NuneEduatirm Today (1988) 8, 140-147 0 Longman Group UK Ltd 1988

The role of tacit knowledge in problem solving in the clinical setting

Elizabeth Carroll

The aim of this paper is to emphasise the important function of so-called ‘tacit knowledge’ in problem solving in the clinical setting. While education theorists recognise tacit knowledge to be an important variable in information processing and decision making, its relevance to nurse education has not yet been sufficiently appreciated. To illustrate the importance of ‘tacit knowledge’ in prescribing health care and to draw out its implications for nurse education and nurse practice, reference will be made to a study conducted by the author in five public hospitals in the South Western region of Sydney in 1985. The study illustrates how ‘tacit knowledge’ can play a role in determining the likelihood of a patient contracting pressure sores.

On the basis of this study it is suggested that nurse education acknowledge the importance of ‘tacit knowledge’ in Nurse Education curricula. This in turn should develop the practising nurse’s skill in recognising the importance of integrating ‘tacit knowledge’ in the decision process about patient care.

INTRODUCTION

Today there is increasing use by health pro- fessionals of mechanistic procedures in the

clinical field to assist in the choice of appropriate health care.

An example of such mechanistic procedures is

the use of scoring charts developed in an attempt to predict persons at risk of developing pressure

sores. While such scoring charts can be a useful

aid in decision making it is the author’s view that an over reliance on mechanistic decision pro-

cedures can lead to neglect of important

Elizabeth Carroll School of Nursing, Macarthur Institute of Higher Education, PO Box 108, Milperra 2214, N.S.W. Australia Manuscript accepted 29 August 1987

information in decisions regarding appropriate

patient care. In an attempt to demonstrate the author’s

view, this paper will proceed as follows. Firstly, I

will define and comment on certain features

about tacit information. Secondly, I will use a

paradigm for problem solving to illustrate the

impact ‘tacit knowledge’ has upon the efficacy of

a decision. Next I will outline and discuss the Norton

scoring chart. The final section will illustrate the

importance of the inclusion of tacit knowledge

upon the decision process. This will be demon-

strated by use of data from a previous study

conducted by the author on the prevalence of pressure sores in five of Sydney’s South Western Public hospitals (Carroll 1985). When the author

began to analyse the results it became increas- ingly evident that the charts gave no role to tacit

140

information. To illustrate the importance of acknowledging tacit information in the decision

making of appropriate patient care, two cases from the 13 patients who developed pressure sores are discussed. While the number of cases referred to here are small the data supports the author’s claims to the importance of tacit information.

Tacit information and its effect on the decision making process

Some educational theorists have described tacit information as an important element in a per- son’s knowledge base. It is the sort of infor- mation about a subject that is not easily definable. As Woods (1985) states:

‘tacit information . . . is usually not given in texts but it is known by the experts in the discipline. However the experts are usually unaware of that knowledge and cannot easily describe it. Usually we acquire that tacit knowledge by “experience” for example an experienced professional “just knows” when a decision sounds wrong yet she/he cannot explain why. Alternatively they might in- tuitively know what to do in a complex situ- ation yet when asked why they might answer “experience”.’

While the discussion of ‘tacit knowledge’ in the educational literature is often sketchy (Glaser 1984; Pylyshyn 1984) and is pitched at an abstract level, it appears to have implications for the use of mechanistic procedures in the clinical setting. Because these mechanistic procedures allow little or no scope for ‘tacit knowledge’ to play a role in nursing practice, they should be used with caution.

Certain features of a person’s cognitive ‘schema’ have been identified as determining the ef’fectiveness of the decision making process.

The features are:

1. the person’s knowledge base 2. the person’s ability to organise information 3. the person’s ability to process information

4.

NL’RSE EDUCATION T’ODA\r 141

the person’s ability to transfer information (Glaser 1984; Pylyshyn 1984;Janis & Mann 1977; Lusted 1976).

If ‘tacit knowledge’ is a component of a person’s knowledge base (Salamon et al 1976; de Dombal 1976) then it may be expected to play a role in the decision making process.

The effect of ‘tacit knowledge’, as opposed to a mechanistic procedure upon a decision, is illustrated in the study where medical prac- titioners’ responses were analysed in an attempt to design a computer programme that could perform similar cognitive functions. The out- come indicated that it would be very difficult to develop such a programme. To replicate such cognitive performance it was necessary that a programme could cope with a

. . dynamic assembly of large chunks of information as the problem-solving process proceeds. These chunks are called up in unpredictable ways, and the selection of any one may have profound effect on the par- ticular realisation’s of others which are used, and the weight attached to each’ (see Gory 1976: 26).

The inability of the computer to replicate the cognitive performance of the medical prac- titioner is due in large measure to the tacit nature of certain ‘chunks of information’ in the decision making process, If the decision maker himself or herself is largely unaware of certain information necessary for informed decision making in complex situation, and if these chunks are ‘called

up in unpredictable ways’, how can others be expected to fully comprehend the elements of a person’s knowledge base?

The importance of a problem solving approach

One method that does allow the decision maker to integrate ‘tacit knowledge’ into the decision about patient care is the so called problem solving approach. This approach allows the decision maker to recognise and use ‘large chunks of information that are called up in unpredictable ways’.

142 NURSE EDUCATION TODAY

Environment (global) Problem-Solving Capability

\ General Specific to Problem Problem-Solving Phases

Stressors

I

I I

\ r - -Plans/Beliefs -

I \

-1 I Information

People. Beh_aviour Relationship! b (norms, rules, -

investments) I

Non-living things, physical entities, phenomenon

l

supports 1

Formulating

Appraising

I State 0

Developing Committmentl

Homeostasis (return to status quo)

T Developm./ State 2 - (becoming capable)

Fig 1 Paradigm of Problem Solving, developed by Pridham, Hansen and Conrad. Nehrig, Durham, Macek- Effective Teaching: A Problem Solving Paradigm. Nurse Educator Vol. 11, No. 3. May/June 1986.

One paradigm for problem solving that depicts the importance of ‘tacit knowledge’ in the decision process is the model developed by Pridham, Hansen and Conrad 1986 (Fig. 1). (Nehrig, Durham & Macek 1986). This para- digm is based on interpersonal problem-solving for instructional use in the primary care setting. What is important about this model is that it takes into account the dynamics of the environ- ment and its effect upon the decision maker’s problem solving process. The identification of the environment and how the decision maker’s perception will affect the problem solving pro- cess indicates the impact that ‘tacit knowledge’ has upon a decision.

The importance of the decision maker developing the essential features within his/her cognitive schema is also represented in the first phase of the problem solving process within this paradigm. The phases are scanning, formulat- ing, appraising, developing commitment/

readiness, planning, implementing evaluating. (Nehrig et al 1986). During the scanning phase data gathering specific to problem or goal identi- fication for a particular patient occurs. Inherent and/or potential goals or problems are delineated. At this phase the decision maker’s knowledge base, and ability to process and transfer information has significant impact upon the quality of the decision (Feletti et al 1986). Furthermore at the scanning phase ‘tacit knowledge’ greatly influences the decision maker’s plans and beliefs about the situation (Fig. I).

In the next section the Norton scoring chart devised to predict accurately the person at risk of developing a pressure sore will be introduced. The purpose of this section is to inform the reader of the structure and mode of evaluation of these charts. As we shall see, ‘tacit knowledge’ appears to be an important determinant of effective decision making in the clinical setting.

NORTON SCORE

The attempt to identify persons at high risk of

contracting pressure sores has led to the development of numerous scoring charts. These charts attempt to gather information about a person’s risk of incurring pressure sores by adopting a ‘checklist’ approach. In some instances variables considered to cause the development of pressure sores are given a numerical weighting. There appears to be an arbitrarv allocation of the weights to be used. In the instructions for use of the charts no rationale is provided to explain the weighting systems adopted to discriminate a patient at risk.

‘The Norton Score (Appendix A) is a chart that consists of five variables (Norton 1975). Each of the variables has four different levels which are measured in terms of the application of a numerical weighting from 1-4. The nurse decides upon the weighting from his or her interpretation of the levels listed on the chart and how those levels for each variable best describe the nurses observation of the patient. The lower the aggregate score of the variables listed, the greater the risk that the patient will develop a pressure sore. An aggregate score of fourteen or less indicates the patient to be at risk.

Research indicates (Goldstone & Goldstone 1982) the difficulty in accurately predicting a person at risk of developing pressure sores when using the Norton Score as a decision instrument. One study (Thiyagaratan & Silver 1984) indi- cates thal there is a variety of reasons why people with spinal cord injury develop pressure sores. Illustrative of this point is that a large proportion of people who develop pressure sores in the initial phase of their spinal cord injury tend to develop pressure sores in the later stages of their life. Information about a person’s background and its impact upon their likelihood of developing a pressure sore is not accounted for by the Norton Score. The importance of information such as the patient’s background is weighted by the nurse’s previous experiences with similar cases. Such experiences influence the nurse’s ‘tacit knowledge’ and can greatly affect the efficacy of a decision about appro-

priate care. Further evidence of the inadequacy of the use of mechanistic procedures is given in an illustration by the designer of rhe Norton Score (Norton 1975). It is stated that not all variables can be evaluated by the scoring chart. To demonstrate this point skin subject to oedema is stated to be more vulnerable to the formation of pressure sores once the oedema has subsided. It is the structure of the scoring charts that makes it very difficult, if not impossible, to include ‘tacit knowledge’ of this nature. Alter- natively ‘tacit knowledge’ can be integrated into the phases of the decision process when the decision maker uses a problem solving approach for decision making about patient care. Within the paradigm for problem solving it is necessar) to include the factors that bring about ‘tacit knowledge’ i.e. the environment and the effect that the environment has upon the decision makers plans and beliefs so that the relevant information can be represented and integrated into the decision.

An illustration of the importance of tacit information in nursing practice

The author distributed a questionnaire in public hospitals in order to gather information about the development of pressure sores (Appendix B). Responses to two of the questions gave vital information that demonstrates the importance of tacit knowledge and its effect upon the efficacy of the decision making process bv nurses and thus nursing practice.

Statistical analysis

A cumulative frequency indicates the number of patients who gained an aggregate score equal to or greater than a specific number. In the study undertaken for the thirteen patients the Norton Scores ranged between 5- 18.

Apparatus

A modified version of a questionnaire formu- lated by Ek and Boman 1982 see (Appendix B) was administered in five public hospitals situated in the South Western region of Sydney.

144 NURSE EDUCATION TODAY

Subjects Subjects were patients admitted or residing in medical/surgical wards of five hospitals situated within the South Western region of Sydney who had or developed pressure sores during the week of 23-30 July, 1985. Of the 610 patients who were hospitalised in the medical surgical wards during this period only 13 were docu- mented to have pressure sores.

Procedure

The modified version of a questionnaire used by Ek and Boman were distributed to the five hospitals. The nursing staff completed the ques- tionnaires on patients who had a pressure sore during the week specified. These questionnaires were then returned to the author. The aggregate score obtained by each patient on the Norton Score is calculated from the responses given by nursing staff to the questionnaire.

Results

During the week of the survey, 13 out of 610 patients had or had developed pressure sores. The cumulative frequency table (see Table 1)

Table 1 The cumulative frequency of the aggregate scores gained on the Norton chart by the thirteen subjects

Cumulative Score Frequency (F) frequency (CF)

Norton 20 0 0 19 0 0 18 1 1 17 0 1 16 0 1 15 2 3 14 1 4 13 2 6 12 2 8 11 1 9 10 0 9 9 2 11 8 1 12 7 0 12 6 0 12 5 1 13

indicates that three of the subjects gained a score of 15 or more on the Norton chart. The remainder of subjects scored fourteen or less. Table 2 indicates how each subject rated on the Norton chart, the recorded diagnoses, and the nurses response to questions from the authors study.

Table 2 Scoring chart-the aggregate scores gained from the Norton charts by the subjects and the diagnoses and nurse comments given as responses to the questionnaire

Subjects Norton Nurse’s responses Diagnosis

1 11 Continual pressure to area Hypoglycemia extensive brain damage 2 12 Poor respiratory function: needed Chronic obstructive airways disease

assistance to be re-positioned: chronically ill man

3 9 Obese: diabetic: immobile because of Diabetes feet

4 13 Unable to move Fractured right femur old C.V.A.

z 14 Restricted movement Arthritis 9 Illness: Immobility: Periphereal vascular C.V.A. Anemia

disease 7 13 Thin; frail; elderly: reluctant to move Pneumonia 8 5 Diarrhoea: Poor general state on Dehydration Diarrhoea

admission. Dehydration Undernourished 9 15 Diarrhoea preadmission and pre-op time: Sigmiodcolectomy

quadraplegic IO 15 Immobility: sites on right foot: Renal disease cerebral

Peripheral vascular disease? Precipitated sclerosis renal disease

11 10 Incontinent: bony thin: cannot ambulate Nil given 12 12 Multiple Myleomer; displaces thoracic Multiple myleoma

spine which causes continuous pressure 13 18 Back slab on right leg: only up with Fractured right patella

assistance non weight bearing

DISCUSSION

The mechanistic procedure (Norton Chart) does

not accurately predict the risk to a patient of the development of pressure sores. The reason for the limitation is related to the difficulty of weighting information important to the evalu- ation of the patients risk of the incidence.

The Cumulative Frequency Index (Table 1) of the Score obtained by patients indicates that three patients would not have been considered at risk. These three patients had a score greater than 14. and given that Norton’s chart assumes that a score greater than 14 does not indicate the patient to be at risk the nurse would not have been alerted to the patients needs. I believe that the information presented in Table 2 demon- strates why mechanistic procedures are inade- quate and how ‘tacit knowledge’ is essential to the efficacy of the decision about appropriate nurs- ing care.

To illustrate this point the discussion will be concentrated on the two subjects that gained the extreme scores on the Norton Chart. Subject 13 gained an aggregate score of 18 on the Norton chart. The diagnosis given is fractured right Patella.

The importance of ‘tacit knowledge’ to the nurses decision is reflected in the nurse’s expla- nation as to why this particular patient developed a pressure sore. Three independent pieces of information were written down viz ‘had a back slab on the right leg’, ‘was up with assistance’ and ‘not able to bear weight’. Review of this information makes it clear that none of it is specifically represented by the scoring chart, nor is it recorded in a text so it is not regarded as general knowledge about pressure sores. It is specific information known by the nurse, it is important and it needs to be accounted for in a decision about patient care. The paradigm for Problem Solving outlined in the introduction (Fig. 1) allows the nurse to include such vital information when making a decision about care of the patient. The three pieces of information are ‘tacit’ to the nurse as it represents the nurses view about the situation. The environment (Fig. 1) gives the nurse ‘tacit knowledge’ about the risk

of the incidence to this particular patient. It is this specific information that will be included in his or her plans and beliefs (see Fig. 1) as it is a belief of the nurse that this particular patient’s pressure sore developed from the patient having a ‘back slab on the right leg’; that the patient was ‘up with assistance’ and ‘not able to bear weight’.

The Norton score does alert the nurse to certain patients at risk of developing a pressure sore. However, it does not represent specific information that would govern the first phase of the Problem Solving process (see Fig. 1) and, as noied earlier, the first phase of problem solving is crucial for efflcacv in decision making about patient care. If we view subject eight and look at the aggregate score gained from the Norton Chart it is five. This score does indicate the patient to be at high risk but it does not give specific information about the situation. When looking at the diagnoses it is stated as ‘diarrhoea’, ‘dehydration’. The nurses comments on the cause of the pressure sore state ‘diarrhoea’. ‘poor general state on admission’, ‘dehydration and undernourished’! Given this information the decision to reduce/prevent the incidence would differ greatly from that decision made about appropriate care for subject thirteen. Specific information that relates to the environment and the nurses plans and beliefs are ‘tacit knowledge’ to the nurse about the particular situation. This ‘tacit knowledge’ greatly influences the scanning phase of the problem solving process. Given the impact that ‘tacit knowledge’ has upon the prob- lem solving process it is crucial rhat such information is taken into account in making the decision. The use of mechanistic procedures to predict accurately the risk of ;I patient developing a pressure sore omits this crucial information.

IMPLICATIONS FOR NURSE EDUCATION

The discussion presented in this paper high- lights the importance of ‘tacit knowledge’ and the omission of this crucial information limits the capacity of mechanistic procedures to predict

B

146 NURSE EDUCATION TODAY

accurately a patient at risk of developing a time nurse educators and other researchers pressure sore. From the discussion certain impli- should conduct studies to develop our under- cations may be deduced that directly relate to standing of the role of tacit information in both nursing practice and education for students decision making regarding appropriate patient of nursing. One implication is that education care. related to nursing practice should acknowledge the importance of ‘tacit knowledge’. Further- more it is also indicated that, not only is the quality of the decision based on the input of ‘tacit Acknowledgement

knowledge’, it is also essential that the decision makers cognitive schema functions effectively. The decision maker’s knowledge base, ability to organise, process, and transfer information, are all essential features of a person’s cognitive schema when attempting to make effective deci- sions. One method that promotes the develop- ment of these cognitive features is a problem solving approach toward decision making. A paradigm for problem solving integrated into a curriculum that educates undergraduates, post- graduate and clinicians about nursing practice should develop the essential features of the nurse’s cognitive schema so as to promote effi- cient decisions about patient care.

Another implication is that the practising nurse should use mechanistic procedure with caution. The nurses ‘tacit knowledge’ about a situation should be expressed and represented in the decision process. Furthermore, the prac- tising nurse should continue to expand her/his knowledge base so as to promote decisions that are a blend of ‘theoretical’ and ‘tacit’ knowledge.

CONCLUSION

Although only a small number of cases were discussed here they show that more attention needs to be paid to tacit information when developing mechanistic procedures to determine patient care. Further research is needed to gain a better understanding of the role of tacit information and its impact upon the decision regarding patient care. Research should proceed on two fronts. Educational theo- rists should continue to study the role of tacit information in problem solving. At the same

I would like to thank Betty Andersen, Michael Hazelton, Dianna Dalley, Glena Ellit, Jane Moses and an anonymous referee for helpful comments on an earlier draft. The usual caveat applies.

References

Carroll E J 1985 Pressure sores: a discussion on causes and a critique of proposed charts to predict people at risk. Unpublished

de Dombal F T 1976 ‘How “objective” is medical data’. In decision making and medical care can information science help? Edited by F T de Dombal and F Gremy. North Holland Publishing Company. Amsterdam, New York, Oxford: 33-34

Ek, Boman A 1982 A descriptive study of pressure sore. The prevalence of pressure sores and the characteristics of patients. Journal of Advanced Nursing 17: 51-57

Feletti G I, Marshall J, McIntosh J, Saunders N 1986 Recent research into final year medical students problem-solving skills using a patient management oroblem. Presented at The Australasian and New Zealand Association for Medical Education Conference on Significant Developments in the Education of Health Professionals at Canberra 25-27 August 1986

Glaser R 1984 Education and thinking: the role of knowledge. American Psychologist: 93-104

Goldstone L A, Goldstone J 1982 The Norton score: early warning of pressure sores. Journal of Advanced Nursing 7: 419426

Gory G A 1976 Knowledge-based systems for clinical problem solving. In decision making and medical care can information science help? Op tit: 26

Gosnell D 1973 An assessment tool to identify pressure sores. Nursing Research 22, 1

Janis I L, Mann L 1976 Decision making: a pyschological analysis of conflict, choice annd commitment. The Free Press a Division of Macmillan Publishing Co. Inc., New York, Collier Macmillan Publishing Ers London: 11

Lusted L B 1976 Clinical decision making. In Janis & Mann 1976. Op tit: 78-80

Nehrig W M, Durham J D, Macek M M 1986 Effective teaching: a problem-solving paradigm. Nurse Educator 11, 3

Norton D 1975 Research and the problem of pressure sores. Nursing Mirror 13: 65-67

Pylyshyn Z 1984 Computation and cognition. A Bradford Book, The Mit Press Cambridge, Massachusetts, London, England: 245-267

Salmon R, Derouesne C, Sampson M, Bernadet M, Gremy F 1976 Decision-making aids used to determine the content of medical teaching. In Janus & Mann 1976. Op tit: 235

Thiyagaratan J, Silver R 1982 Actiology of pressure sores in patients with spinal cord injury. British Medical Journal 289, 1. 1984: 1487-1490

Woods E 1985 Problem-based learning and problem- solving. In Boud D (ed) Problem-based Learning in Education for the Professions. Sydney Higher Education Research and Development Society of Australia (HERDSA)

APPENDIX A Norton Score See Norton 1975 Research and the Problems of Pressure sores in Nursing Mirror Februarv 13th pp. 65-67

Physical Mental condition state Activity Mobility Incontinence

Good 4 Alert 4 Ambulant 4 Full 4 Not 4 Fair 3 Apathetic 3 Walks with help 3 Slightiy limited 3 Occasionally 3 Poor 2 Confused 2 Chairbound 2 Very limited 2 Usually urinary 2 Very bad 1 Stuporous 1 Bedfast 1 Immobile 1 Double 1

APPENDIX B Part A: A survey on the occurrence of decubitus ulcers

1.

2.

3.

4.

5.

Description of decubitus ulcers A. Permanent skin discolouration B. Damage to epithelium/epidermis C. Damage to the full thickness of the skin D. Size of decubitus ulcer in cm E. Site of decubitus ulcer

A. Was the decubitus ulcer present on admission

A. Date of admission of patient to ward

A. Patient’s sex B. Age C. Height D. Weight E. Diagnosis

Mobility. The patient is A. Ambulant B. Ambulant with assistance C. Confined to chair D. Confined to bed; can turn without help E. Confined to bed; cannot change position

without help

The patient is incontinent of A. Urine B. Patient has a urinary catheter in situ C. Patient has a urodome in situ

The patient is incontinent of faeces

Answer column Yes No

q

e I! X

0 cl

f 0 0

i q

cl

B Cl J