Management decision-making in nursing

This study developed a new, valid and reliable evaluation instrument to measure the level, type and pattern of management decisions of fifteen nursing students. The management decision score achieved using this instrument was correlated with two psychological determinants of management decision making: creativity and problem-solving ability. The instrument was a written patient management problem in case format, answered by a free form written response. The student responses were classified for type of management decision according to the sub-categories of technical, inter-personal, environmental and unique. Using statistical analysis a significant difference was found in the type of management decisions most frequently selected by the study sample. The students predominantly selected technical type decisions. This preference for one type of management decision may be due to a number of psychological and environmental factors. These factors may program and mold the type of management decisions student nurses make early in their career. Low but positive correlations were found between the total management score and the two psychological tests. This finding supports the authors cited in the literature who state that although creativity augments the type of management decision making, it is not present or encouraged widely in the nursing profession. These factors are worth considering when the profession becomes concerned over ritualization and lack of individuality in patient care. The tool is easy to administer, lends itself to a variety of professional settings and shows promise with further refinement for computer application.

Do knowledge and experience have specific roles in triage decision-making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.

Critical care nurses' haemodynamic decision making

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study

AIMS AND OBJECTIVES: The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service.

BACKGROUND: There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice.

DESIGN: This study used a sequential exploratory design with data collected in 2014.

METHODS: A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation.

RESULTS: Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need.

CONCLUSION: Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making.

RELEVANCE TO CLINICAL PRACTICE: There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

Ethics in nursing practice: a guide to ethical decision making

Every day nurses are required to make ethical decisions in the course of caring for their patients. Ethics in Nursing Practice provides the background necessary to understand ethical decision making and its implications for patient care. The authors focus on the individual nurse’s responsibilities, as well as considering the wider issues affecting patients, colleagues and society as a whole. This third edition is fully updated, and takes into account recent changes in ICN position statements, WHO documents, as well as addressing current issues in healthcare, such as providing for the health and care needs of refugees and asylum seekers, bioethics and the enforcement of nursing codes.

Decision-Making Incapacity Among Nursing Home Residents: Results From the 1987 NMES Survey.

Recent legislative and regulatory developments have focused attention on older adults' capacity for involvement in health care decision-making. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) focused attention on the rights of nursing home residents to be involved in health care decision-making to the fullest extent possible. This article uses data from the 1987 National Medical Expenditure Survey (NMES) to examine rates of incapacity for health care decision-making among nursing home residents. Elements of the Oklahoma statute were used to operationalize decision-making incapacity: disability or disorder, difficulty in decision-making or communicating decisions, and functional disability. Fifty-three percent of nursing home residents had a combination of either physical or mental impairment and an impairment in either self-care or money management. The discussion focuses on the policy and practice implications of significant rates of incapacity among nursing home residents.

A study of nurses' judgement of and participation in decision-making for nursing home placement for the elderly

This study investigated the effects of patient variables (physical and cognitive disability, significant others' preference and social support) on nurses' nursing home placement decision-making and explored nurses' participation in the decision-making process.^ The study was conducted in a hospital in Texas. A sample of registered nurses on units that refer patients for nursing home placement were asked to review a series of vignettes describing elderly patients that differed in terms of the study variables and indicate the extent to which they agreed with nursing home placement on a five-point Likert scale. The vignettes were judged to have good content validity by a group of five colleagues (expert consultants) and test-retest reliability based on the Pearson correlation coefficient was satisfactory (average of.75) across all vignettes.^ The study tested the following hypotheses: Nurses have more of a propensity to recommend placement when (1) patients have severe physical disabilities; (2) patients have severe cognitive disabilities; (3) it is the significant others' preference; and (4) patients have no social support nor alternative services. Other hypotheses were that (5) a nurse's characteristics and extent of participation will not have a significant effect on their placement decision; and (6) a patient's social support is the most important, single factor, and the combination of factors of severe physical and cognitive disability, significant others' preference, and no social support nor alternative services will be the most important set of predictors of a nurse's placement decision.^ Analysis of Variance (ANOVA) was used to analyze the relationships implied in the hypothesis. A series of one-way ANOVA (bivariate analyses) of the main effects supported hypotheses one-five.^ Overall, the n-way ANOVA (multivariate analyses) of the main effects confirmed that social support was the most important single factor controlling for other variables. The 4-way interaction model confirmed that the most predictive combination of patient characteristics were severe physical and cognitive disability, no social support and the significant others did not desire placement. These analyses provided an understanding of the importance of the influence of specific patient variables on nurses' recommendations regarding placement. ^

Classifying clinical decision making:interpreting nursing intuition, heuristics and medical diagnosis

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches.

An analysis of nursing students' decision-making in teams during simulations of acute patient deterioration

AIM: The aim of this study was to examine the decision-making of nursing students during team based simulations on patient deterioration to determine the sources of information, the types of decisions made and the influences underpinning their decisions.

BACKGROUND: Missed, misinterpreted or mismanaged physiological signs of deterioration in hospitalized patients lead to costly serious adverse events. Not surprisingly, an increased focus on clinical education and graduate nurse work readiness has resulted.

DESIGN: A descriptive exploratory design.

METHODS: Clinical simulation laboratories in three Australian universities were used to run team based simulations with a patient actor. A convenience sample of 97 final-year nursing students completed simulations, with three students forming a team. Four teams from each university were randomly selected for detailed analysis. Cued recall during video review of team based simulation exercises to elicit descriptions of individual and team based decision-making and reflections on performance were audio-recorded post simulation (2012) and transcribed.

RESULTS: Students recalled 11 types of decisions, including: information seeking; patient assessment; diagnostic; intervention/treatment; evaluation; escalation; prediction; planning; collaboration; communication and reflective. Patient distress, uncertainty and a lack of knowledge were frequently recalled influences on decisions.

CONCLUSIONS: Incomplete information, premature diagnosis and a failure to consider alternatives when caring for patients is likely to lead to poor quality decisions. All health professionals have a responsibility in recognizing and responding to clinical deterioration within their scope of practice. A typology of nursing students' decision-making in teams, in this context, highlights the importance of individual knowledge, leadership and communication.

End-of-life decision making for older people

This chapter deals with the increasing issues surrounding end-of-life decision making. As the life trajectory for older people changes, the need for open discussion about their health problems and treatment becomes more critical. Acceptance of the ageing process itself is often not easy so the matter of a good death is even more distressing for some people to consider. The vignette provides an excellent discussion on the need for open dialogue with the older person and their families, whether they are acutely ill or have chronic health problems. How a person wishes to be treated when quality of life is not going to improve, no matter what interventions are put in place, seems essential for person-centred care. The issue of competency is one that must be determined before any decision is made by any person involved in care.

Predictive modelling : parents’ decision making to use online child health information to increase their understanding and/or diagnose or treat their child’s health

Abstract Background The quantum increases in home Internet access and available online health information with limited control over information quality highlight the necessity of exploring decision making processes in accessing and using online information, specifically in relation to children who do not make their health decisions. Objectives To understand the processes explaining parents’ decisions to use online health information for child health care. Methods Parents (N = 391) completed an initial questionnaire assessing the theory of planned behaviour constructs of attitude, subjective norm, and perceived behavioural control, as well as perceived risk, group norm, and additional demographic factors. Two months later, 187 parents completed a follow-up questionnaire assessing their decisions to use online information for their child’s health care, specifically to 1) diagnose and/or treat their child’s suspected medical condition/illness and 2) increase understanding about a diagnosis or treatment recommended by a health professional. Results Hierarchical multiple regression showed that, for both behaviours, attitude, subjective norm, perceived behavioural control, (less) perceived risk, group norm, and (non) medical background were the significant predictors of intention. For parents’ use of online child health information, for both behaviours, intention was the sole significant predictor of behaviour. The findings explain 77% of the variance in parents’ intention to treat/diagnose a child health problem and 74% of the variance in their intentions to increase their understanding about child health concerns. Conclusions Understanding parents’ socio-cognitive processes that guide their use of online information for child health care is important given the increase in Internet usage and the sometimes-questionable quality of health information provided online. Findings highlight parents’ thirst for information; there is an urgent need for health professionals to provide parents with evidence-based child health websites in addition to general population education on how to evaluate the quality of online health information.

"The red dress or the blue?" How do staff perceive that they support decision making for people with dementia living in residential aged care facilities?

Respect for a person's right to make choices and participate in decision making is generally seen as central to quality of life and well-being. When a person moves into a residential aged care facility (RACF), however, decision making becomes more complicated, particularly if the person has a diagnosis of dementia. Little is known about how staff in RACFs perceive that they support decision making for people with dementia within their everyday practice, and this article seeks to address this knowledge gap. The article reports on the findings of a qualitative study conducted in the states of Victoria and Queensland, Australia with 80 direct care staff members. Findings revealed that the participants utilized a number of strategies in their intention to support decision making for people with dementia, and had an overall perception that "a little effort goes a long way."