Introduction
DISPLAY 1.8 Strategies for the New Nurse to Promote Evidence-Based Best Practice
1. Keep abreast of the evidence—subscribe to professional journals and read widely.
2. Use and encourage use of multiple sources of evidence.
3. Use evidence not only to support clinical interventions but also to support teaching strategies.
4. Find established sources of evidence in your specialty—do not reinvent the wheel.
5. Implement and evaluate nationally sanctioned clinical practice guidelines.
6. Question and challenge nursing traditions and promote a spirit of risk taking.
7. Dispel myths and traditions not supported by evidence.
8. Collaborate with other nurses locally and globally.
9. Interact with other disciplines to bring nursing evidence to the table.
Source: Reprinted fromPrevost, S., & Ford, C. D. (2017). Evidence-based practice. In C. Huston (Ed.), Professional issues in nursing:
Challenges & opportunities (4th ed., pp. 17–27). Philadelphia, PA: Wolters Kluwer.
Evidence-based decision making and evidence-based practice should be viewed as imperatives for all nurses today as well as for the profession in general.
It is important to recognize that the implementation of evidence-based best practices is not just an individual, staff nurse–level pursuit (Prevost & Ford, 2017). Too few nurses understand what best practices and evidence- based practice are all about, and many organizational cultures do not support nurses who seek out and use research to change long-standing practices rooted in tradition rather than in science. Administrative support is needed to access the resources, provide the support personnel, and sanction the necessary changes in policies, procedures, and practices for evidence-based data gathering to be a part of every nurse’s practice (Prevost &
Ford, 2017). This approach to care is even being recognized as a standard expectation of accrediting bodies such as The Joint Commission, as well as an expectation for Magnet hospital designation.
Generate Many Alternatives
The definition of decision making implies that there are at least two choices in every decision. Unfortunately, many problem solvers limit their choices to two when many more options usually are available. Remember that one alternative in each decision should be the choice not to do anything. When examining decisions to be made by using a formal process, it is often found that the status quo is the right alternative.
The greater the number of alternatives that can be generated, the greater the chance that the final decision will be sound.
Several techniques can help to generate more alternatives. Involving others in the process confirms the adage that two heads are better than one. Because everyone thinks uniquely, increasing the number of people working on a problem increases the number of alternatives that can be generated.
Brainstorming is another frequently used technique. The goal in brainstorming is to think of all possible alternatives, even those that may seem “off target.” By not limiting the possible alternatives to only apparently appropriate ones, people can break through habitual or repressive thinking patterns and allow new ideas to surface. Although most often used by groups, people who make decisions alone also may use brainstorming.
LEARNING EXERCISE
1.2
Possible Alternatives in Problem Solving
I
n the personal-choice scenario presented in Learning Exercise 1.1, some of the following alternatives could have been generated:Do not take the new position.
Hire a full-time housekeeper and take the position.
Ask your spouse to quit working.
Have an abortion.
Ask one of the parents to help.
Take the position and do not hire childcare.
Take the position and hire childcare.
Have your spouse reduce the law practice and continue helping with childcare.
Ask the Director of Human Resources if you can work 4 days a week and still have the position.
Take the position and wait and see what happens after the baby is born.
A S S I G N M E N T:
How many of these alternatives did you or your group generate? What alternatives did you identify that are not included in this list?
Think Logically
During the problem-solving process, one must draw inferences from information. An inference is part of deductive reasoning. People must carefully think through the information and the alternatives. Faulty logic at this point may lead to poor-quality decisions. Primarily, people think illogically in three ways.
1. Overgeneralizing: This type of “crooked” thinking occurs when one believes that because A has a particular characteristic, every other A also has the same characteristic. This kind of thinking is exemplified when stereotypical statements are used to justify arguments and decisions.
2. Affirming the consequences: In this type of illogical thinking, one decides that if B is good and he or she is doing A, then A must not be good. For example, if a new method is heralded as the best way to perform a nursing procedure and the nurses on your unit are not using that technique, it is illogical to assume that the technique currently used in your unit is wrong or bad.
3. Arguing from analogy: This thinking applies a component that is present in two separate concepts and then states that because A is present in B, then A and B are alike in all respects. An example of this would be to argue that because intuition plays a part in clinical and managerial nursing, then any characteristic present in a good clinical nurse also should be present in a good nurse-manager. However, this is not necessarily true; a good nurse-manager does not necessarily possess all the same skills as a good nurse-clinician.
Various tools have been designed to assist managers with the important task of analysis. Several of these tools are discussed in this chapter. In analyzing possible solutions, individuals may want to look at the following questions:
1. What factors can you influence? How can you make the positive factors more important and minimize the negative factors?
2. What are the financial implications in each alternative? The political implications? Who else will be affected by the decision and what support is available?
3. What are the weighting factors?
4. What is the best solution?
5. What are the means of evaluation?
6. What are the consequences of each alternative?
Choose and Act Decisively
It is not enough to gather adequate information, think logically, select from among many alternatives, and be aware of the influence of one’s values. In the final analysis, one must act. Many individuals delay acting because they do not want to face the consequences of their choices (e.g., if managers granted all employees’
requests for days off, they would have to accept the consequences of dealing with short staffing).
Many individuals choose to delay acting because they lack the courage to face the consequences of their choices.
It may help the reluctant decision maker to remember that even though decisions often have long-term consequences and far-reaching effects, they are not usually cast in stone. Often, judgments found to be ineffective or inappropriate can be changed. By later evaluating decisions, managers can learn more about their abilities and where the problem solving was faulty. However, decisions must continue to be made, although some are of poor quality, because through continued decision making, people develop improved decision-making skills.
Individual Variations in Decision Making
If each person receives the same information and uses the same scientific approach to solve problems, an assumption could be made that identical decisions would result. However, in practice, this is not true. Because decision making involves perceiving and evaluating, and people perceive by sensation and intuition and evaluate their perception by thinking and feeling, it is inevitable that individuality plays a part in decision making. Because everyone has different values and life experiences, and each person perceives and thinks
differently, different decisions may be made given the same set of circumstances. No discussion of decision making would, therefore, be complete without a careful examination of the role of the individual in decision making.
Gender
New research suggests that gender may play a role in how individuals make decisions, although some debate continues as to whether these differences are more gender role based than gender based. Research does suggest, however, that men and women do have different structures and wiring in the brain and that men and women may use their brains differently (Edmonds, 1998–2016). For example, Harvard researchers have found that parts of the frontal lobe, responsible for problem solving and decision making, and the limbic cortex, responsible for regulating emotions, are larger in women (Hoag as cited in Edmonds, 1998–2016). Men also have approximately 6.5 times more gray matter in the brain than women, but women have about 10 times more white matter than men (Carey as cited in Edmonds, 1998–2016). Researchers believe that men may think more with their gray matter, whereas women think more with the white matter. This use of white matter may allow a woman’s brain to work faster than a man’s (Hotz as cited in Edmonds, 1998–2016).
Values
Individual decisions are based on each person’s value system. No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously. The alternatives generated and the final choices are limited by each person’s value system. For some, certain choices are not possible because of a person’s beliefs. Because values also influence perceptions, they invariably influence information gathering, information processing, and final outcome. Values also determine which problems in one’s personal or professional life will be addressed or ignored.
No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously.
Life Experience
Each person brings to the decision-making task past experiences that include education and decision-making experience. The more mature the person and the broader his or her background, the more alternatives he or she can identify. Each time a new behavior or decision is observed, that possibility is added to the person’s repertoire of choices.
In addition, people vary in their desire for autonomy, so some nurses may want more autonomy than others.
It is likely that people seeking autonomy may have much more experience at making decisions than those who fear autonomy. Likewise, having made good or poor decisions in the past will influence a person’s decision making.
Individual Preference
With all the alternatives a person considers in decision making, one alternative may be preferred over another.
The decision maker, for example, may see certain choices as involving greater personal risk than others and therefore may choose the safer alternative. Physical, economic, and emotional risks and time and energy expenditures are types of personal risk and costs involved in decision making. For example, people with limited finances or a reduced energy level may decide to select an alternative solution to a problem that would not have been their first choice had they been able to overcome limited resources.
Brain Hemisphere Dominance and Thinking Styles
Our way of evaluating information and alternatives on which we base our final decision constitutes a thinking skill. Individuals think differently. Some think systematically—and are often called analytical thinkers—
whereas others think more intuitively. About 30 years ago, researchers first began arguing that most people
have either right- or left-brain hemisphere dominance. They suggested that analytical, linear, left-brain thinkers process information differently from creative, intuitive, right-brain thinkers. Left-brain thinkers were supposed to be better at processing language, logic, and numbers, whereas right-brain thinkers excelled at nonverbal ideation and creativity.
Some researchers, including Nobel Prize winner Roger Sperry, suggested that there were actually four different thinking styles based on brain dominance. Ned Herrmann, a researcher in critical thinking and whole-brain methods, also suggested that there are four brain hemispheres and that decision making varies with brain dominance (12 Manage: The Executive Fast Track, 2016). For example, Herrmann suggested that individuals with upper-left-brain dominance truly are analytical thinkers who like working with factual data and numbers. These individuals deal with problems in a logical and rational way. Individuals with lower-left- brain dominance are highly organized and detail oriented. They prefer a stable work environment and value safety and security over risk taking.
In addition, researchers suggested that individuals with upper-right-brain dominance were big picture thinkers who looked for hidden possibilities and were futuristic in their thinking. They were thought to frequently rely on intuition to solve problems and are willing to take risks to seek new solutions to problems.
Individuals with lower-right-brain dominance experienced facts and problem solved in a more emotional way than the other three types. They were sympathetic, kinesthetic, and empathetic and focused more on
interpersonal aspects of decision making (12 Manage: The Executive Fast Track, 2016).
Nauert (1995–2016) suggests, however, that the existence of left or right brain dominance is too simplistic.
He suggests that newer studies have failed to find evidence that individuals tend to have stronger left- or right- sided brain networks. Cherry (2015) agrees, suggesting that recent research has shown that the brain is not nearly as dichotomous as once thought. For example, abilities in subjects such as math are strongest when both halves of the brain work together. Indeed, both sides of the brain collaborate to perform a broad variety of tasks and the two hemispheres communicate through the corpus callosum (Cherry, 2015). Cherry notes that it is absolutely true that some brain functions occur in one or the other side of the brain (language tends to be on the left and attention more on the right), but people don’t tend to have a stronger left- or right-sided brain network.
New evidence suggests the existence of left or right brain dominance may be an oversimplification.
LEARNING EXERCISE
1.3
Thinking Styles
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n small groups, discuss individual variations in thinking. Did some individuals identify themselves as more intuitive thinkers or more linear thinkers? Did group members self-identify with one or more of the four thinking styles noted by Herrmann (12 Manage: The Executive Fast Track, 2016)? Did gender seem to influence thinking style or brain hemisphere dominance? What types of thinkers were represented in group members’ families? Did most group members view variances in a positive way?Overcoming Individual Vulnerability in Decision Making
How do people overcome subjectivity in making decisions? This can never be completely overcome nor should it. After all, life would be boring if everyone thought alike. However, managers and leaders must become aware of their own vulnerability and recognize how it influences and limits the quality of their decision making. Using the following suggestions will help decrease individual subjectivity and increase objectivity in decision making.
Values
Being confused and unclear about one’s values may affect decision-making ability. Overcoming a lack of self- awareness through values clarification decreases confusion. People who understand their personal beliefs and feelings will have a conscious awareness of the values on which their decisions are based. This awareness is an essential component of decision making and critical thinking. Therefore, to be successful problem solvers, managers must periodically examine their values. Values clarification exercises are included in Chapter 7.
Life Experience
It is difficult to overcome inexperience when making decisions. However, a person can do some things to decrease this area of vulnerability. First, use available resources, including current research and literature, to gain a fuller understanding of the issues involved. Second, involve other people, such as experienced colleagues, mentors, trusted friends, and experts, to act as sounding boards and advisors. Third, analyze decisions later to assess their success. By evaluating decisions, people learn from mistakes and are able to overcome inexperience.
In addition, novice nurse-leaders of the future may increasingly choose to improve the quality of their decision making by the use of commercially purchased expert networks—communities of top thinkers, managers, and scientists—to help them make decisions. Such network panels are typically made up of researchers, health-care professionals, attorneys, and industry executives.
Individual Preference
Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking. The need for self- awareness was discussed previously, but it is not enough to be self-aware; people also must be honest with themselves about their choices and their preferences for those choices. In addition, the successful decision maker must take some risks. Nearly every decision has some element of risk, and most decisions involve consequences and accountability.
Those who can do the right but unpopular thing and who dare to stand alone will emerge as leaders.
Individual Ways of Thinking
People making decisions alone are frequently handicapped because they are not able to understand problems fully or make decisions from both analytical and intuitive perspectives. However, most organizations include both types of thinkers. Using group process, talking management problems over with others, and developing whole-brain thinking also are methods for ensuring that both intuitive and analytical approaches will be used in solving problems and making decisions. Use of heterogeneous rather than homogeneous groups will usually result in better quality decision making. Indeed, learning to think “outside the box” is often accomplished by including a diverse group of thinkers when solving problems and making decisions.
Although not all experts agree, many consider the following to be qualities of a successful decision maker:
Courage: Courage is particularly important and involves the willingness to take risks.
Sensitivity: Good decision makers seem to have some sort of antenna that makes them particularly sensitive to situations and others.
Energy: People must have the energy and desire to make things happen.
Creativity: Successful decision makers tend to be creative thinkers. They develop new ways to solve problems.
Decision Making in Organizations
In the beginning of this chapter, the need for managers and leaders to make quality decisions was emphasized.
The effect of the individual’s values and preferences on decision making was discussed, but it is important for leaders and managers to also understand how the organization influences the decision-making process.
Because organizations are made up of people with differing values and preferences, there is often conflict in
organizational decision dynamics.
Effect of Organizational Power
Powerful people in organizations are more likely to have decisions made (by themselves or their subordinates) that are congruent with their own preferences and values. On the other hand, people wielding little power in organizations must always consider the preference of the powerful when they make management decisions. In organizations, choice is constructed and constrained by many factors, and therefore, choice is not equally available to all people.
In addition, not only do the preferences of the powerful influence decisions of the less powerful but the powerful also can inhibit the preferences of the less powerful. This occurs because individuals who remain and advance in organizations are those who feel and express values and beliefs congruent with the
organization. Therefore, a balance must be found between the limitations of choice posed by the power structure within the organization and totally independent decision making that could lead to organizational chaos.
The ability of the powerful to influence individual decision making in an organization often requires adopting a private personality and an organizational personality.
For example, some might believe they would have made a different decision had they been acting on their own, but they went along with the organizational decision. This “going along” in itself constitutes a decision.
People choose to accept an organizational decision that differs from their own preferences and values. The concept of power in organizations is discussed in more detail in Chapter 13.
Rational and Administrative Decision Making
For many years, it was widely believed that most managerial decisions were based on a careful, scientific, and objective thought process and that managers made decisions in a rational manner. In the late 1940s, Herbert A. Simon’s work revealed that most managers made many decisions that did not fit the objective rationality theory. Simon (1965) delineated two types of management decision makers: the economic man and the administrative man.
Managers who are successful decision makers often attempt to make rational decisions, much like the economic man described in Table 1.2. Because they realize that restricted knowledge and limited alternatives directly affect a decision’s quality, these managers gather as much information as possible and generate many alternatives. Simon (1965) believed that the economic model of man, however, was an unrealistic description of organizational decision making. The complexity of information acquisition makes it impossible for the human brain to store and retain the amount of information that is available for each decision. Because of time constraints and the difficulty of assimilating large amounts of information, most management decisions are made using the administrative man model of decision making.