interpretive models during stages of data collection and implementation and evaluation . intuitive - interpretive models are reported in use more during data processing , while during planning both models are perceived to be equally in use . this does not match the findings of lauri and salanter , where one of their major findings was that analytical decision making models were weighted for the stage of data processing in all nursing fields . the nurses in the present study were prompted to relate their answers to how they viewed their cdm with an unknown but elective patient . to our knowledge , this was not done in the study by lauri and salanter   and may be one reason for the difference in these findings . however , when cdm across stages of the decision making process is analyzed according to demographic variables , some groups of nurses do report more analytical - systematic models during data processing than other groups .   although the sample in this study was large , a survey method has limitations as answers to a questionnaire may not represent nurses ' actual decision making . however , we do not have any reason to believe that the questions were viewed as sensitive in any way . the respondents were also informed in the questionnaire that there were no right or wrong answers . since this was a sample of convenience , it may not be representative of all nurses in norway . we also acknowledge that this study was carried out in one country in scandinavia and thus may not reflect cdm use in other countries . personnel departments at norwegian hospitals do not make lists of their employees that automatically include , for example , gender and age , so it is difficult to access such data to verify the demographic similarity between responders and nonresponders . however , all norwegian rn 's have the same undergraduate nursing education as there is only one form of educational program in the country . the limitation of mean imputation methods is discussed in the literature although mean substitution for items in multiple - item scales is often used   in order not to waste information by scoring the entire scale as missing . when data were inspected , the magnitude of missing was rather small and evenly distributed among the items ( between 2740 responses to the first 12 items , and between 6165 responses to the last 12 items ) . the research presented in this paper extends our ways of looking at cdm based on hammond 's   new insights into possible models of cdm . our findings support the prevalence of nurses ' oscillation between analysis and intuition , at least when nurses were confronted with the kind of decision situation introduced in this study . the exploratory nature of this work does not invite definitive conclusions about nurses ' decision making . however , we believe it can stimulate ideas and discussions about additional ways of understanding the thinking processes nurses use in practice . this is the first time the shortened version of lauri and salanter 's   nursing decision making instrument is reported . more extensive evaluation of the cdm model in other countries and in different practice settings is therefore needed in order to explore the merit of this way of conceptualizing nurses ' cdm .
this study analyzed nurses ' perceptions of clinical decision making ( cdm ) in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables . 
 a cross - sectional survey was carried out with 2095 nurses in four hospitals in norway . a 24-item nursing decision making instrument based on cognitive continuum theory 
 was used to explore how nurses perceived their cdm when meeting an elective patient for the first time . 
 data were analyzed with descriptive frequencies , t - tests , chi - square test , and linear regression . 
 nurses ' decision making was categorized into analytic - systematic , intuitive - interpretive , and quasi - rational models of cdm . 
 most nurses reported the use of quasi - rational models during cdm thereby supporting the tenet that cognition most often includes properties of both analysis and intuition . increased use of intuitive - interpretive models of cdm 
 was associated with years in present job , further education , male gender , higher age , and working in predominantly surgical units .