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Phillipa O'Reilly is the Clinical Nurse Consultant: Nutrition and Intravenous Therapy at St Vincent's Hospital, Sydney. |
Clinical decision making is an essential component of professional nursing practice. One of the goals of the nursing profession therefore should be to enhance the clinical decision making abilities of nurses. This paper examines the factors; experience, knowledge, creative thinking ability, education, self concept, work environment and situational stressors, and, discusses how these factors can either enhance or impede decision making for nurses. Strategies to reduce the barriers to clinical decision making are suggested.
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Clinical decision making, the ability to sift and synthesize information, make decisions and appropriately implement these decisions in the clinical environment is an essential component of professional nursing practice. The nursing discipline's pursuit of professional recognition relies heavily upon the ability of practicing nurses to correctly define and solve problems which are uniquely nursing in origin (Jones, 1988: 185).
Nurses are expected to be competent decision makers (Pardue, 1987: 355), therefore the nursing profession has a responsibility to enhance the clinical decision making abilities of its members. One means of doing this is to identify factors which act as barriers to effective problem solving. By recognising the nature and existence of barriers, strategies may be developed to overcome them.
Clinical decision making is a complex process whereby practitioners determine the type of information they collect, recognise problems according to the cues identified during information collection, and decide upon appropriate interventions to address those problems (Tanner, Padrick, Westfall & Putzier, 1987: 358; Thomas, Wearing & Bennett, 1991: 1). The complexity of the process is due to the variation in cues, the magnitude of information to be processed, and the difficulty in predicting outcomes (Hammond, 1960, cited by Pardue, 1987: 355).
Numerous factors influence the clinical decision making process (Pardue, 1987: 55). These factors include individual variables, such as experience and knowledge (Benner, 1984; Benner & Tanner, 1987), creative thinking ability, education (Pardue, 1987: 355), and self concept (Joseph, 1985: 22), as well as environmental and situational stressors (Cleland, 1967; Evans, 1990). These factors may serve to enhance or impede clinical decision making.
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Experience and knowledge are two of the major factors affecting decision making. Decision making within practice disciplines, such as nursing, involves more than the application of theoretical knowledge. A deep understanding of the situation is required if treatment approaches are to address the experience of illness as it relates to a particular patient. This understanding evolves from knowledge and experience (Mattingly, 1991: 979; Correnti, 1992: 91). Experience increases the cognitive resources available for interpretation of data (Liek & Cifford, cited by Evans, 1990: 180), resulting in more accurate decision making.
Tanner et al. (1987), studied the diagnostic reasoning strategies of nurses and nursing students and found that increased knowledge and experience yielded more. systematic data acquisition and greater diagnostic accuracy (Tanner et al., 1987: 362). This difference in diagnostic accuracy has been attributed to the ability of the expert nurse to intuitively determine the correct region for assessment, select relevant data and recognise the changing relevance of cues as the situation evolves (Benner & Tanner, 1987: 31).
Intuition, defined by Benner and Tanner (1987: 23), as "understanding without rationale" represents the hallmark of expert judgement. The ability to rapidly identify the important facts, limits the number of alternatives to be evaluated, and thereby reduces decisional conflict and stress (Evans, 1990: 180). In this context the ability to use intuition in decision making is a factor enhancing decision making.
However, despite research findings which advocate intuition as central to expert judgement (Benner, 1984: xviii; Rew, 1990: 37), intuition has been dismissed as irrational guessing (Correnti, 1992: 92). Many nurses, because of this view, are reluctant to follow their 'gut feelings', and reject the use of intuition in decision making. Often expert nurses know that something is wrong before clinical signs manifest, but they deny this knowledge due to the debasement and suspicion of intuition as a valid nursing assessment technique. This attitude of dismissing intuitive judgement as irrational guessing, generates decisional conflict and substitutes a barrier to expert nursing judgement.
Promotion of nursing expertise requires the acceptance of intuitive understanding as a valid method of decision making, and challenges experts to share their experiences of making decisions (Corcoran, Perry & Bungert, 1992: 69). Nurse educators are encouraged to teach the application of intuitive skills, cultivate intuitive knowledge and promote the development of creative thinking abilities for problem solving (Correnti, 1992: 99).
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Problem solving involves organisation of new and previously learned information to form new responses to novel situations (Brooks & Shepherd, 1990: 392). This incorporates two major components, reasoning and imagination. Reasoning is the basis of critical thinking which produces comprehensible, methodical outcomes. Creative thinking however, is the product of reasoning and imagination. Past impressions are integrated to form unique conclusions (Berger, 1984: 306) which are essential for problem solving.
Education and the learning environment play a crucial role in the promotion of creative thinking ability. Depending on the learning environment and attitudes of educators, the development of creative thinking ability may be either enhanced or delayed (Berger, 1984: 307).
The promotion of creative thinking through education calls for teachers to endorse the creative thinkers' self-worth, listen to them, challenge learners to develop new ideas and to question their taken-for-granted ideas, demonstrate critical thinking ability, encourage breadth of reading, invite learners to talk about what they think and feel, and to adopt a conversational approach (Burnard, 1989: 273-274). Encouraging "success" rather than "failure" enhances problem solving capabilities (Hartnett and Barber, 1981, cited by Berger, 1984: 307) through the promotion of positive notions of self-concept and self-efficacy. In order to effectively make clinical decisions the individual must perceive that they actually can make the decision.
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Perceptions of being less intelligent, less educated and less competent result in relinquished authority to those perceived as being better (Joseph, 1985: 22). An important component of self-efficacy and self-concept is the individual's locus of control (Joseph, 1985: 22). Locus of control refers to the extent to which a person believes they can control events and outcomes. Those with an internal locus of control believe in their ability to influence results, whereas, those possessing an external locus of control believe that events are contingent upon the actions of others (Lazarus & Folkman, 1984: 67). Locus of control has significant ramifications when investigating the effects of stress on decision making, since locus of control is fundamental to the individual's perception of stress.
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Stress arises when an individual perceives the environment as demanding because it exceeds his/her resources and threatens personal well being (Lazarus & Folkman, 1984: 19). As a result of this perceptual component, situations that are anxiety provoking and stressful for one individual may be stimulating for another depending on their appraisal of the situation (Bailey, Steffen & Grout, 1980: 24; Wakefield, 1992: 24). Those with an internal locus of control, usually view life as challenging and perceive themselves to have an influence on the outcomes of stressful life events (Lazarus & Folkman, 1984: 69; Rich & Rich, 1987: 64). By perceiving crises as challenging rather than threatening, stress is minimised. Those with an internal locus of control are therefore inclined to deal with stress more effectively than those with an external locus of control (Rich & Rich, 1987: 65). However, because stress interferes with a persons concept of self-efficacy (Jenkins, 1985: 43), situations of extreme stress can have a negative impact affecting locus of control, thinking (Cleland, 1967: 110), and decision making ability (Neaves, 1989: 15).
Cleland (1967) studied the effects of stress upon nurses thinking. She concluded that a moderate amount of stress was required for optimal thinking. Situations of low stress provided insufficient stimulation and impaired functioning, while moderately high to very high environmental stressors resulted in a deterioration in the quality of thinking. This deterioration was found to be more rapid when complex thinking processes were required (Cleland, 1967: 110). Situations of high or low stress, must therefore adversely affect decision making, since complex thinking is often utilised in the decision making process.
The long term effects of functioning within highly stressful environments include stereotypical, unimaginative thinking, over generalisation and loss of interest (Cleland, 1967: 110). Excessive, unrelieved stress may result in burnout, a syndrome resulting in the development of negative work attitudes, poor professional self-concept and loss of empathy (Rich & Rich, 1987: 63). Many authors (Wakefield, 1992: 24; Rich & Rich, 1987: 65), believe that nurses are particularly prone to developing burnout because of the stresses inherent in nursing. Rich and Rich (1987: 65), identified that young, unmarried nurses are at greatest risk.
Nurses themselves identify individual factors which produce the greatest stress. These include interpersonal conflict, inadequate staffing, lack of support when dealing with death, unresponsive leadership, and physical environment inefficiencies (Bailey et al., 1980: 25). The sources of stress, identified by nurses, fall into five major categories; interpersonal relationships, knowledge and skills, patient care, management problems, and the work environment (Huckabay & Jagla, 1979: 21; Bailey et al., 1980: 16-17).
One of these sources of stress is the shiftwork component of nursing work. Much has been written on the effects of shiftwork on workers. It is believed to be a major factor contributing to tiredness, and it constitutes a source of physical and psychological stress, and predisposes workers to tranquilliser and alcohol use (Siebenaler & McCovern, 1991: 563). All of these factors impair judgement and decision making ability (Thomas et al., 1991: 64; Wakefield, 1992: 24).
Deficient performance as a result of shiftwork is principally due to disruption of normal circadian rhythms (Siebenaler & McCovern, 1991: 558). Circadian rhythms are regular endogenously controlled biological and behavioural patterns, synchronised to a twenty four hour period by external influences such as night and day, clock time and social activities. Performance and cognitive functioning are influenced by circadian rhythms. Shiftworkers therefore, are prone to work performance problems, because their circadian rhythms are disrupted, resulting in impaired attention, judgement, accuracy and safety (Siebenaler & McCovern, 1991: 563). All of these factors impact upon the clinical decision making abilities of nurses. Shiftwork therefore can be seen as a barrier to effective decision making. Another major source identified is that of inadequate staffing.
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That it is stressful to work when staffing levels are inadequate for the tasks required would be disputed by few. However, Huckabay and Jagla (1979: 25) suggest that inadequate staffing may be related, not only to the total staff numbers, but to the skill index as well. It is suggested that most nurses have frequently encountered circumstances when experienced staff are replaced with novices. This situation places stress on staff of all levels. Experienced nurses encounter the additional effort of teaching and supporting inexperienced nurses, particularly in view of Rich and Rich's (1987: 65) suggestion that young nurses require more supervisory and coping support than their older counterparts. For novices, the presence of highly skilled people, the performance of tasks for the first time, and situational factors undermine confidence and increase anxiety (Jenkins 1985: 243). These factors all have an effect on decision making.
Jenkins' (1985) proposition that the presence of skilled expert nurses may undermine the confidence of novice nurses, has implications for management and more experienced practitioners in terms of allocation of patient loads, rostering of nursing staff and the nature of clinical support available. If nurses are to develop perceptions of self-efficacy related to decision making, management should attempt to allocate patient loads that are challenging, without being overwhelming. Clinical support should be provided by rostering inexperienced nurses on shifts with nurses of greater competency so that situational demands encourage perceptions of self-efficacy.
Competent, proficient and expert nurses have the responsibility to guide beginners through decision making processes, demonstrate patience when doing so, and encourage reflective practice. They must endeavour to create an environment in which the learner can fully experience the decision making process.
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The stressors involved with interpersonal conflict constitute another barrier to decision making. Clinical decision making is a social activity involving health care team members and the patient. The social context in which the clinician functions impacts upon decision making (Thomas et al., 1992: 67). A significant influence for nurses involves their relationship with physicians (Haddad, 1991: 151). Stein (1967), identified a fundamental communication pattern used by physicians and nurses, which he called the 'nurse-doctor game'. Interestingly, when Stein (1990, cited by Haddad, 1991: 152) reviewed the 'nurse-doctor game' in 1990 he found only minor changes in the way the game was played today, compared to when it was first discussed.
The principal rule of the 'nurse-doctor game' is that overt disagreement must be avoided. In order to obey this rule, nurses must communicate their recommendations without appearing to make recommendations. (Haddad, 1991: 151; Porter, 1991: 729). Nurses have been socialised into playing the nurse-doctor game, to avoid open debate. The result, as Joseph (1985: 31) found, is that experienced nurses are less likely to feel that nurses should assume responsibility. This reluctance to assume responsibility creates a barrier to effective clinical decision making.
A second factor influencing the nurse-physician relationship stems from the an inequity in power relations between the two groups. Doctors exert direct power in the health care system, determining who will be admitted as well as the type of treatments to be performed (Haddad, 1991: 152). Their professional and financial status also allow them a degree of political power, their statements influencing the actions of politicians when determining health care. policies. Nurses, although an essential component to the functioning of any health care organisation and by far the most powerful group in terms of numbers employed, exert little authority in regard to decisions affecting their work or wellbeing. Their contribution to the organisation often receives little recognition, and their wages often do not reflect the responsibility afforded them (Haddad, 1991: 152).
Porter (1991) examined the nurse-doctor relationship and its impact on nursing participation in decision making in an intensive care unit and a medical ward. He found that while doctors, in particular, the consultant medical officers, still possess power over nurses, the nurse-physician relationship has become more equitable. Some nurses are beginning to be more open in their participation with informal decision making, however many still continue to demonstrate subservience by observing the rules of the doctor-nurse game, and are reluctant to assume responsibility for decision making.
Haddad (1991: 152) offers a third factor influencing the nurse-physician relationship, namely the different approaches doctors and nurses use in decision making. Nurses, because of their holistic approach to health care and the degree of female representation, tend to acknowledge that patients exist within social networks and that the relationships embedded in these networks are central to decision making. As a result, nurses have a tendency to become concerned with the specifics of a situation and therefore, are slow to make decisions. Doctors, due to a reductionist approach to health care and dominant male representation, are inclined to analyse problems, dispensing with details that nurses may believe are important, and take it upon themselves to make decisions with little or no collaboration (Haddad, 1991: 152-53). Shared authority for decision making produces better decisions and promotes greater commitment to the decision (Haddad, 1991: 156). Without this collaboration, decision making can be problematic.
Since each group has a different approach to decision making, and in health care collaborative decision making is encouraged, the only way forward is for doctors and nurses to learn from each other. Consequently, nurses must encourage doctors to develop an understanding of decision making in nursing. Nurses must also learn to be credible and articulate, to expect arguments, be assertive and avoid over-qualifying (Haddad, 1991: 154). This can be achieved by direct communication, the abandonment of the doctor-nurse game, and demonstrated cohesive support by nurses, educators and administrators, for the role of nurses as decision makers (Joseph, 1985: 32, Haddad, 1991: 155).
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Whilst many factors influence the decision making process, it appears that many more serve as barriers to decision making process. It has been shown that the range of barriers faced by nurse decision makers are complex and detailed.
Clinical decision making is an essential component of professional nursing. Nurses must be encouraged to make decisions and assume responsibility for them. The nursing profession, nurse managers, nurse educators and health care administrators, have a responsibility to provide opportunities to encourage, support and promote decision making. To do this the factors affecting decision making must be understood, the barriers identified, and strategies to minimise these barriers developed and implemented.
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