All nurses make decisions frequently. Making many decisions, however, does not necessarily guarantee that an individual will make good decisions. This section will discuss ways to enhance decision-mak-ing skills and strategies. Because decision makdecision-mak-ing is a complex, abstract process, individuals may have many different ways of thinking about it. A discus-sion of various decidiscus-sion-making models can be helpful in explaining and understanding this phe-nomenon (Fig. 10-1).
MODELS RELEVANT TO MAKING DECISIONS
Brief snapshots of the following models are intended to guide readers to an understanding of the decision-making process:
Enhancing Your Critical Thinking, Decision Making, and Problem Solving 153
To Adapt or Innovate
According to McNichol (2002), individuals either adapt or innovate when faced with new or unknown situations that may require problem solving or decision making.
Adaptors are naturally convergent thinkers, whereas innovators are divergent thinkers. Adaptors fit the new situation into known structures, systems, and models.
These people control activity and follow through on tasks but tend to be stressed when lots of changes and uncertain outcomes occur. On the other hand, innovators enjoy experiencing new situations and look for
opportunities to do things differently. While valued for generating ideas and identifying possibilities, these workers are viewed as chaotic and unable to complete their tasks.
Critical Thinking
Critical Thinking
Critical Thinking
Choice
#1
Decision
Choice
#3
Choice
#2
FIGURE 10-1 Decision model.
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■ Information processing model: Continuum consisting of short- and long-term memory using a four-stage process, including weighing the pros and cons of each decision alternative
■ Wheeler’s model: Knowing the context in which choices can be made from options that affect the individual and up through the soci-ety at large as represented in concentric circles
■ Nursing process: Evaluation process allows for continual assessment of the response to any
decision, with new plans being implemented for alternative responses
Information Processing Model
In this model, decision making is seen on a contin-uum and not as an either/or process (Thompson, 1999). This model consists of two components:
short- and long-term memory. Short-term memory contains the stimuli information necessary to
“unlock” factual and experimental knowledge that is stored in the long-term memory. The clinician uses a four-stage process to make decisions in this theory:
1. Gather clinical patient data.
2. Generate hypotheses or predictions about the issue.
3. Interpret the data and confirm or refute the hypotheses.
4. Weigh the pros and cons of each decision alternative.
One of the strengths of this model is that it allows the use of all types of assessment data, including individual “memory” data, which is the information each person carries consisting of previ-ous knowledge and experiences. An experienced clinician can use experience and knowledge to pre-dict that a decision will or will not work. For exam-ple, an experienced nurse manager is faced with completing the summer vacation schedule for the unit. The manager is aware of the restrictions placed by administration about the number of individuals who may be on vacation for each shift and other issues regarding seniority. After weighing the pros and cons of the choices (allowing employee choice takes more time; allowing employee choice makes the nurses happier; allowing choice could propel arguments), the manager could decide to:
1. Complete and post the vacation schedule.
2. Ask for requests in advance and post the vacation schedule.
3. Post a tentative schedule and ask for com-ments and suggestions.
4. Post a blank schedule and ask everyone to complete this schedule within the required administrative restrictions by a certain date.
Based on experience and knowledge of human nature regarding choice, he rejects options 1, 2, and 3 and decides to post a blank schedule. It is a good model to use to process information because it offers the opportunity to consider many alterna-154 Skills for Being an Effective Leader
Dawn Wise is the nursing manager of a 40-bed medical/
surgical unit. Recently, full-time staff resignations for relocation or retirement reasons have created many openings on the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m.
schedule. Although the positions have been posted on the hospital Website, Dawn decides she needs to have her staff assist in filling the open positions on a temporary basis. The problem of staffing offers several options for the manager to consider: additional part-time coverage, per diem staff, agency staff, overtime, or flex-time with change to 12-hour coverage. Dawn’s hospital does not have a central staffing office, nor are there extra nurses from any other department who can work.
Using critical thinking skills, Dawn identifies the underlying assumption that the staffing decision needs to provide cost-effective and safe care for the patients on the unit. She understands that the decision how to provide the necessary coverage will be of great concern to the staff, who want adequate numbers of people to work each shift but will not want coverage decisions mandated by management. Information about how to make this decision will need group input to consider all the possible alternatives.
She decides to discuss the problem and potential solutions with her staff. After the staff meeting, in which brainstorming took place, Dawn talks to each part-time RN and receives a commitment for extra time. As the staff requested, Dawn posts the remaining openings in the next schedule for interested staff to sign up for overtime before seeking per diem or agency staff. The staff agreed with Dawn not to consider 12-hour shifts unless the positions remained open for more than 2 months.
Dawn sums up the decision-making process in this way: “Our philosophy includes shared governance, and our nurses know how important their input is to the work environment. Sharing the decision making increases our shared accountability to the public for providing qualified, competent staff. We rely on administration to support our joint efforts in problem solving and decision making.”
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tives and demonstrates the importance of a thor-ough assessment in order to develop alternative choices.
Wheeler’s Model
Wheeler (2000) suggests that having choices and knowing the context in which choices are made are the most important elements of proactive decision making. Being proactive allows the anticipation of an event and allows one to generate actions before the event. For instance, planning for staff replace-ment during a maternity leave provides options:
temporary replacement with additional part-time use, agency nurses, overtime use, extended shifts, and so on (Fig. 10-2).
Having a choice involves having at least two options. One of the options may be not to act at all,
but that does constitute a choice. In that situation, the decision maker allows other people or events to determine the outcome. Wheeler uses concentric circles to conceptualize the relationships between the five primary areas (contexts) for consideration when determining choice and context. Knowing the context helps to put the choices in perspective. The personal arena is the first level. Here, decisions occur that pertain solely to the individual. The sec-ond level is the family arena. The third is the social arena, where decisions can affect business associ-ates and close friends. The fourth level is the com-munity arena, which includes cultural, ethnic, religious, and national groups. The fifth level is the global or international arena, involving philosophi-cal, politiphilosophi-cal, and financial issues.
Wheeler’s model might have limited usefulness in a nursing environment as it is described; how-ever, changing the labels of the circles (see Fig.
10-2) might allow one to use it to determine context and how far-reaching an anticipated decision might be. For example, levels could be changed to reflect unit personnel, patients/families, budget, the nurs-ing organization, the entire agency, and so on.
Circles could be added to indicate a more complex decision. The strength of this model is the fact that it is graphic. In the example presented in Figure 10-2, choice #1 will affect the unit staff and may also influence the budget to some extent. Choice #2 will definitely affect the budget and may affect patient care if staff becomes overextended or fatigued.
Choice #3 affects the existing staff to orient the agency and traveling staff; patient care might be affected, and the budget will be affected because of the increased cost in hiring nurses. The nursing department will become involved because these nurses will be processed through other depart-ments, such as Employee Health and Nursing Education. Finally, choice #4, which is actually a choice not to make a choice, will affect the entire agency. After all, failing to provide adequate staffing can result in poor clinical outcomes, dissatisfied patients and nurses, increased complaints, the pos-sibility of risk of liability to the agency, and damage to the agency’s reputation. All the individuals involved in the decision can judge what the impact of the decision might be on their part of the entire organization. This model allows one to look at the perspectives of others and what their concerns and issues might be. Finally, it encourages one to con-sider as many alternatives as possible to satisfy the needs of everyone involved.
Enhancing Your Critical Thinking, Decision Making, and Problem Solving 155
Entire Agency
Choice #1
Use existing part-time staff to take on additional shifts.
Choice #2
Use planned overtime and extended shifts.
Choice #3
Use agency staff and traveler RNs.
Choice #4
Provide no additional coverage.
Unit RNs Nursing
Department
Patient Budget Care
Staff Replacement for a Maternity Leave
FIGURE 10-2 Wheeler’s model.
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Nursing Process
Although there are many decision-making models, the nursing process may be the most familiar and comfortable model for nurses to utilize to make decisions.
The nursing process is ongoing and begins with phase I, assessment, according to Figure 10-3. This phase includes defining the assumptions and con-text, collecting data, identifying and naming the problem(s), and deciding on actions or interven-tions. Phase II is implementation or intervention as planned in phase I. Phase III is evaluating the out-comes. Based on the evaluation, the process begins over again with more data collection, if indicated.
For example, during a home visit to a patient, the nurse is concerned about the safety of an elderly man who is post–cerebral vascular accident (stroke) with some mobility problems. She observes many throw rugs on the floor, extension cords that are vis-ible in the walking areas, and several cats who roam around the patient when he gets up to walk into the kitchen or bathroom. The nurse identifies all these as safety hazards and labels the problem “Alteration in safety related to environmental hazards.” She makes a plan to review the environment with the patient and make necessary changes by eliminating the throw rugs or anchoring them to the floor, removing the extension cords or taping them down, and discussing how the cats can be controlled when the patient is walking through the house. The nurse then discusses the problems and possible solutions with the patient, comes to consensus about the changes, and makes arrangements for the alter-ations. This is the implementation phase. Short-term evaluation of the changes will occur on her next home visit; long-term evaluation will be meas-ured by the lack of falls by the patient. This nurse used the nursing process to make decisions about the care of this patient. The same process can be used to make all decisions, even those that do not involve patient care.
Using the nursing process as a guide, start the decision-making process by collecting data and assessing the situation. It is important to make deci-sions with as much information as possible. Leaders make their most successful decisions when they assess the strengths and weaknesses of the people and the environment. Good decision making relies on building relationships, knowing the politics of the players, understanding the time and other
envi-ronmental constraints, integrating cultural values, and staying true to personal and organization ethics. Furthermore, the cultural diversity found in any organization needs to be considered in any decision that affects more than one person.
Differences in frames of reference, perspectives, norms, values, and communication style are often aggravated by prejudices, stereotypes, and misun-derstandings (Broome, et al., 2002). In the home care nursing example, major misunderstandings could occur if the nurse did not include the patient in any environmental alteration. The cats may be very important to the patient, who may be willing to risk falling rather than confining them to a sepa-rate room.
Aside from its familiarity, the strength of this model is its feedback mechanism. If evaluation reveals an unanticipated or unacceptable outcome, the assessment begins again. In today’s health-care environment, the concept of evidence-based prac-tice supports the need to gather as much evidence as possible to make a decision that can lead to best practices. Sources of data for decision making come from more formal sources such as quality assurance, benchmarking, and risk management data (see Chapter 15). Observation and inquiry can also yield information about a situation. Finally, scientific research data make excellent assessment data and should be the basis for much of decision making in nursing whenever possible.
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II Implementation/
Intervention
I Assessment
Diagnosis Plan Nursing
Process
III Evaluation
FIGURE 10-3 Nursing model.
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TYPE OF DECISIONS
Not all decisions are critical or global in their impact. Decisions are made at all levels of the hier-archy in organizations. Some experts believe that a decision should be made as close to the action as possible. At the same time, however, as demon-strated in the Wheeler model, good decision making also means considering the impact the decision will have beyond the immediate environment.
Routine decisions can be used to respond to fre-quently occurring, common, and reasonably well-defined issues. Policies and procedures and established rules can be used to guide the decision-making process. The level of personnel that makes routine decisions can range from the staff nurse to top administrators. For example, when a patient falls, there is a clearly defined process to follow regarding immediate intervention, reporting, and follow-up. Decisions about who will do what and when can be made easily, based on the incident.
Leaders should attempt to determine quickly if there are established guidelines for a particular sit-uation and apply them as soon as possible. Leaders should be careful, however, to avoid generalizing every situation and should make decisions that are appropriate in the context of each event.
Innovative decisions are made when the situa-tion or problem is unusual and the rules and guide-lines do not clearly define or dictate a course of action. Nurses, from the bedside to top administra-tion, need to make these kinds of decisions fre-quently. For innovative decisions, it is helpful if the nurse understands the art of decision making. In any event, there is work to be done before imple-menting the decision-making process at any level.
Innovative decisions generally take longer to make and require more attention to data collection and assessment. Without rules and policies to guide the decision-making process, the leader must be sure to view all possible alternatives.
PRE–DECISION MAKING
Before making a decision, ask several questions based on the assessment data. First, is there really a need to make a decision? Is there a problem that needs to be solved? The perception of a problem is relative. A headache is painful to the individual but is good for the pharmacist. A wise leader needs to
determine first how the issue is affecting the cur-rent situation and if it truly requires intervention.
Another pre-decision question involves timing:
how quickly does the decision need to be made?
One of the characteristics of leadership is the ability to think critically and make difficult decisions quickly and effectively. But delaying decision mak-ing or not makmak-ing a decision is actually makmak-ing a decision not to take any action. Striking a balance between a knee-jerk response and a delayed or non-response is one hallmark of an effective leader. If the decision will affect others and represent a change in procedure, it might be necessary to assess the readiness of others to accept the decision or change (see Chapter 11).
Nurses are very aware of modifiable and non-modifiable risk factors in relationship to cardiac health. The same concept can be applied to decision making. Some situations are controllable, and some are uncontrollable. Before making a decision, a wise leader will identify uncontrollable factors and avoid spending time trying to alter them. Additionally, leaders need to identify situations where factors can be modified but not by them. It is difficult for some leaders to let go of situations that do not fall under their authority. For example, an emergency department manager may be able to control the process by which laboratory diagnostic test requests are made but cannot control the volume of requests that are made from within the department or throughout the hospital.
TOOLS FOR MAKING DECISIONS
After determining that a decision must be made, the effective leader turns to the decision-making tools.
The traditional problem-solving process is well known and was the basis for the development of the nursing process. This traditional model is a seven-step process:
1. Identify the problem 2. Gather data
Enhancing Your Critical Thinking, Decision Making, and Problem Solving 157
Pre–Decision Making Questions Does a decision need to be made?
1. How soon does the decision need to be made?
2. Who has the power to make the decision?
3. What are the controllable and uncontrollable factors?
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3. Explore alternatives 4. Evaluate alternatives
5. Select the appropriate solution 6. Implement the solution 7. Evaluate the results
The managerial model is similar to the tradi-tional model and comprises the following steps:
1. Set the objectives 2. Search for alternatives 3. Evaluate alternatives 4. Choose an alternative 5. Implement
6. Follow up
7. Control the outcomes
Decision making occurs at step four when a choice is made.
Table 10-1 compares the traditional managerial, and nursing process for decision making and prob-lem solving. There are strengths and weaknesses in each model. For example, in the managerial model the objective is determined at the beginning.
Sometimes it is difficult to know what the objec-tives need to be to reach an outcome, and this model does not focus on data collection in order to identify the alternatives. The traditional model requires problem identification as a first step, whereas the nursing process collects data to determine if there is a problem. Both methods can be useful in making a decision, yet the nursing process allows for the pos-sibility that there is no problem or no need to make a decision or take any action. Problem identification is the foundation of good decision making. If the correct problem is not identified initially, a very good decision can be made for the wrong problem.
Specific Decision-Making Tools
The use of tools is a systematic way to collect the data necessary for making a good decision.
Specifically, pros and cons, SWOT analysis, and 2 ⫻ 2 matrix are recommended for beginning nurse managers.
Pros and Cons
A simple strategy is to make a list with one side labeled “Pro (or Advantages)” and the other side
“Con (or Disadvantages).” Writing down options helps to clarify the decision that needs to be made.
More accurate decisions can be made by assigning weights to each factor, with 5 representing very sig-nificant and 1 representing minor significance.
Table 10-2 illustrates the use of this strategy to make a decision about which shifts might be appro-priate for a particular nursing unit. The use of a 158 Skills for Being an Effective Leader
TABLE 10-1 Comparison of the Traditional, Managerial, and Nursing Process Models for Decision Making and Problem Solving
TRADITIONAL MANAGEMENT NURSING
1. Identify problem 2. Collect data 3. Explore alternatives 4. Identify alternatives 5. Evaluate alternatives 6. Select alternative 7. Implement 8. Evaluate results
1. Assessment 2. Identify problem 3. Plan
4. Implement 5. Evaluate 1. Set objectives
2. Search for alternatives 3. Evaluate alternatives 4. Choose
5. Implement 6. Follow up 7. Control
TABLE 10-2 Moving From 8- to 12-Hour Shifts
PROS WEIGHT CONS WEIGHT
Staff satisfaction Ease of scheduling Patient satisfaction
Totals 13 16
5 3 5
Increased fatigue
Need more full-time employees Increased absences Patient satisfaction
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