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Nursing Clinical Decision-Making: A Literature
Review
William J. Muntean
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
N
I. EXECUTIVE SUMMARY
ewly registered nurses have limited experience with
health care practice and yet are required to make clinical
decisions after only a brief orientation period. While
many novices can adapt to the demanding environment
involved with clinical practice, employers reported that a large
portion of novices are inadequately prepared; nearly one out of
two novices were involved in errors of nursing care (see
Saintsing, Gibson, & Pennington, 2011). Furthermore, only
20% were satisfied with the novices’ clinical-decision-making
abilities.
Clinical decision-making plays an intimate role in the
quality of care that nurses provide to patients. Poor
decision-making can lead to adverse events and have negative
consequences for patients. It is estimated that up to 65% of
adverse events could have been prevent had nurses made
better decisions (Brennan et al., 2004; Leape, 2000; Hodgetts
et al., 2002). Given that the decisions nurses make have such
high consequences, it would be prudent to understand what
factors contribute to clinical decision-making (Dowding &
Thompson, 2003). A literature review was conducted to
address this issue.
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 overly generous
amount of articles—roughly 1500 studies. Many of the articles
only briefly mentioned the search terms and were not relevant
to the topic of the review. After sifting though the results,
roughly 200 had strong relevance to clinical decision-making
and were subjected to a more detailed and thorough review.
III. APPLIED DECISION-MAKING RESEARCH:
METHODOLOGICAL DIFFICULTIES
Researching clinical decision-making in an applied setting
requires elaborative methodology so the underlying cognitive
processes are pure and unaltered by the means of data
collection. These methodologies are difficult to implement and
are not always pragmatic. Most applied studies use
observational or think-aloud paradigms—each having
advantages and disadvantages (Aitken, Marshall, Elliott, &
Mckinley, 2011). On the one had, observations have the
benefit of not altering the decision process by asking nurses to
explicate their decisions. On the other hand, observers are not
made aware of the information considered when nurses reach
a decision.
However, regardless of the mode of data collection, a
general methodological theme emerged—studies were
exploratory in nature. Researches analyzed their field notes
and interview transcripts searching for common themes. Once
they were generated, the themes were never tested explicitly
through confirmatory experiments. This runs the risk of
capitalizing on chance and discovering spurious effects.
Despite this weakness, there are “clusters of recurring
findings” (Thompson, 1999 pg. 816) that suggest these factors
should be given some a priori theoretical consideration.
In contrast to applied settings, laboratory experiments use
vignettes and written patient scenarios to study clinical
decision-making. These studies can place more control on
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W. J. Muntean | Clinical decision-making | Executive summary
confounding elements that freely vary in realistic
environments. In addition, specific variables can be
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
in applied settings immediate decision feedback is almost
never possible. While laboratory experimentation has greater
control than observational paradigms, it risks external validity
and generalizability (Gould, 1996).
IV. CLINICAL DECISION-MAKING MODELS AND
FRAMEWORKS
Clinical decision-making models are templates that describe
the process nurses use to reach decisions. They provide a
theoretical framework that breaks down the complex decision
process into smaller subcomponents, each of which can be
subjected to experimentation and validated. Three major
models are put forth in the literature, the humanistic-intuitive
model, the information-processing model, and the cognitive
continuum theory (for a review, see Banning, 2007; Cader,
Campbell, & Watson, 2005).
The humanistic-intuitive approach emphasizes personal,
emotional, and contextual elements in decision-making. The
main focus of this model is to describe the changes in decision
processes between novice and expert nurses. As a novice, a
nurse will use a more systematic and analytical (e.g., rule
based) method to make decisions, neglecting contextual
elements of the decision task. By contrast, an expert will make
fluid intuitive decisions accounting for decision task
idiosyncrasies. There are various definitions of intuition in the
literature, but most theorists agree that intuition is
phenomenological in spirit and described as a feeling of
knowing something without conscious use of reason (Banning,
2007).
In the information-processing model, decisions are reached
in a systematic and analytical manner. They follow a set of
procedures that describe cue acquisition, hypothesis
generation, cue interpretation, and hypothesis evaluation. In
contrast to intuitive approaches, the information-processing
model is context-invariable and is said to apply in all
decision-making environments. Communication and clarity in
decisions are the key strengths of this model. Because it is
systematic nurses are able to explicate how they arrived to a
decision and what factors they considered in the process
(Banning, 2007).
The cognitive continuum theory severs to reconcile the
stark differences between systematic-analytical and intuitive
approaches by assuming that both are needed to achieve
optimal decisions. According to the theory, a decision is
defined by how well-structured or ill-structured the task is. If a
decision task is well-structured then systematic reasoning will
lead to the best decisions, whereas ill-structured tasks are best
suited for intuition. The mode of decision-making is assumed
to vary across a continuum (as does the structure of a task) and
therefore brings resolution to the opposing theories of
decision-making (Cader et al., 2005).
V. FACTORS IMPACTING NURSING CLINICAL
DECISION-MAKING
Individual Factors
Age and Educational Level. Some of the most researched
factors of clinical decision-making are age and educational
level, presumably because the data are easy to collect and easy
to use as statistical covariates. However, the research is at best
inconclusive (see, e.g., Thompson, 1999). One potential
reason for this is that studies use a coarse measure of
education (e.g., comparing nurses with only high school
diplomas to all other levels of education) and therefore have a
difficult time detecting differences. Another reason might be
because many studies use ad-hoc dependent variables, such as
themes that emerge from interview transcriptions. Regardless,
there is not enough consistent evidence to assume that
educational level or age has an impact on clinical
decision-making.
Experience, Knowledge, and Cue Recognition. Accurate
decisions cannot be reached without some level of
knowledge—it is the foundation of decision-making.
Knowledge gives nurses the ability to identify information
cues relating to the decision problem. If a nurse’s knowledge
base is limited or impaired, fewer decision cues will be
recognized and decisions will be based on partial
information—leading to poorer decisions. Clinical experience
adds to the practical and functional knowledge that nurses
need to make complex decisions. However, novice nurses
have little or no experience in clinical settings. This poses
some limitations on their general ability to recognize relevant
information cues relating to the decision-problem at hand,
hence there is more potential for erroneous decision-making
(Thiele, Holloway, Murphy, & Pendarvis, 1991).
Hypothesis updating. Expert nurses have been shown to use
a broad approach to decision-making (Corcoran, 1986). They
form general hypotheses and then update and refine them
when receiving new information cues. By contrast, novices
use a more focused approach and immediately form specific
hypotheses. They then have trouble updating their original
hypothesis when receiving new information, which can lead to
decision errors (Hammond, Kelly, Schneider, & Vancini,
1967).
Communication. One method to gather additional
information cues is to consult with the peer nursing staff
(Hedberg & Larsson, 2003). This is especially important for
complex decisions where a new perspective might offer some
insight. Communication facilitates cue acquisition and is a
necessity for gathering information from patients. However,
novices are unconfident in their communication abilities and
struggle to communicate in the essential areas of nursing
(Casey, Fink, Krugman, & Propst, 2004). This increase the
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W. J. Muntean | Clinical decision-making | Executive summary
risk of making decision errors.
Emotions and Perceptions. A nurse’s current state of
emotion will affect their decision-making abilities. A
confident nurse will be more assertive in their
decision-making and this allows them to take control of
situations. By contrast, a nurse who is not confident will have
self-doubt in their decisions, feel powerless, and be unsure of
their choices. Proactive decision-making is also associated
with confidence. Confident nurses were initiators and made
preventative decisions rather than merely responding to
problems (Hagbaghery, Salsali, & Ahmadi, 2004).
Environmental Factors
Task Complexity. The most robust environmental factor of
clinical decision-making is the complexity of the decision-task
(see, e.g., Lewis, 1997). Complexity can involve any number
of factors that increase the cognitive load on the
decision-maker. The most common manipulations are the
number of redundant cues, contradicting cues, cues that
indicate either positive or negative changes, or increasing the
number of irrelevant cues. Empirically, decision quality is
shown to suffer when complexity is increased (Corcoran,
1986; Hughes & Young, 1990).
Time Pressure. Another robust environmental factor that
impairs clinical decision-making is time pressure. Thompson
et al. (2008) had nurses make decisions about interventions
either under no time constraints or under time pressure. Nurses
with more experience made better decisions when they were
self-paced, but introducing time pressure eliminated this
advantage and all nurses performed poorly. In the nursing
practice, time pressures can be found in many forms. For
example, novices feel pressure to complete their rounds and
leave a clean sheet for the incoming nurses. This presents a
self-imposed time pressure, which can compromise their
decision-making.
Interruptions. Interrupting the decision-making process
places additional cognitive strain on the decision-maker by
forcing them to processes information that is usually irrelevant
to the current task. The competing information displaces
memory contents, some of which is important and relevant to
the decision. However, this does not necessarily lead to poorer
decisions, per se. Only when cognitive demands surpass the
decision-maker’s cognitive capacity will decision accuracy
suffer. Hence, this factor interacts with task complexity
(Speier, Valacich, & Vessey, 1999).
Area of Specialty and Professional Autonomy. Decision
tasks are not similar in all nursing departments and units. They
differ on many dimensions such as average task complexity,
time pressure, or the number of supporting nurses. This results
in unequal decision-error base rates across the areas of nursing
specialties. Additionally, professional autonomy—the freedom
to make decision—can differ across departments. Autonomous
nurses have been shown to make better quality decisions than
nurses who are less autonomous (Bakalis, Bowman, & Porock,
2003). Autonomy allows nurses to place greater focus on
patients, which facilitates decision-making.
VI. CONCLUSION
Factors identified in this literature review either affect the
decision-maker or the decision-task—perhaps even an
interaction of both. Some of these factors can be taught or
tested to improve decision-making (e.g., cue recognition,
hypothesis updating, task complexity). Cue recognition is the
foundation of all decision-making and is built through
knowledge that is gained in nursing school. While this can be
supplemented with clinical experience, novice nurses must
enter the profession with an acceptable level knowledge. This
can be easily tested to ensure that novices do not lack the
fundamentals.
But not all factors in this review can be tested (e.g.,
education, clinical experience, or propensity to communicate).
These factors are a byproduct of exploratory studies—ones
that rely on observational and survey studies. These studies
are insightful and provide the motive for future confirmatory
studies, but the method of data collection places a limit on the
type of factors that can be researched (Aitken et al., 2011).
Methodological innovations are underway and recent studies
show promise that more testable factors will be discovered
(Thompson et al., 2008).
Overall, nursing research on clinical decision-making is
very challenging because of the dynamic environment in the
applied setting. The research reviewed in this paper clearly
demonstrates this. While no single experiment or study can
account for all the variables affecting clinical
decision-making, researchers have made good attempts to
isolate factors and investigate them to the extent possible.
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