Problem solving

Barrow and Pickell (1991) developed a strategy for problem solving which allows a
staged approach to the concept of clinical decision making. It was primarily developed
for medical students but it fits well today for the advanced nurse practitioner who is
required to assess patients and draw up differential diagnosis prior to formulating a
management plan for their patient group. Barrow and Pickell state that there are 2
components that relate to problem solving in clinical practice. Firstly the concept of
content, this is the knowledge base that the nurse has. Secondly, process this is the ability
of the nurse to apply their knowledge to patient care.
There are nine areas that Barrow and Pickell use as the foundation for their model/
framework:
- Forming the initial concept
- Generating hypothesis
- Formulating and enquiry strategy
- Applying appropriate clinical skills
- Developing the problem
- Laboratory and diagnostic findings
- Diagnostic decision making
- Therapeutic decision making
- Reflection in and on practice
1.1 Forming the initial concept
At this first point the practitioner will form an initial concept. This is primarily from the
presenting complaint but may also include perceptions gathered from the patients
appearance and who accompanies the patient. Also consider a possible hidden agenda.
Look at the patient as a whole rather than just the presenting complaint
Communication is essential throughout the assessment process. But at this point the
practitioner needs to draw on all aspects of their interpersonal skills to ensure that they
fully understand why the patient has presented. Also to ensure they build a positive
therapeutic relationship.
Although you begin to consider what is wrong hypothesis- it is too early to draw such
conclusions. Be careful not to make assumptions over what is wrong with the patient e.g.
chest pain is not always and MI
1.2 Generating hypotheses
This relates to the practitioners ideas of what may be wrong with the patient- differential
diagnosis. In reality this often happens immediately the patient presents. You have to then
rule the differential diagnosis in and out.
Ask more detail flesh out the bones by looking at the history of the presenting
complaint. Consider PQRST

1.3 Formulating the enquiry strategy

This is described by Barrows and Pickell as a period of searching/ scanning. Look at
patients past medical history, drug history, allergies, family history, social history,
smoking, alcohol and overseas travel. Then consider systems review, asking pertinent
questions from each system.
This may all provide more information that will add further hypotheses differential
diagnosis- and may help rule out others as well as lead to definite conclusions about a
diagnosis already considered.
1.4 Applying appropriate clinical skills
At this point the practitioner will carry out a detailed physical examination. This provides
precise information e.g. location of pain.
It must be noted that most diagnosis are made on the history alone and the physical
examination allows the practitioner to rule out or in their earlier hypothesis
1.5 Developing the problem synthesis
At this stage the practitioner puts all the information they have gathered so far together to
from an overview of the patients problem. This can then be compared to the hypotheses
that the practitioner is considering with regard to the presenting compliant.
Throughout this process it is essential that the accuracy of the findings is checked with
the patient. This allows them to understand how a diagnosis is arrived at and therefore
the patient will also be able to understand the treatments that may be required.
1.6 Laboratory and diagnostic findings
To allow hypotheses- differential diagnosis- to be ruled in or out secondary data may be
required.
The practitioner needs to also ensure they consider the sensitivity, specificity and
relevance of the secondary data.
1.7 Diagnostic decision making
At this point a diagnosis is made. Sometimes the practitioner will still have two or more
hypothesis so further investigations may be required before reaching a final diagnosis.
1.8 Therapeutic decision making
The practitioner will need to prescribe a course of treatment/ nursing/ medical
management plan for the patient.
It is essential that the patient is fully aware of what the management is for their
presenting complaint, allowing them to voice there concerns etc. Also consider patient
education at this point.

1.9 Reflection in and on practice

Reflect on what want well and areas that can be improved.
The practitioner can also identify skills which they need to develop.

Further information can be found in

Walsh M (2005) Nurse Practitioners: Clinical Skill and Professional Issues (2 nd
ed). Butterworth-Heinemann: London