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confounding elements that freely vary in realistic therefore brings resolution to the opposing theories of
environments. In addition, specific variables can be decision-making (Cader et al., 2005).
manipulated (e.g., task-complexity, difficulty, time pressure)
to show their impact on the decision-making process.
Accuracy of decisions can be studied and measured, whereas V. FACTORS IMPACTING NURSING CLINICAL
in applied settings immediate decision feedback is almost DECISION-MAKING
never possible. While laboratory experimentation has greater
control than observational paradigms, it risks external validity Individual Factors
and generalizability (Gould, 1996).
Age and Educational Level. Some of the most researched
factors of clinical decision-making are age and educational
IV. CLINICAL DECISION-MAKING MODELS AND level, presumably because the data are easy to collect and easy
FRAMEWORKS to use as statistical covariates. However, the research is at best
inconclusive (see, e.g., Thompson, 1999). One potential
Clinical decision-making models are templates that describe reason for this is that studies use a coarse measure of
the process nurses use to reach decisions. They provide a education (e.g., comparing nurses with only high school
theoretical framework that breaks down the complex decision diplomas to all other levels of education) and therefore have a
process into smaller subcomponents, each of which can be difficult time detecting differences. Another reason might be
subjected to experimentation and validated. Three major because many studies use ad-hoc dependent variables, such as
models are put forth in the literature, the humanistic-intuitive themes that emerge from interview transcriptions. Regardless,
model, the information-processing model, and the cognitive there is not enough consistent evidence to assume that
continuum theory (for a review, see Banning, 2007; Cader, educational level or age has an impact on clinical decision-
Campbell, & Watson, 2005). making.
The humanistic-intuitive approach emphasizes personal, Experience, Knowledge, and Cue Recognition. Accurate
emotional, and contextual elements in decision-making. The decisions cannot be reached without some level of knowledge
main focus of this model is to describe the changes in decision —it is the foundation of decision-making. Knowledge gives
processes between novice and expert nurses. As a novice, a nurses the ability to identify information cues relating to the
nurse will use a more systematic and analytical (e.g., rule decision problem. If a nurse’s knowledge base is limited or
based) method to make decisions, neglecting contextual impaired, fewer decision cues will be recognized and
elements of the decision task. By contrast, an expert will make decisions will be based on partial information—leading to
fluid intuitive decisions accounting for decision task poorer decisions. Clinical experience adds to the practical and
idiosyncrasies. There are various definitions of intuition in the functional knowledge that nurses need to make complex
literature, but most theorists agree that intuition is decisions. However, novice nurses have little or no experience
phenomenological in spirit and described as a feeling of in clinical settings. This poses some limitations on their
knowing something without conscious use of reason (Banning, general ability to recognize relevant information cues relating
2007). to the decision-problem at hand, hence there is more potential
In the information-processing model, decisions are reached for erroneous decision-making (Thiele, Holloway, Murphy, &
in a systematic and analytical manner. They follow a set of Pendarvis, 1991).
procedures that describe cue acquisition, hypothesis Hypothesis updating. Expert nurses have been shown to use
generation, cue interpretation, and hypothesis evaluation. In a broad approach to decision-making (Corcoran, 1986). They
contrast to intuitive approaches, the information-processing form general hypotheses and then update and refine them
model is context-invariable and is said to apply in all decision- when receiving new information cues. By contrast, novices
making environments. Communication and clarity in decisions use a more focused approach and immediately form specific
are the key strengths of this model. Because it is systematic hypotheses. They then have trouble updating their original
nurses are able to explicate how they arrived to a decision and hypothesis when receiving new information, which can lead to
what factors they considered in the process (Banning, 2007). decision errors (Hammond, Kelly, Schneider, & Vancini,
1967).
The cognitive continuum theory severs to reconcile the Communication. One method to gather additional
stark differences between systematic-analytical and intuitive information cues is to consult with the peer nursing staf
approaches by assuming that both are needed to achieve (Hedberg & Larsson, 2003). This is especially important for
optimal decisions. According to the theory, a decision is complex decisions where a new perspective might ofer some
defined by how well-structured or ill-structured the task is. If a insight. Communication facilitates cue acquisition and is a
decision task is well-structured then systematic reasoning will necessity for gathering information from patients. However,
lead to the best decisions, whereas ill-structured tasks are best novices are unconfident in their communication abilities and
suited for intuition. The mode of decision-making is assumed
struggle to communicate in the essential areas of nursing
to vary across a continuum (as does the structure of a task) and
(Casey, Fink, Krugman, & Propst, 2004). This increase the
W. J. Muntean | Clinical decision-making | Executive summary 3
differ on many dimensions such as average task complexity, Casey, K., Fink, R., Krugman, M., & Propst, J. (2004). The Graduate Nurse
Experience. Journal of Nursing Administration, 34, 303-311.
time pressure, or the number of supporting nurses. This results Corcoran, S. (1986). Task complexity and nursing expertise as factors in
in unequal decision-error base rates across the areas of nursing decision making. Nursing Research, 35, 107-112.
specialties. Additionally, professional autonomy—the freedom Dowding, D., & Thompson, C. (2003). Measuring the quality of judgment
and decision-making in nursing. Journal of Advanced Nursing, 44, 49–57.
to make decision—can differ across departments. Autonomous
Gould, D. (1996). Using vignettes to collect data for nursing research studies:
nurses have been shown to make better quality decisions than how valid are the findings? Journal of Clinical Nursing, 5, 207–212.
nurses who are less autonomous (Bakalis, Bowman, & Porock, Hagbaghery, M., Salsali, M., & Ahmadi, F. (2004). The factors facilitating
2003). Autonomy allows nurses to place greater focus on and inhibiting effective clinical decision-making in nursing: a
patients, which facilitates decision-making. qualitative study. BMC nursing, 3, 1-11.
W. J. Muntean | Clinical decision-making | Executive summary 4