Decision making by baccalaureate nursing students in the clinical setting

Many researchers who have explored nurse decision making have concluded that decision making is a learned skill that must be taught by nurse educators. Yet little research has been conducted to explore nursing students' decision making. If nurse educators are to teach this skill, it is necessary to have a better understanding of the kinds of decisions students are making in the clinical setting and the factors that influence this process. Once we have a greater knowledge in this area, curricular materials can be developed to ensure this skill is taught throughout an undergraduate education, resulting in graduates who possess strong, independent, and interdependent decision making skills. This article will describe one component (the kinds of decisions) of a larger qualitative case study that explored the kinds of decisions and the factors that influenced nursing students' decision making throughout a baccalaureate degree program.     

患者偏好与医患共同决策

循证医学提倡医务人员应用证据并考虑患者价值和偏好作出决策。医患共同决策基于医患双方均为"专家"的理念, 即医生作为医学专家提供医学专业意见, 而患者作为了解自身偏好的专家, 双方在充分讨论后共同作出医学决策。在此过程中, 医务人员应同时具备获取最佳证据以及应用决策辅助系统实现医患共同决策的能力。本文通过比较不同医学决策模式, 讨论医患共同决策的理论与实践, 并列举与中国医疗环境相关的、医患共同决策可能面临的挑战与障碍因素, 以期为临床作出合理决策以及提高医疗服务质量提供借鉴。     

The decision making of heart failure specialist nurses in clinical practice

Aims and objectives. To explore decision processes and types of decisions made by heart failure specialist nurses. Background. Heart failure specialist nurses are key to the management of patients with heart failure in the community. In previous studies heart failure specialist nurses have reported difficulty in developing decision making skills. Cognitive continuum theory can be used to examine the relationship between decision tasks and the processes used by heart failure specialist nurses to make decisions. Design. A qualitative study using non‐participant observation and semi‐structured interviews. Methods.  Six heart failure specialist nurses were observed while they carried out consultations with three patients each (n = 18). Twelve heart failure specialist nurses were interviewed about their decision making in practice. Data were analysed using thematic content analysis. Results. Two areas of decision making were identified by heart failure specialist nurses as key; pharmacological management and managing patients in the palliative phase of their condition. Pharmacological management decisions involved the trading off of risks and benefits of titrating medication, with nurses using internalised guidelines to inform their practice. In contrast, nurses relied on support from other health care professionals when making decisions about a patient’s need for palliative care. Conclusions. Medication titration decisions have a mixture of intuition and analysis inducing features making them amenable to the use of decision tools. The timing of the need for palliative care is less predictable, suggesting an intuitive approach to decision making may be more appropriate. Relevance to clinical practice. There are several strategies that could be used to improve the match between the decisions that heart failure specialist nurses take and the decision processes they use. These include the development of more tailored decision support tools for medication titration decisions and the provision of structured decision aids for assessing patients’ need for palliative care.     

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).     

Percutaneous endoscopic gastrostomy (PEG): the role and perspective of nurses

Aims and objectives. To study the perspectives of nurses on (i) the process of decision‐making regarding the placement of feeding gastrostomies, (ii) their role in the process, (iii) the impact this participation has on them personally and (iv) gastrostomy placement in general. Background. The decision to commit patients to long‐term feeding using a gastrostomy tube can be very difficult, particularly when the anticipated benefits are uncertain. Strategies to improve such decision‐making are required. Nurses are in an excellent position to provide valuable insights regarding this decision‐making and their increased participation in this process might substantially improve it. Design. A cross‐sectional, exploratory design using in‐depth semi‐structured interviews and a self‐administered questionnaire. Methods. In‐depth semi‐structured interviews with 17 nurses experienced in percutaneous endoscopic gastrostomy decision‐making were undertaken and analysed. Results. Individuals making decisions regarding feeding gastrostomy placement were observed to be insufficiently informed regarding the device and the ramifications of its placement. Nurses were perceived to play an important, although underused, role in decisions to commit patients to long‐term feeding. Participation in the making of these decisions may be stressful to nurses, particularly when the only result anticipated is the sustaining of a life of poor quality. Sixteen nurses reported that they would not want to have a gastrostomy for themselves if they were unable to maintain some quality of life. Strategies that could improve decision‐making were suggested. Conclusions. Decision‐making could be improved by providing better information to decision makers. A team‐orientated approach and more active dialogue with regard to care planning among health professionals, especially between doctors and nurses is needed. Effective decisions regarding feeding gastrostomy placement require adequate resources, especially sufficient time for caregivers to communicate effectively with those who must make these decisions. Relevance to clinical practice. The role of nurses in decision‐making regarding commitments to long‐term feeding using gastrostomy tubes could be effectively augmented.     

How do children's nurses make clinical decisions? Two preliminary studies

Aims and objectives. To gain an understanding of how children's nurses make clinical decisions. Background. Several studies have explored how nurses make clinical decisions and the factors that may affect the decision‐making strategies used. However, the results of these studies are contradictory. Further, little is known about children's nurses’ decision‐making strategies. Design. The think aloud technique. Methods. Nurses (n = 12) from three surgical wards and nurses (n = 15) from three medical wards in a Scottish children's hospital were presented with clinical scenarios and asked to think aloud. The verbal protocols were analysed to provide an indication of how children's nurses made decisions. Whether there were any differences in decision‐making between experienced and less experienced nurses and between graduates and non‐graduates was also explored. Results. Analysis of verbal protocols obtained using the think aloud technique suggested that all the nurses in the sample used a hypothetico‐deductive (analytical) model of decision‐making. Further, all participants appeared to use backward reasoning strategies regardless of their level of expertise. This is a characteristic of non‐expert decision‐making. Experienced and less experienced nurses collected similar additional information before planning nursing interventions, supporting the conjecture that they were functioning at a non‐expert level in relation to decision‐making. No differences were seen in the information collected by graduate and non‐graduate nurses. Conclusions. The decision‐making strategies of children's nurses need exploring further and further research is needed to identify factors that may affect decision‐making strategies. Several strategies to support nurses’ clinical decision‐making have been proposed but need testing to ascertain their effectiveness. Relevance to clinical practice. In clinical practice nurses make numerous decisions throughout the course of a shift. Sub‐optimal decision‐making strategies may adversely affect the quality of nursing care provided. It is imperative, therefore, to ascertain how nurses make clinical decisions and the factors that may influence the decision‐making strategies used.     

End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review

BackgroundEnd-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment.ObjectivesThe purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses?Review methodThis review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review.ResultsThere were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological ‘burnout’.ConclusionsFurther research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.     

Parental role in decision making about pediatric cardiac transplantation: familial and ethical considerations

Parents of children with complex or terminal heart conditions often face agonizing decisions about cardiac transplantation. There are differences in the level of involvement that parents prefer when making such decisions. The purpose of this study was to identify and describe parents' preferences for their roles in decisions related to cardiac transplantation. A prospective ethnographic method was used to study 24 parents of 15 children prior to their decision of accepting or rejecting the transplant option for their children. Findings revealed that the style of parent decision making ranged from a desire to make an independent, autonomous choice to a wish for an authoritarian, paternalistic choice. Nurses and physicians can best support families in this situation, showing sensitivity to the steps that parents use to make their decisions. An ethical model of decision making is proposed that includes respect for differences in beliefs and values of all persons involved in the transplantation discussion.     

Factors influencing decision making among ambulance nurses in emergency care situations

The aim of this study was to investigate which factors that influences decision making among Swedish ambulance nurses in emergency care situations. Nurses in ambulance are sometimes forced to make decisions without adequate information. Data collected from interviews with 14 ambulance nurses was analyzed. The informants described 30 incidents during which they had to make fast decisions. A qualitative content analysis of the text was made, from which different categories were identified. It was found that when nurses are called to an emergency, the extent and degree of difficulty of the incident is decisive for how decisions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision-making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex. Further studies are needed to understand the complexity of decision making in emergency situations.     

RN and RPN decision making across settings

Nursing decision making was a focus of the Province-Wide Nursing Project (PWNP), a 3-year project to promote best nursing practice. In much of the growing literature on nursing decision making, it is assumed that there are differences in the way RNs and RPNs make decisions. However, there is little scientific evidence to support this assumption. The RN and RPN decision making across settings questionnaire was completed by nurses employed in the 23 agencies of the 4 Participating Complexes taking part in the project. The survey questions were subjected to factor analysis and reduced to five factors. Results revealed measurable differences between the way that RNs and RPNs made decisions. Both RNs and RPNs reported making decisions frequently and experiencing little difficulty in making them. However, there were statistically significant differences in the frequency with which RNs and RPNs perceived they made decisions and the difficulty they found in making them. To plan effective health care, it is important to take account of the strengths of different health care workers. There is a need for further research to investigate the reasons behind the differences revealed in these findings.     

Parent decision making for life support for extremely premature infants: from the prenatal through end-of-life period

Most deaths of extremely premature infants occur in the perinatal period. Yet, little is known about how parents make life support decisions in such a short period of time. In the paper, how parents make life support decisions for extremely premature infants from the prenatal period through death from the perspectives of parents, nurses, and physicians is described. Five cases, comprised of five mothers, four neonatologists, three nurses, and one neonatal nurse practitioner, are drawn from a larger collective case study. Prenatal, postnatal and end-of-life interviews were conducted, and medical record data were obtained. In an analysis by two research team members, mothers were found to exhibit these characteristics: desire for and actual involvement in life support decisions, weighing pain, suffering and hope in decision making, and wanting everything done for their infants. All mothers received decision making help and support from partners and family, but relationships with providers were also important. Finally, external resources impacted parental decision making in several of the cases. By understanding what factors contribute to parents' decision making, providers may be better equipped to prepare and assist parents when making life support decisions for their extremely premature infants.     

Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy

Background and Purpose . Physiotherapists have been increasingly interested in investigating physiotherapy clinical reasoning and decision‐making processes. Cardiorespiratory physiotherapy has received little attention within this increasing body of research. This study aimed to investigate characteristics and processes of cardiorespiratory physiotherapy decision making and to contribute to the broader understanding of physiotherapy reasoning and decision making. Methods . Fourteen cardiorespiratory physiotherapists took part in the study. Qualitative research methods were used, guided by a philosophical hermeneutic approach. Participants were observed undertaking their usual daily patient care activities and were later interviewed about their decision making. In‐depth, iterative hermeneutic strategies were used to interpret the texts created by these processes to identify the nature and processes of decision making. Results . Clinical decision making in cardiorespiratory physiotherapy is focused on making decisions about the nature of patients' problems, physiotherapeutic intervention and interaction, and evaluation of effectiveness of actions. Cardiorespiratory physiotherapy decisions varied in their difficulty according to the attributes of the decisions. The variable nature of decisions influenced the reasoning processes used. Clinical decision making involved complex reasoning processes that were cyclic, evolving and flexible in nature, with interdependence and interrelation between the different foci of clinical decision making. Clinical decision making was also found to be a social and collaborative process. Conclusions . This study contributes to the body of literature on physiotherapy reasoning and decision making by revealing details about the characteristics and processes of cardiorespiratory physiotherapy decision making. This research can be used to shape the education of beginning practitioners and provide practicing physiotherapists with a basis for critical appraisal of their decision making. Copyright © 2008 John Wiley & Sons, Ltd.     

Intuition and Analysis in Decision Making and Choice

Purpose: To discuss the need for a shift in focus from intuitive to more analytic ways of examining both the process and outcomes of professional decisions based on "best evidence."
Scope: Different assumptions inherent in intuitive and analytic explanations of nurses' decision making are outlined, and the two approaches are compared. The benefits and limitations of such approaches to decision making in nursing and health care are discussed, using available research evidence to show that in most instances the analytical approaches are more effective.
Conclusions: A systematic approach to decision making in health care is needed, so that both health professionals and patients have a means for knowing the basis of decisions about treatment.     

An exploratory study into a methodology for the examination of decision making by nurses in the clinical area

This study was undertaken to explore decision making in the clinical area and why it is that some nurses make seemingly irrational decisions In the past simulations and decision frames have been used by psychologists and clinician researchers to examine decision making, although none of these methods were reported to have been used in the clinical area In the study 11 subjects were observed in the clinical area for 2 hours each and a total of 18 decisions were made by these subjects Each observation was followed by an interview in which the decisions were further explored and three simulations and four decision framed questions were also employed as comparative tools The subjects were also asked about their decision making strategies The method of using observation to collect data was effective and the effect of expenence was highlighted as one of the main factors influencing decision making The other methods proved useful as tools to examine particular aspects of decision making The effect of experience on decision making has wide reaching effects on future nurse education, as well as having professional implications in the area of autonomy, accountability and responsibility Further research in this area is then recommended     

Concept analysis of decision making

TOPIC: Client decision making in relation to health care. PURPOSE: To develop a conceptual analysis of client decision making regarding health care that represents the current state of the science in order to better understand how clients make decisions. SOURCES: Published literature. CONCLUSIONS: A model of client decision making is presented with implications for nursing. Defining attributes, antecedents, consequences, and empirical referents of decision making are developed and illustrated by case presentations.     

Naturalistic decision making: a model to overcome methodological challenges in the study of critical care nurses' decision making about patients' hemodynamic status.

The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.     

Research Article: Perceptions of Japanese patients and their family about medical treatment decisions

Internationally, nurses and physicians are increasingly expected to undertake roles in communication and patient advocacy, including in Japan, where the reigning principle underlying medical ethics is in transition from paternalism to respect for patient autonomy. The study reports the results of a survey in two Japanese teaching hospitals that clarified the perspectives of 128 patients and 41 family members regarding their current and desired involvement in health decision‐making. The commonest process that was desired by patients and their family was for patients to make decisions after consultation with both the physician and their family. The decision‐making preferences for competent patients varied among the participants, who believed that families have a crucial role to play in health‐care decision‐making, even when patients are competent to make their own decisions. The findings will inform health professionals about contemporary Japanese health‐care decision‐making and the ethical issues involved in this process, as well as assist the future development of a culturally relevant model to support patients' preferences for ethical decision‐making.     

Judgements and processes in care decisions in acute medical and surgical wards

The decisions which health care professionals make are the basis of treatment and care given. In order to evaluate effective care it seems logical to suggest that an awareness of the decisions which health care professionals make and how they make them is needed. This study examines the processes nurses use when making decisions about the health care needs of acutely ill patients. In stage one, 104 qualified nurses were interviewed to identify how they decide health care needs. In stage two, a 'think aloud' technique was used with patient simulations to obtain verbal protocols from a further 55 qualified nurses to identify the information strategies they used when making these decisions. The results suggest that nurses base their health care decisions mainly on their assessment of qualitative patient states or conditions. Initial indications are that the processes used differ from those characterized in the diagnostic reasoning model, with the context in which decisions are made being an important influence together with nurses' experience. It is suggested that, in order to develop effective predictive models and clinical guidelines which aid decision making, more research into the nature of health care professionals' decision making is carried out.