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

Raffik 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: 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

Raffik Cader, 49(4), 397–405
School of Health, Cognitive Continuum Theory in nursing decision-making
Community and Education Studies,
Aim. The purpose of this paper is to analyse and evaluate Cognitive Continuum
Northumbria University,
Theory and to provide evidence for its relevance to nurses’ decision-making.
Manor House,
Coach Lane West, Background. It is critical that theories used in nursing are evaluated to provide an
Newcastle Upon Tyne NE7 7XA, understanding of their aims, concepts and usefulness. With the advent of evidence-
UK. based care, theories on decision-making have acquired increased significance.
E-mail: raffik.cader@unn.ac.uk Method. The criteria identified by Fawcett’s framework has been used to analyse
and evaluate Hammond’s Cognitive Continuum Theory.
Findings. There is empirical evidence to support many of the concepts and pro-
positions 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 con-
tributions 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

Theory in providing a middle ground for decision-making in

Introduction
The implementation of evidence-based care in clinical prac-
tice 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 under-
standing. 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 Hammond’s Cognitive Continuum
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 understand-
ing of its aims, concepts and usefulness. Fawcett’s (1993)
framework is useful for the purpose of analysing and evaluat-
ing 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

2005 Blackwell Publishing Ltd 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, pro-
vides 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 non-
nursing theories do not reflect 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 Bandura’s (1977) Self-Efficacy Theory, which has
been used by practitioners to empower clients through educa-
tion (Oetker-Black & Kauth 1995; Fleming et al. 2003).
Another example is Ajzen and Fishbein’s (1980) Theory of
Reasoned Action, which has helped to inform studies on
nurses’ attitudes and caring behaviour (McKinlay et al. 2001).
In the field 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 deficit. 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).
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 Hammond’s theory. The more structured a task
is, the more analytically induced will be the decision-making
mode. Conversely, with an ill-structured task decision-
making is likely to be intuition-induced.
Fawcett’s framework
Fawcett’s (1993) framework has two components – analysis
and evaluation – with separate criteria for each component.
Identifying a theory’s strengths and weaknesses to make it
more understandable is undertaken through analysis, which
398
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397–405
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 theorist’s published work. The result informs the evalu-
ation process that is undertaken from interpretations and
critiques by other scholars, from research reports and from
reports of practical application.
The evaluative criteria identified by Fawcett (1993) are:
significance, internal consistency, parsimony, testability,
empirical adequacy, and pragmatic adequacy. The signifi-
cance criterion is achieved when the metaparadigmatic,
philosophical and paradigmatic origins of the theory are
made explicit. The criterion for internal consistency is
fulfilled when all the elements of the theorist’s work are
congruent and when there is semantic clarity, semantic
consistency and structural consistency. To meet the parsi-
moniousness 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 consti-
tuting Fawcett’s (1993) framework are general enough to be
used in the analysis and evaluation of Cognitive Continuum
Theory.
Analysis of Cognitive Continuum Theory
Scope of the theory
Cognitive Continuum Theory focuses exclusively on judge-
ment and decision-making. It can be appropriately classified
as a middle-range, descriptive theory as Hammond offers
explanations about general and specific 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 Con-
tinuum Theory offers researchers of judgement and decis-
ion-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
Nursing theory and concept development or analysis
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 individual’s 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 reflect the
real situation, then the judgement will be accurate (Dowding
2002); otherwise an inaccuracy in judgement is likely.
Fawcett’s (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 specifically 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 judge-
ment and decisions. Reconciling these two approaches
strengthens research endeavours by understanding judgement
and decision-making.
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, func-
tional relations, oscillation, and alternation (Hammond
1996). The definitions of these concepts are included for
clarity and understanding.

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397–405
Cognitive Continuum Theory in nursing decision-making
Modes of cognition
The concept modes of cognition are not clearly defined by
Hammond; however, the three dimensions associated with
this concept have been clearly defined: analysis, intuition and
quasirationality.
Analysis is defined 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-specific organizing principle and
high confidence 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 confidence 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
Brunswik’s (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 sub-
tasks, visual or quantitative presentation and time available to
undertake the task). The two identified 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 significance of the tracing from an electrocar-
diograph, 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 intu-
ition. 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.
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R. Cader et al.
Modes of inquiry
Borrowed from Churchman (1971), ‘modes of inquiry’ repre-
sent the different reasoning strategies needed to ensure episte-
mological safeguarding in decision-making (Hamm 1988a).
This is justified by Hammond (1996), who states that ‘different
modes of inquiry make different demands on human judge-
ment’ (p. 233). He identifies the six dimensions to ‘modes of
inquiry’ as modes 1–6, with modes 1–3 being biased towards
analysis and modes 4–6 biased towards intuition.
Mode 1 exemplifies pure analytical cognition requiring ‘true
experiments’ to support the evidence for decision-making.
Mode 2, based on statistical inference, is seen as less ana-
lytical 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 obser-
vations of statistical data.
Oscillation describes the process by which modes of cogni-
tion 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 quasiration-
ality providing the link between the intuition and analysis
endpoints on the cognitive continuum.
• Tasks can be placed on a continuum depending on their prop-
erties, 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 influence 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.
400
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397–405
Evaluating Cognitive Continuum Theory
Significance
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 Hammond’s Theory, in particular
the influence 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 Brunswik’s
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 significance of this Theory is that it
counteracts the traditional view that judgement and decis-
ion-making can be either intuitive or analytical. Instead it
presents a unifying theory for these two modes of cogni-
tion, 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 definitions 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
Hammond’s published work in the consistent use of terms,
with the same definition attached to each of them. There are
no concept redundancies, as each concept contributes some-
thing 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 justifies the relevance of the theory in many
Nursing theory and concept development or analysis
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 identifies them as
dimensions of the concept of modes of cognition. Similarly,
well-structured and ill-structured tasks have been identified 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 1–6. Extensive explanations of the
concepts and propositions (Hammond 1996, 2000) have
served to clarify the complexity of the Cognitive Continuum
Theory without oversimplification. On the whole, the
arrangement of the concepts, as shown in the analysis
section, provides a parsimonious structure for the theory.
Testability
The dynamic interaction of the parallel concepts of task and
cognition has been identified 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 identified 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), 397–405
Cognitive Continuum Theory in nursing decision-making
Empirical adequacy
Hammond et al. (1997) undertook the first 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 com-
plete 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 work-
ing in elder care and medical–surgical wards in Canada,
Finland, Sweden, Switzerland and the United States of
America (USA). They used a structured questionnaire based
on the Theory, and found that nurses used five 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 environ-
ments have been shown to use cognitive processes that are
reflected 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 demonstra-
ting that nurses use a range of sub-tasks with different levels
of complexities and structure in the evaluative process. The
sub-tasks identified 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 Hammond’s
(1988) definition of ill-structured tasks, the sub-tasks of
‘Assessing the cultural origin of WWW information’, and
‘Assessing user-friendliness of websites’ are labelled as ill-
structured. 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 Hammond’s
(1988) definition 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
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 func-
tional 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 field
of engineering, social policy-making, medicine and nursing.
In engineering, to reduce the many design failures attrib-
uted 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
scientific medical knowledge has to be applied to specific
patient complaints before reaching a decision. In his
version of the cognitive continuum, he has replaced
Hammond’s ‘modes of inquiry’ with ‘modes of practice’
Well structured
Quasi-
experiment
Mode 3
Task
System-aided
judgement
Mode 4
Peer-aided
judgement
III structured
Mode 5
Intuitive
judgement
Mode 6
Intuition Cognitive mode
402
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’ sim-
ply becomes ‘quasi-experiment’, ‘controlled trial’ replaces
‘control-group experiment’ and ‘scientific experiment’
replaces ‘true experiment’. His work in medicine has been
influential in making these changes.
Thompson (1999) has argued that Hamm’s 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 Hamm’s version
of the Theory to medicine has exemplified 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 frame-
work to assist nurses to aim for accuracy in their decision-
making process. Adjusting modes of cognition to corres-
pond to judgement tasks leads to accuracy in decision-
making (Hamm 1988a). Not adhering to this basic premise
of the Theory is likely to lead to judgement inaccuracies.
Scientific
experiment
Mode 1
Controlled
trials
Mode 2
Figure 1 After Hamm’s (1988a) Cognitive
Analysis Continuum.

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397–405
Nursing theory and concept development or analysis
Secondly, when practising within a multiprofessional envi-
ronment, 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 rational-
ity, depending on the activities being undertaken and the
nature of the cues associated with these activities. With
Hammond’s (1981) support for equity in modes of cogni-
tion, nurses can also argue that, with the Theory’s
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 specific 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 decision-
making 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
Theory’s framework. To operate within the framework,
Harbison (2001, p. 132) has identified ‘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

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(4), 397–405
Cognitive Continuum Theory in nursing decision-making
2001), supporting Dowie’s (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
identified 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 inter-
action 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 trans-
parent 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 infor-
mation on which decisions are based should be known, to
allow for choices from related outcomes to be made
explicit. The current dichotomous view that decision-
making can be either intuitive or analytical does not
clearly reflect 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 judge-
ments, then its impact on nursing practice can only be
positive.
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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 pro-
cess.
• The majority of published nursing research has adopted
either an analytical or intuitive approach to explaining
decision-making in nursing.
• Hammond’s Cognitive Continuum Theory can be
applied to the decision-making process of many pro-
fessionals, 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 Fawcett’s (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 profes-
sionals 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.
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