Nurses decision-making in clinical practice

AIM: To identify what decisions nurses make in medical, surgical and critical care areas and compare the results. METHOD: A clinical decision-making questionnaire (CDMQ) consisting of 15 statements was developed. A total of 60 nurses completed the questionnaire: 20 from each of three clinical areas. RESULTS: Most nurses, in all specialties, regularly made clinical decisions on direct patient care, which included providing basic nursing care and psychological support, and teaching patients and/or family members. Although nurses in all specialties regularly managed the work environment, they did not make decisions on the ward or unit budget, supervise junior staff or mentor student nurses. Critical care nurses regularly made decisions on their extended roles, such as acting in emergency situations and deciding to change patient medication, while medical and surgical nurses only did this occasionally. Length of clinical experience is significantly related to the frequency of decision-making. CONCLUSION: The decisions nurses make are directly related to the clinical areas in which they work. However, it would be interesting to know if nurses showed particular aptitudes for different types and levels of decision-making and if this is related to other factors such as personality, education and experience in nursing.     

Nurses' views on situations related to privacy in providing home care for persons with long-term mental illness: an exploratory study

The main aim of this exploratory study was to explore the views of nurses and mental health care workers on situations related to patient privacy in the home care of persons with long-term mental illness in Sweden. A specifically designed questionnaire was developed from theoretical constructs obtained in a qualitative study and distributed to 1,139 respondents. Data from 660 district nurses, psychiatric nurses, and mental health care workers revealed significant differences in perceptions by age, gender, and professional groups. For example, psychiatric nurses and mental health care workers indicated to a greater extent than district nurses feelings that relate to intrusion on patient privacy. Respondents who were 41 years or younger also indicated to a greater extent than those who were older that they felt home care was an intrusion on patient privacy. Moreover, men indicated to a greater extent than women feelings of insecurity in their professional role. Further investigation is needed, especially into how nurses deal with situations that intrude on patient privacy and how nursing intervention impacts on the patients' own sense of privacy.     

NURSES' VIEWS ON SITUATIONS RELATED TO PRIVACY IN PROVIDING HOME CARE FOR PERSONS WITH LONG-TERM MENTAL ILLNESS: AN EXPLORATORY STUDY

The main aim of this exploratory study was to explore the views of nurses and mental health care workers on situations related to patient privacy in the home care of persons with long-term mental illness in Sweden. A specifically designed questionnaire was developed from theoretical constructs obtained in a qualitative study and distributed to 1,139 respondents. Data from 660 district nurses, psychiatric nurses, and mental health care workers revealed significant differences in perceptions by age, gender, and professional groups. For example, psychiatric nurses and mental health care workers indicated to a greater extent than district nurses feelings that relate to intrusion on patient privacy. Respondents who were 41 years or younger also indicated to a greater extent than those who were older that they felt home care was an intrusion on patient privacy. Moreover, men indicated to a greater extent than women feelings of insecurity in their professional role. Further investigation is needed, especially into how nurses deal with situations that intrude on patient privacy and how nursing intervention impacts on the patients' own sense of privacy.     

The decision making process in a district nursing assessment

Assessment is a key element of district nursing practice and a cornerstone of community care. Yet very little research has been undertaken in this area. Given the current emphasis on evidence-based practice in health care, there is a need to ensure that district nurses, nursing students and educators can draw from an empirically derived and sound knowledge base. This article explores the relationship between knowledge and decision-making in district nursing assessment. It is based on a case study of one district nurse participant from a qualitative study of district nursing assessment. The case study material illustrates key findings from this study in order to examine the relationship between theoretical perspectives and everyday decision-making, based on the stages of decision-making identified by Carroll and Johnson (1990).     

Nurses' and physicians' perceptions of nursing authority

This study compared perceptions of 163 nurses and physicians of the current and ideal status of the decision-making authority of professional nurses. Each nurse and physician agreed or disagreed with 25 items, in two contexts, in the Authority in Nursing Roles Inventory (ANRI). Items in the ANRI describe a variety of nursing roles, functions, and behaviors in health and patient care. The results of the study were statistically significant overall both between and within professional groups. Disparities in several specific areas were revealed. The findings support the premise that in spite of expanded nursing roles emphasizing nursing authority, there are disagreements between nurses' and physicians' perceptions of the current and ideal authority of nurses as well as areas of dissatisfaction within each professional group. Implications of continuing conflicts between nurses and physicians as barriers to professional nursing role enactment, as well as strategies to address the problem, are discussed.     

Nurse–patient negotiation: assumption or reality?

The current socio-political philosophy in the United Kingdom promotes the belief that consumers of health care should exercise choice and express opinions about the care they receive. This view challenges the traditional paternalistic approach to health care which espoused that 'the professional knows best'. In association with general socio-political trends, nursing is undergoing radical reform. The nursing literature widely promotes the importance of a nurse–patient relationship which fosters the involvement of the patient in negotiation and decision-making regarding his care. Nurses who advocate individualized, holistic care must hold such an ideology as a central tenet to their philosophy. However, it is questionable whether this philosophy is widely expressed in the reality of clinical practice. There is also an absence of empirical evidence to support the assumption that patients wish to participate in decision-making. This paper critically reviews some of the debate centred around the concept of nurse–patient negotiation. It is suggested that the issues are complex and that there remains a need for further research which takes into account multiple factors, including the social and organization context of nursing care.     

Health Outcomes for Better Information and Care (HOBIC): integrating patient outcome information into nursing undergraduate curricula

Nursing-sensitive outcomes provide common information across sectors, thus eliminating duplication that frequently occurs as individuals move across settings. These outcomes also facilitate increased trust among colleagues and support common understandings of patient care needs, thus enhancing continuity of care. Outcomes-oriented information is also likely to increase patient safety and improve overall quality of care. Shared standards and data support consistent decision-making, as nursing decisions can be tracked back over time to assess patient care outcomes. Consequently, nurses will have the means to determine the impact of their interventions on patient outcomes. At the same time, adoption of common approaches to patient assessment leads to greater professional accountability and moves nursing care from a task orientation to an outcomes focus. For administrators, such improvements in monitoring and evaluating patient outcomes translate into improvements in efficiencies and effectiveness, thus providing a return on investment in implementing these outcomes within their agency. For nurses, integration and utilization of outcomes information increases the visibility and significance of their decision-making and patient care. Together with patients, nurses can utilize the outcomes information to make evidence-based decisions and advocate for appropriate care. At an aggregate level, the use of outcomes information creates a continuous feedback loop that is essential to ensuring evidence-based care and the best possible patient outcomes, not only for individuals, but also for families, communities and populations. Outcomes-oriented care provides a gateway for transforming the way we care for patients; puts safe, ethical, high-quality care for patients first; embodies the principles of evidence-based practice; ensures that the value of nursing is clearly understood within the larger system; and ensures that the requirements for measurability and accountability can be achieved. This journey is continuous and is being expanded to engage all other health disciplines in understanding and documenting their contributions to patient care, both as individual practitioners and as members of a healthcare team. Preparing nursing students in an outcomes approach will facilitate systemwide adoption of HOBIC patient outcomes over time and provide a means to determine the impact of nursing care on our patients.     

Decision-making autonomy in nursing.

Current nursing literature has suggested that nurses may have low needs or preferences for decision-making autonomy. In this study, the authors found that nurses differed in their preferences for decision-making autonomy in three types of work-related decisions. Employed nurses with a greater preference for autonomy were more satisfied with their jobs, and those with little or no such preference were less satisfied, as they gained decision-making influence over patient care and unit management. The authors discuss implications for designing and implementing decision-making programs.     

Measuring care: the case of district nursing

This paper describes a district nursing study that considered the experiences and responses of primary health care professionals and their patients to changes taking place within the community. As a qualitative study it employed interviews as the main method of data collection and was informed by both ethnography and interpretative phenomenology. Forty-three study participants were interviewed, eliciting opinion on whether care is more than just a hands-on activity, whether patient need is being met and to what extent service policy is in tune with care delivery. Describing the views of primary health care professionals and patients in order to illustrate the complexity of the district nursing service and professional roles, the paper finds little shared vision between staff and managers of each other's responsibilities. It concludes that a more holistic approach to understanding professional roles is needed in order to satisfy the differing agendas of managers, staff and patients. It propounds the need for closer collaborative practice between health care professionals, for it finds that they value the ability to communicate as an essential element of their jobs. It reflects that, without such collaboration, it will be difficult for nurses to take a lead position on changes shaping community care.     

Reflexiones acerca del uso y utilidad de los modelos y teorías de enfermería en la práctica asistencial

Theory is essential to explain and understand nursing practice. The theoretical framework helps to examine, organize, analyze and interpret patient data, supporting and facilitating decision-making. Likewise, the theoretical framework helps nurses to plan, predict and evaluate the results of nursing care. Therefore, the theoretical approach is a useful tool for reasoning and critical thinking and, moreover, helps nurses to use and manage all the information on a patient and to provide nursing care in a structured and effective manner.The use of Conceptual Models of Nursing in nursing care guarantees that all nurses share a common language and similar concepts with respect to the nursing paradigms, person, health, environment and care that characterize their professional role. The present article provides a reflection on an issue that continues to be of great importance - the dichotomy between nursing theory and practice.     

U.S. and Australian Nurses'Attitudes and Beliefs about the Good Death

The purpose of this study was to ascertain the attitudes and beliefs of nurses in Australia and the United States regarding aspects of passive euthanasia, or the "good death." Two foci guided the study: (a) the possible discrepancies that these nurses might perceive between what they thought would be done in a given clinical situation and what they thought ought to be done, and (6) the possible differences and similarities between the American and the Australian nurses. Responding to the 8 vignettes, 30 American and 32 Australian nurses took part in the study. The lack of agreement between the Australian and American nurses on issues of euthanasia reflects differences in the health care system; the general social position of nursing as a profession; the relationship among health professionals, patients and families, which serves as the context for definition of ethical duties and patient rights; and the role of the law in health care decisions.     

Mixed messages: hospital practices that serve as disincentives for associate degree-prepared nurses to return to school

Nearly 80% of associate's degree-prepared nurses do not return to school for a more advanced degree in nursing, which is an issue of concern to many nursing leaders. This interpretive phenomenological study investigates what influences associate's degree-prepared nurses to refrain from continuing their professional education and obtain a baccalaureate or higher-level degree. Although these nurses generally wished they had a higher degree, they did not feel pursuing one was necessary. They did not perceive that their standard of patient care would change with further professional training involved in obtaining a higher educational degree. Furthermore, they did not perceive any distinctions in professional ability between themselves and colleagues with more advanced nursing degrees. The culture of service health care organizations in which associate's degree-prepared nurses are employed, as well as other factors, are likely directly responsible for the practicing nurses' lack of appreciation for the relevancy and rewards of returning to school.     

Resource allocation decisions in critical care nursing

One of the major challenges for critical care nurses is to distribute their professional services in a manner that is consistent with the moral imperatives of nursing. The central values of respect for individual patients, patient-centered beneficence, full beneficence, and justice must be woven together into an ethical framework that assists nurses in allocating their skills. Professional organizations, such as the AACN, are actively trying to order this ethical disorder by proposing guidelines that, on the one hand, acknowledge societal interests in cost-effective utilization of health care resources, and on the other hand, safeguard the interests and well-being of individual patients. In addition to the guidance from professional organizations, health care institutions should address the inequities in health care by developing policies that guide the health care team through an ethical decision-making process. Nurses, as members of the multidisciplinary health care team and as members of an essential and scarce resource, should participate in formulating these directives. Not only is bedside and institutional involvement important, but participation at the local, state, and national levels will empower nurses to influence decisions of resource allocation at the micro and macro levels.     

Surrogate Decision-Making: How to Promote Best Outcomes in Difficult Times

Respect for patient autonomy is highly valued in American society and in nursing professional codes of ethics. US law protects the right of patients to self-determination in health care decisions. Advanced practice registered nurses must be able to identify patients who are not competent to make these decisions and the surrogates who will make decisions in their place. Advance planning with patients and providing optimal support for their surrogates are part of individualized, total-patient care and key to promoting best outcomes for patients and their families who are experiencing extremely difficult choices and significant life transitions.     

Is the professional code still the cornerstone of clinical nursing practice?*

Although codes of practice for those concerned with the health care of others have always been inherent in the structure of societies, they have been institutionalized within the nursing discipline since the end of the last century Up until the early 1970s they promulgated subservience to the medical discipline As a result of the processes of emancipation and professionalization, the philosophy of the nurse has come to contain concepts of autonomy, accountability and patient-advocacy, based on a personal and individualized care system Research in recent years has shown that nurses are making morally sound and ethically acceptable choices based on their own decision-making abilities, whilst having little or no active knowledge of the existing professional codes Based on the literature, the author discusses ethical codes in relation to their perception by nurses in the clinical situation The influence of the code in the areas of moral decision making, administration and management, and education are likewise discussed and the conclusion is reached that codes remain the cornerstone of nursing practice     

Oncology nursing: Finding the balance in a changing health care system.

Health care restructuring has resulted in significant changes in the workload and work environment for oncology nurses. While recent studies describe the impact of these changes on the general nursing workforce in several countries, there have been no published studies that have focused on worklife issues of Canadian oncology nurses. Therefore, a qualitative study was conducted to gain insight about how oncology nursing has changed over the past decade and how Canadian oncology nurses are managing these changes. Analysis of telephone interviews with 51 practising oncology nurses employed across Canada revealed three major themes. The first theme, "health care milieu", portrayed a picture of the cancer care environment and patient and professional changes that occurred over the past decade. The second theme, "conflicting demands", reflects how the elements of change and social forces have challenged professional oncology nursing practice. The third theme, "finding the way", describes the patterns of behaviour that nurses used to manage the changing health care environment and make meaning out of nurses' work in cancer care. Overall, the findings portray a picture of Canadian oncology nurses in "survival mode". They face many workplace challenges, but are able to keep going "for now" because they find ways to balance their responsibilities on a daily basis and because they know and believe that their specialized nursing knowledge and skills make a difference in patient care.     

Meeting the policy agenda, part 1: the role of the modern district nurse

The challenges posed by the current context of health and social care offer opportunities for different models of care delivery. District nursing has evolved, and continues to evolve to meet these challenges. The traditional reactive role of district nursing has developed as contemporary practice expects district nurses to meet both planned and unplanned care required by practice populations. Modern anticipatory care approaches to care are being adopted, while care and case management is being facilitated and delivered to patients and families with complex health and social care needs. Additionally, district nurses are recognizing the need to further develop management and leadership skills as the teams delivering care consist of a skill mix of nurses and other disciplines. They are also charged with evidencing the impact of what they do and influencing care delivery at every level of healthcare organizations. This first paper of two will explore the current UK policy context and ways in which district nursing services within each country are changing to meet the challenges posed. A second article will argue the need to ensure the district nursing workforce is underpinned by robust educational standards that ensure protection of the public. The influences of education and development from professional and organizational perspectives will be examined.