Occupational ideology and clinical decision-making in British nursing

As the first phase of a study to assess the usefulness of the nursing process model of nursing practice, a survey was carried out in one health district to ascertain the predominant occupational ideology of clinical nurses, their perception of decision-making about individual patient care in everyday work, and their view of whether they ought to exercise a decision-making role with respect to 23 aspects of patient care. Two hundred ideology scale questionnaires were processed, together with perceived and normative decisions inventories. Subjects were representative of six nursing fields, i.e. general nursing, geriatric nursing, psychiatric nursing, mental handicap nursing, health visiting and district nursing. The main findings were that nurses predominantly espouse a professional ideology, they perceive decision-making to be part of their everyday work and contend that they ought to be able to make decisions in 22 out of the 23 areas of patient care included in the inventories. Differences in ideology between the groups and between men and women are identified and discussed, and some areas of role conflict highlighted. The professional ideology was found to correlate significantly with decision-making and a significant correlation was established between paramedicine and bureaucracy.     

Clinical decision making on the use of physical restraint in intensive care units

Physical restraint is a common nursing intervention in intensive care units and nurses often use it to ensure patients' safety and to prevent unexpected accidents. However, existing literature indicated that the use of physical restraint is a complex one because of inadequate rationales, the negative physical and emotional effects on patients, but the lack of perceived alternatives. This paper is aimed to interpret the clinical decision-making theories related to the use of physical restraint in intensive care units in order to facilitate our understanding on the use of physical restraint and to evaluate the quality of decisions made by nurses. By reviewing the literature, intuition and heuristics are the main decision-making strategies related to the use of physical restraint in intensive care units because the rapid and reflexive nature of intuition and heuristics allow nurses to have a rapid response to urgent and emergent cases. However, it is problematic if nurses simply count their decision-making on experience rather than incorporate research evidence into clinical practice because of inadequate evidence to support the use of physical restraint. Besides that, such a rapid response may lead nurses to make decisions without adequate assessment and thinking and therefore biases and errors may be generated. Therefore, despite the importance of intuition and heuristics in decision-making in acute settings on the use of physical restraint, it is recommended that nurses should incorporate research evidence with their experience to make decisions and adequate assessment before implementing physical restraint is also necessary.     

Observations,confirmations and strategies – useful tools in decision‐making process for nurses in practice?

The aim of the study was to describe how nurses make decisions on measures in clinical practice. The data-collection method consisted of audio-taped interviews with six nurses. The interviews were then transcribed verbatim. The questions in the interviews were based on nursing situations observed earlier when the nurses initiated and implemented patient-related measures and the focus was on the nurses' experience of decision making. A content analysis was performed. The results show that the nurses' decisions on measures were based on three themes: observation of cues related to the patient's situation, confirmation of information gathered and implementation of action strategies. The results are discussed in relation to earlier empirical research on decision-making activities in the nurse's clinical practice and the nurse's utilization of knowledge during the decision-making process. It is concluded that the nurse's awareness of the patient's situation, together with a well-founded basis for decisions, can have positive effects on the nursing care provided by the nurse.     

Decision-making models of Finnish nurses and public health nurses

This study described nursing decision-making models and variables related to these models For this purpose a 56-item Likert-type questionnaire was constructed according to the Dreyfus model of skill acquisition as applied to nursing by Benner and information processing theory The target group consisted of 100 registered nurses working in inpatient clinics and 100 public health nurses working in preventive health care The decision-making variables explored were nurses' experience, education and knowledge as well as the nature of the nursing task and context The results revealed four different types of decision-making (a) unquestioning/questioning decision-making, (b) creative—diversive decision-making, (c) patient/nurse-oriented decision-making, and (d) rule- and situation-based decision-making The most important factors related to decision-making were experience and the nature of the nursing task and context     

Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care

OBJECTIVE: To explore whether attitudes and opinions in areas of importance to patient safety expressed by nurses with medical responsibility were related to the knowledge of diabetes among home care personnel. DESIGN: A questionnaire survey was used to evaluate the knowledge of diabetes among 3144 nurses' aides' and assistant nurses working in 15 municipalities in Sweden. In each municipality a nurse with medical responsibility answered another questionnaire dealing with patient safety matters in general and diabetes in particular. RESULTS: There were large differences in the knowledge of diabetes among home care personnel on the municipality level. Attitudes and opinions of the nurses with medical responsibility in the areas of leadership, guidance and continuing education were significantly related to the knowledge of diabetes among nurses' aides' and assistant nurses. CONCLUSIONS: Our study shows that factors that are related to attitudes and opinions about patient safety among nurses with medical responsibility can increase the risk of home care personnel to make mistakes in the direct care of patients with diabetes.     

Decision making in Greek and English registered nurses in coronary care units

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.     

An Exploratory Study of Clinical Decision-Making in Five Countries

Purpose: To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making.
Method and Samples: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States.
Findings: Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented.
Conclusions: The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.     

Autonomy among intensive care nurses in Finland.

The purpose of this study was to describe Finnish ICU nurses' (n=172) experiences of autonomy in their work. The research was carried out as part of a project concerned with empowerment in intensive care nursing. Viewed from a psychological perspective, empowerment is understood as referring to the ability to make goal-directed decisions and to take action towards meeting the goals set out. Autonomy, then, is seen as part of empowerment. The data were collected with a structured questionnaire specially designed for this study. The random sample was drawn from 31 Finnish adult intensive care units. The respondents were registered nurses working in eight adult intensive care units. The data were analysed using statistical methods. Autonomy was defined as being composed of three bases: knowledge base (independence, right and responsibility in decision-making), action base (independence, right and responsibility in actions) and value base (independence, right and responsibility in values). The majority of the respondents felt they had more autonomy in decision-making and actions concerning patient care than in decision-making and actions concerning the intensive care unit as a whole. Autonomy usually increased with work experience. Work will be continued to study the autonomy of nurses in different health care organisations in Finland.     

Decision-making skills and critical thinking ability among associate degree, diploma, baccalaureate, and master's-prepared nurses

A key component of nursing practice is the nurse's ability to process information and to make decisions. One goal of most educational programs for nurses is to enhance students' cognitive abilities and clinical decision-making skills. This study investigated the differences in critical thinking ability and decision-making skills among 121 associate degree, diploma, baccalaureate, and master's-prepared nurses. Results indicated that nurses with master's and baccalaureate degrees had the highest scores in critical thinking ability. Subjects' decision-making skills were measured related to: 1) frequency in making decisions, 2) difficulty in making decisions, and 3) factors which influence decision making. No significant differences were found among the four groups related to the three dimensions of decision-making skills. Experience and knowledge were the most influential factors in decision making. Study findings have implications for investigating differences among nursing students related to cognitive abilities.     

High technology and nursing: ethical dilemmas nurses and physicians face on high-technology units in Norway

Results from two studies of ethical dilemmas nurses and doctors experience on two high-technology units are compared and discussed. The qualitative comparative methodology of grounded theory was used to generate theoretical frameworks grounded in the empirical realities of the units. The ethical dilemmas they faced were related to: treating the one vs. the common good; end of life questions; and resource allocations with inadequate staffing. Similarities were related to intensity and urgency of nursing care and patient treatment, clear nursing ideologies based on treating humans within a framework of hope, embracing technology and scarce resources. Differences between the two study units were patient diagnosis, hierarchical structure on one unit while one had a vertical structure and decision-making processes, and finally how nursing knowledge and autonomy were used. The two studies demonstrated that clinical, ethical and administrative interactions and decisions are highly compounded, stressful and intertwined.     

Trialing collaborative nursing Models of Care: the impact of change.

OBJECTIVE: The aim of the project was to develop and trial a nursing Model of Care (MoC) and devise a framework to investigate the impact of nursing staff mix on patient outcomes and job satisfaction (nurses). SETTING AND SUBJECTS: In 2001-2002 a pilot project was undertaken to explore issues related to the delivery of patient care by nurses on two medical inpatient wards, one acute and one subacute, at a referral teaching hospital in New South Wales (NSW), Australia. The framework employed was an adaptation of, and based on, the Clinical Practice Improvement (CPI) model developed by NSW Health. PRIMARY ARGUMENT: Countries across the world are seeking solutions to a shortage of registered nurses and their ability to sustain quality care services. It becomes imperative that organisations develop strategies to attract and retain nurses in the health care system. CONCLUSIONS: Results of the project highlighted areas related to the quality of care delivery: clinical supervision; continuity of staffing; trust; employer of choice; more effective nurse to patient ratios; educational preparation; and recognition of prior experience.     

Moral dilemmas of nursing in end-of-life care in Hungary: a personal perspective

The authors' aim is to bring to the attention of readers the inadequacies of care for people in Hungary who are terminally ill. They believe that both objective and subjective factors cause these inadequacies. Most of these factors arise from moral dilemmas that could be eased or even solved if ethics education had a much more prominent place in the nursing curriculum. Even if nurses would not become automatically better persons morally, a much wider knowledge of medical/nursing ethics could significantly improve nursing care both before and at the end of life. Although the article is also critical of the nursing care provided, it is not its purpose to make any generalizations. The study utilized selected passages from essays written by 76 practicing nurses on their personal experience of ethical dilemmas in their work environment, and a questionnaire administered to 250 students (registered nurses and health care students) studying for a college degree. This article is written by two authors who have formed an unusual alliance: a registered nurse with 29 years' experience of bedside nursing, but who is currently a teacher of nursing ethics at a local health college, and a lawyer turned bioethicist.     

Clinical Decision-Making Styles of Home Healthcare Nurses

Using grounded theory method, this study of 21 home health nurses describes three clinical decision-making styles: skimming, surveying, and sleuthing. Experienced home health care nurses switch from one style to another when managing varying patient care situations. This study provides a broad view of clinical decision-making by integrating the context of nursing practice with the patients' clinical status, nurse-patient interaction, and nurses' knowledge and experience.     

Swedish ambulance nurses' experiences of nursing patients suffering cardiac arrest

Effective pre‐hospital treatment of a person suffering cardiac arrest is a challenging task for the ambulance nurses. The aim of this study was to describe ambulance nurses’ experiences of nursing patients suffering cardiac arrest. Qualitative personal interviews were conducted during 2011 in Sweden with seven ambulance nurses with experience of nursing patients suffering cardiac arrests. The interview texts were analyzed using qualitative thematic content analysis, which resulted in the formulation of one theme with six categories. Mutual preparation, regular training and education were important factors in the nursing of patients suffering cardiac arrest. Ambulance nurses are placed in ethically demanding situations regarding if and for how long they should continue cardio‐pulmonary resuscitation (CPR) to accord with pre‐hospital cardiac guidelines and patients’ wishes. When a cardiac arrest patient is nursed their relatives also need the attention of ambulance nurses. Reflection is one way for ambulance nurses to learn from, and talk about, their experiences. This study provides knowledge of ambulance nurses’ experiences in the care of people with cardiac arrest. Better feedback about the care given by the ambulance nurses, and about the diagnosis and nursing care the patients received after they were admitted to the hospital are suggested as improvements that would allow ambulance nurses to learn more from their experience. Further development and research concerning the technical equipment might improve the situation for both the ambulance nurses and the patients. Ambulance nurses need regularly training and education to be prepared for saving people's lives and also to be able to make the right decisions.     

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.     

Using a patient satisfaction survey to close the theory-practice gap

AIM: The objective of this study was to determine whether a patient satisfaction survey could be used as a research tool to improve nursing practice. METHOD: A postal questionnaire was sent to patients after discharge. Questions covered primary nursing, information, ward environment, discharge planning and social activities. RESULTS: A number of respondents were dissatisfied with the information they had received and with their lack of involvement in decisions about care. This was often correlated with lack of primary nurse recognition. The role of the associate nurse was poorly understood. There were high levels of satisfaction with discharge procedures, but little enthusiasm for the introduction of an activities programme. CONCLUSION: The results highlighted areas where changes were needed. This resulted in a nurse-led programme of managed change, including making all experienced D and E grade nurses primary nurses, improving information provision, and involving patients in the decision-making process.