Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study

ObjectiveIntensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline.Research MethodologyA qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia.Main Outcome MeasuresObservational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis.FindingsFourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity.ConclusionExperiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources.Implications for Clinical PracticeNurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.     

Clinical decision-making in the intensive care unit: A concept analysis

AimTo operationally define clinical decision-making as it relates to intensive care unit nursing.BackgroundClinical decision-making is an intricate cognitive process that is demanding on intensive care nurses due to the severity of their patients’ illnesses, consistent exposure to high-stakes situations, and prevalent patient mortality. When compromised, it can lead to adverse patient events. However, clinical decision-making specific to the intensive care unit is a concept seldom defined in nursing research.DesignConcept analysis.MethodsUsing Walker and Avant’s eight-step method, nursing databases were searched for studies between 1980 and 2022 describing the antecedents, defining attributes, consequences, and empirical referents of clinical decision-making in the intensive setting.FindingsIntensive care unit clinical decision-making is a complex cognitive process in which nurses recognize a clinical problem in their patient and respond promptly by implementing interventions to improve their patient’s rapidly and frequently changing health status to a more favorable condition in an intensive care setting. The defining attributes are: assessment of the patient situation, prompt recognition of cues, efficient comprehension of patient data abnormalities, prior knowledge and experience, prompt response to the clinical problem(s), colleague collaboration, formulation of interventions to treat clinical problem(s), and appraisal of risks/benefits.ConclusionIntensive care unit clinical decision-making is a skill that is different from traditional clinical decision-making in nursing. Prompt action characterizes this concept due to the unstable health status of these patients. More research on this concept is needed to enhance nurse performance and patient outcomes in intensive care.Implications for clinical practiceA definition of this concept opens doors for potential studies on promoting effective decision-making among intensive care nurses. This can improve the safety and outcomes of critically ill patients. Additionally, it generates new questions regarding how nursing schools and hospital orientation programs can promote and develop competent decision-making skills in future intensive care nurses.     

Deriving the Practice-Primed Decision Model from a naturalistic decision-making perspective for acute care nursing research

AimThe purpose of this article is to present the derivation of the Practice Primed Decision Model from a naturalistic decision-making framework for use in guiding future nursing decision-making research.BackgroundAcute care nurses make decisions in demanding environments under the influence of many factors. The influence of these factors on nurse decision-making is not well understood leading to gaps in understanding how to best support acute care nurse decision-making.MethodsThe strategy of theory derivation was used in the development of a new model for use in nursing research. This model incorporates important elements identified in naturalistic decision making, a Recognition Primed Decision Model and an integrative review of nurse decision-making literature.ConclusionThe new model, Practice Primed Decision Model, provides a new perspective to guide nurse decision-making research. This model includes factors influential to the nurse decision-making process that is more realistic in time limited, high stakes decision-making situations.     

Decision-making processes of a nurse working in mental health,regarding disclosure of confidential personal health information of a patient assessed as posing a risk

BackgroundNurses working in mental health routinely face difficult decisions regarding confidentiality and disclosure of patient information. There is public interest in protecting patient confidentiality, and there is a competing public interest in disclosing relevant confidential information to protect the patient or others from harm. However, inappropriate disclosures may constitute a breach of confidentiality. Despite the gravity of this situation, there is a paucity of literature to guide nurses’ decision-making processes regarding confidentiality and disclosure.AimTo examine decision-making processes of a nurse working in mental health, regarding disclosure of personal health information of a patient assessed as posing a risk.MethodsQualitative interpretivist approach using thematic analysis of data derived from an instrumental case study of NK v Northern Sydney Central Coast Area Health Service 2010, a Civil and Administrative Tribunal matter in New South Wales, Australia.FindingsThree important legal concerns relevant to nurses’ decision-making processes are illuminated. Firstly, for risk assessment there was an emphasis on a static notion of dangerousness. Secondly, rules of confidentiality and disclosure were not adequately observed. Thirdly, confidential information was disclosed without valid justification.DiscussionInappropriate decision-making processes that may lead to a breach of patient confidentiality were evident in the findings. Gaps in understanding nurses’ decision-making processes pertaining to confidentiality and disclosure of patient information that may be addressed by future research were also revealed.ConclusionFuture research that addresses gaps in understanding nurses’ decision-making processes identified by this instrumental case study would provide greater guidance for nurses when making decisions regarding confidentiality and disclosure related to risk.     

Did We Interpret the Same Thing?

PURPOSE: Motivated by the potential application of "similarity theory" in nursing communication, the primary objectives of this paper are (a) to seek an in‐depth understanding of how nurses identify like concepts when comparing two similar but different images, and (b) to pinpoint the thinking process nurses use to determine "similarity" as a pretest of a framework that is meant to improve nursing communication for better patients' care. METHODS: A think‐aloud approach is used to elicit both written and verbal responses from six participants, who are medical‐surgical registered nurses with an associate degree, by comparing two specifically designed images for similarity determination. Data collected from participants include responses about four levels of similarities, a similarity rating using a 1–10 Likert‐type scale, and a most meaningful concept shared by the image pair. FINDINGS: Collected data indicate noticeable variability in the level and quality of details, which in turn demonstrates inconsistencies. The findings from analyzing the collected think‐aloud responses indicate that the proposed framework of thinking process was undertaken by at least three participants (i.e., 50%) before they reached the similarity rating and a meaningful concept. This study shows how misunderstandings in interpretation can occur simply because nurses used different similarity approaches. Anomalies are also found in the collected data (i.e., think‐aloud responses). Possible causes and explanations are given, along with suggestions for further investigation and validation of the proposed framework. CONCLUSIONS: In this study, a communication framework based on similarity theory was proposed to highlight the thinking process of nursing concept development. A think‐aloud pilot study was conducted. Results suggest that similarity theory and the proposed framework can be used to explain how nurses classify and determine similarities, though an in‐depth validation is needed. This framework may guide nurse educators to promote higher levels of thinking when educating students and nurses in the process of extracting quality information during patient care. The limitations of current research have been addressed. Additional research issues and extensions to this study are also provided in order to further improve nursing communication education.     

Development and testing of the theory of collaborative decision-making in nursing practice for triads

BACKGROUND: Although nurses depend heavily on informal family caregivers to provide care to clients and to be involved in care planning and decision-making, no nursing theories that include the client, the caregiver, and the nurse were available to guide collaborative care planning and decision-making. AIM: The purpose of this paper is to describe the construction and initial testing of the theory of collaborative decision-making in nursing practice for a triad. The theory represents an extension of Kim's theory of collaborative decision-making in nursing practice. Kim's theory was developed to describe and explain collaborative decision-making in a dyad (client and nurse). The inclusion of a third person (family caregiver) in the theory required the addition of concepts about the caregiver, coalition formation, and nurse and caregiver outcomes. The expansion of Kim's dyadic theory to a triadic theory was achieved by means of a modified version of the theory derivation process described by Walker and Avant. CONCLUSIONS: The theory of collaborative decision-making in nursing practice for a triad can be used to guide further research and clinical practice. The theory provides a framework for researchers who are interested in studying the effects of collaboration regarding decision-making among nurses, family caregivers, and clients. The initial testing of the new theory in home health care nursing revealed variety in the nature of the client-caregiver-nurse relationships, the many processes used by the nurses in proceeding with the home visits, a multitude of decisions considered and different collaborative, noncollaborative, and coalition-forming interactions. The limited evidence of the empirical adequacy of the theory precludes development of definitive guidelines for clinical practice at this time. More studies are required before clinical practice guidelines can be developed.     

Supporting sexual activity in long-term care

Although nurses in almost every long-term care facility face daily challenges involving issues related to residents' sexual lives, guidelines for ethically supporting sexual activity are rare and inadequate. A decision-making framework was developed to guide care providers in responding to the sexual expression of residents in long-term care. The framework recommends that nurses should weigh the documented substantial benefits of having a sexual life against harm to the resident and others, and against offence to others. This article illustrates the use of this ethical decision-making framework by using the example of nurses supporting a resident's expression of his sexuality. It is suggested that nurses use this framework to guide their practice when related ethical issues arise.     

The “elephant in the room”: using emotion management to uncover hidden discourses in interprofessional collaboration and teamwork

Abstract

Shared decision-making and interprofessional collaboration are important approaches to achieving consumer-centered care. The concept of shared decision-making has been expanded recently to include the interprofessional healthcare team. This study explored healthcare providers’ perceptions of barriers and facilitators to both shared decision-making and interprofessional collaboration in mental healthcare. Semi-structured interviews were conducted with 31 healthcare providers, including medical practitioners (psychiatrists, general practitioners), pharmacists, nurses, occupational therapists, psychologists and social workers. Healthcare providers identified several factors as barriers to, and facilitators of shared decision-making that could be categorized into three major themes: factors associated with mental health consumers, factors associated with healthcare providers and factors associated with healthcare service delivery. Consumers’ lack of competence to participate was frequently perceived by mental health specialty providers to be a primary barrier to shared decision-making, while information provision on illness and treatment to consumers was cited by healthcare providers from all professions to be an important facilitator of shared decision-making. Whilst healthcare providers perceived interprofessional collaboration to be influenced by healthcare provider, environmental and systemic factors, emphasis of the factors differed among healthcare providers. To facilitate interprofessional collaboration, mental health specialty providers emphasized the importance of improving mental health expertise among general practitioners and community pharmacists, whereas general health providers were of the opinion that information sharing between providers and healthcare settings was the key. The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environment) to implement effective shared decision-making and interprofessional collaboration in mental healthcare.     

Decision-making in palliative care: a reflective case study

Critical examination of the processes by which we as nurses judge and reach clinical decisions is important. It facilitates the maintenance and refinement of good standards of nursing care and the pinpointing of areas where improvement is needed. In turn this potentially could support broader validation of nurse expertise and contribute to emancipation of the nursing profession. As pure theory, clinical decision-making may appear abstract and alien to nurses struggling in 'the swampy lowlands' (Schon 1983) of the realities of practice. This paper explores some of the key concepts in decision-making theory by introducing, then integrating, them in a reflective case study. The case study, which examines a 'snapshot' of the patient and practitioner's journey, interwoven with theory surrounding clinical decision-making, may aid understanding and utility of concepts and theories in practice.     

Transition experiences of newly qualified registered graduate nurses employed in a Neonatal Intensive Care Unit

ObjectiveTo explore the experiences of newly qualified registered graduate nurses’ clinical and professional learning experiences, during their first six-months of post registration employment within a graduate nurse transition program in a Neonatal Intensive Care Unit (NICU).MethodNarrative inquiry with thematic analysis was used to explore the newly qualified registered graduate nurses’ accounts via semi-structured interviews, conducted between January 2018 – January 2019, of their clinical and professional learning during their employment in the Neonatal Intensive Care Unit.SettingIn total, eight newly qualified registered graduate nurses employed at two Western Australian Hospitals sites were recruited.FindingsThemes identified included: feeling unprepared; experiences of horizontal violence; the need for a supportive structural environment and seeking feedback. Participants reported overwhelming feelings of stress, emotional exhaustion, concerns for patient safety and for some, fear of early career burnout.ConclusionIn this study, newly qualified registered graduate nurses were clinically underprepared for entering a Neonatal Intensive Care Unit with all participants reporting high levels of psychosocial distress. This was further compounded by a lack of structured support, horizontal violence, and inadequate or no regular feedback from preceptors, resulting from a negative workplace culture and poor educator behaviours. Recommendations for improving the experiences of newly qualified registered graduate nurses employed in the Neonatal Intensive Care are discussed.     

Themes surrounding novice nurse near-miss and adverse-event situations

OBJECTIVE: The study purpose was to identify human performance factors that characterized novice nurse near-miss/adverse-event situations in acute-care settings. BACKGROUND: Increased focus on recruitment and retention of newly graduated registered nurses (RNs) in light of patient safety improvement goals will challenge healthcare educators and administrators. What we are beginning to learn about human performance issues during real work situations from patient safety research provides information related to human performance in complex environments that may guide education and system supports for novice RNs. METHODS: Data collected during 8 retrospective interviews of novice RNs about details surrounding their individual near-miss or adverse event were analyzed for common themes. RESULTS: Nine themes were identified. Seven themes were present in at least 7 of the 8 cases and included environmental and social issues, as well as novice lack of expertise. CONCLUSIONS: Findings suggest that support for novice nurses in acute care environments requires attention to the following: consistent availability of expertise in light of workload unpredictability, the social climate regarding expectations of novice performers, realistic expectations of novice decision-making ability during complex situations even up to a year after graduation, and strategies to recognize and intervene when novices are at risk for error.     

Shared Decision-Making for Patients Using Cannabis for Pain Symptom Management in the United States

ObjectivesGaps in research evidence and inconsistent policies regarding use of cannabis for pain and associated symptoms result in confusion for healthcare providers and patients. The objective of this review was to synthesize information on cannabis use for pain with legal and policy implications to create a shared decision-making model that can be used to guide patient care interactions.ApproachCurrent cannabis policies, state laws, research, and patient care practices related to medical and recreational cannabis in the United States were reviewed, along with best practices in shared decision-making. Reviewed literature was then synthesized to create a model that can be used by registered nurses and others to address cannabis use, where legal, for pain and related symptoms.Result and conclusionsCannabis is a legal option for many patients with pain. To minimize harms and optimize benefits, nurses can play a key role when authorized by law in assisting with decision-making surrounding cannabis use.     

A conceptual framework for end-of-life care: A reconsideration of factors influencing the integrity of the human person

In this article, we examine emerging themes in the research and theoretical literature on care at the end of life to develop a conceptual framework to guide further research in this area. The integrity of the human person is the organizing concept, and the spiritual domain is at the core of the psychological, physical, and functional domains. This framework extends beyond previous frameworks for care at the end of life by including the relationship of the health professional and the health care organization to the integrity of the person. Also, outcomes in this framework extend beyond quality of life and comfort to include patient decision-making methods and achievement of life goals. Attention is given to the cultural dimension of personhood in our multicultural society, and the definition of end of life is expanded to include both the acute phase of terminal illness and the frailty of health associated with advanced age.     

Help-seeking behaviour: a concept analysis

The concept 'help-seeking behaviour' has gained popularity in recent years as an important vehicle for exploring and understanding patient delay and prompt action across a variety of health conditions. The term is used interchangeably with health seeking and is described as part of both illness behaviour and health behaviour. Concept clarification is required to aid nurses and other health-care professionals understanding of the attributes of help-seeking behaviour and to guide theory development, practice and research. The Walker and Avant method of concept analysis was used to guide the analysis. Help-seeking behaviour was shown to be a complex decision-making process instigated by a problem that challenges personal abilities. According to the literature, the process is characterized by the following attributes: problem focused, intentional action and interpersonal interaction. Help-seeking behaviour for a health problem can therefore be defined as a problem focused, planned behaviour, involving interpersonal interaction with a selected health-care professional.     

The sum of us. Implementing a Person Centred Care Bundle - A narrative inquiry

AimThis study is a narrative inquiry that aims to better understand the experience of nurses implementing a Person-Centred Care (PCC) bundle onto an acute care ward in a large hospital in Melbourne, Australia.BackgroundThe PCC includes five key focus areas aimed at streamlining nursing practice 1) Nursing assessment and care planning, 2) bedside handover, 3) patient safety rounding, 4) patient whiteboards, and 5) safety huddles. The PCC bundle outlines a nursing care process that is interactional with the patient, focused on information sharing, safety and respect.MethodA narrative inquiry was used to explore the nurse's experiences implementing the PCC. Surveys and focus groups were used to collect data and thematic analysis was used to identify any key themes.ResultsThe three themes were; Passing the baton; Keeping the cogs moving when time poor; and Deep interpersonal relating-The sum of us.