Increasing nurses’ participation in decision-making has been used as a mechanism to assist nurses to manage the increasing complexity of their work and facilitate positive nurse and patient outcomes.1,2 When nurses participate fully in decision-making, they are more satisfied with their work,3-5 and they tend to stay in their positions as evidenced by higher retention rates.5 Nurses’ participation in decision-making has also been correlated with greater patient satisfaction6 and has been found to affect the extent to which patients perceive that their expectations for symptom management have been met.7 Further, researchers have found that hospital units in which nurses reported high levels of participation in decision making had fewer infections and pressure ulcers.8
This growing body of evidence suggests that nurses’ participation in decision-making in hospitals positively affects nurse and patient outcomes; however, the relationship between the types of decisions that nurses participate in and where they work is unclear. This study seeks to better understand nurses’ participation in decision-making in different types of hospital nursing units.
Although nurses tend to participate more in clinical decisions than in administrative decisions,1,8,9 their participation can vary depending on the situation3 and the phase of the decision-making process.10,11 Typical clinical decisions include consulting with others when solving complex patient problems and adjusting the nursing plan of care, whereas typical administrative decisions include revising and evaluating nursing policies and procedures and determining appropriate staffing for a unit.1,8 Some scholars suggest that understanding the effects of clinical decisions may be key to understanding the effects of nurse decision making on nurse and patient outcomes.1,12
Only 1 study was found exploring nurses’ participation in decision making in different types of units.13 Researchers found differences in how nurses perceived their influence over decisions involving patient care management, with low levels in general care units and high levels in critical care units. These findings lend support to the notion that participation in decision making may vary by unit type.
This study explored the type of decisions that nurses made in different types of adult general care, intermediate care, and critical care units and differences in decision making based on the unit types. The research questions were as follows: 1) In general, intermediate and critical care hospital nursing units, how are nurses participating in clinical and administrative decisions? 2) Are there differences in nurses’ participation in clinical and administrative decision-making based on the type of unit? 3) Are there differences in nurses’ participation in the phases of clinical and administrative decision making based on the type of unit?
Study Design and Sample
This study utilized a cross-sectional correlational design. Fifty-one nursing units were selected from a convenience sample of 6 hospitals in the Southeastern United States. There were 2 urban teaching hospitals (500+ and 900+ beds), 3 suburban community hospitals (200+, 175, and 50 beds), and 1 rural community hospital (100 beds). All except 1 of the hospitals (the 175-bed community hospital) were Magnet designated and utilized shared governance models. All regularly scheduled nurses in adult acute and critical care units in the study hospitals were eligible to participate. A total of 307 nurses (40%) in 24 nursing units (47%) were represented in the final analysis of a total possible sample of 774 nurses and 51 nursing units.
Data assessing nurses’ participation in decision making were collected using the Participation in Decision Activities Questionnaire (PDAQ).10 Nurses were asked for general demographic information, and the remainder of the questionnaire was in 2 parts, which gave examples of decisions made by nurses. Part 1 described 12 activities representing clinical decisions, and Part 2 described 11 activities representing administrative decisions. These decisions are outlined in Table 1. For each decision, 3 statements asked nurses to describe the extent of their participation in each of the 3 phases of decision-making. To illustrate, nurses who were caring for patients experiencing pain rated the extent to which they participated in the decision-making phases of managing patients’ pain on a 6-point scale, ranging from a score of 1 for “no participation to a score of 6 for “a great deal of participation.” The 3 phases included raising the issue and clarifying the problem (identification), generating and evaluating alternatives (design), and selecting among alternatives (selection). Detailed scoring information for the PDAQ is published elsewhere.10
The PDAQ has published psychometric support.10,14 Interitem correlations were between 0.3 and 0.7 for the items on participation in the identification, selection, and design phases of clinical and administrative decisions. Standardized Cronbach α’s supported the internal consistency of both the clinical decision subscales (α’s were 0.86 for identification and 0.85 for design and selection) and the administrative decision subscales (α’s were 0.86 for identification, design, and selection) of the PDAQ.10
Institutional review board approval was received from each of the 6 hospitals, and all nurses who responded to the survey consented to participate. Nurses completed PDAQ paper tools, which were distributed and collected by nurse study coordinators at each hospital. Measures to maximize nurse survey responses included using Dillman and colleagues,15 methods in order to minimize drawing conclusions based on response rates that make the data nonrepresentative of the population. Hospital-appointed study coordinators followed up with all nurses in each unit at regular intervals during the data collection period to encourage participation in the study.
Data were analyzed at the individual level. Data on nurses’ participation in the decision variables were collected on a 6-point scale, ranging from a score of 1 for “no participation” to a score of 6 for “a great deal of participation.” The PDAQ 6-point scale data on nurses’ participation in decision, ranging from a score of 1 for “no participation” to a score of 6 for “a great deal of participation,” were changed to 3 levels by collapsing categories to high participation,5,6 medium participation,3,4 and low participation1,2 for these analyses.
The association between nurses’ participation in the decision variables and nursing care units were determined using χ 2 tests. The Kruskal-Wallis test was used to check the difference in nurses’ decisions among general care, intermediate care, and critical care units.
Characteristics of the Sample
The final sample consisted of 307 nurses in 24 nursing units from 6 acute care hospitals. There were 5 critical care units (21%), 5 intermediate care units (21%), and 14 general care units (58%). Table 2 lists descriptive data for the sample. Characteristics of the nurses in the units were very similar across the 3 types of units.
Response rates were calculated for each unit in the sample. Response rates for the units ranged from 26% to 50%, which was deemed sufficient for our analyses.16 Nurses participated in both clinical and administrative decision making in all of the different types of nursing units in the sample; however, they participated at much higher amounts (high vs low or medium participation) and at higher levels of critical thinking (determining and choosing alternatives to be used in solving the problems instead of simply raising the issue and recognizing the problem situation) in clinical decisions than administrative decisions.
Nurses in all 3 types of units participated in very high amounts in several of the clinical decisions. In contrast, nurses in all 3 types of units participated in less amounts in most of administrative decisions except for serving on a nursing division committee. Across the 3 types of units, most nurses participated at medium or high amounts in serving on a nursing division committee.
There were differences in nurses’ participation in the amount (low, medium, or high) of clinical and administrative decision-making based on the type of unit. For clinical decisions, nurses in critical care units participated at higher amounts in preventing skin breakdown, refusing to carry out physician orders, advocating for patient/family’s choice to refuse further treatment, and handling physician complaints about patient care than nurses in intermediate or general care units. Nurses in intermediate care units participated at higher amounts in medication teaching with the patient and family and determining discharge from the unit than nurses in critical care or general care units. For administrative decisions, nurses in critical care units participated at higher amounts in serving on a nursing division committee than nurses in intermediate or general care units. Nurses in intermediate care units participated in higher amounts in decisions about equipment and supplies and method of delivery of care and staff mix than nurses in critical care or general care units When compared with intermediate and critical care units, there were no areas where general care units participated in significantly higher amounts in either clinical or administrative decisions.
There were also differences in nurses’ participation in the level or phase of clinical and administrative decision making based on the type of unit. Overall, nurses in critical care units participated more in higher-level decision-making including generating alternatives and selecting among alternatives. Nurses in intermediate care units participated in the selecting phase of decision-making, the highest level, more than general or critical care units for several clinical decisions (Table 3). For administrative decisions, however, only serving on a nursing division committee showed any big differences in participation related to the phase of decision making. Nurses in intermediate care units participated least in the selecting phase. Nurses in critical care units participated in the selecting phase of decision making more than general or intermediate care units for several clinical decisions (Table 3). There were differences in the phases of decision-making that these nurses participated in; however, the χ 2 tests only detected that nurses are participating differently in these decisions, not significance based on the types of units where the nurses worked (Table 3).
For clinical decisions, handling physician complaints about patient care was statistically significant and different among nurses for the lowest level of decision making, raising the issue. Informing the patient or family about the risks associated with surgery, determining discharge from the unit, and advancing physician diet and activity orders were statistically significant and different among nurses for higher levels of decision-making and generating and selecting alternatives. Refusing to carry out a physician order, advocating patient/family choice to refuse further treatment, and handling physician complaints about patient care were statistically significant and different among nurses for higher levels of decision-making and generating and selecting alternatives.
For administrative decisions, serving on a nursing committee was statistically significant and different among nurses for higher levels of decision-making and generating and selecting alternatives level, and statistically significant and different among nurses for raising the issue, the lowest level of decision-making. Choosing new equipment and supplies for the unit and determining the method of delivery of care and staff mix were statistically significant and different among nurses for all 3 levels of decision-making including raising the issue and generating and selecting alternatives.
These findings have important implications for both practice and future research. As was found in other studies,1,8 nurses in this study participated more in clinical decisions than administrative decisions. What was interesting were the differences in decision making that were found among the different types of units. Nurses in critical care units participated in higher amounts and at higher levels of clinical decisions overall than either intermediate or general care units. Nurses in critical care units participated in higher amounts and at higher levels in clinical decisions related to refusing to carry out physician orders, advocating for patient/family’s choice to refuse further treatment, and handling physician complaints about patient care. Critical care nurses may have been more comfortable speaking up in difficult situations due to slightly longer tenure in their roles, which could also lead to stronger relationships with their team members. They also may be more comfortable in difficult situations due to the rapidly changing nature of their work environment.
With certain clinical decisions, however, nurses in intermediate care units participated at higher amounts and at higher levels—including medication teaching with the patient and family and determining discharge from the unit—than nurses in both critical care or general care units. It is possible that intermediate care nurses possess a wider breadth of knowledge as they may care for patients from wider range of conditions and acuity levels than the other types of units, which may influence their input into discharge decisions. It is unclear why intermediate care nurses would participate more in medication teaching, particularly as compared with nurses in general units where most patients would be expected to be preparing for discharge from the hospital. This is an area for future research.
It is also interesting that there were no areas where nurses in general care units participated in decisions at significantly higher amounts in either clinical or administrative decisions than the other types of units. It is possible that general care unit nurses desire higher levels of participation but face barriers to participating more, a lack of an open culture supporting participation, or issues of less clinical confidence than their critical care and intermediate peers. Nurse leaders should determine barriers to decision making in general care units and explore mechanisms that can be put into place to increase their participation.
Nurse leaders should assess the decision-making participation of nurses in their work groups. Nurses may participate less in certain clinical decisions, such as disagreeing with physicians on the plan of care, because they are less comfortable with conflict and dealing with these types of difficult situations. Nurses may need training and support in difficult communication in order to participate more fully in these types of decisions. Nurse leaders should consider involving critical care nurses skilled in this decision making in such training and may want to pair critical care nurses with intermediate and general care nurses in peer training. Nurse leaders, particularly new or emerging ones, may also benefit from training in decision making, particularly about difficult communication, so that they can better facilitate nurse participation in difficult decisions.17
Nurses overall participated far less in administrative decisions, which is consistent with previous research8,10,12,18 yet perplexing considering that most of the nurses in the sample (85%) worked in Magnet hospitals where shared governance and employee empowerment are an important structural component of the nurses’ work environment. Our research team expected that participation in both types of decisions would be high among the Magnet organizations. Although nurses’ participation in these administrative decisions was high in terms of amount and level of the decisions, we were not able to determine any statistically significant differences in administrative decision making in the different unit types. This is an area for future study.
Staff nurse involvement in organizational structures that support nurse empowerment is essential for a healthy work environment.19 A key factor in nurses’ participation in decision making may be the organizational and unit culture and the empowering behaviors of the unit nurse leader. When nurse leaders provide the organizational structure that enables this support (ie, nurse participation in physician rounds at the bedside) and they role model these behaviors for their staff, nurses may be more empowered to participate in both clinical and administrative decisions on the nursing unit.
Nurse leaders should be aware that staff nurses may prefer participation in only select administrative decisions. Nurse leaders should consider tailoring staff nurse job descriptions and clinical ladders so that expectations for some administrative decision making occur within boundaries, primarily for nurses who have some administrative responsibilities along with their clinical responsibilities. For example, clinical staff nurses in charge or supervisory roles may be more interested and willing to participate in staffing, budget decisions, research, and educational activities. For other administrative decisions, however, nurse leaders should query their staff nurses to determine their participation in decisions about standards of care, staff nurse job descriptions, and quality improvement. These are areas where staff nurse input is critical as staff nurses hold the expert clinical knowledge critically important to informed decision making related to these activities.
Developing an understanding of the associations between the different types of decisions made by nurses and nurse outcomes is important for nurse leaders so that they can design work environments that maximize participation in the kinds of decisions most associated with positive nurse and patient outcomes. Nurse managers can structure decision making on the nursing unit so that nurses have appropriate levels of input into the relevant clinical and administrative decision-making activities that occur.
This study utilized nonprobability sampling through use of a convenience sample, which is a limitation. The study was also limited by the use of cross-sectional team member participant data, which may provide only a snapshot of the variables included in the study and thus preclude the ability to make causal statements. Although self-report data are a valid measure of attitudes and other perceptual constructs, the use of self-report data to assess nurses’ participation in decision making may be viewed as a limitation in this study because it has the potential to introduce bias if participants provide socially acceptable responses. Further, most nurses in the sample practiced in a Magnet-certified hospital, which may not be generalizable to non-Magnet nurses. Finally, data analysis was planned at the unit level but was conducted at the individual level. Data analysis at the unit level was limited because of the small sample size. An additional limitation was the varying cultures at the 6 organizations in the sample. The inclusion of 6 different organizations does support the generalizability of the findings to other settings, although they may not be generalizable to hospitals outside the Southeast United States.
Implications for Future Research
Future studies are needed to explore the relationship between organizational factors, such as hospital Magnet status, hospital and unit size and type, and nurses’ decision making and nurse and patient outcomes in larger, broader samples. Future studies are also needed to examine nurses’ decision making and additional nurse outcomes such as turnover and additional patient outcomes such as symptom management and hospital-acquired infections. Future research should also examine the impact of new graduate nurse residency programs on nurses’ decision making and on differences between new graduate and more experienced nurses’ decision making. This would provide insight into best methods to train nurses based on their level of experience.
This study expands what is known about nurses’ decision making and addressed some existing knowledge gaps. Although links between nurses’ participation in decision making and nurse outcomes have been established, this is one of only a few studies that are known to have examined linkages between the types of decisions made by nurses and whether these linkages differ depending on the type of unit where nurses work. It is 1 of a limited number of studies known to examine nurses’ decision making in different types of hospital units. Information learned in this study is important for nurse leaders and may help them tailor interventions for their nurses specific to their unit type.
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