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Abstract—Clinical judgment and decision-making is a

required component of professional nursing. Expert nurses are known for their efficient and intuitive decision-making processes, while novice nurses are known for more effortful and deliberate decision-making processes. Despite taking longer to make decisions, novices still have trouble with effective decision-making. The aim of this paper is to review the factors that contribute to clinical judgment and decision-making of novice nurses. This was achieved by reviewing over two hundred articles produced by searches through PsycINFO. These articles used various methods of data collection, ranging from observation to well-controlled experimentation, although the majority of the studies were exploratory in nature. Factors that influenced decision-making were categorized as either individual or environmental factors. Individual factors captured elements unique to the decision-maker and included factors such as experience, cue recognition, and hypothesis updating. By contrast, environmental factors captured elements surrounding the decision-task. Among these factors were task complexity, time pressure, and interruptions. The reliability and robustness of these factors are discussed. Keywords: novice nurses, clinical decision-making, clinical

reasoning, clinical judgment

I. INTRODUCTION ound clinical reasoning and clinical decision-making is largely considered a “hallmark” of expert nursing (Simmons, Lanuza, Fonteyn, Hicks, & Holm, 2003). The

ability to carry out competent decision-making is a critical and fundamental aspect of professional nursing. Decision-making abilities distinguish professional nurses from ancillary health care workers (Hughes & Young, 1990). In professional health care, it is often the case that decision consequences approach high risks, leaving little room for errors. Furthermore, the current health care environment has trended towards placing more accountability and responsibilities on nurses (Simmons

Paper completed in August, 2012. This work was supported in part by the National Council of State Boards of Nursing (NCSBN). Nursing clinical decision-making: A literature review.

W. J. Muntean is with the Department of Psychology, University of Oklahoma.

Correspondence concerning this paper should be addressed to William J. Muntean, Department of Psychology, University of Oklahoma, Dale Hall Tower, 455 West Lindsey Street, Norman, OK 73019. E-mail: [email protected]

et al., 2003; Saintsing, Gibson, & Pennington, 2011; Ebright, Urden, Patterson, & Chalko, 2004; Casey, Fink, Krugman, & Propst, 2004; Hickey, 2009).

Nurses are at the forefront of patient care, usually the first link in the causal chain between identifying complications and eventual rescue (Thompson et al., 2008). This, coupled with the increasing responsibilities, underscores the importance of sound clinical reasoning and decision-making. Choosing appropriate interventions accurately and timely is crucial (Clarke & Aiken, 2003).

Brennan and colleagues estimate that up to 65% of adverse events that hospital inpatients endure may be preventable—a result of poor clinical decision-making (Brennan et al., 2004; Leape, 2000). Hodgetts et al. (2002) report that 60% of cardiac arrests suffered by inpatients during hospitalization could have been prevented, with nearly half of those cases showing clinical signs of deterioration recorded in the preceding 24 hours, but not acted on (as cited in Thompson et al., 2008). Shockingly, the values recorded—but not acted upon—are the part of the basic knowledge of nursing practice, and are essential cues used to make clinical decisions (e.g., hear rate, respiratory rate, and oxygenation; see Goldhill, 2001). Surely, nurses must be aware that the decisions they make have significant impact on the healthcare outcome of their patients, yet these reports raise major concern (Long, Young, & Shields, 2007; Dowding & Thompson, 2003). What factors contributed to such lapses in clinical judgments?

Given the nature of the profession, nurses must perform at high levels—but can this be expected of novice nurses who just enter the field? A descriptive survey of employers of new nurses found that, in general, newly licensed nurses tend to be inadequately prepared to enter practice (Smith & Crawford 2002), with half the novice nurses being involved in errors of nursing care (Saintsing et al., 2011; Smith & Crawford 2003; Kenward & Zhong 2006). In addition, Saintsing et al. (2011) reported that only 20% of employers were satisfied with decision-making abilities of new nurses. Given the high involvement in errors and the assumption that decision-making is an integral part of nursing, it would prudent to carefully inspect the factors contributing to clinical decision-making in novice nurses. In what follows, I present a review of the emerging themes that have been explored in nursing clinical decision-making and highlight the known and suspected influencers on clinical decision-making.

Nursing Clinical Decision-Making: A Literature Review

William J. Muntean

S

W. J. Muntean | Clinical decision-making 2

II. LITERATURE REVIEW PROCESS

An evaluation of the peer-reviewed literature generated from PsycINFO with various combinations of the terms “decision-making”, “judgment”, “clinical”, “novice”, and “nursing” was carried out. The following limits were placed on the search: (1) articles must come from peer-reviewed journals; (2) only English language publications were reviewed; and (3) full text of the article must be available. Using these criteria, the search produced an overwhelming set of articles—over 1500 studies. Of these articles, roughly 800 were loosely related to nursing clinical decision-making and were reviewed. This subset of articles produced about 200 articles that had strong relevance to clinical decision-making and were subjected to a more detailed and thorough review.

The following paper summarizes research from the final subset of articles. In addition to a database search, citations to and from articles were also used. This led to the review of several book chapters, but to foreshadow a general theme found in the literature, most chapters are not reported because of the highly subjective nature of the content. Overall, this process uncovered three research themes on clinical decision-making—research on factors that influence nurse participation in clinical decision-making, research comparing decision-making processes between novice and expert nurses, and research on factors known (or suspected) to influence decision-making in nursing.

The single primary objective of this literature review was to uncover factors that influence clinical decision-making (either positively or negatively) in first-year novice nurses. However, there is a dearth of studies conducted with such a specific research goal; studies either deviate on participants used or focus on other aspects of clinical decision-making. There are several likely reasons that research on clinical decision-making of novice nurses is limited. First, there is a lack of consistency as to what constitutes a novice nurse (Simmons et al., 2003). Several researchers qualify nursing students (perhaps inappropriately) as novices (Tanner, Padrick, Westfall, & Putzier, 1987; Thiele, Holloway, Murphy, & Pendarvis, 1991; Baxter & Rideout, 2006; Lofmark, Smide, & Wikblad, 2006; Shin, 1998), whereas others define it within a single year (Ebright et al., 2004; Wainwright, Shepard, Harman, & Stephens, 2011; Saintsing et al., 2011; Greenwood & King, 1995; Forneris & Peden-McAlpine, 2007) and still others define it as within two years (Hoffman, Aitken, & Duffield, 2009; Grobe, Drew, & Fonteyn, 1991).

Second, a substantial number of clinical decision-making researchers have seemingly focused on the development of decision-making abilities and therefore include novice nurses as a mere baseline comparison group (Chunta & Katrancha, 2010; Benner, Tanner, & Chesla, 1992). Lastly, researchers focusing on the core decision-making process are more interested in nurses whose decision-making abilities are purportedly fully developed (e.g., expert nurses), which makes the implicit assumption that all novice decision-making is inferior and unstable (Buckingham & Adams, 2000a, 2000b). Often times these studies are carried out on specialized nurses, requiring more expertise and experience than most novice

nurses have (Kaasalainen et al., 2007; Marshall, West, & Aitken, 2011; Monterosso et al., 2005). Despite the dispersive focus of the field, studies that had strong implications for novice decision-making were included and described accordingly.

The three lines of research that emerged from the review are intimately related and need to be considered collectively. For instance, factors that influence the frequency of participation in decision-making may have differential effects on expert and novice nurses (Hoffman, Donoghue, & Duffield, 2004; Prescott, Dennis, & Jacox, 1987). Frequency of decision-making participation is assumed to play a critical developmental role in clinical competency (see, e.g., Thiele et al., 1991). Those who receive more opportunity in clinical decision-making are provided with more feedback on their decisions and interventions, ultimately leading to better quality decisions in the future (Thiele, Baldwin, Hyde, Sloan, & Strandquist, 1986). This is not to say that experience alone accounts for the development of decision-making skills (Benner, 1984), but instead it allows for more occurrences of factors that contribute to clinical decision-making skill development (Zinsmeister & Schafer, 2009).

Studies comparing novice and expert nurses are important for understanding clinical decision-making. This line of research focuses on the underlying decision-making process involved when nurses make clinical decisions. Various theoretical frameworks are put forth in the literature and each is useful for investigating decision-making factors because the frameworks break down the decision process into subcomponents—providing simpler methods of investigating influencers. For instance, expert nurses have been shown to use more forward reasoning in decision-making (e.g., data evaluation triggers a hypothesis), while novice nurses are shown to use more backward reasoning (e.g., hypothesis constrains data evaluation). Therefore, any manipulation affecting the collection of information (e.g., the quality of information, the ratio of confirming/disconfirming evidence to a particular action plan, etc.) will differentially impact expert and novice nurses in their ability to update their hypothesis. Hence, offering a method to differentiate between novice and expert nurses (Lamond, Crow, & Chase, 1996; Lauri & Salantera, 1995).

The final theme in the literature review is research that investigated factors contributing to clinical decision-making. These studies tend to be qualitative in nature (e.g., focus groups, think-aloud, observations) and use self-report questionnaires or survey methods for data collection (Funk, Tornquist, & Champagne, 1995), which might be problematic because conclusions are drawn on an ad hoc, exploratory basis (for a lengthier explanation, see Thompson, 1999a). That is, researchers explore transcriptions of interview or observation data and find general decision-making factors that are reported by participants. No further confirmatory research is conducted to determine whether the factors in question are discovered through chance or are actually found in the nursing population.

Few studies employ experimental techniques (e.g., manipulation of variables, proper controls, randomization, etc.). This speaks to the difficulty and complexity of conducting nursing research in applied environments

W. J. Muntean | Clinical decision-making 3

(Dowding & Thompson, 2003; Aitken, Marshall, Elliott, & Mckinley 2011). Although experimentation has the benefit of controlling for nuisance variables (e.g., confounds) and showing causality, it runs the risk of oversimplification. And while reducing nursing environments to vignettes for the sake of experimentation might show the basic processes of decision-making, doing so can lose sight of the overall picture of applicability. It is the classic argument of in vitro versus in vivo—applied versus laboratory research. Therefore, regardless of the exploratory nature of nursing clinical decision-making research, these studies lay the groundwork for future experiments to confirm the critical factors that impact clinical judgment and decision-making.

Collectively, these three themes highlight two categories of variables that impact nursing clinical decision-making, individual factors (e.g., cue recognition, knowledge structure, ability to update working hypothesis, communication, current state of emotion, etc.) and environmental factors (e.g., task complexity, time pressure, interruptions, professional autonomy, etc.). Individual factors focus on the decision-maker and various properties of information processing. By contrast, environmental factors relate to the to-be-processed information. For example, a nurse’s cue recognition ability will directly impact the efficiency and accuracy of their decisions—an individual factor. However, task complexity— an environmental factor—affects the presentation of cues and has an indirect impact on the decision-maker. The agreement on these factors in the literature is mixed. Some factors, such as task complexity, have repeatedly been shown to impact clinical decision-making (Corcoran, 1986a; Hicks, Merritt, & Elstein, 2003; Hughes & Young, 1990; Lewis, 1997). However, there has been less agreement on other factors, such as education level or experience (Sanford, Genrich, & Nowotny, 1992; del Bueno, 1983; Shin, 1998; Bechtel, Smith, Printz, Gronseth, 1993). Where appropriate, reasons for disparate results are discussed.

III. APPLIED DECISION-MAKING RESEARCH: METHODOLOGICAL DIFFICULTIES

As mentioned above, the majority of studies reviewed

implement qualitative methods, varying primarily between either observational designs or think aloud protocols, although there are a substantial amount of studies that collect data through surveys. There are several issues with these methods that are worth mentioning. First, for qualitative research, regardless of the means of collection, data must be coded either descriptively or thematically. This requires multiple trained coders to ensure reliability in coding. Furthermore, statistics should be provided as to the amount of agreement between coders, also known as inter-rater reliability. Given that the majority of nursing research is qualitative (Cullum, 1997; Thompson, McCaughan, Cullum, Sheldon, & Raynor, 2004; Thompson, 1999a), reliable coding is imperative so results and conclusions are not contingent on researcher bias

or ambiguous constructs. However, nearly all articles reviewed either failed to include multiple raters or included multiple raters but provided no measure of inter-rater reliability. This issue is so prevalent in the nursing clinical decision-making literature that Thompson and colleagues published a paper calling on researchers to be more transparent in coding procedures (Thompson et al., 2004).

Employing questionnaires as a means of collecting data affords the luxury of obtaining a large sample, but information collected through this method is contingent on the decision maker’s retrospective memory capabilities. These memories are particularly susceptible to a slew of memory biases (e.g., misattribution, suggestibility, hindsight bias, fluency effects, etc.). Caution should be given when interpreting results from studies that use questionnaires to investigate clinical decision-making (Aitken et al., 2011). To add to the problem, questionnaire response rates in some studies drop as low as 29%, raising the issue of selective sampling bias (Thompson, 1999a).

An additional method used to investigate nursing clinical decision-making is through constructed interviews or focus groups. These studies use an introspective approach to collect data: An interviewer guides nurses to explain the decision-making process and factors that affect it. The main concern with all introspective approaches is that it capitalizes on idiosyncrasies of the participant and the environment that surrounds them. Generalizability is very limited, unless the proper sampling techniques are used. For instance, factors that impact novice nurses in one hospital setting might be unique and not prevalent in other hospitals—a conclusion made by Bucknall and Thomas (1995). In complex areas of study, such as nursing, it is extremely challenging and very costly to implement appropriate sampling techniques and still control for nuisance variables.1

Setting aside the issue of sampling and generalizability, introspective methodology is not necessarily an improper tool for investigating nursing clinical decision-making factors. In fact, can be an exceptionally powerful technique for grasping a broad range of influential variables—it casts a wide net on seemingly important factors. However, with any broad research approach, additional studies (and to the extent possible, experimentation) should be carried out to provide corroborating evidence and rule out any idiosyncrasies.

Decision classification presents another difficulty in applied clinical decision-making. What constitutes as a correct decision? This issue is exacerbated by the fact that most applied nursing research lack the feedback to ascertain whether a nurse’s action plan reached an appropriate outcome. For instance, most observational studies examine nurses for several hours over a sequence of several days and observers receive no feedback on the outcome of their nurse’s decisions (Buckingham & Adams, 2000a; Long et al., 2007; Dowding & Thompson, 2003). Furthermore, not all decisions or action

1 Stratified random sampling is not the be-all and end-all technique in nursing research. Many authors argue that it is more important to get subjects and data likely to generate robust, rich, and deep understanding (Thompson, 1999a).

W. J. Muntean | Clinical decision-making 4

plans can be classified as binary. Decisions are often considered on gradient scales. Take for example two decisions or action plans that reach the same conclusion. Despite no differences in outcome, the two decisions could differ in efficiency, resources needed, complexity required, and therefore ultimately differ in quality. One solution offered by Bucknall (2000) and King and Clark (2002) is to encourage researchers to conduct larger scale longitudinal studies. This is an admirable request, indeed, but also a rather costly and difficult paradigm to implement, hence only several studies use this technique (Casey et al., 2004; Standing, 2007; O'Neill & Dluhy, 1997).

Lastly, when comparing observational methods to think aloud protocols, systematic differences have been observed. Think aloud protocols have been shown to collect a greater frequency of decisions than that of observation (Aiken et al., 2011). Specifically, when investigating decision-making involving assessment, diagnosis, and evaluation, think aloud protocols should be used because it affords information that cannot otherwise be collected by observation. However, there are limitations with think aloud protocols. Nurses must be comfortable with a continuous verbalization and they must be given adequate practice sessions. In addition, the very nature of thinking aloud might itself change the decision process that occurs with covert thinking (e.g., Heisenberg effect and/or Hawthorne effect; see Thompson, 2011). Observational methods also have some limitations. They require the observer to become a participant in the environment and their interactions can influence the patient-nurse dynamics—the consequence is creating an artificial setting (Luker & Kenrick, 1992). Therefore, the literature reviewed includes a mix of both observational methods and think aloud protocols.

Before detailing each category of factors, I briefly describe several frameworks of nursing decision-making that have been endorsed throughout the literature. Although these frameworks have been put forth primarily to distinguish between novice and expert nurses, they are insightful and explain the core elements involved in decision-making. Additionally, these frameworks provide the context in which the contributing factors are described in nursing research and, to some degree, in the current review.

IV. CLINICAL DECISION-MAKING MODELS AND FRAMEWORKS

One source of complexity that surrounds nursing clinical

decision-making is that different nurses use different decision strategies. Depending on the dynamics of the task a single nurse can even use multiple strategies (Corcoran, 1986a, 1986b; Jenks, 1993; Cader, Campbell, & Watson, 2005). Factors that influence one method of decision-making may not have the same effect on another decision strategy (Baker, 1997). A unifying approach to nursing clinical decision-making is exceptionally difficult for this reason. There are a few proponents of this approach, though.

Buckingham & Adams (2000a, 2000b) suggest that the major clinical decision-making theories are so similar that they only differ in terminology and semantics. They argue that decision-making research would be much more efficient and communicable if the research community endorsed this approach rather than placing so much energy on distinguishing theories apart2. Despite the similarities (or differences) three popular theories are summarized below.

Skills acquisition and the humanistic-intuitive approach

Perhaps the most influential framework of nursing decision-making is Benner’s (1984) modification of the skills acquisition theory (for a review, see Dreyfus & Dreyfus, 1986). Benner postulated that clinical decision-making expertise is developed through experience as one progresses through five stages of skill acquisition. The first stage is the novice stage, which describes a beginner in the nursing domain. They learn through instruction and learn domain-specific facts, features, and actions (Gobet & Chassy, 2008). Novice decision-making is context free, meaning that novices ignore idiosyncrasies of the situation. This results in decision-making that is primarily rule based. It is inflexible and resulting in very limited performance.

After acquiring a fair amount of experience, a novice progress to an advance beginner. Advance beginners account for more situational variables when making decisions. Decision-making attributes start to become context dependent. They also make use of limited past experience (given that they have had a similar past encounter). The competence stage involves organization structures such as hierarchical long-range plans. Decisions are reached with greater efficiency, albeit still relying on conscious, abstract, analytical, and deliberate planning.

The proficiency stage marks holistic thinking rather than fragmented subcomponents. Problem features are viewed as salient or irrelevant, allowing decision-makers to organize and analyze a situation intuitively, but analytical thinking is still required to choose the action plan. Lastly, expertise stage represents those who can understand a situation intuitively and make decisions intuitively as well. Accordingly, experts act naturally and often reach conclusions without explicit understanding. Experts can revert to previous stages of analytical thinking if a situation is novel or their initial intuition is incorrect.

A strength of the humanistic-intuitive model of decision-making is its simplicity. It describes the progression from novice to expert succinctly—from a slow and hesitant decision-maker to a fast and fluid problem solver. It captures the relationship between knowledge and experience. Another strength of the theory is that it captures the involvement of emotion, namely in the intuition process (Benner et al., 1992; Jenks, 1993). Perhaps this is the reason why the framework has been adopted as the standard in nursing clinical decision-making (Agan, 1987; Benner & Tanner, 1987;

2 For an example of the lively ongoing debate on nursing clinical decision-making theories, see English, 1993; Darbyshire, 1994; Benner & Tanner, 1987; Cash, 1995; Benner, 1996.

W. J. Muntean | Clinical decision-making 5

Corcoran, 1986a, 1986b; Crandall & Getchell-Reiter, 1993; Pyles & Stern, 1983; Rew, 1988, 1990, 1991; Schraeder & Fisher, 1986, 1987; Young, 1987). Intuition is phenomenological in spirit and is often described as a feeling of knowing something without conscious use of reason (Banning, 2007) or an understanding without rationale (Benner & Tanner, 1987). For this reason, hypothesis testing is not necessarily used as a criterion for accurate or inaccurate propositions and reasoning, which raised much skepticism as to whether this approach is scientifically based (Banning, 2007; Cash, 1995; English, 1993).

Due to the phenomenological nature, researchers using this approach have a difficult time unifying the definition of intuition (Buckingham & Adams, 2000b). As a consequence, nursing decision-making literature is filled with this loose construct. For example, over 25% of the articles reviewed used the term ‘gut feeling’ as a proxy for intuition when surveying nurses on factors that led to their decisions (see, e.g., Burman, Stepans, Jansa, & Steiner, 2002; Pretz & Folse, 2011; Ericsson, Whyte, & Ward, 2007). This raises the question, how can this body of research differential between ‘gut feelings’ and guesses? If surveys included a guess option, how would the endorsement of this choice be interpreted—especially when a guess resulted in the correct decision? Would that constitute as intuition, being a gut feeling guess? Hence, therein lies the biggest criticism of this framework, construct specificity (Rew, 2000). Recent studies have made attempts to better define intuition as it is used in nursing clinical decision-making (e.g., domain specific intuition; Rew, 2000; Smith et al., 2004; Smith, 2006, 2007; Miller, 1995; Pretz & Folse, 2011). Rew (2000) conducted a three-phase study on validating an intuition assessment scale, hoping that it would provide a way to measure a nurse’s propensity of utilizing intuition. The scale started out with a 50-item questionnaire that covered six conceptual categories relating to complex decision-making: uses sudden/immediate insight, creativity, risk taking, rigidity, cautiousness, and realistic approach (Rew, 1986; Masters & Masters, 1989). An expert nursing panel reviewed the assessment and reduced the number of questions to 28 items. Following the review, a Content Validity Index was carried out and revealed a high level of agreement (CVI = .96).

In the next phase, the assessment was sent out to 106 nurses and responses were subjected to a principal component factor analysis. This analysis led to a six-factor model. However, seven questions had very low factor loadings and thus the scale was reduced to 21-items. For the final phase of the study, the reduced scale was administered to an additional set of nurses. As before, a factor analysis was conducted on these responses. This time three factors were retained, and only a single factor clearly came from the original domain. The author then further reduced scale to a unidimensional measure of seven questions and labeled it as the Acknowledges Using Intuition in Nursing Scale (AUINS) (see Table 1). Interestingly, this measure has yet to be explicitly tested in the decision-making literature. How does this measure correlate with the quality and efficacy of decisions that nurses make? Smith and colleagues have also made attempts at better defining intuition (Smith, Thurkettle, & dela Cruz, 2004; Smith, 2006). Using similar exploratory factor analyses that Rew (2000) used, Smith et al. (2004) developed their own intuition measurement scale. This resulted in a 25-item scale with seven factors: physical sensations, premonitions, spiritual connections, reading cues, sensing energy, apprehension, and reassuring feelings (see Table 2). The most striking issue with this study (and the follow-up study, Smith, 2006) was that nursing students were used as participants. This is seemingly problematic because according to Benner’s theory, novice nurses lack the intuition abilities that expert nurses have (Benner et al., 1992). Collectively, these studies take on the

TABLE I ACKNOWLEDGES USING INTUITION IN NURSING SCALE

QUESTION # SCALE ITEM

1 There are times when I suddenly know what to do for a patient, but I don’t know why.

2 I am inclined to make decisions based on a sudden flash of insight.

3 There are times when I immediately understand what to do for a patient, but I can’t explain it to other people.

4 There are times when I feel that I know what will happen to a patient, but I don’t know why.

5 There are times when a decision about my patient’s care just comes to me.

6 There are some things I suddenly know to be true about some of my patients, but I am unable to support this with concrete data.

7 Sometimes I act on a sudden knowledge about a patient to prevent a crisis from developing even when I can’t explain it.

Note—Reproduced from Rew (2000)

TABLE 2 INTUITION FACTORS

FACTOR SCALE ITEM

Physical sensations

I get a shiver down my spine when I think something is wrong with my patient.

The hair on my arms a

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