An exploratory study of clinical decision-making in five countries

Role of emotions in the clinical decision-making process of the hospital nurse: A multicentre qualitative study

While for a long-time emotional reaction and moral distress, have been primarily investigated for the possible outcomes of the nursing decision-making process rather than in terms of their role as antecedents of the final decision taken. The primary study's aim is to explore how inpatient nurses' decision-making takes place in different care settings, with a special focus on the role played by emotions during decision-making. The secondary aim is to explore the subjective experience of hospital nurses in relation to successful and unsuccessful decision-making situations. Multicentre qualitative study, consisting of three phases with different designs: participatory study, grounded theory study, and phenomenological study. Participants will be nurses and may be doctors with various levels of professional experience working in hospital, outpatient, or ward settings. Participants will be recruited through different sampling (purposive and convenience). Data will be collected through focus groups and in-depth interviews with nurses working in different hospital care settings. The researchers expect to find themes that will contribute to a better understanding of the role of emotions in decision-making. The results of this study have the potential of providing important implications to support nurses in the recognition and management of their emotions during the decision-making process.

Cognitive Continuum Theory: Can it contribute to the examination of confidentiality and risk-actuated disclosure decisions of nurses practising in mental health?

Nurses practising in mental health are faced with challenging decisions concerning confidentiality if a patient is deemed a potential risk to self or others, because releasing pertinent information pertaining to the patient may be necessary to circumvent harm. However, decisions to withhold or disclose confidential information that are inappropriately made may lead to adverse outcomes for stakeholders, including nurses and their patients. Nonetheless, there is a dearth of contemporary research literature to advise nurses in these circumstances. Cognitive Continuum Theory presents a single-system intuitive-analytical approach to examining and understanding nurse cognition, analogous to the recommended single-system approach to decision-making in mental health known as structured clinical judgement. Both approaches incorporate cognitive poles of wholly intuition and analysis and a dynamic continuum characterised by a 'common sense' blending of intuitive and analytical cognition, whereby cues presented to a decision-maker for judgement tasks are weighed and assessed for relevance. Furthermore, Cognitive Continuum Theory promotes the importance of determining pattern recognition and functional relations strategies, which can be used to understand the operationalisation of nurse cognition.

A Concept Analysis of Nurses' Clinical Decision Making: Implications for Korea

The study's purpose was to identify the meaning and the attributes of Korean nurses' clinical decision making. A sequential and systematic literature review with reflection according to the conceptual analysis method of Walker and Avant was used in this study. Data sources included the National Assembly Library, the National Digital Science Library, ProQuest, PubMed, MEDLINE, and CINAHL. Finally, twenty-six articles were included in this concept analysis. The concept of Korean nurses' clinical decision making consisted of the following attributes: clinical reasoning, choosing and applying challenging alternatives, and professional assessment and resetting. Antecedents consisted of: recognizing complex and diverse patient situations with high uncertainty, the need to solve problems according to priority, prior experience in clinical decision making, and interrelationships with fellow medical staff. Consequences consisted of: providing high-quality nursing services, improving the patient's safety, and increased satisfaction with clinical decision making. Based on these results, the conceptual attributes of Korean nurses' clinical decision making had slightly different characteristics but were organically interrelated. The results of analyzing the concept of Korean nurses' clinical decision making provide a better understanding of it and contribute to expanding nursing knowledge and developing a valid and reliable measurement.

Simulation-based education and the effect of multiple simulation sessions - A randomised controlled study

BACKGROUND

Simulation-based education may improve clinical decision-making skills and supplement clinical placement of nursing students to prepare them for real healthcare settings. Exposing students to several simulation sessions could maximise learning, but longitudinal randomised studies are lacking regarding the effects of simulation-based education.

OBJECTIVE

In this randomised study, we followed a class of nursing students to assess the effect of multiple simulations on the students' self-reported clinical decision-making skills and self-confidence.

DESIGN

A randomised controlled trial, collecting data four times throughout a 3-year nursing program; at the beginning of the second semester as baseline and at the end of each of the following academic years. Students experienced either a single (control) or a double (intervention) set of simulation scenarios in four simulation days, including several simulation scenarios for each session.

SETTING

A university in Norway, 2018-2020.

PARTICIPANTS

The study included 146 baccalaureate nursing students who volunteered to participate.

METHODS

The participants completed two validated instruments, the 24-item Nurse Decision-Making Instrument and the Self-Confidence Scale, and demographic data were collected. Analysis of covariance and linear mixed-effect models were applied to analyse the effect of the double compared to the single scenario simulations.

RESULTS

Complete data were obtained for 71 participants. The results showed no significant differences between double vs single scenario sessions on clinical decision-making scores (B = -0.2; 95% confidence interval, -2.1 to 1.7; p = 0.806) or self-confidence score (B = -0.1; 95% confidence interval, -0.4 to 0.2; p = 0.467). However, the overall self-confidence scores increased significantly over time.

CONCLUSION

In this randomised study, we found no effects of double vs single scenario simulations on clinical decision-making or self-confidence scores among nursing students during their 3-year program.

Clinical decision making in undergraduate nursing students: A mixed methods multisite study

BACKGROUND

Clinical decision making is an integral part of what nurses do, yet little is known about how students learn how to make clinical decisions or about the nature of the clinical decisions they make-whether intuitive or analytical. This multischool, multistate embedded mixed methods study was conducted to better understand these phenomena within the context of Hammond's Cognitive Continuum Theory. The content for this manuscript was taken from the primary author's dissertation.

METHODS

Students (N = 168) completed the NDMI-Revised 2014; followed by focus groups.

RESULTS

Three quarters of the participants (n = 127) scored in the quasi-rational range of clinical decision making indicating they are flexible making decisions dependent on the situation. Six themes described how students made clinical decisions.

CONCLUSIONS

Participants were flexible decision makers who used the help of others, lessons learned, the wisdom of nurses, experience, the situation at hand, and systematic cognitive processing to make clinical decisions.

Theories behind a nursing intern's error in terms of clinical decision-making

Clinical decision-making and judgment is an essential skill that should be acquired by nursing interns. However, many studies reveal that a large proportion of nursing interns have difficulty in meeting the basic expectation of clinical decision-making. This article begins with a brief review of some theories related to clinical decision-making. Then it takes a case, for example, to show how the wrong decision is made. Furthermore, it makes a general analysis on the case drawing on the concept of bounded rationality, dual-process model, and skills acquisition theory. This article ends with some reflections from the case, to improve the consciousness and skills in decision-making for nursing interns.

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.

Evaluating Medical Students' Clinical Reasoning in Psychiatry Using Clinical and Basic Science Concepts Presented in Session-level Integration Sessions

OBJECTIVE

The objective of this study was to evaluate improvement in clinical reasoning by preclinical medical students following participation in a clinical presentation curriculum that included both course and session-level integration of psychiatric and basic science concepts. A Script Concordance Test (SCT) for psychiatry was developed to assess differences in clinical reasoning in the students.

METHODS

Pre- and post-integration session tests were used to evaluate clinical reasoning among second-year medical students (MSII) who attended three integration sessions. Scores were compared between experts and medical students, and the validity and reliability of the SCT for psychiatry was assessed.

RESULTS

MSII scores improved 11% between the pre-and post-test (p < .001). There was no significant difference in scores between experts and MSII after attending the integration sessions. The SCT for psychiatry that was developed and used in this study provides reliable and valid results.

CONCLUSION

The concepts included in the integration sessions for this study highlighted possibilities for helping novice learners elaborate causal networks with the intention of cultivate illness script formation and clinical reasoning. Additional studies in this area should be considered to further enhance understanding of the possible benefits of this curriculum model.

Beyond competencies - describing work ready plus graduates for the New Zealand medical imaging workforce

INTRODUCTION

Medical imaging is a profession where technology and practice is moving forward at a fast pace, while also being situated within rapidly evolving models of healthcare delivery. This requires capabilities in our graduates beyond the competencies to undertake the role. This study used an existing Professional Capability Framework as the foundation for the development of a survey tool to identify those capabilities most valued by the health services that provide placement opportunities for students.

METHODS

A prospective survey, conducted online, was used to gather the data from senior medical imaging staff who work regularly with students and new graduates.

RESULTS

The results identified the top capabilities within each of three domains of personal, interpersonal, and cognitive capabilities. The results from the personal domain show that remaining calm under pressure or when things take an unexpected turn; understanding personal strengths and limitations; being willing to face and learn from errors; wanting to do as good a job as possible and having energy, passion and enthusiasm for the profession and role are most valued by the profession. We have identified links between the most desired interpersonal capabilities and attributes of well-functioning interprofessional teams and the cognitive capabilities align to those required for critical thinking and clinical reasoning.

CONCLUSIONS

These results have allowed the curriculum development team to review the graduate profile of medical imaging technology graduates. The curriculum development team has begun a process to incorporate learning strategies that will encourage the development of these capabilities in our graduates.

Design principles for simulation games for learning clinical reasoning: A design-based research approach

BACKGROUND

Nurses sometimes lack the competence needed for recognising deterioration in patient conditions and this is often due to poor clinical reasoning. There is a need to develop new possibilities for learning this crucial competence area. In addition, educators need to be future oriented; they need to be able to design and adopt new pedagogical innovations. The purpose of the study is to describe the development process and to generate principles for the design of nursing simulation games.

METHOD

A design-based research methodology is applied in this study. Iterative cycles of analysis, design, development, testing and refinement were conducted via collaboration among researchers, educators, students, and game designers.

RESULTS

The study facilitated the generation of reusable design principles for simulation games to guide future designers when designing and developing simulation games for learning clinical reasoning.

CONCLUSION

This study makes a major contribution to research on simulation game development in the field of nursing education. The results of this study provide important insights into the significance of involving nurse educators in the design and development process of educational simulation games for the purpose of nursing education.

Cognitive continuum theory in interprofessional healthcare: A critical analysis

Effective clinical decision making is among the most important skills required by healthcare practitioners. Making sound decisions while working collaboratively in interprofessional healthcare teams is essential for modern healthcare planning, successful interventions, and patient care. The cognitive continuum theory (CCT) is a model of human judgement and decision making aimed at orienting decision-making processes. CCT has the potential to improve both individual health practitioner, and interprofessional team understanding about, and communication of, clinical decision-making processes. Examination of the current application of CCT indicates that this theory could strengthen interprofessional team clinical decision making (CDM). However, further research is needed before extending the use of this theoretical framework to a wider range of interprofessional healthcare team processes. Implications for research, education, practice, and policy are addressed.

Factors that impact on emergency nurses’ ethical decision-making ability

Background:

Reliance on moral principles and professional codes has given nurses direction for ethical decision-making. However, rational models do not capture the emotion and reality of human choice. Intuitive response must be considered.

Research purpose:

Supporting intuition as an important ethical decision-making tool for nurses, the aim of this study was to determine relationships between intuition, years of worked nursing experience, and perceived ethical decision-making ability. A secondary aim explored the relationships between rational thought to years of worked nursing experience and perceived ethical decision-making ability.

Research design and context:

A non-experimental, correlational research design was used. The Rational Experiential Inventory measured intuition and rational thought. The Clinical Decision Making in Nursing Scale measured perceived ethical decision-making ability. Pearson’s r was the statistical method used to analyze three primary and two secondary research questions.

Participants:

A sample of 182 emergency nurses was recruited electronically through the Emergency Nurses Association. Participants were self-selected.

Ethical considerations:

Approval to conduct this study was obtained by the Adelphi University Institutional Review Board.

Findings:

A relationship between intuition and perceived ethical decision-making ability ( r = .252, p = .001) was a significant finding in this study.

Discussion:

This study is one of the first of this nature to make a connection between intuition and nurses’ ethical decision-making ability.

Conclusion:

This investigation contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions.

The Relationship Between the Clinical Orientation of Substance Abuse Professionals and Their Clinical Decisions

In this study, the authors examined the relationship between the clinical orientations of substance abuse professionals (SAPs) and their clinical decisions. Cluster analysis grouped a sample of 245 SAPs on two clinical orientations that differed in their relative endorsement of traditional versus contemporary substance abuse counseling processes and beliefs. Logistic regression revealed that SAPs' clinical orientations, labeled neo-traditional and precontemporary, could be predicted by their clinical decision-making tendencies and education level. Implications for rehabilitation counselor education, supervision, and research are discussed.

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.

An exploration of the correlates of nurse practitioners' clinical decision-making abilities

AIMS AND OBJECTIVES

This study investigated nurse practitioners' clinical decision-making abilities and the factors that affect these abilities.

BACKGROUND

Nurse practitioners play an important role in clinical care decision-making; however, studies exploring the factors that affect their decision-making abilities are lacking.

DESIGN

A cross-sectional descriptive survey was employed.

METHODS

A purposive sample of 197 nurse practitioners was recruited from a medical centre in central Taiwan. Structured questionnaires consisting of the Knowledge Readiness Scale, the Critical Thinking Disposition Inventory and the Clinical Decision-Making Model Inventory were used to collect data.

RESULTS

The intuitive-analytical type was the most commonly used decision-making model, and the intuitive type was the least frequently used model. The decision-making model used was significantly related to the nurse practitioners' work unit. Significant differences were noted between the nurse practitioners' clinical decision-making models and their critical thinking dispositions (openness and empathy). The nurse practitioners' years of work experience, work unit, professional knowledge and critical thinking disposition (openness and empathy as well as holistic and reflective dispositions) predicted the nurse practitioners' analytical decision-making scores. Age, years of nurse practitioner work experience, work unit and critical thinking disposition (holistic and reflective) predicted the nurse practitioners' intuitive decision-making scores.

CONCLUSIONS

This study contributes to the topic of clinical decision-making by describing various types of nurse practitioner decision-making. The factors associated with analytic and intuitive decision-making scores were identified. These findings might be beneficial when planning continuing education programmes to enhance the clinical decision-making abilities of nurse practitioners.

RELEVANCE TO CLINICAL PRACTICE

The study results showed that nurse practitioners demonstrated various clinical decision-making types across different work units. Consideration of nurse practitioners' knowledge readiness and their specific needs while planning on-duty education programmes is necessary.

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.

Relationships Between Clinical Decision-Making Patterns and Self-Efficacy and Nursing Professionalism in Korean Pediatric Nurses

As pediatric nurses must make decisions on a regular basis when caring for hospitalized children, clinical decision-making abilities are necessary in this profession. In the present study, we explored clinical decision-making patterns and their association with self-efficacy and nursing professionalism in pediatric nurses. We surveyed 173 pediatric nurses and analyzed the relationships between their clinical decision-making patterns and self-efficacy and nursing professionalism. Factor analysis identified 5 clinical decision-making patterns: patient-family-nurse collaborative (PNC), individual patient-oriented (IP), nurse model-oriented (NM), pattern-oriented intuitive (PI), and nursing knowledge-oriented (NK). The most frequently observed clinical decision-making pattern was the PNC. The self-efficacy and nursing professionalism were found to be higher in pediatric nurses using the IP and NM, and were lower for those using the PNC. Thus, the present results suggest that pediatric nurses' clinical decision-making patterns are influenced by nursing professionalism and self-efficacy. Therefore, intervention programs focusing on these variables might improve clinical decision-making in pediatric nurses.

Nurses' actions in response to nursing assistants' observations of signs and symptoms of infections among nursing home residents

Aims

To describe what nurses do during episodes of suspected infection in elderly nursing home residents and if these actions are linked to who is initiating an episode and whether the episode is considered an infection or not.

Design

Prospective descriptive study. Data were collected in 2008–2010.

Methods

Summarized and categorized documentation by nursing assistants and nurses was used for summative content analysis.

Results

Nurses' actions seem to be related to who initiated the episode and if the episodes are categorized as ‘non‐infection’, ‘possible infection’ or ‘infection’. Actions could be ‘observation’, ‘screenings’, ‘engaged in waiting’, ‘follow‐ups’, ‘nurse‐prescribed actions’, ‘diagnosing’, ‘contacting the physician’, ‘carrying out an action prescribed by the physician’, ‘contacting an ambulance or arranging an emergency visit to the hospital’ and ‘prescribing screening’. As NAs often initiate episodes of suspected infection by observing changed conditions, it seems important to include the NA in the decision‐making process as these observations could detect possible early signs and symptoms of infections.

Relationship between intuition and emotional intelligence in occupational therapists in mental health practice

OBJECTIVE

Clinical reasoning studies have acknowledged tacit aspects of practice, and recent research suggests that clinical reasoning contains intuition informed by tacit knowledge. Intuition also appears to be influenced by awareness and understanding of emotions. This study investigated the relationship between intuition and emotional intelligence among occupational therapists in mental health practice.

METHOD

We mailed a survey containing measures of cognitive style and of use of emotional competencies at work and demographic questions to 400 members of the national occupational therapy association; 134 occupational therapists responded.

RESULTS

A moderate relationship was found between intuitive cognitive style and emotional intelligence. Experienced therapists scored higher on the use of emotional competencies at work and reported a preference for an intuitive cognitive style to a greater extent than novices.

CONCLUSION

This study represents the first attempt to explore occupational therapists' preferred cognitive style and self-reported emotional intelligence. Findings suggest that exploring emotions through reflective practice could enhance intuitive aspects of clinical reasoning.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice.

Reducing uncertainty in triaging mental health presentations: examining triage decision-making

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses' decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.

Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology

BACKGROUND

Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delirium when caring for people with cancer, the elderly or older people requiring psychiatric care in the inpatient setting.

METHODS

Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses' views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective.

RESULTS

A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others.

DISCUSSION

Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.

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.

Decisional involvement of senior nurse leaders in Canadian acute care hospitals

AIM

The aim of the present study was to describe the scope and degree of involvement of senior nurse leaders (SNLs) in executive level decisions in acute care organizations across Canada.

BACKGROUND

Significant changes in SNL roles including expansion of decision-making responsibilities have occurred but little is known about the patterns of SNL decision-making.

METHODS

Data were collected by mailed survey from 63 SNLs and 49 chief executive officers (CEOs) in 66 healthcare organizations in 10 Canadian provinces. Regression analyses were used to examine whether timing, breadth of content expertise and the number of decision activities predicted SNL decision-making influence and quality of decisions.

RESULTS

Breadth of content expertise and number of decision activities with which the SNL was involved were significant predictors of decision influence explaining 22% of the variance in influence. Overall, CEOs rated SNL involvement in decision-making higher than the SNL.

CONCLUSIONS

Senior nurse leaders contribute to organizational processes in healthcare organizations that are important for nurses and patients, through their participation in decision-making at the senior team level.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings may be useful to current and future SNLs learning to shape the nature and content of information shared with CEOs particularly in the area of professional practice issues.

Home care nurses' decisions about the need for and amount of service at the end of life

AIMS

We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice.

BACKGROUND

Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care.

METHODS

Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison.

FINDINGS

Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care.

CONCLUSION

Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

Foetal monitoring: a woman-centred decision-making pathway

PROBLEM

Many midwives continue to use continuous foetal monitoring on low risk women in labour, despite evidence based clinical guidelines to the contrary. Continuous foetal monitoring has been linked to increased rates of medical intervention during labour and birth with no improvement in long term neonatal outcomes.

PARTICIPANTS

Midwives who used continuous foetal monitoring on low risk women in labour at two regional Queensland hospitals.

METHODS

This Grounded Theory study explored midwives' decision-making processes related to the use of continuous electronic foetal monitoring on low risk labouring women. Primary data were gathered in semi-structured interviews with five purposively selected midwives and concurrently analysed using Grounded Theory techniques of theoretical sampling and constant comparison.

FINDINGS

The midwives made the decision that led to continuous electronic foetal monitoring on low risk women at two key decision points during labour care; the first during the midwives' initial assessment of the woman and foetus, and the second when the midwives categorised the women as high or low risk. However, various factors impacted on these decisions including trust and staff workloads within a context of risk management and medical dominance. There was limited opportunity for women to be involved in the decision-making process about foetal monitoring and only partial information was provided prior to cardiotocography.

CONCLUSIONS

Consistent with current clinical guidelines which recommend open, consultative discussion with the woman about foetal monitoring and a partnership approach towards decision-making following informed choice, a woman-centred foetal monitoring decision-making pathway is proposed. This pathway is applicable in midwifery education, research and clinical practice to promote both evidence based practice and woman-centred decision-making.

Exploring decision making in intellectual disability nursing practice: a qualitative study

Due to the dearth of relevant research, intellectual disability nurses may have difficulty identifying sources of evidence on which they can base their clinical decisions. The aim of the present research was to explore how intellectual disability nurses make decisions and how their decisions are influenced by evidence. The method was guided by interpretative phenomenology and the analysis adopted an idiographic approach. Twelve National Health Service intellectual disability nurses in Wales participated in semi-structured interviews. Four key themes were identified: getting to know the person; working as a team; evidence to support decision making; and understanding of evidence-based practice. In the context of the myriad of other professionals involved in caregiving, the nurses conveyed a commitment towards ensuring that the person with intellectual disability is at the centre of decision making. Although using empirical evidence to support practice was acknowledged, these nurses considered person centred decision making to be paramount.

A Grounded Theory of Intuition among Occupational Therapists in Mental Health Practice

Objectives:

This study aimed to explore occupational therapists' understanding and use of intuition in mental health practice.

Method:

Using a grounded theory approach, a theoretical sample of nine occupational therapists practising in mental health settings participated in semi-structured interviews. Data were analysed using the constant comparative method.

Findings:

Intuition was found to be embedded within clinical reasoning. From the data, intuition was defined as knowledge without conscious awareness of reasoning. The participants viewed intuition as elusive and underground, and suggested that professional experience led to a more comfortable use of intuition. Using intuition relied on therapists' understanding of their own and others' emotions, and intuition partnered analysis within their clinical reasoning. A grounded theory of the use of intuition in mental health settings is proposed.

Conclusion:

Occupational therapists practising in mental health settings understand intuition to be an instinctive understanding of situations, resulting from their professional experience and the understanding of emotions.

Factors determining nurses' clinical judgments about hospitalized elderly patients with acute confusion

Acute confusion(AC)/delirium is a common clinical phenomenon in hospitalized elders that is often overlooked or misdiagnosed by nurses of various cultural backgrounds. The aim of this study was to better understand factors affecting nurses' clinical judgments regarding the detection of AC in elderly Taiwanese patients. Nurses from two hospitals in Taiwan (n = 654, response rate = 71.3%) participated in the study. A two-level hierarchical linear model analysis was used to examine the data. The characteristics of patients explained the most variance of the model (86.2%), with characteristics of nurse participants and their health organizations accounting for 13.8% of the variance. Patient characteristics of age, infection, hydration, and hypoactive subtypes of AC, as well as a nurse's strong belief in traditional Chinese values, such as respect for elders, hard work, modesty, noncompetitiveness, and respect for tradition, were positively associated with difficulty detecting acute confusion. Findings of this study indicated that the accuracy of nurses' clinical judgments in detecting AC were most related to characteristics of patients.

Cross-cultural nursing research

BACKGROUND

International cross-cultural comparative nursing research is considered important for the advancement of nursing knowledge offering a global perspective for nursing. Although this is recognised in policy statements and quality standards, international comparative studies are rare in database citations.

OBJECTIVES

To highlight the need for cross-cultural comparative research in nursing and to share some of the insights gained after conducting three international/cross-cultural comparative studies. These are: an examination of patients' autonomy, privacy and informed consent in nursing interventions BIOMED 1998-2001, the ICProject International Patient Study 2002-2006 and the Ethical Codes in Nursing (ECN) project 2003-2005.

RESULTS

There are three critical issues raised here for discussion from the international cross-cultural studies. These are: the planning and formulating of an international study, the conduct of cross-cultural research including the implementation of rigorous data collection and analysis and the reporting and implementing the results.

CONCLUSION

International and cross-cultural nursing research is powerful tool for the improvement of clinical nursing practise, education and management and advancement of knowledge. Such studies should be carried out in order to improve European evidence based health care development in which the patients' perspective plays an important part in the evaluation and benchmarking of services.

Clinical Constructions by Nurses in Korea, Norway, and the United States

Nursing practice involves engagement of nurses in clinical fields through deliberation and enactment. In the phase of deliberation, nurses observe, recognize, form ideas about and decide on clinical situations, and construct clinical pictures. Clinical pictures are critically connected to nursing enactments, thus it is important to discover how nurses arrive at clinical pictures. The purpose of this article is to describe how nurses construct meanings of clinical situations and arrive at specific clinical pictures. The results are from a clinical fieldwork study replicated in Korea, Norway, and the United States, with samples of nurses working in acute-care hospitals. Data were collected through participant observations and in-depth interviews. A general model of clinical construction was derived from the results, which specifies four dimensions (i.e., problem, progress, status, and particularism) as the bases for clinical picture evocations. Clinical pictures are constituted by nurses' elicitations of meanings of clinical situations on these dimensions.

A review of clinical decision making: models and current research

AIMS AND OBJECTIVES

The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model.

BACKGROUND

Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition.

DESIGN

Literature review.

METHODS

Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005.

RESULTS

The characteristics of the three models of decision making were identified and the related research discussed.

CONCLUSIONS

Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed.

RELEVANCE TO CLINICAL PRACTICE

It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

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

AIMS AND OBJECTIVES

To gain an understanding of how children's nurses make clinical decisions.

BACKGROUND

Several studies have explored how nurses make clinical decisions and the factors that may affect the decision-making strategies used. However, the results of these studies are contradictory. Further, little is known about children's nurses' decision-making strategies.

DESIGN

The think aloud technique.

METHODS

Nurses (n = 12) from three surgical wards and nurses (n = 15) from three medical wards in a Scottish children's hospital were presented with clinical scenarios and asked to think aloud. The verbal protocols were analysed to provide an indication of how children's nurses made decisions. Whether there were any differences in decision-making between experienced and less experienced nurses and between graduates and non-graduates was also explored.

RESULTS

Analysis of verbal protocols obtained using the think aloud technique suggested that all the nurses in the sample used a hypothetico-deductive (analytical) model of decision-making. Further, all participants appeared to use backward reasoning strategies regardless of their level of expertise. This is a characteristic of non-expert decision-making. Experienced and less experienced nurses collected similar additional information before planning nursing interventions, supporting the conjecture that they were functioning at a non-expert level in relation to decision-making. No differences were seen in the information collected by graduate and non-graduate nurses.

CONCLUSIONS

The decision-making strategies of children's nurses need exploring further and further research is needed to identify factors that may affect decision-making strategies. Several strategies to support nurses' clinical decision-making have been proposed but need testing to ascertain their effectiveness.

RELEVANCE TO CLINICAL PRACTICE

In clinical practice nurses make numerous decisions throughout the course of a shift. Sub-optimal decision-making strategies may adversely affect the quality of nursing care provided. It is imperative, therefore, to ascertain how nurses make clinical decisions and the factors that may influence the decision-making strategies used.

Influences that drive clinical decision-making among rheumatology nurses. Part 1: literature review

Decisions nurses make while providing patient care to their client group will impact on the patient's immediate and long-term outcomes and will also impact on service provision. Although many studies have focused on the clinical decision-making process itself within general nursing areas, little has been published as to what factors influence decisions in rheumatology nursing at the clinical level. Initial review of the literature suggested the following themes could influence decision-making: clinical decision-making, intuition, evidence-based practice, experiential learning, knowing the patient, skilled knowledge and rheumatology nursing. This article examines the literature surrounding clinical decision-making which may influence decision-making within rheumatology nursing practice.

Thinking like a nurse: a research-based model of clinical judgment in nursing

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation

AIM

This paper reports a study of nurses' attitudes towards the use of nursing diagnoses in perioperative documentation and the factors affecting these attitudes.

BACKGROUND

There are both international and national requests for nurses to move from natural language-based narrative documentation to electronic documentation and clinical use of nursing classifications. However, nurses' attitudes toward nursing classifications have not been widely studied.

METHODS

A questionnaire was distributed to a purposive sample of perioperative nurses (n = 146) who had participated in clinical testing of nursing diagnoses. The response rate was 60% (n = 87). The data were collected in 2003.

RESULTS

In general, nurses' attitudes toward nursing diagnoses were positive. Those over 40 years of age who had clinical experience from 10 to 19 years, postbasic nursing education and previous knowledge of nursing diagnoses were most positive in their attitudes. However, the use of nursing diagnoses in perioperative practice was not seen as either necessary or accurate in describing patients' problems. Furthermore, the documentation of perioperative routines was seen as time-consuming and frustrating.

CONCLUSIONS

Nursing classifications should be included in both preregistration nursing curricula and in-service educational programmes to ensure theoretical knowledge of and practical skills in standardized clinical languages. The perioperative nursing diagnoses should be reviewed to fit better with clinical practice. In addition, current perioperative documentation practices should be reconsidered and updated as appropriate to address clinical requirements better.

Practice and clinical decision-making autonomy among Hellenic critical care nurses

BACKGROUND

Nursing autonomy has been associated with better patient-outcomes; therefore, it is a priority for critical care nursing management. Low authority has been a persistent complaint of Hellenic intensive care unit nurses; however, issues of nursing autonomy have not been previously addressed empirically in Hellas.

PURPOSE

To investigate: (1) the perceived contribution to clinical decision-making, (2) the degree of autonomy in technical tasks, and (3) factors related to practice autonomy in critical care nurses in Hellas. Additionally, because of the lack of sufficient tools, this study also aimed to construct and to validate a new tool for assessing practice and clinical decision-making autonomy among Hellenic intensive care unit nurses.

MATERIALS AND METHODS

A Hellenic intensive care nursing autonomy scale, focused on technical aspects of care, was developed through literature review, a panel of experts and a pilot study in a random sample of 120 respondents. Items were refined by factor analysis, which revealed three major conceptual categories of autonomy: (1) basic technical, (2) advanced technical, and (3) clinical decision. Hellenic intensive care nursing autonomy (Likert 4, range: 38-152), was distributed to all nurses employed in intensive care units in Hellas (n = 807; attrition: 27%). Comparisons, correlation and multivariate regression were employed.

RESULTS

The Hellenic intensive care nursing autonomy scale exhibited appropriate reliability (Cronbach's alpha = 0.86) and validity properties. Autonomy scores were moderate (mean: 105.24 +/- 9.58). Highest autonomy was attributed to basic technical tasks, followed by advanced technical tasks and decision-making. Male gender and higher education were predictors of higher overall, advanced technical and decision-making autonomy (P = 0.01). Bachelor degree graduates scored higher in decisional autonomy (P = 0.03). Intensive care unit experience and type of intensive care unit were also important determinants of decisional autonomy (P = 0.02).

CONCLUSIONS

The results revealed moderate autonomy in technical tasks and low decisional autonomy among Hellenic intensive care unit nurses. Factors related to the educational preparation of nurses, gender issues and institutional characteristics might hinder intensive care unit nurses' autonomy in Hellas.

Cognitive Continuum Theory in nursing decision-making

AIM

The purpose of this paper is to analyse and evaluate Cognitive Continuum Theory and to provide evidence for its relevance to nurses' decision-making.

BACKGROUND

It is critical that theories used in nursing are evaluated to provide an understanding of their aims, concepts and usefulness. With the advent of evidence-based care, theories on decision-making have acquired increased significance.

METHOD

The criteria identified by Fawcett's framework has been used to analyse and evaluate Hammond's Cognitive Continuum Theory. Findings. There is empirical evidence to support many of the concepts and propositions of Cognitive Continuum Theory. The theory has been applied to the decision-making process of many professionals, including medical practitioners and nurses. Existing evidence suggests that Cognitive Continuum Theory can provide the framework to explain decision-making in nursing.

CONCLUSION

Cognitive Continuum Theory has the potential to make major contributions towards understanding the decision-making process of nurses in the clinical environment. Knowledge of the theory in nursing practice has become crucial.