Dimensions of Nursing Decision Making

NERU January 11, 2010

Purpose

Decision making is considered a critical component of professional practice. Complexities of practice require the health care professional to possess a number of decision making and clinical reasoning skills, and the ability to deliberately select and apply the most appropriate one(s) in often rapidly changing contexts. The purpose of this session was to:

  1. engage in dialogue about nursing decision making;
  2. identify and understand the elements and dimensions of nursing DM;
  3. articulate how decision making is enacted; and
  4. explore our roles as educators in promoting nursing decision making.

Dr. Sheryl Boblin asked participants a series of questions to lead them through the discussion.

Nursing Decision Making

Question: What cognitive skills are required of the nurse to engage in DM?

  • Cognitive skills/dispositions include attentionality and awareness, curiosity, courage, memory
  • Judgment, clinical reasoning, knowledge, reflexivity, inner knowledge, ability to discriminate, differentiate between decision making (uncertainty) & problem solving, comfort with/tolerant of ambiguity
  • Understanding of foreground & background
  • Knowledge of nursing process, knowledge of illness/condition & expertise

Question: What is the process of decision making

  • Trying to come up with determination of what needs to happen based on a thorough assessment. This involves the nurse asking: “What does my previous knowledge tell me will be the likely outcome for the patient?”
  • Application of a systematic way of applying criteria to make a choice
  • Weighing/ranking of relative importance to identify what are the appropriate steps/choices.
  • Assessment of level of risk – What is my level of risk? What are the consequences or if I do? If I don’t? Participants concluded that decision making is a complex skill that requires a high level of knowledge/expertise.
  • Positive or negative consequences may be considered.
  • What is the risk to me as a nurse? What are the personal consequences if I follow a certain pathway? This is an aspect of decision making not addressed in most decision making models. The risk is these models is considered in relation to the patient, but not so for the nurse or other health care provider.
  • The process of decision making involves beliefs and values, within the context of the practice setting. Complexity involved in individual decision-making balanced with client/workload. Decision-making relates to nurse within context i.e. cannot separate nurse from context.
  • A participant raised the question: “What if you have nurses that believe in their pathway of a “just” or “right” path but system issues may preclude this action?” Nursing decision-making is thus a socially constructed concept. That may involve emotional/moral distress.
  • Characteristics of environment and urgency of task may influence the process and the decisions made.
  • Nurses need to consider foreground and background influences on decision making. The role of educators is to make background and foreground influences explicit.
  • Part of decision making is being able to through experience and knowledge, learn to discriminate the appropriate and evolving assessment data. Involves thinking critically and learning to prioritize.
  • Decision making involves learning how to manage challenge of “not knowing what I don’t know”. How can you deconstruct something that you know nothing about? This presents a particular dilemma for the novice nurse/student.
  • Skills: judgment, pattern recognition, intentionality, memory, personal knowing, initiative, clinical reasoning, problem-solving, intuition

Characteristics influencing decision-making

Question: How do the characteristics of the nurse influence decision-making?

  • Strength, resilience, knowing oneself, courage to stand up for decisions, validate when you are getting push back, personal philosophy, awareness, comfort with uncertainty or ambiguity, flexibility, information-seeking behavior
  • Need to work within philosophy of organization/system; need knowledge of organizational culture
  • Formal and informal understanding of organization’s mission, vision, philosophy
  • Ability to transfer/replicate/adapt to fit situation
  • Patterns of recognition that may evolve over time with additional knowledge/expertise
  • Heuristics of decision-making i.e. recent similar decisions

Question: How do the characteristics of the environment influence decision-making?

  • Environment: power structures and inequities, perception of other providers (nursing, multidisciplinary), leadership/management style within unit/organization, learning environment, resources to support decision, understanding the context of having limited resources, access to information resources, speed/urgency of need to make a decision, allowing students opportunities to make decisions.
  • Power gradients are a reality of the clinical environment. Power issues and confidence can influence decision-making. Part of decision making autonomy involves building confidence to take the initiative.
  • Other providers foci, purpose of the setting, role of the nurse within that environment

Question: How do the characteristics of the decision influence decision-making?

  • Socially constructed, importance of external variables
  • Urgency of task/decisions
  • Complexity of task
  • Shared decision making (within profession, hierarchical, with client)
  • Interdisciplinary decision making

What is our role as educators in helping develop decision-making skills?

  • When asked “how do we get students to develop astute skills in recognizing and setting priorities?”participants responded that we need to deconstruct decision-making process to articulate it for students.
  • This deconstructing involves illuminating elements of discriminating, prioritizing, reflecting, assessing and determining risk, adaptability, flexibility, resilience, knowledge, confidence.
  • Our role includes helping students identify that they have made a decision. Deconstructing activities to understand at what point decisions had been made. Need framework for understanding when and how decisions are made. “What is it that determines that I have made a decision?”
  • May need to try to simplify this complex process into simple language for students. Reflecting back on conversation, language and behavior. Building layers of decision-making to identify “choice points”.
  • Using simulation as an opportunity to safely test decision-making, reflect during debriefing session, deconstruct actions taken, anticipated outcomes. Acknowledge that there needs to be some baseline knowledge to engage in simulation.
  • Suggestion to build on personal experiences when students do not have “nursing” knowledge/expertise i.e. when teaching bed baths, how you would talk to your mother when discussing advance cancer diagnosis (to learn empathy).
  • Need to look at critical learning skills that students need to have to be able to support students in learning decision-making. Understanding gaps in skill sets that need to be developed.