2. Continue smoking
lung cancer (10%)
no lung cancer (90%)
lung cancer (90%)
no lung cancer (10%)
death
• early detection
• cancer responds to treatment
• survival
• minor symptoms death
• early detection
• cancer responds to treatment
• survival
• minor symptoms death
• early detection
• cancer responds to treatment
• survival
• minor symptoms death
• early detection
• cancer responds to treatment
• survival
• minor symptoms
Figure 4-4 Sample decision-making grid. (Delmar/Cengage Learning).
Methods of Reduction Lay off the two most senior full-time employees Lay off the two most recently hired full-time employees
Reduce by staff attrition
Cost Savings
$93,500
$63,200
$78,000
Effect on Job Satisfaction Significant reduction
Significant reduction
Minor reduction
Effect on Patient Satisfaction Significant reduction
Moderate reduction
Minor reduction
Figure 4-5 Sample decision-making grid. (Delmar/Cengage Learning).
Elements
Work at hospital A Learning experience Good mentor support Financial reward Growth potential Good location Total
10 8 6 8 10
10 8 6 8 10
100 64 36 64 100 364 Importance Score
(out of 10)
Likelihood Score (out of 10)
Risk (multiply scores)
Work at hospital B Learning experience Good mentor support Financial reward Growth potential Good location Total
8 7 8 9 6
8 7 8 9 6
64 49 64 81 36 294
from beginning to end an implementation of case management. See Figure 4-6. The chart shows the amount of time required to complete the project and the sequence of events necessary to complete the project. A Gantt chart can also be useful for decision makers to illustrate a project from beginning to end.
Figure 4-7 illustrates a Gantt chart.
Dos and Don’ts of Decision Making
A foundation for good decision making comes with experience and learning from those experiences.
Table 4-4 gives the student some additional tips to consider when making decisions.
Group decision making
Certain situations may call for group decision making. A group may offer innovative alterna- tives and decisions and afford some protection from mistakes because it uses the combined knowledge of all its members. Today’s leadership and management styles include people in the decision-making process who will be most affected by the decision. The effectiveness of groups depends greatly on the group’s members. The size of the group and the personalities of group mem- bers are important considerations when choosing participants. More ideas can be generated with
4 6 7
9
8 5
2
1 A B 10 11
.5 1
.5 C C .5
D, E 1
F, G 2, 1
1 J
1 2 H
1
K, L 1
M 3 3
Figure 4-6 PERT diagram with critical path for implementation of case management. (Delmar/Cengage Learning).
The vice president for nursing plans to change all units to include case managers. She believes that this can be accom- plished within a year and one half. In order for this to be achieved, the following activities and events have to occur:
Activity Symbol Activity Descriptions Immediate Predecessor
A. Form a multidisciplinary advisory group None
B. Agree upon defi nitions A
C. Notify members of subcommittees B
D. Write job descriptions C
E. Advertise for candidates for case manager D
F. Review qualifi cations of candidates E
G. Select candidates for case manager F
H. Review patient charts None
I. Write patient care maps H
J. Meet with case managers None
K. Orient case managers J
L. Orient unit and hospital staff K
M. Utilize case management process L
Events
1. Project begins
2. Meeting of multidisciplinary committee 3. Formation of subcommittees
4. Subcommittee for description meets 5. Subcommittee for patient care maps meets 6. Candidates for case managers are interviewed
7. Candidates are hired
8. Subcommittee for patient care maps meets to fi nalize maps
9. Orientation begins
10. Implementation begins 11. Project is evaluated
Expected Time Calculations
Activity Duration
A 0.5 month
B 1 month
C 0.5 month
D 1 month
E 1 month
F 2 month
G 1 month
H 1 month
I 2 month
J 1 month
K&L 1 month
M 3 month
Techniques of Group Decision Making
There are various techniques of group decision making. The nominal group technique, Delphi tech- nique, and consensus building are different methods to facilitate group decision making.
Nominal Group Technique
The nominal group technique was developed by Delbecq, Van de Ven, and Gustafson in 1971. The word nominal refers to the nonverbal aspect of this approach. In the fi rst step, there is no discus- sion; group members write out their ideas or re- sponses to the identifi ed issue or question posed by the group leader. The second step involves groups, thus allowing for more communication
and more choices. This increases the likelihood of higher-quality outcomes.
A major disadvantage of group decision mak- ing is the time involved. Without effective leader- ship, groups can waste time and be nonproductive.
Group decision making can be more costly and can also lead to confl ict. Groups can be dominated by one person or become the battleground for a power struggle among assertive members.
Group decision making may, however, increase the acceptance of the decision by all members.
Vroom and Yetton (1973) identifi ed elements indi- viduals should consider before making a decision alone or with a group. See Table 4-5.
A nurse manager has agreed to have her unit pilot a new care delivery system within six months. The Gantt chart can be used to plan the progression of the project.
Activities Discuss project with staff Form an ad hoc planning committee Receive report from committee Discuss report with staff Educate all staff about the plan Implement new system Evaluate system and make changes Key
Sept Oct Nov Dec Jan Feb Mar Apr May
X
X
X
X
X
X
X
Proposed Time Actual Time Complete
X
Figure 4-7 Gantt chart: implementation of care delivery system. (Delmar/Cengage Learning).
Do Don’t
Get good information before making a decision. Make snap decisions.
Make notes and keep ideas visible about decisions to utilize all relevant information.
Waste your time making decisions that do not have to be made.
Write down pros and cons of an issue to help clarify your thinking.
Distort your memories of chosen and rejected options to make the chosen options seem relatively more attractive.
Make necessary decisions as you go along rather than letting them accumulate.
Prolong deliberation about decisions.
Consider those affected by your decision. Be unduly infl uenced by initial information that shapes your view of subsequent information.
Trust yourself. Delay or revise a decision as needed.
Always base decisions on the “way things have always been done.”
Source: Adapted from The Small Business Knowledge Base (1999). Retrieved January 19, 2002, from www.bizmove.com
Table 4-4 Dos and Don ’ ts of Decision Making
Table 4-5 Individual vs. Group Decision Making
1. Does the individual have all the information and resources needed to make the best decision?
2. Does the group have supplementary information needed to make the best decision?
3. Will individual personalities within the group work well together?
4. Is it absolutely critical that the group be involved in the decision and accept the decision prior to implementation?
5. Will the group accept a decision made by an individual? By the group?
6. Is there time for a group decision?
7. Will the course of action chosen make a difference to the organization?
8. Do the group and individual have the best interest of the organization foremost in mind when considering the decision?
9. Will the decision cause undue confl ict among the group?
Source: Adapted from Vroom, V. & Yetton, P. (1973). Leadership and Decision-Making (pp. 21–30). Pittsburgh, PA: University of Pittsburgh Press.
consensus means that all group members can live with and fully support the decision regardless of whether they totally agree. Building consensus is useful with groups because all group members participate and can realize the contributions each member makes to the decision. A disadvantage to the consensus strategy is that decision making re- quires more time.
Use of
technology in decision making
The best source of clinical decision making and judgment is the professional practitioner. How- ever, computer technology offers many ways to support evidence-based information needs of nurses.
These include:
Electronic Health Records
■
Patient decision support tools, clinical- and
■
business-related
Laboratory and x-ray results reporting and
■
viewing systems
Computerized prescribing and order entry,
■
including barcoding
Community and population health manage-
■
ment and information
Communication, patient classifi cation staffi ng
■
systems, and administrative systems
Evidence-based knowledge and information
■
retrieval systems
Quality improvement data collection/data sum-
■
mary systems
Documentation and care planning
■
Patient monitoring and problem alerts
■
Inventory control
■
Many nurses today are using PDAs (see Figure 4-8) to improve patient care. PDAs are used for obtaining information about medications and pathophysiol- ogy, and for developing nursing care plans and nurs- ing diagnoses. NCLEX questions are also available on PDAs.
presentation of the ideas to the group members, along with the advantages and disadvantages of each. These ideas are presented on a fl ip board or chart. The third phase offers an opportunity for discussion to clarify and evaluate the ideas. The fourth phase includes private voting on the ideas.
The ideas receiving the highest number of votes are the solutions implemented.
Delphi Group Technique
The Delphi technique differs from the nominal technique in that group members are not meet- ing face to face. Questionnaires are distributed to group members for their opinions, and the re- sponses are then summarized and disseminated to the group members. This process continues for as many times as necessary for the group members to reach consensus. An advantage of this technique is that it can involve a large number of participants and thus a greater number of ideas.
Consensus Building
Consensus is defined by the Merriam-Webster’s Collegiate Dictionar y (2003) as “a general agreement; the judgment arrived at by most of those concerned; group solidarity in sentiment and belief” (p. 265). A common misconception is that consensus means everyone agrees with the decision 100%. Contrary to this misunderstanding,
Case Study 4-1
Y
ou have been working on a medical-surgical unit. As you complete your nursing program, you begin to interview at several hospitals.Set up a decision-making grid to help you analyze your choices. What factors are most important to you as you begin to consider your decision? Use Figure 4-5.
For 2007 and 2008, the changes and additions to these goals include:
Provide a complete list of medications to the
■
patient when discharged
Encourage patient’s active involvement in his
■
own care as a patient safety strategy
Tell patients and their families how they can
■
report concerns about safety and encourage them to do so
Offer the infl uenza vaccine to all staff
■
Identify safety risks in the patient population
■
Improve recognition of and response to
■
changes in a patient’s condition
Psychiatric hospitals should identify patients
■
at risk for suicide
General hospitals should identify those pati-
■
ents being treated for emotional or behavioral disorders who are at risk for suicide (www.joint- commission.org/~Click on National Patient Safety Goals).
Attainment of many of these Goals requires the judicious use of technology.
Leapfrog Group
The Leapfrog Group is another force advocating for technology. Leapfrog is a voluntary program aimed at using employer purchasing power to alert America’s health industry that big leaps in health care safety, quality, and customer value will be rec- ognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information, as well as rewards for hospitals that have a proven record of high quality care.
Leapfrog measures how hospitals are doing with respect to the following:
Computerized practitioner order entry into
■
computers linked to error-prevention software ICUs staffed by practitioner intensivists
■
Evidence-based hospital performance on fi ve
■
high-risk procedures and care for two high- risk neonatal conditions
Progress on 13 National Quality Forum Safe
■
Practices (www.leapfroggroup.org). Data support services are offered to Leapfrog by Thomson Medstat (see www.medstat.com).
Joint Commission National Patient Safety Goals
Several other forces have highlighted the need for increased patient technology. The Joint Commission (JC), formerly the Joint Commission on Accredita- tion of Healthcare Organizations ( JCAHO), has set the following National Patient Safety Goals for 2006, many of which require the use of technology:
Improve the accuracy of patient identifi cation
■
Improve the effectiveness of communication
■
among caregivers
Improve the safety of medication use
■
Eliminate wrong site, wrong patient, wrong
■
procedure surgery
Improve the effectiveness of patient-specifi c
■
clinical alarm systems that alert staff to patient emergencies
Reduce the risk of health care-associated
■
infections
Accurately and completely reconcile medica-
■
tions across the continuum of care Reduce the risk of patient harm from falls
■
Reduce the risk of infl uenza and pneumococ-
■
cal disease in older adults Reduce the risk of surgical fi res
■
Encourage active involvement of patients
■
and families in patients’ own care as a patient safety strategy
Prevent health care-associated pressure ulcers
■
Figure 4-8 Nurse with a PDA. (Source: Courtesy PEPID, Heather Hautman).
The National Quality Forum
The National Quality Forum (NQF) is a not-for- profi t membership organization created to develop and implement a national strategy for health care quality measurement and reporting (www.
qualityforum.org). A shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and health care costs prompted leaders in the public and private sectors to create the NQF as a mechanism to bring about national change.
In 2003, the NQF endorsed a set of 30 safe prac- tices that should be universally utilized in applica- ble clinical care settings to reduce the risk of harm to patients. NQF has now formally launched the Safe Practices Consensus Standards Maintenance Committee to review the practices and recommend additions or changes for members to consider so that the set remains current and appropriate (see www.qualityforum.org; click on Safe Practices).
The Specialty of Nursing Informatics
According to the American Nurses’ Association (ANA, 2001), nursing informatics (NI) is a discipline- specifi c practice within the broader perspective of health informatics. NI was recognized as a specialty for RNs in 1992.
Critical Thinking 4-2
V
isit the American Nurses Credentialing Center at www.nursingworld.org. Click on“careers and credentialing/certification.”
Choose a specialty in which a nurse can be certifi ed and compare it to the certifi cation in informatics.
How are they similar? How are they different?
Evidence from the Literature
Citation: White, A., Allen, P., Goodwin, L., Breckin- ridge, D., Dowell, J., & Garvy, R. (2005). Infusing PDA technology into nursing education. Nurse Educator, 30(4), 153–154.
Discussion: Article discusses the Nursing Educa- tion program at Duke University, where students use PDAs and software to access current drug and infectious disease information, calculations, growth charts, immunization guidelines, and Span- ish and English language translations to improve clinical decision making. Information about this can be accessed at www.pepidedu.com.
Implications for Practice: Use of the PDA can improve clinical decision making. Go to www.
rnpalm.com.
In 2004, 18 regional nursing informatics groups, representing 2,000 nurses, formed the Alliance for Nursing Informatics (ANI) in collaboration with Healthcare Information and Management Systems Society (HIMSS), the American Nurses As- sociation (ANA), and Capital Area Roundtable on Informatics in Nursing Group (CARING). Several nursing and health informatics scholarly journals, such as Computers, Informatics, and Nursing (www.
cinjournal.com) and Journal of the Medical Infor- matics Association (www. jamia.org), provide essen- tial nursing informatics education. The American Nurses Credentialing Center (ANCC) offers certi- fi cation examinations for a variety of specialties in nursing, including informatics (www.nursingworld.
org/ancc).
Using the Internet for Decision Making
You can use a variety of strategies to search the Internet, including quick and dirty searching, links, and brute force. Keep in mind that you must be per- sistent: no single search strategy or search engine is
Draw on search engines, such as Mayo Clinic
■
(www.mayoclinic.com), WebMD (www.webmd.
com), and so forth, that collect information from reliable online health resources rather than relying on the “bots” or robots typically used by search engines to “crawl” the Web, such as Google.
Refine your Internet searches with filters.
■
Filtering is mechanically blocking Internet content from being retrieved through the identifi cation of key words and phrases. For example, you can narrow your search by the type of medical viewpoint (traditional or going to work all the time. Here are some strategies
and tactics to render Internet searches more effi - cient and reduce search time (Jones, 2003):
Use Web sites published by governmental
■
or professional organizations or other repu- table organizations. See Table 4-6.
Use Consumer health sites organized by medi-
■
cal librarians.
Use precise terms, such as “Diabetes Type
■
I” instead of just “Diabetes,” to reduce the number of hits when searching for very spe- cifi c information.
List of Favorite Health Care Web Sites
www.acb.org www.acsh.org www.ahrq.gov
www.allnursingschools.com www.ama-assn.org www.americanheart.org www.arthritis.org www.cancer.org
www.cancernet.nci.nih.gov www.caringinfo.org www.cdc.gov www.cinahl.com www.clinicaltrials.gov www.cms.hhs.gov www.cochrane.org www.diabetes.org
www.digestive.niddk.nih.gov www.eatright.org
www.eMD.com
www.epilepsyfoundation.org www.fda.gov
www.familydoctor.org www.healthAtoZ.com www.healthcentral.com www.healthfi nder.gov www.healthgrades.com www.health.discovery.com
www.healthy.net www.intelihealth.com www.kidshealth.com www.lungusa.org www.mayoclinic.com www.medlineplus.gov www.medscape.com www.ncsbn.org www.netwellness.org www.nhlbi.nih.gov www.nia.nih.gov www.ngc.gov www.nih.gov www.noah-health.org www.nursingworld.org www.oncolink.com www.pain.com www.pdr.net
www.personalMD.com www.rarediseases.org www.realage.com www.rxlist.com www.shapeup.org www.vh.org www.webMD.com
www.yourtotalhealth.ivillage.com
Table 4-6
an enormous number of found references (called
“hits”), but you are interested only in the fi rst 10 to 20. Look at the universal resource locators (URLs), that is, the addresses of the sites that are returned by your search, and try to decipher what they mean. Pay attention to the domains: .com is com- mercial; .edu is an educational institution; .gov is the government. Quickly visit a few sites. Look for the information you need, or useful links. If a site is not relevant, use the back button on your browser to return to your search results and go to the next site. Once you fi nd a site that appears to be useful, begin to explore the site. Many sites will connect you to other sites, using links, or hot buttons. If you click on a link, it will take you to a related site.
If the site you are looking at has links (most do), use them to connect to other relevant sites. This process—quick search, quick review, clicking, and linking—can provide a starting point for finding useful information in a relatively short period of time. When you fi nd a site of interest, “bookmark”
it and add it to your list of favorites.
A bookmark list, or list of favorites, is like a per- sonal address book. Each time you fi nd a site that is particularly useful, you can add it to your list of favorites, using the appropriate feature in your browser. Eventually, you will have a comprehensive list of sites that are relevant to your work and inter- ests. By having this list, you will be able to quickly return to sites during future Internet sessions.
Brute Force
Brute force searching is another alternative. To do this, type in an address in the URL box (the ad- dress box at the top of the browser window) and see what happens. The worst outcome is an an- noying error message, but you may land on a site that is exactly what you want. To be effective, think how URLs work: they usually start with “www” (for
“World Wide Web”).Then there is the “thing in the middle” followed by a domain. Perhaps you are trying to fi nd a school of nursing at a certain university. What is the common name for the uni- versity? www.unh.edu is the very logical URL for the University of New Hampshire. Organizations are also quite logical in their URLs: www.aorn.org is the Association of periOperative Registered Nurses alternative), reading level (easy, moderate, or
complex), and type of site (commercial, non- commercial, government, or nonprofi t) that you use in your key words to fi lter your search (Nicoll, 2003).
The result of your searches after using these strate- gies will probably be a more focused and helpful list of links matching your specifi c request. You will then want to evaluate your search data using P-F-A Assessment.
The P-F-A Assessment
One strategy to develop your Internet search is to conduct a “purpose-focus-approach” (P-F-A) as- sessment. To determine your purpose, ask yourself why you are doing the search and why you need the information. Consider questions such as the following:
Is it for personal interest?
■
Do you want to obtain information to share
■
with coworkers or a client?
Are you verifying information given to you by
■
someone else?
Are you preparing a report or writing a paper
■
for a class or project?
Based on your purpose, your focus may be as follows:
Broad and general (basic information for
■
yourself)
Lay-oriented (to give information to a patient)
■
or professionally-oriented (for colleagues) Narrow and technical with a research orienta-
■
tion (Nicoll, 2003)
Purpose combined with focus determines your approach. For example, information that is broad and general can be found using brute force meth- ods or quick and dirty searching.
Quick and Dirty Searching and Links
Quick and dirty searching is a very simple, but sur- prisingly effective, search strategy. First, start with a search engine, such as AltaVista (www. altavista.
com) or Google (www.google.com). Next, type in the term of interest. At this point, do not worry about being overly broad or general. You may retrieve