W6 PPT MORAL DISTRESS

1
Moral Distress and Ethical Issues in Nursing Presentation PPT
General Guidelines:
1. Presentation should be between 10-15 slides.
2. Each content slide should be succinct and have no long paragraphs to read.
3. Utilize notes pages may be utilized for explanation if needed and to expand on subject area to
cover all criteria on rubric.
4. Use pictures to enhance presentation.
Content Criteria: (see below)
1. Describe and identify moral distress as an ethical issue in nursing. Describe this issue as
it relates to a post COVID-19 work environment in nursing. The background about this
issue, what is meant by moral distress in nursing? Why it is such an important and
essential issue for healthcare organizations and nursing leadership.
2. Analysis & Evaluation of Moral Distress as an ethical issue in nursing. Discuss the
repercussions among nurses and what role healthcare organizations and nursing
leadership has on this in both a positive and negative way.
3. Explore ethical principles that are impacted. How does moral distress impact nursing
decision making and overall work performance? Does moral distress differ among critical
care nurses such as ICU and ED nurses compared to other types of nursing (support your
responses);
4. Recommendations on Effective Solutions/Strategies: Explain ways nurse
managers/leaders/healthcare organizations can employ in terms of leadership style,
ethical principles, practice standards, policies and decision-making strategies that include
real-world solutions and recommendations. Make sure to look at what other healthcare
organizations are using to address these issues in practice and also creative strategies that
can be adopted.
5. Links moral distress to nursing ethical dilemmas to course readings and additional
research.
6. Writing Mechanics and Formatting Guidelines
PowerPoint Presentation Rubric
CRITERION
Identification of Moral
Distress as an Ethical
Issue in Nursing (15%)
STRONG
10-15 pts
Identifies, describes and
demonstrates a
sophisticated understanding
of moral distress as an
ethical issue and dilemma
AVERAGE
5-9 pts
Identifies, describes and
demonstrates an
accomplished
understanding of moral
distress as an ethical issue
WEAK
0-4 pts
Identifies, describes and
demonstrates acceptable
understanding of moral
distress as an ethical
issue and dilemma with
2
with a strong background
about the issue in relation to
COVID-19. Importance &
essential issue to healthcare
organizations & nursing
leadership.
Analysis and Evaluation
of Ethical Dilemma
15%
Explores ethical nursing
principles as they apply
to moral distress and the
impact this has on
nursing decision
making and overall
work performance. Are
there differences in
moral distress
depending on the type
of nursing? (15%)
Explains how nurse
managers, leaders &
healthcare organizations
can employ leadership,
ethical principles,
and dilemma with a
strong background about
the issue in relation to
COVID-19. Importance
of issue to healthcare
organizations & nursing
leadership is evidence but
not clearly described
10-15 pts
5-9 pts
Presents an insightful and
Presents a somewhat
through analysis of moral
thorough analysis of
distress as an ethical
moral distress as an
dilemma. Sophisticated
ethical dilemma.
discussion of the
Somewhat thorough
repercussions among nurses discussion of the
and the role healthcare
repercussions among
organizations and nursing
nurses and the role
leadership has on moral
healthcare organizations
distress from both a
and nursing leadership
positive and negative
has on moral distress from
perspective. Ethical
both a positive and
principles are well
negative perspective.
integrated into presentation Ethical principles are
somewhat well integrated
into presentation.
10-15 pts
5-9 pts
Explore ethical nursing
Appropriate but
principles that are impacted somewhat vague
in moral distress. How
exploration of ethical
does moral distress impact
nursing principles that
nursing decision-making
impact moral distress.
and overall work
Somewhat vague
performance? Does moral
description of how moral
distress differ among
distress impacts nursing
critical care nurses
decision making and
compared to other types of
overall work
nurse’s (support responses
performance. Discusses
with rationale).
moral distress differ
among critical care nurses
compared with other
nurses?
10-15 pts
5-9 pts
Sophisticated explanation
Appropriate explanation
of ways nurse
of ways nurse managers,
managers/leaders/healthcare leaders, healthcare
organizations can employ in organizations can employ
an acceptable
background about the
issue in relation to
COVID-19. Importance
of issue to healthcare
organizations & nursing
leadership is vague and
unclear.
0-4 pts
Little to no analysis of
moral distress as an
ethical dilemma. Little
to no discussion of the
repercussions among
nurses and the role
healthcare organizations
and nursing leadership
has on moral distress
from both a positive and
negative perspective.
Ethical principles are not
well integrated into
presentation.
0-4 pts
Little to no exploration
of ethical nursing
principles that impact
moral distress. Little to
no description of how
moral distress impacts
nursing decision making
and overall work
performance. Discusses
but limitedly moral
distress differ among
critical care nurses
compared with other
nurses?
0-4 pts
Limited explanation of
ways nurse managers,
leaders, healthcare
organizations can
3
practice standards,
policies and decisionmaking strategies of
real-world solutions and
recommendations
(15%)
terms of leadership style,
ethical principles, practice
standards, policies and
decision-making strategies
that include real-world
solutions and
recommendations.
Integration of other
organizational practices
and creative strategies
to address the issue in
nursing (15%)
10-15 pts
Integrated and full
descriptions of what other
healthcare organizations are
using to address these
issues in practice and also
creative strategies that can
be adopted.
Links ethical dilemma
of moral distress to
Course Readings and
Additional Research
(15%)
10-15 pts
Makes appropriate
connections between
identified ethical and moral
issues from both
sides; supplements
presentation with
relevant and
thoughtful research
and documents all
sources of information.
Writing Mechanics and
Formatting Guidelines
including correct
references and APA
formatting
(10%)
8-10 pts
Demonstrates clarity,
conciseness and
correctness; no
paragraphs to read on
slides; utilizes notes on
each slide to expand;
APA formatting is
appropriate and
writing is free of
grammar and spelling
errors
Total
in terms of leadership
style, ethical principles,
practice standards,
policies and decisionmaking strategies that
include real-word
solutions and
recommendations.
5-9 pts
Somewhat integrated but
not full description of
what other healthcare
organizations are using to
address these issues in
practice and also creative
strategies that can be
adopted.
5-9 pts
Makes appropriate but
somewhat vague
connections between
identified ethical and
moral issues from both
sides; supplements
presentation with some
relevant and thoughtful
research and documents
all sources of information.
4-7 pts
Occasional grammar or
spelling errors, but still
a clear presentation of
ideas; lacks
organization. Slides
contain too much text
to read
employ in terms of
leadership style, ethical
principles, practice
standards, policies and
decision-making
strategies that include
real-world solutions and
recommendations.
0-4 pts
Limited to no
description of what other
healthcare organizations
are using to address
these issues in practice
and also creative
strategies that can be
adopted
0-4 pts
Makes inappropriate or
little connections
between identified
ethical and moral issues
from both sides;
supplements
presentation with some
relevant and thoughtful
research and documents
all sources of
information.
0-3 pts
Many deficiencies on
grammar, spelling, or
APA formatting. Slides
have paragraphs to
read and are not
concise or notes on
each slide are not
utilized.
PLOS ONE
RESEARCH ARTICLE
Identifying factors that nurses consider in the
decision-making process related to patient
care during the COVID-19 pandemic
Nicholas Anton1, Tera Hornbeck2, Susan Modlin2, Md Munirul Haque3, Megan Crites1,
Denny Yu1*
1 School of Industrial Engineering, Purdue University, West Lafayette, IN, United States of America,
2 School of Nursing, Purdue University, West Lafayette, IN, United States of America, 3 RB Annis School of
Engineering, University of Indianapolis, Indianapolis, IN, United States of America
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
* dennyyu@purdue.edu
Abstract
Background
OPEN ACCESS
Citation: Anton N, Hornbeck T, Modlin S, Haque
MM, Crites M, Yu D (2021) Identifying factors that
nurses consider in the decision-making process
related to patient care during the COVID-19
pandemic. PLoS ONE 16(7): e0254077. https://doi.
org/10.1371/journal.pone.0254077
Editor: Manuel Fernández-Alcántara, Universitat
d’Alacante, SPAIN
Received: March 5, 2021
Accepted: June 21, 2021
Published: July 2, 2021
Copyright: © 2021 Anton et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Data cannot be
shared publicly because of subject identifiable
information. Data are available from the Purdue
Institutional Data Access / Ethics Committee
(contact via irb@purdue.edu) for researchers who
meet the criteria for access to confidential data.
Funding: DY, TH, and MH received a grant funded
by the National Science Foundation (Grant #: IIS1928661) to support this work. www.https://www.
nsf.gov/ The funders had no role in study design,
Nurse identification of patient deterioration is critical, particularly during the COVID-19 pandemic, as patients can deteriorate quickly. While the literature has shown that nurses rely on
intuition to make decisions, there is limited information on what sources of data experienced
nurses utilize to inform their intuition. The objectives of this study were to identify sources of
data that inform nurse decision-making related to recognition of deteriorating patients, and
explore how COVID-19 has impacted nurse decision-making.
Methods
In this qualitative study, experienced nurses voluntarily participated in focused interviews.
During focused interviews, expert nurses were asked to share descriptions of memorable
patient encounters, and questions were posed to facilitate reflections on thoughts and
actions that hindered or helped their decision-making. They were also asked to consider the
impact of COVID-19 on nursing and decision-making. Interviews were transcribed verbatim,
study team members reviewed transcripts and coded responses, and organized key findings into themes.
Results
Several themes related to decision-making were identified by the research team, including:
identifying patient care needs, workload management, and reflecting on missed care opportunities to inform learning. Participants (n = 10) also indicated that COVID-19 presented a
number of unique barriers to nurse decision-making.
Conclusions
Findings from this study indicate that experienced nurses utilize several sources of information to inform their intuition. It is apparent that the demands on nurses in response to pandemics are heightened. Decision-making themes drawn from participants’ experiences can
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data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Nurse decision-making during pandemics
to assist nurse educators for training nursing students on decision-making for deteriorating
patients and how to manage the potential barriers (e.g., resource constraints, lack of family)
associated with caring for patients during these challenging times prior to encountering
these issues in the clinical environment. Nurse practice can utilize these findings to increase
awareness among experienced nurses on recognizing how pandemic situations can impact
to their decision-making capability.
Introduction
In hospital settings, the failure to identify deteriorating patients can lead to delays in appropriate patient care [1–3], which can cause increased morbidity and mortality [4, 5]. A recent qualitative study of surgical intensive care unit (ICU) nurses found that their ability to quickly
identify deteriorating patients led to the early deployment of the rapid response team [6]. Early
nurse intervention to manage patient deterioration may be particularly critical in managing
patients suffering from the SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19).
Patients suffering from COVID-19 can deteriorate quickly requiring rapid decision-making
and responses from health care providers [7]. Although it is known that nurses routinely make
accurate, life-saving decisions, it is less well known what sources of information nurses utilize
in their clinical decision-making.
Investigators have shown that expert nurses possess both an understanding of specific disease processes and a broad holistic understanding of acute patient care situations [8]. Based on
their wealth of experience, expert nurses may utilize intuitive or subconscious decision-making processes to quickly grasp complex clinical situations, rapidly and confidently come to an
accurate assessment and provide safe quality care to patients [9, 10]. According to Benner et al.
(1992), the application of the Dreyfus model of skill acquisition to clinical nursing practice has
helped explain how nurse decision-making develops over time [11, 12]. The authors suggest
that over time, nurses transition from reliance on abstract principles to use of past experiences
to guide performance. Expert nurses shift from reliance on rule-based thinking (e.g., checklists
or rigid protocols) to using intuition, therefore the expert nurse is able to attend selectively to
details of increasingly complex situations [11]. However, the literature also emphasizes the
importance of nurses’ critical thinking in their decision-making processes.
Shoulders et al. (2014) define the nursing process as the thought process used to collect
information, assess that information, and solve patient care problems [13]. Upon systematically gathering data, nurses utilize critical thinking to interpret that data and identify task-relevant data to focus on during the assessment process. Nurses may also utilize critical thinking
in their analysis of the reliability of important information and as a method to validate initial
judgments in the assessment process [14]. It is important to note that according to the Cognitive Continuum Theory, decision-making is executed using a combination of intuition and
critical thinking processes and fluctuates depending on the demands of the task (e.g., if adequate time or information is available to afford critical thinking) [15].
While research has shown that experienced nurses rely on a combination of intuition and
critical thinking, few studies have attempted to identify what specific factors or sources of data
inform experienced nurse decision-making when caring for deteriorating patients. Furthermore, there is a dearth of research on how immense disruptions caused by the onset of global
pandemics can affect nurse clinical decision-making. Accordingly, the purposes of this study
were to:
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Nurse decision-making during pandemics
1. Identify specific sources of data and factors that inform nurse decision-making when caring
for deteriorating patients, and
2. Explore how COVID-19 has impacted nurse decision-making.
The ultimate goal of this qualitative study is to synthesize key aspects of experienced nurse
intuition and decision-making that can be disseminated to nurses in training and to provide
understanding of how pandemics can influence these processes.
Materials and methods
In order to achieve the aims of this study, interviews were conducted virtually with experienced nurses. Inclusion criteria for the study consisted of practicing nurses (i.e., no longer in
training), who were in clinical practice at the time of interviews (i.e., not full-time academic
appointment). Exclusion criteria included nurses still in training or who were non-clinical. Indepth, semi-structured interviews with nurses focused on two areas: 1) decision-making in the
context of deteriorating patient recognition, and 2) the impact of COVID-19 on nurse decision-making capabilities. This study was approved by the Institutional Review Board (IRB2020-11) and met university safety standards for conducting research during COVID-19.
Participant and site information
Nurses with diverse backgrounds (e.g., ICU, emergency department, etc.) were invited to participate via email. Prior to the interviews, participants were provided with general information
about the purpose of the study, specific examples of questions were provided to participants
during recruitment, and informed consent was obtained from each participant electronically.
The stopping criteria for participant recruitment was when data saturation was reached (i.e.,
no new information was gathered from the participants) [16]. No repeat interviews were carried out. All participants were interviewed after April 2020.
Questionnaire—Demographics
Participants provided demographic information using a REDCap survey system including age,
gender, nursing and other degrees obtained, years of clinical experience, clinical specialty, bed
size of the hospital, and the average number of hours worked per week.
Focused interviews
Due to COVID-19 restrictions about face-to-face meetings and increased work demands for
nurses, we hosted virtual interviews with small groups of 1–3 participants. Regardless of group
size, the interviewer deliberately solicited responses to each question from each participant to
prevent individuals from dominating group interviews and allow all participants to respond.
While we intended to utilize a snowball sampling approach to participant recruitment, the
increased work demands for nurses during the COVID-19 pandemic prevented our team
from accruing an adequate sample size, as participants’ colleagues were unable to participate
due to time constraints. We instead relied on purposive sampling that targeted nurses who
were known to the research team and who were experienced (i.e., more than 5 years of clinical
experience) and had substantial nursing education. All participants engaged in virtual focused
interviews conducted via Webex (Cisco Webex, Cisco Systems, Milpitas, California), which
were moderated by an expert qualitative researcher for 60–90 minutes. Aside from participants
and researchers, no one else was present during the focused interviews.
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Nurse decision-making during pandemics
Each focused interview began with introductions and an overview of the purpose of the
study. At this time, the interviewer shared details about her role at the university as faculty and
her research interests in decision-making. Participants were then asked to share a description
of their most memorable patient encounter. Additional questions were then posed to elicit
clinical examples of a patient who was stable and deteriorated or a patient who was unstable
but returned to being stable. Prompts were utilized to facilitate reflection on their thoughts
and actions that helped or hindered their decision-making. The first two interviews our team
conducted occurred in April of 2020, and the COVID-19 pandemic had already significantly
affected healthcare systems in the United States. During these interviews, both participants discussed the impact of COVID-19 on nursing practice. Accordingly, our team felt questions
about how nurse decision-making had been affected by the pandemic were important to
include in our study. In all remaining interviews, nurses were asked to consider the impact of
COVID-19 on nursing and their decision-making capabilities. The finalized interview guide
can be found in S1 Appendix.
Data analysis
All interviews were audio-recorded, and field notes were taken during and after each interview. Recordings were de-identified and professionally transcribed verbatim. Transcriptions
and findings were not made available to participants for comment or correction, as we aimed
to maintain a robust data set and avoid artificially deriving consensus among participant
responses if agreement was not obtained naturally. Utilizing a qualitative description approach
[17], and an inductive content analysis process, each interview transcription was reviewed by
study team members (i.e., including clinical subject matter experts and human factors engineers) individually and collectively after each interview. Qualitative description is a process of
discovering and understanding phenomena or perspectives from a target population [18].
Qualitative description is particularly useful in healthcare-based studies, as this approach seeks
to understand the perspective of those experiencing key phenomena and provides a direct
description of the phenomena according to participants.
In the present study, each transcript was reviewed carefully and key themes were
highlighted and assigned a code. Transcripts were then carefully reviewed again and meaningful codes were grouped into themes and sub-themes. This process was iterative, as themes
were refined further or removed upon subsequent analyses of additional transcripts. NVivo 12
(QSR International, Melbourne, Australia) was used as a data repository to sort codes, themes,
and complete an analysis of participants’ responses based on common words to identify which
participants used similar terminology [19, 20].
In order to increase the rigor of our findings, our team utilized a triangulation approach to
our analysis (i.e., as defined by Lincoln & Guba, 1985) [21]. Triangulation among our interdisciplinary study team included regular virtual meetings to reach consensus about a coding
framework, to aggregate codes into themes, and identify sub-themes. Data saturation was
reached with 10 participants, as no new themes emerged from the final interview.
Results
A total of 10 nurses (100% females) participated in the focused interviews (Fig 1). No prospective participants refused to participate or dropped out from the study. Units where nurses
spend the majority of their time were: primary care (n = 1), intensive care unit (n = 3), palliative care (n = 1), long-term care (n = 2), medical-surgical acute care(n = 2), and risk analysis
(n = 1).
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Nurse decision-making during pandemics
Fig 1. Demographic information collected from participants (note that one participant did not provide age).
https://doi.org/10.1371/journal.pone.0254077.g001
Factors impacting nurse decision-making
Findings from the focused interviews established fundamental components of nurse decisionmaking, and also emphasized the complex tradeoffs between systems-level barriers (e.g., available resources) and the provision of safe and quality care to patients. Themes and subthemes
are presented in Fig 2.
Identifying patient care needs. Through holistic information gathering (i.e., assessing the
patient, listening to patients and their families, and critically evaluating clinical findings), experienced nurses are able to narrow the scope of possible clinical problems the patient may be
experiencing and rapidly identify their needs. Due to their extensive experience managing
myriad presenting patients, experienced nurses possess substantial knowledge that allows
them to quickly identify subtle changes in a patient’s status, and to effectively identify patient
care needs.
Fig 2. Interview themes and subthemes.
https://doi.org/10.1371/journal.pone.0254077.g002
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Nurse decision-making during pandemics
Importance of patient assessment. Experienced nurses recognize the importance of performing a thorough patient assessment and utilizing observational skills to obtain critical patient
information.
“I think that’s [observational skills] what makes nurses good nurses. I mean, I tell people, ‘I get
paid to be observational.’ That’s what I’m good at, so I’m observing the old-fashioned everything: color, demeanor, motion, breathing. . . If there’s family there, how are they acting. That’s
probably the most important. I don’t even necessarily have to have the numbers.” (N2)
“I’m going to obviously look at the person, look at the skin color, look at the breathing pattern, blood pressure, the pulse rate, listen to the heart rate, check the peripheral pulses, the
skin, temperature, the color if there is anything, the anxiety in the person, if they’re short of
breath, if they feel short of breath, what their symptoms are, what the position of the bed is,
what exactly they’re doing, what medications they’re on, what kind of disease processes do
they have that could be part or contributory to what’s going on with them. . .what kind of
things really put them at risk.”(N4)
Holistic approach to patient assessment. Beyond physical observations, experienced nurses
consider the effects of the patient’s environment outside the care setting.
“As I’m more experienced, they’re [factors contributing to patient risk] going through my
mind faster and I’m either accepting or denying whatever that is. What’s that risk, it could
be this, it could be that. So, really thinking about all the different scenarios that could be
occurring and could be contributory to the deterioration that I see.” (N4)
Identifying potential risks and considering the big picture. Experienced nurses also know to
expect the unexpected and can use their foundation and experiences to consider the big picture of patient care.
“What are the risks to that person? . . . If I don’t think about what the risks are, I’m just going
to be responding to the next task, to the request, to what’s going on in front of me versus really
thinking about it. . . . That context has to include everything that could possibly happen to that
person. Not just what I see, what the monitor says, but pulling all of that together. (N4)
Establishing relationships with patients and families. Experienced nurses recognize the
importance of the patient’s perspective when obtaining information about their status. The
patient and their family often knowingly and unknowingly share clinical information that may
relate (i.e., directly or indirectly) to their acute illness or a change in status, which nurses use in
their assessment of patients.
“I am a firm believer that you talk to your patient because they are going to tell you everything you need to know. You can have all the diagnostic data in the world, but you’re not
going to know anything unless that patient talks to you and tells you how they’re feeling
because that directs your entire focus of what to look into.” (N5)
“I would always talk to the family and say, ‘This is your loved one. You know them best. I
want to hear how it differs from how they were before. Were they able to tell you what they
ate for breakfast today? Is that a change, or what is their baseline. . . I mean before and
after,’ and I even like to put that in my notes so that anybody following can say, ‘This is
what their normal is.’” (N1)
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Workload management. Experienced nurses are able to prioritize and bundle their care
tasks based on the needs of their patients. Accordingly, this prioritization of tasks and information allows nurses the ability to retain all critical information, which enhances the effectiveness
of their decision-making processes.
Prioritizing critical information. Experienced nurses in the present study describe the development of cognitive schema to help them prioritize critical information and pull relevant
information from long-term memory to support their decision-making processes.
“When you’re a new nurse, you have a really short stack because you can’t remember it all.
When you’re more experienced, you have a bigger stack and it’s not stacked like a stack of
pancakes. It’s stacked vertically [so] that if it goes too far back, it’s going to fall off or we’re
not going to remember what’s in the stack or your stack’s full and it falls out, it falls totally
out and you forget something that’s going to be critical. I think that’s what happens as a
nurse. You either are able to stack and control and pull out the important volumes or not.”
(N4)
Bundling care tasks. Experienced nurses bundle their face-to-face care tasks allowing them
to spend more time in rooms with patients. Given the importance nurses place on building
rapport with patients and gathering information through listening to information provided by
patients and their families, bundling care tasks may allow for more time to potentially observe
patient status changes.
“Now I do that with my patients. I do my physical assessment with my patients, and now
the rest of day I can think about real things happening with my patients. I’m not cluttered
up with these other shenanigans.” (N9)
Missed care opportunities inform learning. Experienced nurses seek to learn from their
patient experiences through critical reflection of unforeseen events or errors during care interventions, case reviews, medical researching, and debriefing with other members of the care
team.
“After every trauma or CPR or anything like that, we always have that debriefing of what
we could do better. . . . I maybe not have seen something that I . . . or another nurse done
[sic] wrong that we can do to prepare us for another patient that comes in. Maybe . . . I
didn’t know how to put the LUCAS on one day, so they showed me a different way that we
could put it on for the next patient that comes in. I guess it’s just people telling you, criticism, to make you stronger is all it is. That’s what I like. And learning.” (N3)
“You call it debriefing, I call it a root cause analysis because we got to find out what happened. What was the process break that occurred that allowed these things to happen? So
when we have an event, we have to go back through the situation, look at the steps, look at
what we currently would do and what were the breaks, what do we have to fix so that this
doesn’t happen the next time.” (N4)
Impact of COVID on patient care and nurse decision-making
The rapid emergence of COVID-19 has had wide-ranging effects on nurses’ ability to deliver
patient care. The effects of the pandemic on decision-making reported by experienced nurses
ranged from the individual or intrapersonal factors (e.g., maintaining awareness for rapidly
changing patient status), the interpersonal level (e.g., the inability to gather information from
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Nurse decision-making during pandemics
Fig 3. Impact of COVID-19 on nursing care processes and care delivery.
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patient families), and to the systems level (e.g., availability of personal protective equipment
(PPE) to facilitate direct contact with patients). Findings are summarized as a work system
model (Fig 3) by adapting the Systems Engineering Initiative for Patient Safety (SEIPS) model
[22, 23]. The original model posits that multiple work-system elements (i.e., people, environment, tasks, technology/tools, and organizational factors) interact and influence healthcare
processes.
Importantly, we have adapted the SEIPS model to focus on key aspects relevant to nurse
decision-making that emerged through our thematic analysis. Specifically, we divided the
“people” domain into interpersonal and intrapersonal factors, and have focused the “processes” on “identifying care needs”, as we feel this better captures the impact of different
domains on nurses’ decision-making, and ultimately, their ability to identify care needs for
patients.
Environment/Organization. This theme focuses on key macro organizational effects of
COVID-19 on nurses’ ability to deliver safe, quality care. Specifically, it describes organizational resources that affect nurses’ ability to make effective and timely decisions. These factors
include things such as physical resources (e.g., PPE) that enable interactions with infected
patients and the ability to deliver care in the clinical environment, as well as time resources to
sufficiently identify care needs and treat patients.
Resource availability refers to the availability of key resources, such as technology (e.g.,
respiratory ventilators), PPE (e.g., N-95 masks), and staff that has changed as a result of the
high prevalence of COVID-19 and the high demand for these resources. Experienced nurses
find that greater resource availability enhances their decision-making ability, as nurses are able
to spend more time with their patients if they do not need to strictly ration PPE, they can recognize potential patient complications or deterioration if technology is available, and additional staff coverage can compensate for staff who contract COVID-19. Unfortunately, due to
the abrupt onset of pandemics, PPE is extremely scarce. Nurses now must choose between
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conservation of supplies and patient monitoring which can potentially reduce their ability to
administer care.
“That’s a problem, even now with our COVID units, because you know, the national is like,
‘Conserve PPE, conserve PPE, don’t go in your rooms, spend all your tasks together.’ Well,
while that’s true, that doesn’t mean that that supersedes my monitoring of the patient. And
so I’m constantly struggling, I’m looking at the patients every day over there saying, ‘Why is
there a four hour gap between vitals? Don’t you think that we need to go in there and document what the respirations were like earlier? . . . [Why] are we waiting another four hours
to check him again?’” (N10)
Time spent with patients is critical for nurse decision-making as it affords nurses more
opportunities to observe changes and collect information, which informs their ability to identify potential issues and respond. A surprising finding on the impact of COVID-19 is on time
resources. Prior to the pandemic, time spent interacting with families represented a significant
time allocation for nurses on care delivery. Since the onset of COVID-19 and the elimination
of family visitors, nurses may experience more time availability to directly interact with
patients, as additional time is needed to observe changes and recognize health abnormalities in
COVID-19-infected patients.
“Being with a patient face to face, I can assess them no matter what I’m doing. Just being
person to person, it’s an important thing. . . . [whereas] if I was running errands for families
and doing this and that, [it] would take it away from patient care.” (N2)
However, there is also the possibility that due to COVID-19, nurses must spend more time
donning and doffing PPE and following COVID-19-related protocols than before. This time
requirement could ultimately offset the additional time afforded by restrictions to family and
visitors that would normally demand nurses’ attention.
“So it’s [PPE] exhausting like I would say physically and emotionally just exhausting in
regards to what they go through and so that [PPE Protocol] burns them out, you know,
especially when you’re doing all these extra tasks and when you add all these tasks to nurses
that’s less time they get to actually spend with the patients.” (N1)]
Technology is a resource whose availability can significantly impact the quality of care. The
integration of various physiological sensors and monitors into the electronic medical record
(EMR) can allow for automatic charting and trending data to be extracted by nurses, which
can give them in-depth insight into how a patient’s status has evolved since their arrival at the
hospital. This is particularly helpful to document trends in COVID patient status.
“It’s helpful for me because I can get into the charts and I can look . . . at the trending graphs
. . . and I can easily see . . . with all the patients on the COVID unit . . . what’s their trend for
their temperature what’s the trend for the respiratory rate, what’s their trend for their heart
rate?” (N10)
Interpersonal factors. Interpersonal factors refer to the key individuals or groups of people who are involved in the COVID-19 care process mentioned by experienced nurses in the
interviews. The healthcare team consists of providers who care for patients, specifically nurses
and physicians. Under normal conditions and depending on the patient’s situation, they may
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have a support system consisting of family members present throughout their stay in the hospital. As a result of COVID-19, families are unable to be in the healthcare facility with the
patient. Thus, families play a smaller role in the care process than usual. Although this is a
change due to necessity and not choice, the nurses in this study find that the absence of family
members in the COVID-19 restricted care setting prevents nurses from having an additional
source of information about potential changes in patient status. Additionally, the lack of family
presence can also result in patients experiencing negative emotional states.
“We can’t have any family or visitors, and so I feel like that impacts my patients. Like some
of them get very disoriented and their mood can be very low because they don’t get to see
their family members.” (N1)
The heightened workload associated with COVID-19 has also put a strain on staff interpersonal relationships. For nurses in leadership positions, they must be mindful about acknowledging the contributions of team members.
“I had a CNA [Certified Nursing Assistant] tell me that she didn’t think I was listening to
her and I had to explain to her, I heard you and it’s on my list, but I have to prioritize my
entire day. Please don’t ever think I’m not listening or I didn’t put you down on my list.
They need to feel like you’ve heard them when they come to you. That’s an important part
of the relationship too because they are your eyes.” (N2)
Intrapersonal factors. Intrapersonal factors refer to key psychological or experiential
traits of persons that can ultimately contribute to clinical care outcomes. Experienced nurses
highlight the importance of situation awareness and close monitoring of patient status, including vital signs and behavior, particularly during COVID-19, as patient status can change
rapidly.
“Nurses really need to be looking for the monitoring and seeing that changing in the trending to recognize those things to prevent failure to recognize and failure to rescue. And that
goes for all patients, but especially to me in this COVID situation that we have right now.
. . . looking ahead like, I need all their vital signs, I need their oxygenation saturation so I
can see who we really need to focus on.” (N1)
Nurses report that despite the stressful care environment that COVID-19 presents, their
care teams maintain a more determined and grateful mindset and an overall comradery with
other members of the care team that helps them maintain a positive disposition, accomplish
the tasks required for effective patient care, and enable them to more easily recognize patient
issues.
“What I found to be the most impactful with the nurses and the staff working on those
COVID floors when they cared for these patients, they didn’t let their fear get in the way.
. . . I said, ‘You know, it’s pretty incredible. The morale here is so high. It’s so good,’ and
one of the nurses said, ‘Yeah. I’ve not heard anybody complain once. Everyone is just so
thankful to be here, to be alive,’ and I just thought that was a really neat and unique experience that I’ve never felt before. . . . It definitely impacted our patient care.” (N5)
However, not all healthcare environments are positive. In situations and settings where
there is failure or extreme exhaustion when caring for COVID-19 patients and dealing with
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protocols related to COVID-19 (e.g., PPE), nurse morale suffers. Therefore, it is likely that
patient care can be compromised due to disengagement.
“I feel like the PPE is very exhausting, so I feel like it creates a negative impact. . .I feel like
the majority [of nurses] go in trying to do the best they can do that day. When you throw all
these extra tasks and things and give them all these other things that they need to be doing
to complete their work for that day, if they don’t get that done they feel very defeated. . .if
you throw in a patient who possibly wasn’t on their radar and declines and they miss something, you know that also makes them feel very defeated. I feel it [COVID-19] has definitely
impacted nursing emotionally.” (N1)
Discussion
The goals of the present study were to identify what elements contribute to experienced nurse
decision-making when caring for deteriorating patients and explore how the COVID-19 pandemic has impacted nurse decision-making. In summary, we found that experienced nurses
are cognizant of the importance of conducting a thorough patient assessment and consulting
trends in patients’ health status that are documented in the EMR, but also consider factors in
their patients’ environment (i.e., socio-economic status, living situation, etc.) that could be
impacting their health and presenting illness. Furthermore, experienced nurses gather information from communicating with patients and their families. All of these factors help nurses
maintain a perspective on the “big picture” and identify risks to their patients’ health based on
all of the aforementioned factors.
The experienced nurses in this study referenced their ability to systematically work through
this multitude of factors quickly, and utilize critical thinking to accept or deny information
based on its credibility or pertinence. This finding is supported by the literature on critical
thinking in nurse decision-making, as the use of critical thinking for data verification and analysis is an important cognitive skill for nurse effectiveness [13, 14]. Furthermore, participating
nurses reported that, through experience, they have learned to rapidly process this information
to consider the potential reasons for patient deterioration. While critical thinking is assuredly
a component of this analysis, it is likely combined with experience-derived intuition to rapidly
rule out reasons for patient deterioration in the assessment process. Utilizing the Cognitive
Continuum Theory [15], we can better understand that experienced nurses likely use a combination of critical thinking and intuition in their decision-making processes.
Experienced nurses also highlighted the importance of workload management in their ability to make effective clinical decisions. Working memory is a cognitive system responsible for
the temporary storage of information used in complex cognitive actions including learning,
reasoning, and comprehension [24]. However, this system has finite capacity limits. Cognitive
load refers to the demands imposed on working memory, which, if excessive, can exceed an
individual’s capacity and lead to undesired consequences [25]. For example, cognitive overload
can reduce an individual’s sensitivity to task-relevant information, slow their decision-making,
and reduce their capacity to attend to task-relevant verbal information [26, 27]. Nurses are
faced with inherently high cognitive load in their work, and experienced nurses in this study
reported utilizing cognitive schema to “stack” and prioritize critical patient care information,
which effectively transitions information from working memory to long-term memory and
allows them to incorporate large amounts of information in their decision-making process.
Furthermore, cognitive schema also allows experienced nurses to pull relevant information
from their long-term memory to help make effective decisions. Conversely, novice nurses may
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not have developed cognitive schema to manage patients due to their inexperience, which
leads to inhibited working memory and high cognitive load in the clinical environment [28].
Helping nurses manage their workload effectively is paramount for educators, as high cognitive load can lead nurses to a failure in situation awareness and recognition of deteriorating
patients in a timely manner [29]. However, due to COVID-19, nurses are currently being
forced to significantly adapt their practice, and it is important to consider the potentially deleterious effects pandemics can have on their decision-making.
Preventing patient families from being in hospitals due to COVID presents a double-edged
sword to nurses. While nurses are not being asked to “run errands” for families, which can be
time-consuming, they are losing a vital source of information to inform their decision-making.
We also found that PPE restrictions were limiting the amount of face-to-face contact they
were able to have with patients, which again represents the loss of a vital source of patient
information. Failure to recognize deteriorating patients has been highlighted in the literature
as one of the leading causes of poor patient outcomes when they are hospitalized, and leads to
significantly higher morbidity and mortality due to delays in provision of timely and appropriate care [1–5]. This is particularly true during pandemics, as the experienced nurses interviewed in the current study highlighted the importance of recognizing rapidly deteriorating
COVID patients in being able to effectively treat them. That being said, if nurses are limited in
their ability to have direct contact with patients due to PPE restrictions or losing families as a
source of patient data, they may miss important markers of patient status changes and fail to
recognize patient deterioration.
It is clear that the demands on nurses in response to pandemics are heightened. Nurses are
required to care for critically sick patients that could rapidly deteriorate [30]. Therefore, nurses
can easily experience heightened stress, fatigue due to staff constraints (i.e., other nurses
becoming ill and not being able to work, and a high number of patients per nurse), and even
burnout. These factors could, in turn, negatively impact nurses’ awareness and vigilance of
patient status, which has been shown to negatively impact nurses’ ability to identify critical status changes and appropriately escalate care protocols [31]. Also, due to the unique clinical
challenges that caring for COVID-19 patients can present, even experienced nurses are not
able to rely on intuition to inform their decision-making. The Dreyfus model of skill acquisition indicates that as a healthcare provider gains experience, they increasingly rely on intuition
to make expeditious clinical decisions [11]. However, given the novelty of COVID-19, experienced nurses may not be able to rely on their previously-developed skills to care for these
patients, and they could be susceptible for cognitive overload that can impedes their awareness
and decision-making.
There were some limitations with this study. First, our team utilized a purposive sampling
approach for study participants, which can potentially bias results due to under-representation
of nursing in general, and a lack of generalizability of findings. Our team did aim to conduct
snowball sampling and recruit participants who were colleagues of initial participants, but
were unknown to the researchers. However, due to the COVID-19 pandemic and the resulting
workforce demands for clinical nurses, our team was unable to accrue an adequate sample size
relying on snowball sampling only. We were instead forced to rely on a more purposive sampling approach, and several participants were known to the researchers. This approach allowed
us to purposely sample very experienced nurses (i.e., 8 of 10 participants had more than 10
years of experience), whose responses may provide valuable insights on the factors that impact
nurse decision-making and how nurses have had to adapt due to the COVID-19 pandemic.
Another limitation of this study was our seemingly homogenous study sample. All interviewed nurses were female, and the majority of respondents were between 40–49 years of age
with MSN degrees. However, as we previously detailed, it was our intention to recruit
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experienced nurses to reflect on their clinical experiences caring for deteriorating patients,
which is why our study sample is older. Furthermore, the fact that all participants in our study
were female is reflective of national nursing employment trends, as the National Sample Survey of Registered Nurses conducted by the United States Health Resources and Services
Administration in 2018 found that only 9.6% of registered nurses in the country were male
[32]. The participating nurses in our study were diverse, however, in their nursing specialties
and work setting (i.e., hospital size), which adds to the generalizability of our findings.
Lastly, we did not solicit participant feedback on emerging themes or their specific
responses to questions for clarification, which some may perceive to limit trustworthiness in
our data. In regards to the trustworthiness or rigor of our findings, Lincoln and Guba (1985)
suggest that in naturalistic studies, there are several techniques that are appropriate to establish
validity, reliability, and objectivity [21]. These techniques include member checks, triangulation, and prolonged engagement, among others. According to the authors, member checks, or
the process of continuously soliciting reactions of participants to the investigator’s reconstruction of data themes based on responses is the most important technique for establishing trustworthiness [33]. However, Sandelowski (1993) contends that member checks are designed to
achieve consensus among participants on key response themes, and any attempt to increase
reliability through forced consensus typically leads to diminished validity of findings [34].
Instead of utilizing member checks, our team aimed to establish trustworthiness through
triangulation among sources of data and members of our research team when analyzing
responses. While typically considered to be a method for establishing validity in a qualitative
data set [21], this perspective assumes that triangulation between multiple sources will overcome weaknesses with certain components of the data set [35]. Conversely, our team utilized
triangulation to develop a robust sample of responses from diverse nurse participants and multiple perspectives during data analysis. Our participants represented various experience levels,
clinical specialties, and work settings, and our research team was constructed of nurse educators with experience in qualitative methodology and clinical education, and human factors
engineers with expertise studying DM in healthcare. Thus, we are confident that our triangulation approach has allowed our data to represent multiple viewpoints from the respondent and
researcher perspective.
Currently, our team is in the process of obtaining validity evidence of the findings in the
current study by studying nurse decision-making in simulated clinical situations. We have
recruited experienced nurses to participate in two simulated cases, one being involving caring
for patients suffering from COVID-19, and are utilizing objective approaches to study decision-making including eye-tracking and electroencephalogram (EEG). We hope the data
obtained in this simulation-based study confirms our findings about the sources of information nurses utilize in decision-making, and the challenges nurses face when caring for patients
during pandemics.
Conclusions
Decision-making themes drawn from our participants’ experiences can assist nurse educators
training nursing students on decision-making. An interprofessional partnership between
nurse educators, experienced practicing nurses, and bioengineering can develop technology to
assist in training novice nurses to manage potential barriers (e.g., resource constraints, lack of
family) associated with caring for patients during challenging times prior to encountering care
issues in the clinical environment where the patient is ultimately at risk for injury. Nursing
practice can utilize these findings to increase awareness among experienced nurses on recognizing how pandemic situations can impact to their decision-making capability.
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Supporting information
S1 Appendix.
(DOCX)
Author Contributions
Conceptualization: Tera Hornbeck, Susan Modlin, Md Munirul Haque, Denny Yu.
Data curation: Megan Crites.
Formal analysis: Nicholas Anton.
Funding acquisition: Md Munirul Haque, Denny Yu.
Investigation: Tera Hornbeck, Susan Modlin.
Methodology: Denny Yu.
Project administration: Megan Crites.
Supervision: Denny Yu.
Visualization: Nicholas Anton.
Writing – original draft: Nicholas Anton, Susan Modlin, Denny Yu.
Writing – review & editing: Nicholas Anton, Tera Hornbeck, Susan Modlin, Md Munirul
Haque, Denny Yu.
References
1.
Ghaferi AA, Dimick JB. Understanding failure to rescue and improving safety culture. Ann Surg. 2015;
261:839–40. https://doi.org/10.1097/SLA.0000000000001135 PMID: 25607758
2.
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of
root causes and improvement strategies. J Patient Saf. 2020. https://doi.org/10.1097/PTS.
0000000000000720 PMID: 32453105
3.
Vincent JL, Einav S, Pearse R, Jaber S, Kranke P, Overdyk FJ, et al. Improving detection of patient
deterioration in the general hospital ward environment. Eur J Anaesthesiol. 2018; 35:325–33. https://
doi.org/10.1097/EJA.0000000000000798 PMID: 29474347
4.
Bacon CT. Nurses’ experiences with patients who die from failure to rescue after surgery. J Nurs Scholarsh. 2017; 49:303–11. https://doi.org/10.1111/jnu.12294 PMID: 28384381
5.
Abe T, Komori A, Shiraishi A, et al. Trauma complications and in-hospital mortality: failure-to-rescue.
Crit Care. 2020; 24:223–36. https://doi.org/10.1186/s13054-020-02951-1 PMID: 32414401
6.
Mohammmed Iddrisu S, Hutchinson AF, Sungkar Y, Considine J. Nurses’ role in recognising and
responding to clinical deterioration in surgical patients. J Clin Nurs 2018; 27:1920–30. https://doi.org/
10.1111/jocn.14331 PMID: 29495093
7.
Fusi-Schmidhauser T, Preston NJ, Keller N, Gamondi C. Conservative management of Covid-19
patients—emergency palliative care in action. J Pain Symptom Manage 2020; 60:e27–30. https://doi.
org/10.1016/j.jpainsymman.2020.03.030 PMID: 32276101
8.
Brier J, Carolyn M, Haverly M, et al. Knowing ‘something is not right’ is beyond intuition: development of
a clinical algorithm to enhance surveillance and assist nurses to organise and communicate clinical findings. J Clin Nurs 2015; 24:832–43. https://doi.org/10.1111/jocn.12670 PMID: 25236182
9.
Shinnick MA, Cabrera-Mino C. Predictors of Nursing Clinical Judgment in Simulation. Nurs Educ Perspect. 2021; 42:107–9. https://doi.org/10.1097/01.NEP.0000000000000604 PMID: 32028376
10.
Nibbelink CW, Brewer BB. Decision-making in nursing practice: An integrative literature review. J Clin
Nurs 2018; 27:917–28. https://doi.org/10.1111/jocn.14151 PMID: 29098746
11.
Benner P, Tanner C, Chesla C. From beginner to expert: gaining a differentiated clinical world in critical
care nursing. Adv Nurs Sci 1992; 14:13–28. https://doi.org/10.1097/00012272-199203000-00005
PMID: 1550330
12.
Dreyfus HL, Dreyfus SE. Mind over machine. New York, NY: The Free Press. 1985.
PLOS ONE | https://doi.org/10.1371/journal.pone.0254077 July 2, 2021
14 / 15
PLOS ONE
Nurse decision-making during pandemics
13.
Shoulders B, Follett C, Eason J. Enhancing critical thinking in clinical practice: Implications for critical
and acute care nurses. Dimens Crit Care Nurs. 2014; 33:207–14. https://doi.org/10.1097/DCC.
0000000000000053 PMID: 24895950
14.
Papathanasiou IV, Kleisiaris CF, Fradelos EC, Kakou K, Kourkouta L. Critical thinking: the development
of an essential skill for nursing students. Acta Informatica Medica. 2014; 22:283–86. https://doi.org/10.
5455/aim.2014.22.283-286 PMID: 25395733
15.
Hammond KR. Human judgment and social policy: Irreducible uncertainty, inevitable error, unavoidable
injustice. Oxford University Press on Demand; 1996.
16.
Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization
and operationalization. Qual Quant 2018; 52:1893–907. https://doi.org/10.1007/s11135-017-0574-8
PMID: 29937585
17.
Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: A systematic review.
Res Nurs Health. 2017; 40:23–42. https://doi.org/10.1002/nur.21768 PMID: 27686751
18.
Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care
research. Glob Qual Nurs Res. 2017; 4:1–8. https://doi.org/10.1177/2333393617742282 PMID:
29204457
19.
Krippendorff K. Content analysis: An introduction to its methodology. Thousand Oaks, CA: Sage publications; 2018.
20.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;
15:1277–88. https://doi.org/10.1177/1049732305276687 PMID: 16204405
21.
Lincoln YS, Guba EG. Establishing trustworthiness. In: Naturalistic inquiry. Beverly Hills, CA: Sage
Publications; 1985, 289–327.
22.
Carayon PA, Hundt AS, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual
Saf Health Care 2006; 15:i50–8. https://doi.org/10.1136/qshc.2005.015842 PMID: 17142610
23.
Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human factors framework for studying and
improving the work of healthcare professionals and patients. Ergonomics 2013; 56:1669–86. https://doi.
org/10.1080/00140139.2013.838643 PMID: 24088063
24.
Baddeley A. Working memory. Science 1992; 255:556–9. https://doi.org/10.1126/science.1736359
PMID: 1736359
25.
Paas F, Renkl A, Sweller J. Cognitive load theory and instructional design: Recent developments. Educ
Psychol 2003; 38:1–4. https://doi.org/10.1207/S15326985EP3801_1
26.
Speier C, Valacich JS, Vessey I. The influence of task interruption on individual decision making: An
information overload perspective. Decis Sci 1999 Mar; 30:337–60. https://doi.org/10.1111/j.1540-5915.
1999.tb01613.x
27.
Zanto TP, Gazzaley A. Neural suppression of irrelevant information underlies optimal working memory
performance. J Neuroscience 2009; 29:3059–66. https://doi.org/10.1523/JNEUROSCI.4621-08.2009
PMID: 19279242
28.
Josephsen J. Cognitive load theory and nursing simulation: An integrative review. Clin Simul Nurs
2015; 11:259–67. https://doi.org/10.1016/j.ecns.2015.02.004
29.
Koch SH, Weir C, Haar M, et al. Intensive care unit nurses’ information needs and recommendations for
integrated displays to improve nurses’ situation awareness. J Am Med Inform Assoc 2012; 19:583–90.
https://doi.org/10.1136/amiajnl-2011-000678 PMID: 22437074
30.
Goh KJ, Kalimuddin S, Chan KS. Rapid progression to acute respiratory distress syndrome: Review of
current understanding of critical illness from coronavirus disease 2019 (COVID-19) infection. Ann Acad
Med Singapore 2020; 49:108–8. PMID: 32200400
31.
Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses’ work hours on vigilance and
patients’ safety. Am J Crit Care 2006; 15:30–7. PMID: 16391312
32.
U.S. Department of Health and Human Services Health Resources and Services Administration Bureau
of Health Workforce: National Sample Survey of Registered Nurses. 2018. Retrieved from: https://data.
hrsa.gov/DataDownload/NSSRN/GeneralPUF18/nssrn-summary-report.pdf. Accessed: 05/20/2021.
33.
Guba EG, Lincoln YS. Fourth generation evaluation. Newbury Park, CA: Sage Publications; 1989.
34.
Sandelowski M. Rigor or rigor mortis: the problem of rigor in qualitative research. Adv Nurs Sci. 1993;
16:1–8. https://doi.org/10.1097/00012272-199312000-00002 PMID: 8311428
35.
Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;
34:1189–1209. PMID: 10591279
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THE INFLUENCE OF CLINICAL
SUPERVISION ON NURSES’ MORAL
DECISION MAKING
Ingela Berggren and Elisabeth Severinsson
Key words: clinical supervision; moral decision making; responsibility; self-assurance
The aim of this study was to investigate the influence of clinical supervision on nurses´
moral decision making. The sample consisted of 15 registered nurses who took part in
clinical supervision sessions. Data were obtained from interviews and analysed by a
hermeneutic transformative process. The hermeneutic interpretation revealed four
themes: increased self-assurance, an increased ability to support the patient, an increased
ability to be in a relationship with the patient, and an increased ability to take responsibility. In conclusion, it seems that clinical supervision enhances nurses´ ability to provide
care on the basis of their decision making. However, the qualitative and structural aspects
of clinical supervision have to be investigated further in order to develop professional
insight into the way that nurses think and react.
Introduction
The reported effectiveness of clinical supervision includes an increase in job
satisfaction,1 the development of competence,2 increased moral sensitivity,3 and a
reduction in stress and burnout.4 The implementation of clinical supervision gives
nurses the opportunity to plan, reflect on and evaluate their job situation. Clinical
supervision is also believed to increase nurses’ ability for decision making.1
Research shows that nurses develop their decision-making function as a result
of clinical supervision, particularly their ethical standpoints.5 To make decisions
and to solve problems is a part of nurses’ everyday work situation, in which interaction between people occurs continuously. Decision making is fundamental to
nursing.6 Furthermore, nurses of the future will be decision makers and supervisors regarding ethical questions. Nurses make their choice based on their competence, skills and ethical ability.7 According to Busby and Gilchrist,8 nurses
should take an active role in decision making, and be clear and participative in
discussions. Experience and education develop nurses’ ability to make clinical
decisions.9 This research indicates that it is important to support nurses in the
Address for correspondence: Ingela Berggren, Lecturer, PL 7709, Åsmule, SE-464 92 Mellerud,
Sweden.
Nursing Ethics 2000 7 (2)
0969-7330(00)NE335OA © 2000 Arnold
Clinical supervision and nurses’ moral decision making 125
decision-making process. According to Ellis,10 decision making is a very complex
process in the daily life of nurses. They have to make decisions about whether a
problem exists or not, its cause, and what to do to solve it legally and with timeliness. The decision-making process is itself complex. The patient may have
multiple problems, signs and symptoms, which add to the complexity of making
ethical decisions.
Simon11 points out that, when a person makes a choice (i.e. chooses a special
direction for action), that person gives up another choice of direction. The
decision-making process is hierarchical in that each step builds on a goal reached
in a earlier step. Every decision is a compromise. The final choice is never perfect but is, for the moment, the best solution in the actual circumstances. Decisions
consist of part fact and part judgement, an ethical part. The evaluation of decisions implies, for example, that all attempts were made to understand the opposite point of view as well as the ethical content of the decisions: ‘What was the
goal and how did you reach the goal?’11
Of previous studies on clinical supervision that are related to decision making,
only a few deal with the complexity of clinical decision making and the problems
embedded therein. Research into the effects of supervision has increased.
However, an integrated analysis of these studies for the purpose of investigating
the influence of clinical supervision on nurses’ decision making is still lacking.
Therefore, the aim of this study is to describe and analyse its influence on nurses’
moral decision making.
Method
Context and selection of participants
The sample consisted of 15 registered nurses who took part in a group supervision programme (75 hours) pursued in two medical wards in a district hospital
in southwest Sweden. Their ages ranged from 23 to 52 years and their work experience from one to 20 years. There were 14 women and one man. The hospital
has a total of 434 beds, of which the Department of Medicine has 102; it serves
120 000 inhabitants. Two wards were selected for participation in the project. They
have a total of 36 beds, which can be increased to 44 without creating a crisis.
Ward A treats patients with pulmonary disease; Ward B treats those with haematological and renal diseases. Patients with stroke and heart disease are treated on
both wards. During the study, Ward A had a mean length of stay of 9.5 days and
a bed occupancy of 109%, and Ward B had a mean length of stay of seven days
and an occupancy of 104%. The mean length of stay for the medical department
overall was seven days, the bed occupancy being 106%.
Clinical supervision
Clinical supervision, based on a holistic nursing model,12,13 was implemented
during two semesters. The relationship between the patient and the nurse is the
foundation of all caring; the health of the patient depends on this relationship.
According to Eriksson,13 health has no meaning if life lacks meaning. Suffering
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I Berggren and E Severinsson
motivates all forms of caring and is its fundamental concept.
The clinical supervision was organized by groups, with five registered nurses
in every group. They received one-and-a-half hours of supervision once a week.
The session started with a ‘check-up’ on how supervisees wished to use the time.
They were invited to share feelings and thoughts about the caring situations that
were brought up for discussion. Each had the opportunity to share what he or
she felt and thought in relation to what was said. An analysis of the patient situation was carried out among the group members. The supervisors facilitated this
process by helping the nurses to describe their experiences of caring. The session
ended with a question, when the nurses were given the opportunity to express
what they had found to be especially important.
Data collection
Data were obtained from the transcriptions of interviews14 with the registered
nurses who attended supervision after its implementation. The interviews were
conducted by the first author (IB) and lasted approximately one hour. All interviewed nurses volunteered for the study and gave their informed consent. Openended questions were asked: ‘Will you please tell me about how you make
decisions in your nursing?’, ‘Which factors influence your decision making?’, and
‘In what way has clinical supervision influenced your decision making?’ The
interviews were tape recorded and transcribed verbatim.
The hermeneutic transformative process for analyses of the data
The text was listened to in its entirety, every question separately. In hermeneutics, a single text is open to different interpretations. The meaning of a text is not
simply defined in terms of the subjective intentions of its author but is the outcome of the fusion of the views of the text and the interpreter. Interpretation contains two elements: a descriptive phase from the meaning of the text and a later
phase from the interpreter’s view of its meaning.15 The practice of interpretation
involves a continuous dialectic movement between the two views. The descriptive component of interpretation may be based upon a systematic process of categorization. The hermeneutic circle asserts that both the parts and the whole are
important in understanding. Hermeneutic interpretation involves, but is not limited to, the systematic description of the text within the terms of its own scope.
One of its strengths is that it permits the scholar to respect and retain the perspective of the research participant.15 Hermeneutics involves an ontological and
an epistemological approach and has recently become a model for human understanding of the world.16 The hermeneutic circle is cyclic, step by step, because the
understanding of the phenomenon changes from time to time.17 The first phase
in hermeneutic analysis is to develop a sense of the whole of the text. This is done
by reading it through several times. It is then necessary to move from the whole
to consideration of the separate parts. This phase of the analysis involves the
development and definition of basic units of meaning, known as ‘themes’.
Secondly, a sentence by sentence analysis was commenced with the questions
asked, to bring the underlying phenomena out of the statements. Finally, a
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Clinical supervision and nurses’ moral decision making 127
hermeneutic interpretation was made of the statements, in order to reach a deeper
understanding of the whole, according to the hermeneutic circle.
Findings
The hermeneutic interpretation revealed four themes: increased self-assurance; an
increased ability to support the patient; an increased ability to be in relationship
with the patient; and an increased ability to take responsibility.
Theme 1: increased self-assurance
The most pronounced impact of the clinical supervision was increased selfassurance in decision making. The professional role had been clarified and the
nurses were encouraged in their moral decision making. One nurse said:
I feel more secure in myself, my way of thinking, and I feel, for example, take this with
medical drugs, I do not know if it is unlawful not to carry out a prescription. I would
never have done it if I did not have clinical supervision. Earlier, I would have carried
out the order in spite of thinking that it was wrong. Another time, there was a female
patient from whom I had to take tests several times during the night. She was dying,
but she was sleeping and was comfortable, so I did not take any tests. The process of
clinical supervision has made me more secure, so that I can say that ‘this is wrong’.
The climate on the ward has also changed, and, when I report, the reports are different now.
The following statement shows that the nurse dares to make decisions that she
considers are ethically justifiable. She feels more secure so she is able to refuse to
do what she thinks is wrong. Increased self-assurance implies increased courage
to make decisions: ‘I dare to take more decisions. I’m not so hesitant . . . I dare to
take a decision and take responsibility for it; I have more self-assurance.’
Furthermore, the nurses consider that their increased self-assurance is related
to their professional role having become clearer: ‘I think that I am the person who
takes decisions and has to delegate work. Before, maybe I did all the tasks myself,
but now I can delegate to others.’
The clinical supervision influenced the nurses to feel an increase in their selfassurance in ethical issues; they dared to react when something was wrong.
Furthermore, it gives the opportunity for nurses to compare notes, leading to the
development of their professional competence.18
Theme 2: increased ability to support the patient
The nurses had different strategies for decision making; some of them observed
the patient directly while others managed to collect information in other ways.
They reflected on the data gained and then prioritized the decisions they had to
make to support the patient. The concept of competence includes knowledge and
experience, which they used in their decision making concerning how to provide
care:
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I Berggren and E Severinsson
I can see the patient in front of me and know how he feels, and then I use my
knowledge and experience. I try a little of everything. For example, a patient has
dyspnoea. I stay with him and observe him, and I have my instructions. I know which
drugs I have to give the patient, and I stay with him. I explain to the patient what will
happen, injections and pills, and how he may feel after the medication. I have to give
the patient confidence. I can say that the situation will get better.
The decisions that are made support the patient because it is for the patient’s
sake that the decision has to be made. The nurse acts as the patient’s advocate:
It depends on which decision it is. First I have to find out if I have the right to make
the decision. If I have the right to make the decision, I must think what consequences
my decision might have, which decision supports the patient; it is this that is important.
Knowing the patient’s wishes is fundamental in nurses’ decision making:
I have to know the patient’s wishes before I make a decision; I have to weigh for and
against, and if it is possible. I need to have knowledge about the decision I have to
make, and if I am uncertain I always ask somebody.
Nurses’ ability to observe the patient’s needs is fundamental to their decision
making. By observing, nurses identify problems and continue the decisionmaking process: First I have to see the patient and identify the problem. Maybe
I have encountered the problem earlier, or I discuss it with another nurse.
Clinical supervision has effects on nurses and their care of patients. Previous
research shows an increased ability to reflect, increased job satisfaction and an
increased quality of care.19 Clinical supervision implies, among other things, that
nurses have the opportunity to reflect on activities performed. To reflect is to
learn,20 as well as being a method of nurses taking responsibility for their own
development.21 Patients’ wishes and right of self-determination are very important in the professional nurse’s decision-making process.22 Nursing competence
is more than knowledge and skills, critical thinking, creativity and reflection. To
make decisions and to solve problems within the nursing process, the nurse has
to show skills in argumentation and decision making.23 According to Gilligan,24
nurses’ reasoning in ethical dilemmas is different from that of physicians; nurses
focus on the ethics of care while physicians focus on the ethics of justice. Research
also shows that nurses’ decisions are focused on care instead of cure.25 Health
care professionals consider that the patient is the authority in the decisionmaking process.26
To take time for reflection, before the decision is made, is a factor that the
following statements illustrate:
I think of the lady who wanted to report to the Patient Secretary, and I was responsible for her care; but then I thought, what shall I do now? The first thing I did was to
speak with the patient and after that I thought that I had to think of what is right and
wrong, and the patient’s feelings and thoughts. I had to try to do what I could, but I
thought first – don’t rush it.
To determine priorities is important in decision making; the ability to prioritize
depends on the nurse’s competence: ‘Sometimes, in emergency situations, I must
know how to act and to make decisions directly; sometimes I have to discuss.’
Decisions that nurses have to make in their work with patients support the
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Clinical supervision and nurses’ moral decision making 129
patient. The patient’s will has to be respected and the nurses’ competence in
making decisions that support the patient is of great importance. These aspects
were clarified through the clinical supervision sessions.
Theme 3: increased ability to be in a relationship with the patient
In specific acts of nursing, for example, when a patient is crying, worried or anxious, it is important to stay with the patient, to be present, to listen and to be sensitive to his or her specific needs. The patient should not be left with feelings of
being abandoned or alone:
I stay with the patient. I can give him a sedative and, when I leave him, he knows that
I can stay with him if he wants it. I try to find out the cause of the patient’s trouble.
One nurse expressed the importance of using nursing knowledge, one’s own
competence, like this:
I try to see what is fitting for this patient, and to understand why he is crying, and not
talk too much. I have to listen instead and try to find out what to do without asking
the physician for help.
Sometimes the patient wants to be alone and the nurse has to respect that. This
is about interpreting the signs from the patient. It is important to be careful and
considerate:
I do as much as I can. It is not obvious that I shall go on consoling. It can be a normal
reaction but to console is the first thing I think of, but it depends on the situation.
The nurses regard that it is important to listen to the patients who are crying,
worried or anxious, but this depends on the patient’s age. If the patient is young
or of the same age as the nurse, it is more difficult for the nurse than if the patient
is old:
If it is an older patient, I can handle it more easily than if the patient is of my own age.
It is much easier if I can talk directly to the patient about cancer or another disease
when the patient is worrying and wondering what is happening. With this man, I did
not know it myself; I had not got the diagnosis yet. I sat down and talked to the patient
and asked him.
The decision-making process depends on the decision-maker’s knowledge,
experience and flexibility. Experience separates the expert from the novice.
Knowledge is important at every step of the process as well as being another significant factor in separating the novice from the expert. Flexibility implies skills,
communication and perception; it is inherent in every step of the decisionmaking process.27
An activity is an expression that is coloured by the individual’s personal, cultural and religious values; it is a result of a decision-making process. To choose
is an issue in the process; the choice is coloured by the context and the content.28
Theme 4: increased ability to take responsibility
In specific nursing situations, for example, if the patient cannot feed himself or
herself or take initiatives, the nurse assumes responsibility for the patient. This
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I Berggren and E Severinsson
can be shown by bringing clarity to the patient’s inability, by performing a
nursing activity or delegating it to others. To take responsibility for patients who,
for various reasons, cannot take responsibility for themselves, is important:
I help them. I measure their liquids, I want to have control of how much they drink
. . . It depends, if the patient has had a stroke and cannot feed himself I help him. If it
is a patient who does not want to eat for some reason, I have to find out why. Maybe
the patient can be helped by cortisone or some other drug. Or a drug can be left out.
I try to find out the reason why the patient does not want to eat. Maybe the patient is
in pain. It can be many factors.
This statement by the nurse about control is evidence of responsibility. To attend
to a patient who needs help is to take responsibility:
If the patient cannot feed himself and, if I have the time, I will help the patient to eat;
but, if I do not have the time, I will delegate the task to another person. I have to pay
attention to patients who need help.
Friedman and Marr21 assert that only when the nurse has become an expert
can he or she make decisions about moral and ethical problems, and give advice
to colleagues about responsibility and accountability. Clinical supervision promotes responsibility, peer support and confirmation. The efficiency of clinical
supervision can be judged by the prevalence of illness among the staff, their level
of job satisfaction and the receiving of compliments from the patients.2,29 Most
essential in moral decision making is the opportunity to choose and the willingness to take responsibility for the choice made.24
To delegate information to other staff is both a decision that nurses have to
make and their responsibility. These nurses reported that they delegate when they
do not have the time themselves.
Interpretation and discussion
The aim of this study was to describe and analyse the influence of clinical supervision on nurses’ moral decision making. Data were collected by means of interviews. The analysis was performed by hermeneutic interpretation. The validity
of the findings in this study lies in the researchers’ pre-understanding and interpretation of the statements given by the respondents. The analysis has been carried out stepwise, according to the hermeneutic circle.15–17 The authors’
independent interpretations were compared and then reflected upon, in the light
of their pre-understanding of clinical nursing supervision, in order to gain a
deeper inderstanding of the ‘whole’.
The implementation of clinical nursing supervision is likely increasingly to
influence nurses’ self-assurance, their ability to support the patient by being in a
relationship with him or her, and their taking responsibility for the care provided.
Clinical supervision helped these nurses to reflect on how to make the best
ethical decisions. This supports Simon’s11 theory of decision making (i.e. to identify the alternative strategies, reflect on the consequences of these strategies and
to compare the consequences). Supervision encouraged the nurses to reflect upon
and analyse their feelings and reactions in their relationship with patients. This
is consistent with Gilligan,24 who claims that moral decision making depends on
Nursing Ethics 2000 7 (2)
Clinical supervision and nurses’ moral decision making 131
nurses’ will to take decisions and to take responsibility for these decisions as a
consequence of their choice. Taking responsibility for decision making and acting
accordingly are also reported as a result of supervision.30 Nurses’ responsibility
is the essence in the caring relationship. Furthermore, nurses have to make personal choices and moral decisions based on their knowledge and experience of
nursing practice. Active reflection is central to clinical supervision.10 To take
responsibility is one outcome of clinical supervision reported by Severinsson and
Hallberg.1 The supervisor is a role model and takes responsibility directly for the
supervisees and indirectly for the patients and the quality of care.
Patients want nurses to take part in the decision-making process.15 Co-operation between patients and nurses in this process is therefore nesessary. The findings of this study show that these nurses developed an increased ability to sustain
a dialogue with the patient, which faciliated their co-operation in the decision
making. Moreover, the nurses were encouraged, by their clinical supervision, to
decide to stay with the patient to discuss any problems, when they could then
make decisions together. The dialogue could be about alternative strategies or perhaps the different consequences of the decision.19,21 Benevolence is a motivating
factor when nurses make decisions on behalf of the patient.31 The findings in this
research show that the nurses developed their self-assurance. This corresponds
with de Raeve’s32 opinion that clinical supervision can reduce the anxiety a nurse
may feel in the relationship with the patient. Nursing is a moral and practical art,
based on many kinds of knowledge, but clinical supervision preserves or
enhances nurses’ moral sensitivity. Furthermore, their moral decision making is
developed through clinical supervision. Anxiety can contain the feeling of fear
and timidity, but clinical nursing supervision can reduce nurses’ anxiety and
encourage them. When nurses feel that they have courage, they stay close to the
patient, even those who are very ill or dying.
Feelings are of importance for developing moral responsibility. To articulate the
feelings engendered by mistakes, or by guilt or shame, helps nurses in the
decision-making process. For example, guilt can be regarded as an inability of or
an inhibition to taking action. For example, compare the avoidance of responsibility to the exercise of moral responsibility, which is an ability to act, provided
there is an awareness of responsibility. If one can share responsibility, one has
taken a step towards a solution. To articulate the consequences in the process of
supervision gives insight into the difficulty of making decisions, which can lead
to humility. In these clinical supervision sessions the nurses learned to act with
confidence and sensitivity, which affected their ethical decision-making capabilities.26,31,33
In conclusion, the effects reported are that clinical nursing supervision enhances
the caring process, the nurses’ ability to provide care on the basis of their selfassurance, and their ability to support the patient by being in relationship with
him or her and taking responsibility. These abilities may motivate these nurses to
be more ethically conscious in their decision-making process.
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I Berggren and E Severinsson
Acknowledgements
We are grateful to the nurses who participated in this study and to Gullvi Nilsson
for reviewing the English.
Ingela Berggren, Vänersborg University, Vänersborg, Sweden.
Elisabeth Severinsson, University of Oslo, Oslo, Norway.
References
1
Severinsson E, Hallberg I. Clincial supervisors’ views of their leadership role in the clinical
supervision process within nursing care. J Adv Nurs 1996; 24: 151–61.
2 Bégat I, Severinsson E, Berggren I. Implementation of clinical supervision in a medical
department: nurses’ views of the effects. J Clin Nurs 1997; 6: 389–94.
3 Severinsson E, Kamaker D. Clinical nursing supervision in the workplace – effects on moral
stress and job satisfaction. J Clin Nurs 1997; 7: 81–90.
4 Hallberg I, Norberg A. Strain among nurses and their emotional reactions during one year
of systematic clinical supervision combined with the implementation of individualized care
in dementia nursing. J Adv Nurs 1993; 18: 1860–75.
5 Johns C. Professional supervision. J Nurs Manage 1993; 1: 9–18.
6 Turley J. Nursing decision making and the science of the concrete. Holist Nurs Pract 1996; 1:
6–14.
7 Hindsén U, Fridlund B. The nurse in clinical practice: a qualitative analysis of nursing
competence. Scand J Caring Sci 1995; 9: 139–44.
8 Busby A, Gilchrist B. The role of the nurse in the medical ward round. J Adv Nurs 1992; 17:
339–46.
9 Kai-Cheung Chuk P. Clinical nurse specialists and quality patient care. J Adv Nurs 1997; 26:
501–506.
10 Ellis PA. Processes used by nurses to make decisions in the clinical practice setting. Nurs
Educ Today 1997; 17: 325–32.
11 Simon HA. Administrative behaviour. A study of decision-making processes in administrative
organisation. New York: The Free Press, 1976.
12 Eriksson K. The basic idea behind caring (Swedish). Stockholm: Almqvist and Wiksell, 1986.
13 Eriksson K. The nursing process (Swedish). Stockholm: Almqvist and Wiksell, 1988.
14 Polit D, Hungler B. Nursing research: principles and methods. Philadelphia, PA: Lippincott, 1995.
15 Draper P. Nursing research and the philosophy of hermeneutics. Nurs Inquiry 1995; 3: 45–52.
16 Dreier O, Kvale S. Dialectical and hermeneutic psychology. Scand J Psychol 1984; 25: 5–29.
17 Gadamer HQ. Truth and method. London: Shed and Ward, 1960.
18 Butterworth T, Faugier J eds. Clinical supervision and mentorship in nursing. London: Chapman
and Hall, 1993.
19 Severinsson E, Borgenhammar E. Expert views on clinical supervision: a study based on
interviews. J Nurs Manage 1997; 5: 175–83.
20 Snowball J, Ross K, Murphy K. Illuminating dissertation supervision through reflection. J
Adv Nurs 1994; 19: 1234–40.
21 Friedman S, Marr J. A supervisory model of professional competence: a joint service/
education initiative. Nurs Educ Today 1995; 15: 239–44.
22 Kuuppelomäki M. Ethical decision making on starting terminal care in different health-care
units. J Adv Nurs 1993; 18: 276–80.
23 Fitzpatrick JM, While A, Roberts J. The role of the nurse in high-quality patient care: a review
of the literature. J Adv Nurs 1992; 17: 1210–19.
24 Gilligan C. In a different voice. Cambridge, MA: Harvard University Press, 1982.
25 Biley F. Some determinants that affect patient participation in decision-making about
nursing care. J Adv Nurs 1992; 17: 414–21.
26 Watt P. Living wills: how do they inform care? Br J Nurs 1995; 19: 1156–59.
27 Hamers JPH, Huijer Abu-Saad H, Halfens RJG. Diagnostic process and decision making in
nursing. J Prof Nurs 1994; 3: 154–63.
Nursing Ethics 2000 7 (2)
Clinical supervision and nurses’ moral decision making 133
28
Grundstein-Amando R. Ethical decision-making processes used by health care providers. J
Adv Nurs 1993; 18: 1701–709.
29 Jones A. Clinical supervision in moderating organisational conflict and preserving effective
working relationships. Int J Palliat Nurs 1997; 5: 293–99.
30 Severinsson E. The phenomenon of clinical supervision in psychiatric health care. J Psychiatr
Ment Health Nurs 1995; 2: 301–309.
31 van Hooft S. Moral education for nursing decisions. J Adv Nurs 1990; 15: 210–15.
32 de Raeve L. Maintaining integrity through clinical supervision. Nurs Ethics 1998; 5: 486–96.
33 Lützén K. Moral sensitivity: a study of subjective aspects of the process of moral decision making
in psychiatric nursing [Dissertation]. Stockholm: Department of Psychiatry, Karolinska
Institute, Huddinge University Hospital, 1993.
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Author Manuscript
Appl Nurs Res. Author manuscript; available in PMC 2020 April 01.
Published in final edited form as:
Appl Nurs Res. 2019 April ; 46: 20–23. doi:10.1016/j.apnr.2019.01.003.
Deriving the Practice-Primed Decision Model from a Naturalistic
Decision-Making Perspective for Acute Care Nursing Research
Christine W. Nibbelink, PhD, RN1 and Pamela G. Reed, PhD, RN, FAAN2
1University of California, San Diego, Department of Biomedical Informatics
2University of Arizona, College of Nursing
Author Manuscript
Abstract
Aim—The purpose of this paper is to derive a Practice Primed Decision Model from a Naturalistic
Decision-Making framework for use in guiding future nursing decision-making research.
Background—Acute care nurses make decisions in demanding environments under the
influence of many factors. The influence of these factors on nurse decision-making is not well
understood leading to gaps in understanding how to best support acute care nurse decision-making
Methods—The strategy of theory derivation was used in the development of a new model for use
in nursing research. This model incorporates important elements identified in Naturalistic Decision
Making, a Recognition Primed Decision Model and an integrative review of nurse decisionmaking literature.
Author Manuscript
Conclusion—The new model, Practice Primed Decision Model, provides a new perspective to
guide nurse decision-making research. This model includes factors influential to the nurse
decision-making process that is more realistic in time limited, high stakes decision-making
situations.
Keywords
acute care nursing; decision-making; decision support; informatics; Naturalistic Decision Making;
Recognition Primed Decision Model
Introduction
Author Manuscript
Acute care registered nurses (RN) make decisions in a highly demanding environment. To
better understand the complex nature of nurse decision-making in acute care, research
guided by theory is needed. Theory guides the study of relevant influences as drawn from
existing empirical results and organized into a framework that facilitates needed research
Correspondence: Christine W. Nibbelink, PhD, RN, University of California, San Diego, Department of Biomedical Informatics. 9500
Gilman Drive, La Jolla, CA 92093. Phone number: 858-534-9655., cnibbelink@ucsd.edu.
Publisher’s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
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Conflicts of Interest
The authors declare that they have no conflicts of interest associated with this paper.
Nibbelink and Reed
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Author Manuscript
into a problem. This article proposes a theoretical model to facilitate research into decisionmaking in acute care nursing. The framework was based in part upon results from a recent
integrative literature review (Nibbelink & Brewer, 2017) and on applicaton of the strategy of
theory derivation. Theory derivation was useful in moving from a psychological theory, the
Recognition-Primed Decision model (Klein, 1993) to formulate a nursing model relevant to
a practice context of acute care nursing.
Author Manuscript
Decision-making research in nursing has traditionally focused on a classical model (Cioffi,
2012). The classical decision-making model begins with a thorough examination of options
and ends with a final selection of an ideal option (Lipshitz, Klein, Orasanu, & Salas, 2001).
However, experienced decision makers found this classical decision-making model of
minimal use in time limited real-world situations where decision-making drew from
experience and contextual influences (Lipshitz et al., 2001). Clinical nurse specialists as well
as professions outside of nursing (such as power plant operators and anesthetists) have found
a naturalistic approach to decision-making, specifically the Naturalistic Decision Making
(NDM) model, as a perspective helpful in describing decision-making (Carvalho, dos
Santos, & Vidal, 2005; Hepgul et al., 2012; Klein, Calderwood, & Clinton-Cirocco, 2010;
Phipps & Parker, 2014).
Naturalistic Decision Making
Author Manuscript
The field of decision-making encompasses a wide variety of theories about how people
make decisions, from an emphasis on rationality and achieving the ideal solution in
traditional models to models that incorporate more realistic elements and decision outcomes.
One significant influence was the ground-breaking work of Amos Tversky and Daniel
Kahneman (1974), who discovered that decisions more realistically were influenced by
biases – often unconscious—and the use of heuristics rather than on systematic strategies
and judgments. Their findings suggested that two ‘systems’ of thought were involved in
judgments and decisions loosely corresponding to the following: One system being more
intuitive, without conscious computation, or fast; and a second system more analytical,
deliberative, or slow (Kahneman, 2011).
Author Manuscript
The Naturalistic Decision Making (NDM) perspective for research emerged out of this and
other work as an area of study of decision-making based on research outside the laboratory,
as it occurs among professionals such as firefighters, airline pilots, psychotherapists, and
military personnel (Klein, 1993). Naturalistic Decision Making incorporates characteristics
of nursing practice in acute care settings as well, where the problems are ill-structured rather
than well-structured, time is urgent rather than ample, the environment is dynamic and
uncertain, and the stakes are high. The decision is not made in a vacuum but must be
sensitive to organizational goals and values, and multiple players (Zsambok, 1997).
Situation Awareness.
A particular element of the naturalistic decision-making perspective, distinct from the
classical model, is that decision-making begins with situation awareness (Endsley, 1997).
Situation awareness includes perception of factors within the situation, understanding the
significance of these factors, and projection of the potential consequences of these factors on
Appl Nurs Res. Author manuscript; available in PMC 2020 April 01.
Nibbelink and Reed
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the overall system. Effective decision-making relies on accurate perception of the situation,
or situation awareness. Situation awareness, together with other factors identified in
naturalistic decision-making models, provide a broad range of factors for nursing decisionmaking research.
Recognition-Primed Decision Model
Author Manuscript
Several decision-making models were developed that share the basic characteristics of
naturalistic decision-making. A familiar model and the one used in deriving this nursing
theoretical framework, is the Recognition-Primed Decision (RPD) model (Klein, 1993). This
model describes how individuals make decisions about difficult problems under time
pressure. Initially this model was developed through in-depth interviews of fireground
commanders reflecting on personal experiences in non-routine firefighting incidents.
experience factors important to the experts’ decision-making processes were identified
(Klein et al., 2010).
The RPD model desc…