Decision-making in clinical nursing: investigating contributing factors

The Relationship Between Staffing, Nurses' Emotional Exhaustion, and Adverse Patient Events in Critical Care Units in Sultanate of Oman

Background: Ensuring safe practices remains a top priority for healthcare policymakers. However, limited evidence has examined the link between individual, work-related factors, and patient safety within critical care units in Oman. Aim: To assess the relationship between staffing levels, job-related emotional exhaustion, and adverse patient events among nurses working in critical care units. Design: A cross-sectional study was conducted to collect data from critical care nurses in Oman. Nurses were recruited using a stratified proportional sampling method. Results: A total of 694 critical care nurses participated in the study. More than half (64.1%) of the critical care nurses experienced higher levels of emotional exhaustion. Significant predictors of adverse patient events included nurse staffing level (r = 0.09, p < 0.001), emotional exhaustion (β = 0.25, p < 0.001), hospital type (being affiliated with nonteaching hospitals) (p=0.021), and nationality (β = -0.15, p < 0.001). Conclusion: The occurrence of nurse-reported adverse events was associated with several key variables, including nurse staffing levels, emotional exhaustion, hospital type, and nationality. Implications for Nursing Management: To improve patient safety, healthcare policymakers should prioritize optimizing nurse staffing levels and implement strategies to reduce emotional exhaustion, particularly in nonteaching hospitals and among specific nurse demographics.

Clinical decisions-making within diagnostic radiography - A scoping review

OBJECTIVES

To describe and synthesise literature on clinical decision-making within diagnostic radiography, to uncover the important elements, and to identify knowledge gaps for further investigation. The scoping review question was: How do diagnostic radiographers make clinical decisions?

KEY FINDINGS

Radiographers make clinical decisions before, during and after examinations. The primary source of information radiographers use is the clinical request, however, if they doubt something, they rely on their colleague's points of view rather than evidence-based practice. Many elements must be considered in the clinical decision-making process; however, lack of autonomy, sparse information on the clinical requests, and lack of time affect the process, which can lead to a barrier to effective decision-making.

CONCLUSION

Clinical decisions are made based on many different elements before, during, and after examinations in combination with different types of knowledge, as well as technical and organisational aspects within radiography clinical practice.

IMPLICATION FOR PRACTICE

There is a need to focus on giving more attention to developing the decision-making elements. In addition, there must be more focus on improving intra-professional work between radiographers and radiologists to facilitate radiographers' opportunities to act on their clinical decisions.

The effect of nomophobic behaviors among nurses on their clinical decision-making perceptions

AIM

This study aimed to explore the impact of nomophobic behaviors among hospital nurses on their clinical decision-making perceptions. This understanding can offer insights to enhance the work environment, improve the clinical decision-making ability of nurses and guide medical institutions in the management of related equipment and policy development.

BACKGROUND

The term "nomophobia" refers to the anxiety and fear individuals experience when they cannot use their smartphones or when smartphones are not accessible. Nursing clinical decision-making is a complex process, including a meticulous assessment of the patient's pathological condition and medical history, alongside the application of nursing knowledge and experiential learning rooted in critical thinking. The concept of clinical decision-making perceptions is defined as a deliberate cognitive understanding of one's decision-making processes, which significantly influences the clinical decision-making capabilities of healthcare professionals, thereby impacting the quality of patient care. The factors influencing these clinical decision-making perceptions have been the subject of extensive research. However, there is no Chinese research on the impact of nurses ' nomophobic behaviors on their clinical decision-making perception.

DESIGN

A cross-sectional descriptive survey using online-based delivery modes was used.

METHODS

A descriptive cross-sectional survey design was employed. Using convenience sampling, we surveyed the nurses from a tertiary hospital in Nanjing in May 2023. Data were gathered using a sociodemographic data form, the Nomophobia Questionnaire and the Clinical Decision-Making in Nursing Scale. Techniques including the independent sample t-test, one-way ANOVA, Pearson correlation analysis and linear regression analysis were employed to probe the degree of nomophobia and its effects on their perception of clinical decision-making. Out of 284 questionnaires gathered, 272 were deemed valid, resulting in a 95.8% effective response rate.

RESULTS

The data revealed that participants exhibited a medium level of nomophobia (54.01 ± 24.09) and clinical decision-making perceptions (144.94 ± 20.08). A robust negative correlation was discerned between nomophobia and clinical decision-making perceptions (r: -0.365, P<0.001). This study highlighted that as the degree of nomophobia intensified, nurses' clinical decision-making perceptions decreased with the increase in nomophobia.

CONCLUSION

Nomophobic behaviors can hamper nurses' perception of clinical decision-making, potentially leading to inaccuracies or errors. Nurses must use mobile phones judiciously, practice self-regulation and mitigate the disruptive effects of nomophobia on their decision-making. In addition, medical institutions should foster relevant education or craft policies to regularize mobile phone use, augmenting nurses' efficiency and decision-making prowess, enhancing patient care quality, diminishing medical errors and ensuring patient health and safety.

Clinical reasoning skill of nurses working in teaching medical centers in dealing with practical scenarios of King's model concepts

BACKGROUND

The present study was conducted to determine clinical reasoning of nurses working in teaching medical centers in dealing with practical scenarios of King's concepts.

METHODS

The study population in this cross-sectional descriptive-analytical study comprised 133 nurses. Data were collected using scenarios based on the King's model. Data were analyzed in SPSS-16.

FINDINGS

Mean age of the participating nurses was 27.71 ± 8.1 years.The clinical reasoning score was less than average in most participating nurses, and had a significant relationship with education(P < 0.05), service ward(P < 0.001)and organizational position(P < 0.05). In the multivariate analysis of factors relating to clinical reasoning, higher education level (B = 9.5, P = 0.018) and organizational position (B = 4.3, P = 0.017) were predictors of clinical reasoning score.

DISCUSSION

Existing nursing models such as King's, which is closely related to clinical reasoning, can be used more in educational and clinical systems, and as a clinical guide for promoting the clinical reasoning of nurses and students.

The Factors Influencing Nurses' Clinical Decision-Making in Emergency Department

In an emergency, making the correct decision is vital. It is a necessary element of professional nursing care, and the ability of nurses to make successful clinical decisions is the most critical element influencing care quality. The purpose of this study was to assess the factors influencing nurses' clinical decision-making in the emergency department of Palestinan hospitals. A cross-sectional study was targeted at all nurses working in emergency departments at the Palestinian hospitals. The study was completed with 227 nurses, and collecting data was performed with the Clinical Decision Making in Nursing Scale. Results of the study revealed that the average score for the total clinical decision-making score was 3.3 (SD = 0.23). The subscales of clinical decision making were "search for alternatives or options," "canvassing of objectives and values," "evaluation and reevaluation of consequences," and "search for information and unbiased assimilation of new information." Furthermore, multiple linear regression analysis revealed that degree and work hours accounted for 11.7% of the variance in clinical decision-making. The study confirmed the average score for clinical decision-making was slightly higher than the average score. Also, it approved that nursing degree and work hours were predictors of clinical decision-making among nurses in emergency departments.

Automation in nursing decision support systems: A systematic review of effects on decision making, care delivery, and patient outcomes

OBJECTIVE

The study sought to summarize research literature on nursing decision support systems (DSSs ); understand which steps of the nursing care process (NCP) are supported by DSSs, and analyze effects of automated information processing on decision making, care delivery, and patient outcomes.

MATERIALS AND METHODS

We conducted a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed, CINAHL, Cochrane, Embase, Scopus, and Web of Science were searched from January 2014 to April 2020 for studies focusing on DSSs used exclusively by nurses and their effects. Information about the stages of automation (information acquisition, information analysis, decision and action selection, and action implementation), NCP, and effects was assessed.

RESULTS

Of 1019 articles retrieved, 28 met the inclusion criteria, each studying a unique DSS. Most DSSs were concerned with two NCP steps: assessment (82%) and intervention (86%). In terms of automation, all included DSSs automated information analysis and decision selection. Five DSSs automated information acquisition and only one automated action implementation. Effects on decision making, care delivery, and patient outcome were mixed. DSSs improved compliance with recommendations and reduced decision time, but impacts were not always sustainable. There were improvements in evidence-based practice, but impact on patient outcomes was mixed.

CONCLUSIONS

Current nursing DSSs do not adequately support the NCP and have limited automation. There remain many opportunities to enhance automation, especially at the stage of information acquisition. Further research is needed to understand how automation within the NCP can improve nurses' decision making, care delivery, and patient outcomes.

Decision making and the bedside assessment: The Speech Language Therapists' thinking when making a diagnosis at the bed

BACKGROUND

The bedside assessment is often seen as a screener because of its high variability in sensitivity and specificity, whilst the instrumental measures are viewed as gold standards because of the ability of speech-language therapist (SLT) to visualise the swallow more objectively.

OBJECTIVES

This research article explores how the value needs to be placed on the decision-making abilities of the SLT rather than on the assessment measure itself.

METHOD

A mixed methodology concurrent triangulation design was employed to collect data in two phases: the first phase included observing seven SLTs conducting assessments using a standardised bedside measure together with pulse oximetry and cervical auscultation. The second phase was a focus group discussion based on the findings from the first phase. Data were analysed thematically using a bottom-up approach.

RESULTS

The following factors were found to influence the decision-making process at the bedside: bedside assessment data sets, patient, multidisciplinary team, context and then SLT. The availability of more data from the assessment from different data sets improved the confidence of the SLT at the bedside when needing to make clinical decisions. Clinical instincts are developed through experience and observation of those more experienced. These skills need to be developed from junior years.

CONCLUSION

This research study showed that a bedside assessment can provide valuable information that will allow for diagnostic decisions to be made at the bedside. This study also highlighted the importance of critical thinking using clinical instincts, and that these are the factors that need to be valued and emphasised rather than the assessment measures themselves.

Decision-Making Process in Comprehensive Medication Management Services: From the Understanding to the Development of a Theoretical Model

In Comprehensive medication management (CMM), the practitioner applies a decision-making method to assess patients' pharmacotherapy in order to identify and solve drug therapy problems. Grounded theory was used to understand how pharmacists make clinical decisions when providing CMM service. Data collection included individual semi structured interviews with 11 pharmacists, observation of clinical case discussions and CMM consultations provided by the participating pharmacists. Two main categories emerged: 1. Understanding the rational method of decision-making: the foundation of the patient care process. 2. Balancing the care equation: the objective and the subjective, which includes a theoretical proposal explaining the pharmacists' decision-making process and the factors that can modify this process. The pharmacotherapy knowledge should guide the anamnesis. Thus, the professional can evaluate the indication, effectiveness, safety and convenience of medications used by the patient. After exploring patients' medication experiences, pharmacists can follow two courses of action: helping the patient overcome barriers to medication use; or matching the pharmacotherapy to the patient's routine. Professional autonomy and absence of the patient at the time of the decision were some factors that influenced the pharmacist's decision. Findings provide a broad understanding of pharmacists' decision-making process during the care of patients using medications. It can be applied as a basis for educational interventions to train professionals on decision-making.

'To give or not to give medication, that is the question.' Healthcare personnel's perceptions of factors affecting pro re nata medication in sheltered housing for older adults - a focus-group interview study

Background

Residents living in sheltered housing depend on help from healthcare personnel (HCP) with medication management, regarding regular long-term and pro re nata (PRN) medication. The HCP assess the need for PRN medication prior to administration to the residents. The purpose of this study was to describe HCP’s perceptions of factors affecting PRN medication management in sheltered housing for older adults.

Method

This was a qualitative study with five focus-group interviews with 22 HCP working in sheltered housing for older adults. The HCP were heterogenous regarding scholarly education and experiences, working in four different municipalities in mid-Norway, representing urban, sub-urban and rural districts. The analysis was inductive, based on qualitative, manifest, content analysis. The main outcome was HCP perceptions of the factors affecting PRN medication management in sheltered housing.

Results

Four main factors affecting the PRN medication management were identified in the data and were related to either: 1) the medication; 2) the resident; 3) the HCP; or 4) the organisation. These categories included 14 subcategories. Overall, the HCP described the management of PRN medication as a complex process, where the above factors all have impact on the residents’ health and safety.

Conclusion

HCP working in sheltered housing describe that PRN medication management is affected by numerous human factors, that consequently may affect patient outcomes and safety. HCP involved in PRN medication management should be aware of factors that affect their decision-making, and safe management requires a professional practice built on medicines competence, practical skills and experience.

Personality traits of core self-evaluation as predictors on clinical decision-making in nursing profession

Core self-evaluation (CSE) is a theory that includes four personality dimensions: self-esteem, self-efficacy, locus of control and emotional stability. CSE proved to be a significant predictor of the research on cognitive, emotional and behavioral responses across various situations in the workplace. The aim of this study was to examine the relationship between personality traits of the core self-evaluation and clinical decision-making in nurses’ profession. A cross-sectional design was applied. Data was collected with standardized instruments: Core Self-Evaluation Scale and Clinical Decision-Making Nurses Scale, 584 nurses have participated in the study. Correlation and hierarchical regression analysis were used to test the relations and prediction of variables. The findings of the study revealed that there is a significant positive relationship between overall core self-evaluation and nurses’ clinical decision-making, and there is a significant contribution of self-esteem, self-efficacy and locus of control on all dimensions of clinical decision, especially in the area of canvassing of objectives and values. Nurses with high CSE have positive self-views and tend to be confident in their ability and they also feel in control while performing nursing interventions, whereas those with low CSE tend to have fewer accessible positive resources and are more prone to risk aversion.

The Influence of Self-Concept on Clinical Decision-Making in Nurses and Nursing Students: A Cross-Sectional Study

The aim of this study is to examine the influence of nurses’ self-concept (NSC) on clinical decision-making (CDM) among nursing students and hospital nurses. A further aim is to examine whether there is a difference in CDM and NSC between hospital nurses with various levels of experience and nursing students. A cross-sectional study was conducted during 2018 in the Faculty of Dental Medicine and Health and the University Hospital Center, in Osijek, Croatia, EU. The respondents consisted of 568 hospital nurses, and 129 BSc nursing students. Data were collected with the clinical decision-making in nursing scale (CDMNS) and the nurses’ self-concept questionnaire (NSCQ). There was no correlation between CDM and NSC in either students or hospital nurses. Hospital nurses generally had significantly higher scores in CDM than nursing students. On the other hand, students had a significantly higher total NSC level. The results of this study suggest that experience has a positive impact on nurses’ CDM skills. The high NSC estimated by students enables them to easily take up their clinical roles and approach the patient in a holistic manner, which is an attitude that gradually develops during studies and with clinical experience.

Application of PRECEDE-PROCEED Planning Model in Transforming the Clinical Decision Making Behavior of Physical Therapists in Myanmar

Introduction: Physical therapists in Myanmar use a prescriptive model of Clinical Decision Making (CDM). Improving CDM effectiveness is one essential factor in professionalizing practice and enhancing patient outcomes. This study assesses the changes in CDM skills and behaviors using the PRECEDE-PROCEED planning Model (PPM). Methods: In the PRECEDE planning phases, we investigated the current clinical decision making knowledge, and process, clinical practice culture, and contributing factors of CDM among Myanmar physical therapists. A qualitative approach consisted of 18 in-depth interviews and one focus group discussion was used. In the PROCEED evaluation and implementation phases, we developed and presented the CDM educational book at CDM workshop, which was a 4-day intensive program in Yangon, Myanmar with 34 participants. The participant's CDM knowledge and processes were assessed before and after the educational program to explore the potential impact on implementing CDM which can ultimately improve patient care in the health settings of Myanmar. Results: In the PRECEDE phases, we explored the predisposing and reinforcing factors of Myanmar physical therapists' CDM. We found that CDM models and deliberative decision making process that is used internationally were not followed by Myanmar physical therapists who followed the physician's prescriptions. Teaching and learning emphasize a stimulus-response-repeat-outcome cycle without internal processing or application to clinical situations. Using the PROCEED model components, we developed a 14 chapters CDM workbook and a 4-day workshop as a behavioral change intervention. Participants' prior technical CDM behavior was transformed into professional CDM behavior that included an understanding of clinical practice models and improvement in the cognitive process of CDM processes. The workbook coupled with the intensive active-learning, hands-on workshop of examination and intervention procedures were effective in improving CDM. Discussion: The application of PPM provided a through understandings of current CDM process of Myanmar therapists and aided in the development of the tailored CDM educational program to improve participants' CDM. Using the PPM model for developing a set of Physical Therapy educational content and curriculum was new. The application of PPM was beneficial to use accepted clinical practice models, standardized tests and measures, set goals and clinical outcomes, reassessed to determine change and implement evidence-based practice.

Decision-makers and mediators in a home healthcare digitisation process: nurses' experiences of implementation and use of a decision support system

BACKGROUND

This study focuses on a decision support system (DSS) for home healthcare and the implementation of it.

AIM

To describe home healthcare nurses' experiences of the implementation and use of a new DSS, with a focus on how it influences decision making in everyday work practice.

DESIGN

A qualitative research design.

METHODS

Data was collected through three focus group interviews with six home healthcare nurses.The data analysis was drawn from Burnard's method for content analysis.

RESULTS

The DSS was experienced as bringing support to decisions, but sometimes incompatible with home healthcare nurses' work practice. Professional understanding and the DSS were sometimes experienced as parallel support systems not assisting work across healthcare organisations.

CONCLUSION

When a DSS is used to transform work of healthcare organisations several aspects should be highlighted. If the organisation does not consider these aspects, nurses may adopt a role as mediator in the implementation process.

Decision-making in nursing practice: An integrative literature review

AIMS AND OBJECTIVES

To identify and summarise factors and processes related to registered nurses' patient care decision-making in medical-surgical environments. A secondary goal of this literature review was to determine whether medical-surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM).

BACKGROUND

Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making.

DESIGN

PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data.

RESULTS

Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy.

CONCLUSIONS

Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research.

RELEVANCE TO CLINICAL PRACTICE

Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses' decision-making for enhanced patient outcomes.

The embodied nurse: Interdisciplinary knowledge exchange between compassionate nursing and recent developments in embodied leadership studies

AIMS

To report a potential knowledge exchange between nursing studies and the results obtained from a study conducted into the attributes of embodied leadership.

BACKGROUND

Leadership theories have been applied to evaluate, improve, and train nursing practitioners in several previous studies. However, leadership research has entered a new phase where the focus is to produce sustainable leaders through authenticity and compassion, the same two characteristics identified as being of most success in emergent nursing practice. There are few studies that have indicated a knowledge exchange between the latest developments in leadership studies and nursing.

DESIGN

An exploratory and qualitative study.

METHODS

Between February 2012 - July 2012, a focused sample of 14 medical care professionals was interviewed across a chain of hospitals. The aim was to evaluate embodied leadership characteristics and understand the factors that contribute to the manifestation of these characteristics. The transcribed interviews were analysed using thematic analysis.

FINDINGS

Several factors that contribute to the characteristics of embodied leadership have been identified in the interviews and in subsequent literature searches on the characteristics and contributing factors found to be associated with nursing research. These could prompt a knowledge exchange.

CONCLUSION

The results suggest common ground between nursing and contemporary leadership research in the exposition of behaviours; namely, being non-judgmental, listening actively, reflective practice and embracing uncertainty. Several implications can therefore be expected through the exchange of knowledge resulting from collaboration between researchers in the two disciplines.

Nursing perception of risk in common nursing practice situations

As health care organizations seek to be highly reliable, systems that include layers of redundancy have been created to protect patients from harm. Many of these layers of protection are dependent on nurses making a decision to follow or adhere to the human aspects of the process. Because these decisions begin with a perception and identification of risk, understanding what nurses perceive to be a risk to patients is an essential part of designing safer health care systems. The purposes of this qualitative study were to (1) describe what nurses perceive as risky to patients in common nursing practice situations, (2) describe the effects of the perceptions of risk on clinical decision making and behavior, and (3) identify what factors nurses perceive as increasing or decreasing risk.

Analyzing the effectiveness of teaching and factors in clinical decision-making

OBJECTIVE

The aim of this study is to prepare junior physicians, clinical education should focus on the teaching of clinical decision-making. This research is designed to explore teaching of clinical decision-making and to analyze the benefits of an "Analogy guide clinical decision-making" as a learning intervention for junior doctors.

MATERIALS AND METHODS

This study had a "quasi-experimental design" and was conducted in a medical center in eastern Taiwan. Participants and Program Description: Thirty junior doctors and three clinical teachers were involved in the study. The experimental group (15) received 1 h of instruction from the "Analogy guide for teaching clinical decision-making" every day for 3 months. Program Evaluation: A "Clinical decision-making self-evaluation form" was used as the assessment tool to evaluate participant learning efficiency before and after the teaching program. Semi-structured qualitative research interviews were also conducted.

RESULTS

We found using the analogy guide for teaching clinical decision-making could help enhance junior doctors' self-confidence. Important factors influencing clinical decision-making included workload, decision-making, and past experience.

CONCLUSION

Clinical teaching using the analogy guide for clinical decision-making may be a helpful tool for training and can contribute to a more comprehensive understanding of decision-making.

An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing

AIMS AND OBJECTIVES

To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses.

BACKGROUND

Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care.

DESIGN

Integrated literature review.

METHODS

The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review.

RESULTS

Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results.

CONCLUSIONS

Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think. There is also a need for qualitative studies to provide a fresh approach in exploring the relationship between these variables uncovering currently unknown contributing factors.

RELEVANCE TO CLINICAL PRACTICE

This review confirmed that evidence to support the existence of relationships between critical thinking and clinical decision-making is still unsubstantiated. Therefore, it serves as a call for nurse leaders and nursing academics to produce quality studies in order to firmly support or reject the hypothesis that there is a statistically significant correlation between critical thinking and clinical decision-making.

Confidence and clinical judgement in community nurses managing venous leg ulceration - A judgement analysis

BACKGROUND

The variation in the management of venous leg ulceration in the UK is partly attributable to an uncertain clinical environment but the quality of judgements is influenced by the how well nurses' confidence and accuracy are aligned.

OBJECTIVES

To assess UK community nurses' confidence in the accuracy of their diagnostic judgements and treatment choices when managing venous leg ulceration.

DESIGN

Judgement Analysis.

SETTING

UK community and primary care nursing services.

PARTICIPANTS

18 community non-specialist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses.

METHODS

Using judgement analysis methods, 18 community non-specialist nurses and 18 community tissue viability specialist nurses made diagnoses and treatment judgements about compression therapy for 110 clinical scenarios and indicated their confidence for each judgement. An expert panel made consensus judgements for the same scenarios and these judgements were used as a standard against which to compare the participants. Confidence analysis was used to assess the nurses' confidence about their diagnostic judgements and treatment choices.

RESULTS

Despite being very experienced, both non-specialist nurses' and specialist tissue viability nurses' levels of confidence were not well calibrated with their levels of accuracy.

CONCLUSION

The results of this study are important as errors resulting from both over and under-confidence at the diagnostic phase of management may influence treatment choices, and thus increase the chances of treatment error.

Nursing judgement and decision-making using the Sedation Withdrawal Score (SWS) in children

AIMS

The aim of the study was to evaluate registered children's nurses' approaches to the assessment and management of withdrawal syndrome in children.

BACKGROUND

Assessment of withdrawal syndrome is undertaken following critical illness when the child's condition may be unstable with competing differential diagnoses. Assessment tools aim to standardize and improve recognition of withdrawal syndrome. Making the right decisions in complex clinical situations requires a degree of mental effort and it is not known how nurses make decisions when undertaking withdrawal assessments.

DESIGN

Cognitive interviews with clinical vignettes.

METHODS

Interviews were undertaken with 12 nurses to explore the cognitive processes they used when assessing children using the Sedation Withdrawal Score (SWS) tool. Interviews took place in Autumn 2013.

FINDINGS

Each stage of decision-making-noticing, interpreting and responding-presented cognitive challenges for nurses. When defining withdrawal behaviours nurses tended to blur the boundaries between Sedation Withdrawal Score signs. Challenges in interpreting behaviours arose from not knowing if the patient's behaviour was a result of withdrawal or other co-morbidities. Nurses gave a range of diagnoses when interpreting the vignettes, despite being provided with identical information. Treatment responses corresponded to definite withdrawal diagnoses, but varied when nurses were unsure of the diagnosis.

CONCLUSION

Cognitive interviews with vignettes provided insight into nurses' judgement and decision-making. The SWS does not standardize the assessment of withdrawal due to the complexity of the context where assessments take place and the difficulties of determining the cause of equivocal behaviours in children recovering from critical illness.

An Investigation of Factors Influencing Nurses' Clinical Decision-Making Skills

This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution.

Decision Making in Nursing Practice: A Concept Analysis

PURPOSE

The study aims to gain an understanding of the concept of decision making as it relates to the nurse practice environment.

METHODS

Rodgers' evolutionary method on concept analysis was used as a framework for the study of the concept. Articles from 1952 to 2014 were reviewed from PsycINFO, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, PubMed, and Science Direct.

FINDINGS

Findings suggest that decision making in the nurse practice environment is a complex process, integral to the nursing profession. The definition of decision making, and the attributes, antecedents, and consequences, are discussed. Contextual factors that influence the process are also discussed. An exemplar is presented to illustrate the concept.

CONCLUSION

Decision making in the nurse practice environment is a dynamic conceptual process that may affect patient outcomes. Nurses need to call upon ways of knowing to make sound decisions and should be self-reflective in order to develop the process further in the professional arena. The need for further research is discussed.

Saudi Arabian ICU safety culture and nurses' attitudes

PURPOSE

The purpose of this paper is to examine nurses' attitudes towards safety culture in six Saudi Arabian intensive care units (ICUs).

DESIGN/METHODOLOGY/APPROACH

The study is descriptive with a cross-sectional design. The Safety Attitude Questionnaire (SAQ)-ICU version was distributed and 216 completed questionnaires were returned.

FINDINGS

The findings provide a basis for further research on Saudi Arabian ICU safety culture. This study showed that the SAQ-ICU can be used to measure safety climate to identify areas for improvement according to nurse attitudes and perceptions. Findings indicate that ICU safety culture is an important issue that hospital managers should prioritise.

PRACTICAL IMPLICATIONS

The SAQ-ICU questionnaire, used to measure safety climate in Saudi Arabian ICUs, identifies service strengths and improvement areas according to attitudes and perceptions.

ORIGINALITY/VALUE

To the knowledge, this is the first study to use SAQ to examine nurses' safety culture attitudes in Saudi Arabian ICUs. The present findings provide a baseline and further details about Saudi Arabian ICU safety. Study participants represented nine nationalities, indicating the nursing workforce's diversity, which is expected to continue in the future. Such a nursing cultural heterogeneity calls for further studies to examine and evaluate attitudes and values to improve ICU safety culture.

Clinical role of the nurse: concept analysis

AIMS AND OBJECTIVES

To identify the attributes of the concept 'clinical role of the nurse' in the literature.

BACKGROUND

The concept of nurses' clinical role is frequently mentioned in literature, but hardly explored in conceptual terms. This has implications for nursing practice and education.

DESIGN

Qualitative and descriptive study, which corresponds to the first phase in the concept development of the qualitative concept analysis method - identification of concept attributes.

METHODS

The critical literature analysis method was used to identify the antecedents, defining attributes and consequences of the nurse's clinical role. A systematic literature search was undertaken in International Literature in Health Sciences, Cumulative Index to Nursing and Allied Health Literature and Latin American and Caribbean Health Sciences.

RESULTS

The clinical role was shown to be a process of complex interaction between nurse and patient, with critical thinking, informed experience and a sense of clinical autonomy as its antecedents. Consequences of nurses' clinical role include transformations in the organisation and process of nursing practice. A theoretical proposal was elaborated for the concept of the clinical role of the nurse, identifying the defining attributes, antecedents and consequences.

CONCLUSIONS

The clinical role of the nurse concept that was developed represents innovative evidence on the theme. Nevertheless, a deeper understanding of nurses' clinical role is needed, as well as refinement of its conceptual components. This study should be integrated into a field research project, designed to illuminate how nurses manifest and articulate the concept in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of clinical role attributes, associated with nursing competencies, can contribute to reflection on the dimensions involved in nursing practice and inform not only teaching and professional practice, but also health policies.

Enhancing clinical decision making: development of a contiguous definition and conceptual framework

Clinical decision making is a term frequently used to describe the fundamental role of the nurse practitioner; however, other terms have been used interchangeably. The purpose of this article is to begin the process of developing a definition and framework of clinical decision making. The developed definition was "Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action." A contiguous framework for clinical decision making specific for nurse practitioners is also proposed. Having a clear and unique understanding of clinical decision making will allow for consistent use of the term, which is relevant given the changing educational requirements for nurse practitioners and broadening scope of practice.

Assessment of nurses' perceptions of patient safety culture in a Saudi Arabia hospital

The purpose of this study was to identify factors that nurses perceive as contributing to the culture of patient safety in a hospital in Saudi Arabia. A total of 498 registered nurses employed in the hospital completed the survey. The majority of nurses perceived a positive patient safety culture. There were significant differences in nurses' perceptions of patient safety culture based on gender, age, years of experience, Arabic versus non-Arabic speaking, and length of shift.

Clinical decision making of nurses working in hospital settings

This study analyzed nurses' perceptions of clinical decision making (CDM) in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with descriptive frequencies, t-tests, Chi-Square test, and linear regression. Nurses' decision making was categorized into analytic-systematic, intuitive-interpretive, and quasi-rational models of CDM. Most nurses reported the use of quasi-rational models during CDM thereby supporting the tenet that cognition most often includes properties of both analysis and intuition. Increased use of intuitive-interpretive models of CDM was associated with years in present job, further education, male gender, higher age, and working in predominantly surgical units.

Factors that influence the clinical decision making of novice and experienced physical therapists

BACKGROUND

The depth and breadth of prior experience informs clinical decision making in novice and experienced physical therapist clinicians.

OBJECTIVES

The aims of this research were to identify differences in clinical decision-making abilities and processes between novice and experienced physical therapist clinicians and to develop a model of the factors that influence clinical decision making.

DESIGN

Qualitative research methods and grounded theory were used to gain insight into the factors and experiences that inform clinical decision making.

METHODS

Three participant pairs (each pair consisted of 1 novice physical therapist and 1 experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries from each participant provided the basis for within- and across-case analyses. The credibility of the results was established through checking of the case summaries by the participants, presentation of low-inference data, and triangulation across multiple data sources and within and across participant groups.

RESULTS

The factors that influenced clinical decision making were categorized as informative or directive. Novice participants relied more on informative factors, whereas experienced participants were more likely to rely on directive factors. An intermediate effect beyond novice practice was observed.

CONCLUSIONS

The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities for students and novice learners with the aim of facilitating the development of skills and abilities consistent with expert clinical decision making.

'Mutual intacting': a grounded theory study of clinical judgement practice issues

AIM

This paper reports a study conducted to explore how nurses working at advanced practice level in chronic and acute care outpatient contexts responded to decision-making concerns in clinical practice.

BACKGROUND

Current theoretical explanations of clinical judgement offer insight into how healthcare professionals process information; however, they are incomplete as they do not consider psychosocial issues. Research evidence informing clinical judgement practice is based largely on acute care hospital settings. Consequently, little is known about how practitioners make clinical judgements in outpatient contexts where patients can participate in their own care.

METHOD

A grounded theory approach was used to analyse interview data about clinical judgements made in actual clinical practice. Twenty-one nurses working at advanced practice level in mental healthcare clinics and accident and emergency in the Republic of Ireland were recruited. Concurrent data collection and analysis, constant comparative analysis and theoretical sampling were conducted in 2002-2005.

FINDINGS

The core category to emerge from the data was 'mutual intacting'. This refers to the main strategies that practitioners used to resolve concerns about eliciting patient information and selecting treatments that were acceptable to patients. It highlights the clinical judgement practices that practitioners find useful to engage patients to facilitate effective decision-making.

CONCLUSION

Practitioners could draw from the various strategies identified in this research to develop their clinical judgement practice further in ways that include the development of an effective relationship with their patients. Negotiation and compromise are particularly useful strategies that should be used to facilitate effective treatment delivery that takes account of patients' circumstances.

Observing the approaches to weaning of the long-term ventilated patients

BACKGROUND

The weaning process from mechanical ventilation is a complicated issue for patients with respiratory failure who require long-term respiratory support. Although the application of weaning protocols reduces weaning time, and enhances patient outcome, little is known about the actual approaches that clinicians use for the weaning of these patients.

AIM

The purpose of this paper is to explore approaches to weaning of long-term ventilated patients in a Scottish Intensive Care Unit. The findings are part of a larger study on decision-making during the weaning of long-term ventilated patients.

METHOD

Data were collected through participant observation and follow-up interviews with the nursing staff. Twenty-four-hour chart and medical notes review and informal conversation with the bedside nurse were also used to collect information on the weaning process.

FINDINGS

Nine patients were recruited to the study. Two patients were extubated and three patients were extubated but then required a tracheostomy. A further four patients had a tracheostomy performed. Thematic analysis of the data showed that weaning was individualized, and physician led, regardless of the existence of the weaning protocol. Six different weaning approaches were identified. Nurses followed a conservative approach to weaning in comparison to doctors who appeared more aggressive.

CONCLUSION

There are many varieties in the approaches clinicians use when weaning long-term ventilated patients, which acts on the continuity of their care. A shift of focus to identify ways of maintaining continuity of care and a combined 'wake and wean' approach needs to be considered.

The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients

Acute care settings are characterised by patients with complex health problems who are more likely to be or become seriously ill during their hospital stay. Although warning signs often precede serious adverse events there is consistent evidence that 'at risk' patients are not always identified or managed appropriately. 'Failure to rescue', with rescue being the ability to recognise deteriorating patients and to intervene appropriately, is related to poor clinical reasoning skills. These factors provided the impetus for the development of an educational model that has the potential to enhance nursing students' clinical reasoning skills and consequently their ability to manage 'at risk' patients. Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. Effective clinical reasoning depends upon the nurse's ability to collect the right cues and to take the right action for the right patient at the right time and for the right reason. This paper provides an overview of a clinical reasoning model and the literature underpinning the 'five rights' of clinical reasoning.

Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process

BACKGROUND

Prior experience informs clinical decision making and shapes how reflection is used by novice and experienced physical therapist clinicians.

OBJECTIVES

The aims of this research were: (1) to determine the types and extent of reflection that informs the clinical decision-making process and (2) to compare the use of reflection to direct and assess clinical decisions made by novice and experienced physical therapists.

DESIGN

Qualitative research methods using grounded theory were used to gain insight into how physical therapists use reflection to inform clinical decision making.

METHODS

Three participant pairs (each pair consisting of one novice and one experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries of each participant provided the basis for within- and across-case analysis. Credibility of these results was established through member check of the case summaries, presentation of low-inference data, and triangulation across multiple data sources and within and across the participant groups.

RESULTS

Although all participants engaged in reflection-on-action, the experienced participants did so with greater frequency. The experienced participants were distinguished by their use of reflection-in-action and self-assessment during therapist-patient interactions. An intermediate effect beyond novice practice was observed.

CONCLUSIONS

The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities to facilitate clinical decision-making abilities and the development of the skills necessary for reflection in students and novice practitioners.

Protocol-based care: the standardisation of decision-making?

AIM

To explore how protocol-based care affects clinical decision-making.

BACKGROUND

In the context of evidence-based practice, protocol-based care is a mechanism for facilitating the standardisation of care and streamlining decision-making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol-based care does, in the reality of practice, standardise decision-making is unknown. This paper reports on a study that explored the impact of protocol-based care on nurses' decision-making.

DESIGN

Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit.

METHODS

Within each site, data collection included observation, postobservation semi-structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed.

RESULTS

Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision-making. The primary approach to knowledge exchange and acquisition was person-to-person; decision-making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised.

CONCLUSIONS

While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process. This has significant implications for the political goal of standardisation.

RELEVANCE TO CLINICAL PRACTICE

The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses' decision-making processes in parallel to paying attention to the influence of context.

Organisational silos: affecting the discharge of elderly patients

PURPOSE

This paper aims to explore the unintentional formation of internal functional barriers, (organisational silos) during moves towards departmental efficiency, within an acute trust, and the subsequent effects on the discharge process in elderly patients.

DESIGN/METHODOLOGY/APPROACH

This paper presents some of the findings from a qualitative study examining the role of the nurse in the discharge process. Semi-structured interviews were conducted with a purposively selected cohesive sample of 28 registered nurses, from the medical and elderly care wards in an NHS Acute Trust. The interviews were taped, transcribed and their content analysed.

FINDINGS

The problems associated with patient discharge were frequently operational. Each part of the process was hindered, often inadvertently, by attempts on the part of individuals, departments and services to make themselves efficient, without regard for the resulting organisational consequences. This left the ward nurses attempting to overcome the obstacles in an attempt to effectively discharge patients, within a required period of time.

RESEARCH LIMITATIONS/IMPLICATIONS

It is recognised that, the perceptions of those not participating in the study may have been different to those who did participate. As a small study in one trust the results may not be generalisable.

PRACTICAL IMPLICATIONS

It is imperative that evaluation of operational changes is undertaken, with particular regard to the consequences of change, for other services, patients and clients.

ORIGINALITY/VALUE

This type of study can provide a method of diagnosing organisational problems, especially in areas that are reliant on inter-professional and departmental collaboration.

Midwives’ navigation and perceived power during decision-making related to augmentation of labour

OBJECTIVE

to explore and understand how midwives perceive and experience decision-making about augmentation of labour.

DESIGN

focus-group discussions.

SETTING

Stockholm, Sweden.

PARTICIPANTS

20 midwives experienced in working in labour wards.

FINDINGS

five categories were identified that illustrate the factors considered by the midwives to influence decision-making during augmentation of labour: 'regulations and guidelines'; 'shortage of delivery rooms'; 'influence of obstetricians'; 'women in labour'; and 'midwives' professional selves'. The theme identified was how midwives managed to 'navigate' these factors, which provided midwives with a decisive influence during the decision-making process.

KEY CONCLUSIONS AND IMPLICATIONS

midwife job satisfaction can result from a sense of professional power over the possibility of navigating factors that influence decision-making during augmentation of labour. This sense of power can subsequently influence co-operation with both obstetricians and women during labour.

The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making

The combination of intensive care knowledge, and the ability to articulate analytical decision-making processes to the interdisciplinary team, enhances the clinical credibility of the intensive care unit (ICU) nurse. The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved.