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Effective decision-making: applying the theories to nursing practice.

Samantha Watkins

Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley

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Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Decision-making is a fundamental concept of nursing practice that conforms to a systematic trajectory involving the assessment, interpretation, evaluation and management of patient-specific situations ( Dougherty et al, 2015 ). Shared decision-making is vital to consider in terms of patient autonomy and professional duty of care as set out in the Nursing and Midwifery Council (NMC) (2018) Code, which underpins nursing practice. Consequently, the following assessment and decision-making processes were conducted within the remits of practice as a student nurse. Decision-making is a dynamic process in nursing practice, and the theories emphasise the importance of adaptability and reflective practice to identify factors that impact on patient care ( Pearson, 2013 ). Three decision-making theories will be explored within the context of a decision made in practice. To abide by confidentiality requirements, the pseudonym ‘Linda’ will be used throughout. Patient consent was obtained prior to writing.

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Effective decision-making: applying the theories to nursing practice

Affiliation.

• 1 Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley.
• PMID: 31972119
• DOI: 10.12968/bjon.2020.29.2.98

Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.

Keywords: Decision-making; Deteriorating patient; Hypothetico-deductive reasoning; Myocardial infarction; Patient assessment.

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Shared Decision-Making for Nursing Practice: An Integrative Review

Marie truglio-londrigan.

1 Pace University, College of Health Professions, Lienhard School of Nursing 861 Bedford Road Pleasantville, NY 10570, USA

Jason T. Slyer

2 Clinical Assistant Professor, Pace University, College of Health Professions, Lienhard School of Nursing 163 William Street, 5 th Floor New York, NY 10036, USA

Associated Data

Supplementary material is available on the publisher’s web site along with the published article.

Background:

Shared decision-making has received national and international interest by providers, educators, researchers, and policy makers. The literature on shared decision-making is extensive, dealing with the individual components of shared decision-making rather than a comprehensive process. This view of shared decision-making leaves healthcare providers to wonder how to integrate shared decision-making into practice.

To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings.

An integrative review was conducted applying a systematic approach involving a literature search, data evaluation, and data analysis. The search included articles from PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1970 through 2016. Articles included quantitative experimental and non-experimental designs, qualitative, and theoretical articles about shared decision-making between all healthcare providers and patients in all healthcare settings.

Fifty-two papers were included in this integrative review. Three categories emerged from the synthesis: (a) communication/ relationship building; (b) working towards a shared decision; and (c) action for shared decision-making. Each major theme contained sub-themes represented in the proposed visual representation for shared decision-making.

Conclusion:

A comprehensive understanding of shared decision-making between the nurse and the patient was identified. A visual representation offers a guide that depicts shared decision-making as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions.

1. INTRODUCTION

Shared decision-making (SDM) has received national and international attention from providers, educators, researchers, and policy makers [ 1 - 5 ]. Shared decision-making has been described as taking place in a relationship where there is a partnership between the provider and the patient characterized by a collaborative bi-directional mutual exchange of information and discussion involving negotiation leading to a shared decision [ 6 ]. Shared decision-making, therefore, takes place in a relationship that is participatory, collaborative, open, and respectful. The relationship is one in which there are at least two participants: the nurse, as the provider, and the patient. Trust and respect between providers and patients has also been described as foundational for SDM [ 7 - 10 ].

The literature on SDM is extensive. These works describe the individual components of SDM, including the facilitators and barriers to the achievement of SDM [ 10 - 14 ]. Provider SDM competencies have also been explored in the literature [ 15 - 17 ] along with the context of the provider and patient relationship such as the need for resources, including time [ 6 , 18 - 29 ]. Research has also been conducted to examine the effect of SDM on patient outcomes with regard to chronic and acute illnesses [ 20 , 27 , 30 , 31 ]; treatment adherence [ 31 ]; patient coping [ 32 , 33 ]; knowledge attainment and empowerment [ 34 , 35 ]; autonomy and self-determination [ 22 , 36 , 37 ]; and, patient satisfaction [ 26 , 38 , 39 ]. Despite this research, the overall evidence as to the effect of SDM leading to positive patient outcomes is inconclusive [ 40 , 41 ].

Nurses develop relationships and work with individuals, families, communities and populations across diverse healthcare settings. Hildegard E. Peplau [ 42 ] provided a framework for the nursing professions’ understanding of the nurse-patient helping relationship as the nexus from which there is growth. Millard, Hallett and Luker [ 43 ] saw the importance of the nurse-patient relationship as the vehicle for the exchange of information necessary for SDM and suggested that there is a need for nurses to “pay attention to the quality and nature of the relationships they have with their patient” [ 43 ]. Furthermore, Clark, et al. [ 40 ] examined the nurse-patient dyad as an intervention necessary to both sustain the relationship and facilitate SDM towards care management.

The focus on SDM has been on the dyad relationship and the individual components of SDM rather than describing and explaining the process taking place within the relationship. Gulbrandsen [ 44 ] noted that the contemporary literature’s portrayal of SDM does not do an adequate job of illustrating the processes of SDM. A comprehensive understanding of SDM as a process would be meaningful for nurses as they work with patients towards shared decisions about care management.

The aim of this integrative review is to understand the comprehensive process of SDM from the perspective of the patient and provider in all healthcare settings. Understanding the process will create a common language and appreciation of SDM for meaningful nursing practice [ 45 ].

This integrative review applied the comprehensive and systematic approach described by Whittemore and Knafl [ 46 ] consisting of the literature search, data evaluation, and data analysis. This method facilitated the gathering of information and research from a variety of methodologies (quantitative, qualitative, and theoretical) supporting an integrative approach allowing for a comprehensive depiction of the process of SDM.

3.1. Inclusion Criteria

Articles considered for inclusion were qualitative or quantitative research articles or theoretical literature that addressed SDM taking place within a relationship between the patient and the provider. Patients needed to be 18 years of age or older and providers could represent any healthcare field. Only articles published in English were considered. Articles were excluded if they solely addressed intervention strategies such as education to enhance SDM competencies in providers or decision aids as an intervention to assist patients in their shared decision rather than a focus on the process of SDM taking place in a relationship. Articles focusing on shared decision-making in psychiatric or mental health settings were excluded because of the unique issues within this patient population pertaining to SDM.

3.2. Search Strategy

A comprehensive literature search was applied in PubMed, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO. Diverse literature available in English was searched from 1970 through January 2016, including quantitative designs (both experimental and non-experimental), qualitative designs, and theoretical papers. Three searches were conducted in each database in order to identify literature related to SDM inclusive of the patient, the provider, and the environment. (Table ​ 1 1 ) depicts these basic search strategies along with the key terms used.

Basic search term strategies used across all databases.

3.3. Data Evaluation

Articles that met the inclusion criteria were evaluated for methodological quality. The standardized critical appraisal instruments for experimental, observations, quantitative descriptive, qualitative, and expert opinion/theoretical works from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI) were used for this assessment [ 47 ]. This stage reduced the possibility of bias and errors by including only papers deemed reliable/dependable and valid/credible [ 47 ]. Any disagreements between the reviewers were resolved through discussion until consensus was reached. Supplemental (Table S1 ) contains the results of the critical appraisals for all included studies.

3.4. Data Analysis

Data analyses were carried out through the application of an inductive content analysis process that involved creating categories and abstractions [ 48 ]. The categories were then further grouped under higher order headings [ 48 , 49 ]. The synthesis process involved creating categories that describes all of the aspects of the SDM process leading to a new representation of facts offering a visual representation of SDM as a guide for nursing practice [ 50 ].

Upon completion of the initial searches, 4,674 potentially relevant titles were identified. Duplicates were removed, leaving 1,562 articles for review. After reviewing the titles and abstracts, 1,340 articles were excluded for not meeting the inclusion criteria. After full text review, an additional 166 articles were excluded for not meet the inclusion criteria, leaving 55 articles for critical appraisal. Three articles were excluded for methodological weaknesses in the research and limited results sections (Fig. ​ 1 1 ) [ 51 - 53 ].

PRISMA Flow Diagram [ 54 ].

Fifty-two articles published between 1997 and 2016 were included in this review. Supplemental Table ( S2 ) contains an overview of the included articles. Twenty-three of the articles originated from the United States, six from the United Kingdom, five from Germany, nine from Canada, two from the Netherlands, and one each from Australia, Denmark, Norway, Italy, and France. Two articles originated from multiple countries. Sixteen of the articles were quantitative designs, 19 were qualitative, one was mixed method, and 16 were conceptual.

The analysis of this integrative review and the articles retained from data analysis generated three categories: (a) communication/relationship building; (b) working towards a shared decision; and (c) action for SDM, each containing sub-themes that depict the process of SDM. (Table ​ 2 2 ) outlines the three categories and sub-categories along with the corresponding articles informing each category. These categories and sub-categories were further contextualized into a visual representation of the shared decision-making process seen in Fig. ( ​ 2 2 ).

A visual representation for shared decision-making in practice.

Shared decision-marking categories and subcategories.

4.1. Communication and Relationship

Communication and relationship building is the first general category and is foundational for the SDM process. The three sub-themes within this theme are: relationship building—trust and respect; information exchange— communication; and context.

4.1.1. Relationship Building—Trust and Respect

Individuals enter into the relationship and must work towards building a trusting and respectful relationship where SDM is invited and encouraged. The work begins as the patient identifies a need or question. This need and/or question influences the patient’s quest for answers [ 76 ]. The relationship is the vehicle by which providers and patients “act in a relational way” and the individuals are “actively seeking a personal connection with each other” [ 65 ]. The relationship is a partnership where there is collaboration and a sharing of power [ 30 , 34 ]. With the sharing of power, there is mutual responsibility toward one another [ 16 ]. The relationship is strengthened over time leading to bi-directional trust and respect [ 58 , 67 ]. Patients who feel trusted and respected are more open and share information with their provider thereby facilitating communication for SDM [ 13 ].

4.1.2. Information Exchange—Communication

Information exchange via interpersonal and intrapersonal communication sustains the relationship. The interpersonal process of communication is bi-directional between the provider and the patient when there is a mutual exchange of information [ 6 , 19 , 22 , 23 , 25 , 38 , 67 , 70 , 72 ]. The exchange of information also involves active listening [ 29 , 63 , 69 ]. Emotions such as fear, anger, and anxiety can interfere with a patient’s readiness to communicate [ 12 , 14 ]. Furthermore, a provider’s readiness and receptiveness to explore a patient’s feelings and preferences is important [ 65 ]. For example, the emotional tone the provider creates facilitates an atmosphere of compassion and caring that enhances open communication [ 11 , 71 ]. In situations where this emotional tone is not created the patient is less likely to feel compassion or care and may perceive the provider’s approach as “authoritarian.” This perception may prompt the patient’s reluctance to communicate and establishing a “shield” –creating a barrier to SDM [ 21 ].

The intrapersonal process of communication also plays a role in the achievement of SDM taking place within the provider and patient through the process of reflection [ 73 ]. The reflection process takes place at two levels. Mutual reflection takes place when the provider and the patient reflect together via communication, exchanging thoughts about decisions, and clarifying the patient’s perspective [ 73 ]. Individual reflection takes place autonomously within the individual provider or patient [ 73 ]. For example, during an individual reflective moment a provider may identify “blind spots” in a patient’s perception of an experience which may be limiting the patient’s insight about an issue [ 73 ]. During the corresponding mutual reflection, the provider uses communication skills to challenge the patient verbally and non-verbally while encouraging the patient to also engage intrapersonal self-reflection. The mutual reflection process, therefore, encourages patients to engage in their own independent reflections that helps them recognize “a new decision or a new position on the difficulty or challenge on which they had been reflecting” [ 73 ]. Furthermore, providers and patients continually reflect upon their relationship and communication over time known as post-decision deliberation. These deliberations offer an opportunity for reconsideration of past decisions illustrating the on-going process of decision-making [ 68 ].

4.1.3. Context

The provider and the patient work within a particular healthcare context that either facilitates or creates barriers for SDM. From the patient’s perspective, the context includes the patient’s family, friends, and home, including community supports and networks [ 24 , 29 ]. For example, patients who are accompanied by family members to healthcare encounters are more likely to engage in SDM [ 21 , 26 , 27 ]. The context of the provider’s work environment also influences their ability to integrate SDM into practice [ 20 , 22 , 23 , 28 ]. Time and access to resources are facilitators for SDM [ 6 , 18 , 25 , 52 ]. Organizational models and systems that facilitate patients’ access to their provider(s) and/or healthcare team reduce fragmentation and improve collaboration, coordination, and SDM [ 25 ]. Technology capable of tracing patients’ progress through the SDM process is a valuable resource [ 19 , 21 ]. Shared decision-making is prominent in the thoughts of healthcare providers within the larger healthcare system; however, so too are evidence-based practice (EBP) and clinical practice guidelines. The challenge for providers is to ensure that the realities of clinical practice are addressed along with the patient’s preferences [ 25 ].

4.2. Work Toward Shared Decision-Making

Communication and relationship building are foundational for the initiation of SDM. Shared decision-making, however, requires dedicated ongoing work. The second general category, work towards SDM, has four sub-categories: assessment, teaching-learning, finding balance, and decision.

4.2.1. Assessment

The work towards SDM begins with an assessment. The assessment of the individual is foundational as the provider must “come to know one’s patient” [ 29 ] and the patient’s specific preferences [ 35 ]. Understanding the individual patient characteristics begins with an awareness of the patient’s age, gender, race, spiritual and cultural beliefs, education, and life experiences. All of these characteristics influence the patient’s beliefs about SDM and the value placed on SDM [ 35 , 63 ]. For example, the assessment will reveal whether patients see themselves as sharing in decision-making, or whether they prefer the provider to be the primary decision maker? The role a patient chooses to play may change over time, depending on the situation for which the patient is seeking assistance [ 74 ]. Furthermore, as the work towards the shared decision takes place, there will be moments when the provider’s expertise will warrant that they take the lead in the encounter and other moments when the patient will take the lead [ 74 ]. Race too may influence a patient’s behavior if an individual decides not to share information for reasons of racially inspired mistrust [ 58 , 59 ]. Age may influence behaviors as research has shown that younger individuals choose to engage in SDM compared to older adults [ 26 , 28 ]. This is also true of individuals with higher levels of education and literacy [ 14 , 25 , 60 ].

The assessment continues as the provider asks questions about the reasons the patient is seeking assistance. How SDM unfolds varies depending upon the acuity or chronicity of illness [ 27 , 28 , 73 , 75 ]. Acute illness may foster a provider-led approach to SDM. Conversely, chronic illness fosters a patient-led approach with patients who are responsible for the self-management of their illness over time in their own home/community, often with the support of family or friends [ 27 , 29 , 39 ]. Gathering information about social support and social networks, therefore, is a part of the assessment [ 29 ] as these networks have been found to facilitate a patient’s ability to be active and engaged in SDM [ 6 , 26 ]. Ultimately, the assessment offers the provider an opportunity to know the patient, the patient’s family, and home/community, building a practice based on facts and evidence not assumptions.

4.2.2. Teaching-Learning

Shared decision-making warrants that patients have the necessary information that they need to know so that they can share in the decision-making process [ 78 ]. Providers, therefore, will need to teach and provide their patients with this information. What providers teach to support learning depends on the assessment [ 27 , 28 , 33 , 74 ]. For example, the provider needs to consider the readiness of the patient and the amount and type of information that needs to be taught and how to best teach that information for a specific patient [ 21 ]. This is vital in today’s EBP-driven healthcare environment. The EBP process involves sharing information with the patient about diagnosis and treatment, educating the patient about the disease and treatment options, and informing the patient about the strength of the evidence, as well as the risks, benefits, and possible outcomes [ 68 ]. Information gathered during the assessment guides providers so that they are mindful of a patient’s age, literacy, language, and culture in the development and delivery of educational information. Patient-centered education applies specific teaching strategies for specific patients, such as culturally appropriate decision aids, which both guide patient learning and facilitate the patient’s understanding of information [ 15 , 27 , 29 , 60 , 68 , 77 ].

4.2.3. Finding Balance

Providers and patients come together due to identified needs/issues. A need/issue causes uncertainty [ 76 ] and challenges providers and patients to find a resolution through SDM. Part of the work of SDM is achieving balance necessary to arrive at a shared decision [ 20 , 37 ]. This is especially relevant with regard to EBP. For example, in a clinical practice scenario when there is evidence that there may be alternative best practice choices, the provider’s competence in the use of equipoise in the search for a balanced shared decision is sought. The concept of equipoise is exemplified by “talk” where there is the presentation of information, portrayal of options and exploitation of alternatives, as well as deliberation [ 15 ].

What happens, however, in situations where there is no documented evidence for best practice or there is only one best practice choice that a patient considers unacceptable because of personal ideas, values, or beliefs? These encounters invoke the ethics of practice, including the principles of autonomy and beneficence. The provider and the patient together seek to achieve balance between these principles through the application of skills such as talking, openness, and information provision [ 28 , 31 , 36 , 77 ]. Furthermore, part of the work in finding balance requires deliberation and negotiation leading to consensus about the decision [ 6 , 37 , 65 , 69 ].

4.2.4. The Decision

Communication and relationship building, assessment, teaching and learning and the seeking of balance are all part of the SDM process leading to consensus about the decision. The work is individual for every patient and facilitates care that is patient-centered [ 6 , 20 , 35 , 65 , 69 , 74 ]. Ultimately, the shared decision is not the end point but signals the need for the patient to take action and carry out the decision.

4.3. Action for Shared Decision-Making

This third theme, action for SDM, contains two sub-themes: Takes action or no action.

4.3.1. Takes Action

Shared decision-making does not end with the decision. Once the provider and patient come to a shared decision there needs to be action by the patient. The process of SDM, therefore, moves beyond the decision point as the patient engages in the steps necessary to take action to see the decision through [ 73 ]. For example, patients return to their homes/communities where they attempt to carry out their decisions. During this process, the implementation of the decision may be seamless, the patient is satisfied, and the issue or question is addressed. There may be, however, times when patients find the action challenging or the actions that are required are not what was expected. In these situations, the patient may not be satisfied resulting in an unresolved issue or questions prompting the patient to return to the provider to re-evaluate the decision [ 13 , 19 , 21 , 27 , 63 , 68 , 73 ].

4.3.2. No Action

No action occurs when patients return to their homes/communities; however, once in their familiar environment, they chose not to initiate the steps and actions to see their decisions through. For example, patients may feel pressured by the perceived power imbalance they experienced with their provider and as a result found themselves aligning with a particular decision favored by the provider [ 21 , 34 ]. As a result, when patients return to their homes/communities they choose not to act. This realization may trigger the need to return to the provider or in some cases a patient may choose not to return for further care [ 13 , 19 , 21 , 27 , 63 , 68 , 73 ].

5. DISCUSSION

The significance of this integrative review is noted in the presentation of the ongoing process of SDM. Box ( ​ 1 1 ) below provides a case study that exemplifies this ongoing process. This process takes place in practice between a nurse and patient during a healthcare encounter where there is an identified need/issue or question. The relationship is one of a partnership where both parties are collaborating. The relationship that develops is one where trust and respect is fostered by the communication between the nurse and the patient. Communication is both interpersonal and intrapersonal. Interpersonal communication between the nurse and patient takes place during the healthcare encounter. Intrapersonal communication takes place during the encounter when the nurse and patient think about— via reflection —what they are saying, doing, and observing at the moment they are actively engaged [ 79 ]. For example, a nurse may reflect on a patient’s non-responsiveness to a conversation. Nurses who are knowledgeable about communication and skillful in the application of communication techniques will use strategic questioning where options are explored and listening to facilitate a patient’s insight into the presiding issue [ 80 ]. Reflection also continues after the interaction as nurses and patients reflect upon past SDM healthcare encounters. During these moments, patients may have questions and/or decide that the initial decision is no longer acceptable and wish to return to their nurse. This review highlights relationship building and communication in nursing practice that is foundational for SDM and signals that communication is complex, requiring nurses to be ever vigilant about what they are saying and doing, as well as the patient’s response. Being aware of one’s own reflections as well as one’s skills to assist patients in their own self-reflection facilitates a practice based in SDM. In addition, this review highlights the need for a practice environment that fosters relationships and communication by establishing practice models where ongoing connections between the nurse and patient are consistent and continuous, thereby supporting and sustaining SDM.

A case study of shared decision-making.

Flexibility in the nurse-patient relationship is identified as significant in this review and takes place as nurses and patients work together, alternating who takes the lead during SDM. There may be times when the nurse takes the lead to educate the patient about best practices while considering patient characteristics and the patient’s response to the information. As the work continues, the patient may take the lead, being the expert in his/her own life experiences. Flexibility in the SDM process also takes place in the bi-directional communication between the nurse and the patient as discussions take place about EBP. These discussions are a give and take of ideas about EBP and choices about treatments; when balance is achieved, a shared decision can be reached.

This review also highlights the need for nurses to be continually aware of the importance of context in the form of family/friends, community, organization, and the greater healthcare system. For example, practice models that are intra and interprofessionally based will enhance patients’ access to available organizational providers in the event they need to return to re-evaluate a past decision. These practice models also enrich the support, guidance, teaching, and mentoring of patients [ 23 , 25 , 27 , 29 ]. Resources that foster and facilitate SDM such as time, consultation services, reliable and valid decision aids that are culturally appropriate, and clinical information systems that track a patient’s progress in the achievement of shared decisions are necessary. These examples suggest policy changes at the organizational level. At the healthcare system level, the development of standards of practice based in evidence, while beneficial, have been viewed as a challenge by others as there may be the potential for “fewer choices being offered to patients by healthcare providers” [ 25 ].

Education initiatives that enhance the nurse’s ability to integrate SDM into their practice are significant. Competencies need to be achieved in the area of reflective practice, the nurse-patient relationship, communication and strategic questioning, assessment, teaching and learning, ethics, and the role of social supports and social networks within a community. Part of this educational endeavor also includes nurses examining their own comfort levels about SDM. For example, nurses may express positive beliefs about SDM; however, these beliefs may not manifest in practice as the nurse may be ambivalent about a partnership with a patient due to a lack of trust in a patient’s ability [ 16 , 64 ]. Patents too will need to be competent in order to be active and engaged in the SDM process. Their competency, however, is centered around the information that they need to know to participate in SDM. This means that the SDM encounter will require that nurses provide support, guidance, mentoring, coordination, and education to patients throughout the entire SDM process. Nurses, therefore, will need to assume a diverse set of roles beyond caregiver as they adjust to the flexible nature of SDM. For example, the shared decision may require a course of action in which the patient needs to access community resources. Nurses will educate patients on what community resources are available, offer advice and support patients as they access services, and advocate when a patient has difficulty connecting with these services.

The visual representation of SDM Fig. ( ​ 2 2 ) offered in this review provides nurses with a guide for practice and also for research. Contemplating the guide offers cues for hypothesis generation and the raising of qualitative questions that will add to the body of nursing knowledge. For example, there is limited information in the literature about patients returning to their home/communities as they attempt to take the necessary steps and carry out the actions for the shared decision. The development of qualitative descriptive studies to describe what happens as patients attempts to initiate shared decisions once they leave a healthcare encounter would provide valuable evidence for nurses as they address needed practice changes to facilitate SDM.

Shared decision-making has received attention in the recent years, however, this attention has focused on the individual components of SDM rather than a comprehensive process. An understanding of SDM that captures this comprehensive process would facilitate SDM in practice, research, and the development of educational programs for nurses and other healthcare providers that embrace all aspects of the process. To this end, an integrative review was conducted applying the systematic approach described by Whittemore and Knafl [ 46 ]. The outcome of this integrative review provides an understanding of SDM as a comprehensive process that takes place between the nurse and the patient. It provides an opportunity to consider the complexity of SDM as an on-going process that does not end with the decision. The visual representation is a guide that depicts the processes of SDM taking place during the healthcare encounter with implications for the shared decision over time in the event a patient needs to return to the nurse to reconsider earlier decisions.

ACKNOWLEDGEMENTS

Declared none.

LIST OF ABBREVIATIONS

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

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Nursing: Decision-Making Skills for Practice

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Decision-making is a key skill for today's nurses. Nursing: Decision-Making Skills for Practice is an essential guide for student nurses that prepares them to make effective decisions on the ward and in the community. This new title in the Prepare for Practice series details the fundamental knowledge and skills needed to make good decisions across a variety of nursing areas: from involving patients in decision making, to using the best evidence in care planning. Case studies, activities, and exercises ensure that theories of decision-making are brought into real-world nursing situations . Evidence-based and with links to core NMC competencies throughout, this textbook will help undergraduate and qualified nurses to make confident decisions and boost their academic, personal, and professional development.

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Theory, nurse decision-making, and practice

What's all the fuss.

Waters, Virginia Lynn PhD, MBA, MSN, RN, NEA-BC

Virginia Lynn Waters is a retired CNO and adjunct faculty at the University of Phoenix (Ariz.) and Nova Southeastern University in Fort Lauderdale, Fla.

The author has disclosed no financial relationships related to this article.

Theory and practice are tightly woven into most decisions that nurses make, and the impact of those decisions becomes very important when patient outcomes are involved. This literature review explores the application of theory to practice, with a close look at contingency theory and generational identity.

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Clinical Reasoning and Decision-making

In a nutshell . . . ., in this page you're introduced to the clinical reasoning and decision-making idea of the practice competence & excellence (pce) dimension. this idea is the second of the four ideas that make up the pce critical circle of clinical responsibility . you'll see that the idea of clinical reasoning and decision-making is intertwined with and follows directly from the idea of watching-assessment-recognition., you'll read about the main purposes of clinical reasoning and decision-making and how it works hand in hand with the intellectual engagement idea of the therapeutic milieu dimension. you'll be encouraged to think about how the philosophy of science and the philosophy of holism contribute to our understanding of clinical reasoning and decision-making., you'll find a summary of nursing literature and research on clinical reasoning and decision-making and its key components. finally, you'll be asked to consider the complexity of clinical reasoning and decision-making in nursing, how difficult it is to measure and evaluate, and recent research that indicates that we may not be doing very well in implementing this important idea . , introduction.

Clinical reasoning and decision-making is the fourth concept of the Practice Competence and Excellence (PCE) dimension and the second of the four PCE concepts that form the Careful Nursing critical circle of clinical responsibility. This concept is intertwined with and follows directly from the concept of watching-assessment-recognition . Before continuing, please take a minute to review the two figures on the PCE Introduction page above to remind yourself how this concept relates to the other seven PCE concepts (first Figure) and where it fits in the critical circle of clinical responsibility (second Figure).

In Careful Nursing clinical reasoning and decision-making is understood as one concept because reasoning and decision-making processes are so closely interrelated. This concept highlights our distinctively human capacity to reason; it is central to our purposeful application of nursing knowledge; to how our critical thinking guides our practice. Clinical decision-making is considered synonymous with clinical judgement (Manetti, 2019).Clinical reasoning and decision-making are the thinking processes and strategies we use to understand data and choose between alternatives with regard to identifying patient problems in preparation for making nursing diagnoses and selecting nursing outcomes and interventions. Using the different types of clinical reasoning we plan, direct, perform and reflect on patient care.

Purposes of clinical reasoning and decision-making

Purposes are critical to patient safety and the visibility of professional nursing practice:

1) to make decisions based on objective evidence and intuition about actions to be taken to treat as immediately as possible potential or actual physiological deterioration in patients and to collaborate with medicine to manage such deterioration, i.e., identification and management of collaborative problems (see collaborative problems, watching-assessment-recognition previous page)

2) to select nursing diagnoses, nursing-sensitive patient outcomes, and nursing interventions to achieve desired outcomes, in collaboration with patients to the extent that they wish to and are able to be involved (see diagnoses-outcomes-interventions following page) .

In reasoning and decision-making we draw on all relevant knowledge but are concerned particularly with knowledge related to Careful Nursing philosophical principles and professional practice model dimensions and concepts. Clinical reasoning and decision-making is a very complex process and only a brief overview is provided here. 

Relationship between clinical reasoning and decision-making, and intellectual engagement  

Clearly, the concepts of clinical reasoning and decision-making, and intellectual engagement are closely linked. So why is intellectual engagement in the Therapeutic Milieu dimension and clinical reasoning and decision-making in the PCE dimension?

Placement of concepts in the professional practice model dimensions is guided by the Careful Nursing philosophy. According to Aquinas's philosophy of the human person, the human mind and spirit are intimately linked in the inward life and essence of persons (see the philosophical principles pages above).

The intellectual engagement concept intimately concerns the human mind, spirit and inward life of persons, thus is more closely aligned with the spiritual aspect of the Therapeutic Milieu dimension.

The c linical reasoning and decision-making concept is primarily related to the outward bio-physical reality of the human body and senses and objective nursing practice, thus is more closely aligned with the PCE dimension. 

Philosophical foundations of clinical reasoning and decision-making

The distinctive relational nature of nursing and its emphasis on both science-based and holistic practice gives nurses a broad awareness of both scientific and holistic processes of reasoning and making decisions about patients' care.

Philosophy of science

Philosophers of science argue that reasoning concerns the rational consideration of objective facts and that this alone provides all that is necessary to form judgements. Any role for subjective experiences in this process, such as intuition or imagination, is firmly rejected (Honderich, 2005). We know this view very well as the scientific method. 

Some philosophers of science argue from the somewhat broader position that reasoning is any process of drawing a conclusion from a set of ideas where the ideas can be shown to verify the conclusion (Blackburn, 2016). Again, verification must be objective.

We are well aware that the scientific approach to reasoning dominates contemporary knowledge development and that it is very useful. The evidence base it provides is objective so it can be considered probably true or probably false, and it can be measured. As nurses we use scientific reasoning to develop nursing theory, frame our research, and support evidence-based practice. But it is also widely recognised in nursing that philosophy of science does not address all aspects of nursing practice (Krishnan. 2018).

Philosophy of holism

If we understand ourselves and the people we care for as unitary or holistic beings, thus it stands to reason that our reasoning and decision-making involves holistic, subjective processes at some level. For example, factors such as length of practice experience, intuition, matching recognised patterns of patient behaviour, practice confidence, interaction with colleagues, and ward/organisation culture are known to influence nurses' reasoning and decision-making (Cappelletti et al. 2014, Nibbelink & Brewer 2018). One such factor, intuition, is frequently mentioned in the literature as an aspect of reasoning and decision-making. 

Intuition has been defined as "understanding without a rationale" Benner & Tanner (1987), in other words, understanding without reasoning. Although intuition is broadly considered to contribute to decision-making in nursing, theorists have difficulty explaining how intuition works. Nurses in practice commonly describe use of what they call intuition to make often critical clinical decisions about actions to be taken for patients, but for a variety of purposes do not write about these events. However, the validity and trustworthiness of intuitive reasoning processes are not widely accepted (Cappelletti et al. 2014, Nibbelink & Brewer 2018) and decisions based on intuition can be biased and inaccurate (Tiffen et al. (2014). 

Use of intuition in nursing practice is usually explained within a psychological humanist framework (Krishnan, 2018). However, Jacques Maritain, an influential 20 th -century interpreter of the philosophy of Aquinas, argues that human intelligence is in its essence intuitive. Maritain offers a philosophical explanation of intuition as a type of reasoning; he proposes that a natural, semi-conscious, intuitive reasoning is deeply embedded in human persons. As a fundamental human quality, Maritain writes that:

". . . reason possess a life both deeper and less conscious than its articulate logical life. For reason indeed does not only articulate, connect, and infer, it also sees ; and reason's intuitive grasping, intuitus rationis , is the primary act and function of that one and single power which is called intellect or reason. In other words, there is not only logical reason, but also, and prior to it, intuitive reason" (Maritain, 1953, p.75, italics original).

Maritain's explanation of human reasoning is detailed and complex and requires reading and reflection over time. But, even an attempt to read his work, or read about it, is likely to produce an "oh, yes" response because he explains what many nurses see and experience in nursing practice but find it hard to describe and explain. Maritain's explanation offers a structure for rethinking clinical reasoning, with Maritain's "intuitive grasp" proposed as the source of what emerges as both objective logical reasoning and subjective intuitive and analogical reasoning. 

Nursing literature on clinical reasoning and decision-making

In simple terms, reasoning is defined as the power of the mind to think and understand in a logical way in order to form a conclusion or judgement (Reasoning, 2019). Drawing on previous research and analysis, Koharchik et al . (2015) define clinical reasoning as applying formal and informal nursing and other related knowledge to experience in practice for the purpose of analysing and understanding as accurately as possible patients' condition. Nursing decision-making refers to the judgements nurses make regarding treatment of the people they care for; that is, their choice of one course of action rather than another.

Based on a concept analysis of decision-making in nursing, Johansen and O'Brien (2016) likewise define decision-making as a complex process of applying knowledge, analytical and critical thinking, intuition, experience, clinical reasoning and applying rules of thumb, all of which may be influenced by a number of factors, including the following;

Critical thinking . The cognitive process of critical thinking is central to how we draw on and use knowledge developed according to the scientific philosophy of reasoning (Zuriguel Pérez, et al ., 2015). Because we use scientific knowledge so widely in decision-making about risks to patient safety and in making precise judgements about patient care, it is vital that we evaluate it as we use it. However, in their scoping review of critical thinking in nursing, Zuriguel Pérez, et al ., found that its use in practice, as opposed to educational settings, is limited. This limitation requires on-going examination and possible solutions tested.

Intuition and experience . It is well established that, in addition to using objective ways of reasoning, we use a multiplicity of subjective ways of reasoning, particularly intuition. In a concept analysis of intuition in clinical nursing practice, Robert, et al , (2014) concluded that many nurses experience intuition spontaneously and use it in clinical reasoning. However, little is actually known about nurses' clinical reasoning processes (Simmons, 2010), primarily due to lack of discipline-specific approaches to nursing assessment (Griffits et al. 2017).

Situational awareness . Of particular interest for our clinical reasoning and decision-making is that Maritain, in The Range of Reason (1952), emphasizes that how human persons interact with one another and the context in which they interact has an important influence on their perception and understanding.

Maritain suggests that reason's seeing and intuitive grasp is enhanced by what we would call attending to patients with benevolent affection and kindness. A therapeutic nurse-patient relationship, and the Therapeutic Milieu of the practice setting, may enhance clinical reasoning and decision-making skill. This context could enhance our capacity to experience 'reason's seeing ' and an 'intuitive grasp' of key elements of patients' condition in order to best inform our clinical reasoning and decision-making. 

Practical issues . Situational awareness raises the importance of practical reasoning, that is, deliberating on the best course of action attainable in a given clinical practice situation where there is lack of clarity, uncertainty, and likelihood of on-going change based on particular concrete realities. Practical reasoning also influences how research findings are implemented in practice (French 2005). Knowledge underlying practical reasoning is usually accumulated from experience over time in aiming to make the best possible practical decisions. Practical reasoning is contrasted with theoretical reasoning and often linked back to the virtue theory of Aristotle (350BCE/1998).

Values . Values enter our clinical reasoning and decision-making as ethical reasoning. In ethical reasoning we deliberate on values held by patients, ourselves and others related to what is right or wrong, good or bad, for patients, in deciding which actions will best foster their health. Our reasoning is guided by a national nursing professional code of ethics.

In Careful Nursing, ethical reasoning is especially concerned with inherent human dignity, natural justice, and health as human flourishing. Ethical reasoning is widely recognized as an especially complex and difficult process often made more so by competing values in practice settings (Goethals et al ., 2010). 

Urgent need for on-going evaluation of practicing nurses' clinical reasoning and decision-making skills 

Despite the vitally importance of clinical reasoning and decision-making in nursing practice, studies suggest that limitations exist in the scope of nurses' clinical reasoning skills in practice settings which require on-going attention (Lee et al., 2016).

Kavanagh & Szweda (2017) examined critical thinking, clinical reasoning and decision-making in over 5,000 newly graduated nurses in the Unites States. They found that compared with similar previous studies these skills were decreasing; in 2015 only 23% of new graduates demonstrated an acceptable ability to recognise physiological problems in patients, their level of urgency, or how the problems should be managed. They concluded that a "preparation-to-practice gap" in nurses ability to think critically and engage in clinical reasoning and decision-making is widening and must be more effectively addressed.

These findings serve to alert all nurses in practice to constantly work to attain and maintain the highest possible levels of critical thinking and clinical reasoning and decision-making skills. 

Revised Careful Nursing definition of clinical reasoning and decision-making

An earlier definition of clinical reasoning and decision-making in Careful Nursing (Meehan, 2012) requires revision, as follows:

the objective, logical and subjective, intuitive processes used by nurses to understand patient data, apprehend patients' status, and choose one course of action rather than another to address actual or potential threats to patients' physiological safety. Such decision-making is also used to identify needs for assessment and intervention by the medical profession and, or, other members of the multi-professional patient care team. Reasoning and decision-making concerning nursing diagnoses includes patient participation if possible, and is based on objective, evidence-based reasoning using the NANDA-I nursing diagnosis (Herdman & Kamitsuru, 2018), the Nursing Outcomes Classification Moorhead et al., 2018), and the Nursing Interventions Classification (Bucher et al., 2018) standardised nursing languages.

Clinical reasoning and decision-making summary  

Neither the scientific nor the holistic approach to reasoning are adequate in themselves as a basis for decision-making (Krishnan, 2019). Rather, use of both scientific and holistic methods of reasoning best enable nurses to understand and meet the needs of the people they care for.

The central role of clinical reasoning and decision-making in our application of nursing and other knowledge is a complex and vital component of our practice. Powered by intellectual engagement and together with watching-assessment-recognition it directs how we implement the other concepts of the Careful Nursing critical circle of clinical responsibility. 

Your clinical reasoning and decision-making self-rating:

On a scale of 1 to 10, rate your ability to make intuitive decisions about patients' status and actions required that are later validated by objective evidence? Following the Performance-Based Development System © widely used to test critical thinking, clinical reasoning and decision-making, rate yourself: 

On a scale of 1 to 10, rate your ability to identify correctly all possible causes of physiological deterioration in particular patients?

On a scale of 1 to 10, rate your ability to identify correctly the level of urgency of physiological deterioration in patients?

On a scale of 1 to 10, rate your ability to identify correctly nursing interventions to minimise deterioration in particular patients' physiological status?

On a scale of 1 to 10, rate your ability to identify correctly appropriate medical orders you expect medical doctors to prescribe for particular deteriorating patients?

On a scale of 1to 10 rate your ability to justify your actions?

Based on your assessment of your current skill in clinical reasoning and decision-making decide what you will do to further develop your skill in implementing this concept.

Make your own 'i will' statements . . ., examples of clinical reasoning and decision-making 'i will' statements:.

. . . keep a personal record of my clinical decisions and critically review them once a month

. . . identify times that I have used intuition to make a decision about patients' care and reflect critically on my use of intuition once a month

. . . critically reflect on how I justify my nursing decision-making actions once a month 

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Therese C. Meehan ©    July 2020

• Research article
• Open access
• Published: 01 June 2021

Shared clinical decision-making experiences in nursing: a qualitative study

• Fen-Fang Chung 1 ,
• Pao-Yu Wang 2 ,
• Shu-Chuan Lin 3 ,
• Yu-Hsia Lee 3 ,
• Hon-Yen Wu 4 , 5 , 6 , 7 &
• Mei-Hsiang Lin 8  

BMC Nursing volume  20 , Article number:  85 ( 2021 ) Cite this article

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Shared decision making (SDM) is a patient-centered nursing concept that emphasizes the autonomy of patients. SDM is a co-operative process that involves information exchange and communication between medical staff and patients for making treatment decisions. In this study, we explored the experiences of clinical nursing staff participating in SDM.

This study adopted a qualitative research design. Semistructured interviews were conducted with 21 nurses at a medical center in northern Taiwan. All interview recordings were transcribed verbatim. Content analysis was performed to analyze the data.

The findings yielded the following three themes covering seven categories: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors.

Conclusions

The results of this study describe the experiences of clinical nursing staff participating in SDM and can be used as a reference for nursing education and nursing administrative supervisors wishing to plan and enhance professional nursing SDM in nursing education.

Peer Review reports

Shared decision making (SDM) is increasingly advocated as the preferred model to engage patients in making decisions regarding their diagnosis, treatment, or follow-up when more than one medically reasonable option is available [ 1 ]. SDM is a patient-centered medical care service model that emphasizes the provision of high-quality patient-based clinical care and focuses on improving patient satisfaction [ 2 , 3 ]. SDM is defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” [ 4 ]. Various models have been developed to demonstrate how SDM can be applied in the clinical setting [ 5 ]. Elwyn et al. [ 4 ] proposed a model demonstrating the application of SDM in clinical practice; this model was based on three key steps: choice talk, option talk, and decision talk. The essential elements of SDM are as follows: (1) defining or explaining the problem, (2) evaluating available options, (3) discussing the advantages and disadvantages of those options, (4) clarifying the patient’s values and preferences, (5) discussing the patient’s ability or self-efficacy, (6) discussing health care professionals’ knowledge or recommendations, (7) checking and clarifying the patient’s understanding; (9) making or explicitly deferring a decision; and (9) arranging a follow-up [ 5 ]. In recent years, the centrality of the patient’s voice in SDM has been increasingly discussed [ 6 ]. Mathijssen et al. [ 7 ] investigated the SDM-related knowledge, attitude, and experience of 147 medical staff in the field of rheumatism and indicated that enhancing medical care professionals’ understanding of SDM concepts is the critical first step for improving the application of SDM in clinical practice.

The literature on SDM is extensive. Studies have described the individual components of SDM including facilitators and barriers to the achievement of SDM [ 1 , 8 ]. In the nursing literature, SDM is discussed from an evidence-based practice perspective [ 9 ] and the practice perspective of critical nurse–patient interaction [ 10 ]. Nurses who participate in SDM can more effectively control their practice and have higher job satisfaction; moreover, hospitals that adopt SDM can improve patient care [ 11 ]. Nursing staff are the essential members of a medical team; their participation in the SDM process as well as their understanding of basic concepts and principles related to the decision-making process are particularly crucial [ 9 , 12 ]. Tariman et al. [ 13 ] investigated the role of nursing staff in the SDM process for cancer care and reported that nursing staff play different roles under differing time points and environments in the cancer SDM process; these roles include health educator, spokesperson, data collector, symptom and side-effect handler, information sharer, and psychological supporter.

Jo, An, and Lee [ 14 ] indicated that SDM is a comprehensive concept based on the values and autonomy of patients, family members, doctors, and nursing staff and involves the sharing of information regarding treatment options and decision-making methods. In addition, these partnerships may extend into a large network including family members and other professionals or nonprofessional community organizations. This collective involvement further compounds the decision-making process [ 15 ]. Elwyn et al. [ 4 ] indicated that low health literacy and low numeracy are barriers to SDM, and the cultural backgrounds of some patients restrict them from making autonomous decisions. To better serve individuals, assessments and interventions should be selected after considering cultural factors including cultural preferences and norms [ 16 ]. In some non-Western cultures, the family plays a dominant role in decision making. The family is often an extension of the patient and assists the nurse in ensuring that the patient processes and understands information [ 6 , 17 ]. Evidence suggests that people are influenced by their cultural background when making decisions regarding their health. These cultural values affect the manner in which people conduct themselves in the health care system and give patients a set of ethical priorities guiding their decisions regarding diagnosis and treatment [ 17 ].

Nursing staff account for the majority of the professional medical care team and are key members. They have many opportunities to participate in the SDM process with patients from various clinical departments. Truglio-Londrigan [ 6 ] indicated that studies on SDM experiences in nursing are limited. Although researchers have covered numerous medical and health care environments, no study has yet investigated the process or content of SDM. In particular, in most studies, the views of clinical nursing staff regarding SDM have been obtained from Western cultures [ 18 ]. In traditional Asian families (such as those in Taiwan), patients are more likely to play a silent role in the decision-making process because of traditional cultural pressure [ 17 ]. Thus, health care professionals should respect patients’ beliefs and values and what is important to them rather than what is important to the professionals themselves [ 19 ]. The family is crucial to patients in many aspects regardless of their cultural background. Moreover, the level of dominance shown by the family when a patient is involved in making crucial decisions can vary [ 17 ]. Therefore, given that cultural differences exist in the medical environment, exploring the SDM experiences of clinical nurses is necessary. This study explored the SDM experiences of clinical nurses to ensure that appropriate medical care is provided to patients and improve clinical care quality in the future.

Design and participants

A qualitative descriptive study aims to comprehensively summarize an event by using easy-to-understand sentences from the event [ 20 ]. Therefore, this study used a qualitative descriptive design to explore the course of SDM and the experiences of clinical nursing staff.

Participants

In this study, intentional sampling was employed to recruit participants from a medical center in northern Taiwan from September 2018 to February 2019. Registered nurses who had worked in a hospital for a minimum of 1 year and who were willing to share their cultural experiences of being in clinical nursing care were included in this study. Nurses who had depression or other major illnesses (e.g., malignancies) were excluded. Depression is complex and often associated with other chronic conditions [ 21 ]. Nurses with depression are likely to be negatively affected by illness themselves, but their illness may also affect their coworkers and potentially the quality of the care they provide [ 22 ]. Therefore, these nurses were excluded from this study.

Data collection

Interviews were arranged after obtaining the consent of research participants who met the inclusion criteria. The location of the interview was selected to ensure that interviewees could comfortably describe their experiences. In-depth, semistructured, face-to face interviews were conducted to collect data. Each interview began with general questions, followed by more specific questions. Some of the interview questions were as follows: “What do you know regarding the concept of shared decision making?” and “What do you think are the obstacles to implementing shared decision making?”. The audio recordings of the interviews ranged from 60 to 90 min in length and were immediately transcribed by a research assistant. In this study, data collection was continued until the data saturation point was reached. After interviewing 21 participants, we reached data saturation.

Data analysis

All interviews were transcribed verbatim. Transcripts were first open coded word by word and line by line. Content analysis is usually begun in the early stage of data collection. The content analysis method reported by Zhang and Wildemuth [ 23 ] was used to analyze the interview data. This method consists of the following steps: preparing the data, defining the unit of analysis, developing categories and a coding scheme, testing the coding scheme on a sample text, coding all the text, assessing the coding consistency, drawing conclusions from the coded data, and reporting the methods and findings.

Qualitative content analysis goes beyond merely counting words or extracting objective content from texts; it involves examining meanings, themes, and patterns that may manifest or be latent in a particular text [ 23 ]. The content analysis in this qualitative research was performed as follows. First, the data were coded manually. All researchers participated in the data-coding process. After reading interview transcripts several times, crucial statements were identified and then the transcripts were compared across cases to determine similarities and differences in codes. Meaningful units were marked with codes, and a comparative analysis was performed to extract the primary code. Subsequently, the primary codes were according to differences and abstract the similarities in the categories and form the coding scheme. After testing the coding scheme on text samples, all text was coded. The data analysis started from the coding and was continued until the end of data collection.

Lincoln and Guba [ 24 ] developed four indicators to describe the suitability of qualitative research: dependability, confirmability, transferability, and credibility. These indicators were used to examine the rigor of our research results. Entire interviews were recorded, and the text analysis files were saved to ensure the dependability and confirmability of the data. This study used intentional sampling to determine the transferability of the research. The researcher interviewed each participant to obtain credible and promotional data regarding their experiences in the context of the medical care environment. In addition, the five researchers closely discussed and repeatedly examined the implications of the original data, determined which categories fit the original data, and provided operational definitions (peer debriefing) during the data analysis process to ensure credibility. After completion of the initial data analysis, three participants were asked to indicate whether the analysis results correctly described their experiences (member checks). These three participants responded that the results of this study were relevant to their experiences.

Ethical considerations

This study began recruiting participants after obtaining approval from the human testing institution of a medical center in northern Taiwan (Institutional Review Board: 18MMHIS123e). Before including a participant in this study, the researcher first explained the purpose and implementation steps of the research and proactively informed them that they had the right to withdraw from the study. The interview was conducted after obtaining signed informed consent from each participant.

A total of 21 participants who had been employed as nursing staff for an average of 18.7 years were included in this study. The most senior nurse had 37 years of work experience, whereas the most junior nurse had 3 years. In terms of work units, 9 (42.85%), 10 (47.61%), and 2 (9.5%) participants were from the departments of internal medicine, internal medicine intensive care, and pediatric intensive care, respectively. The findings of in-depth interviews and data analysis yielded three themes of clinical nurses’ experience in the SDM process: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors. In SDM, nursing staff played the role of a “translator” by conveying the medical team’s findings and empirical information to the patient and their family members in an easy-to-understand manner. In addition, nursing staff were required to help family members make choices after listening to the thoughts of the patient and their family members.

Knowledge regarding SDM

Knowledge regarding SDM led to health care professionals having a positive attitude and enhanced their willingness to practice SDM. Clinical nurses should possess knowledge regarding SDM. This theme consisted of the following categories: gaining relevant professional knowledge, reading and integrating evidence, and editing media regarding SDM.

Gaining relevant professional knowledge

To participate in the SDM process, nursing staff should be familiar with the concept of SDM in advance and then agree to it and be willing to implement it.

Interviewee M said the following:

... the most basic [thing] for nursing staff is to know what SDM is. How did it start? Why did it start? What is its purpose? If the concept of SDM is not clear to nursing staff...Therefore, nursing staff should have good understanding regarding SDM before they can decide whether SDM will be helpful for the patient and they will be willing to implement it…

During the SDM process, nurses must give a detailed explanation to the patient and their family members as well as respond to their various questions. Therefore, nurses must possess professional knowledge related to the theme of decision making. As stated by interviewee D, “... I think professional ability is the most basic [ability]. You must be very clear regarding professional ability in the field because family members may ask various strange questions at any time and you must know how to respond to them... ”

Interviewee H indicated,

... when we were in the process of SDM, the supervisor would arrange relevant on-the-job training...By using SDM auxiliary tools, we could focus more on patient care...Otherwise, sometimes, the nursing staff could not clearly answer questions relevant to the treatment of the patient. This is not okay.

Reading and integrating evidence

SDM is relevant in the context of evidence-based practice. Evidence-based practice involves use of the best research with clinical expertise and patient values to facilitate decision making, leading to optimal clinical outcomes and quality of life. Therefore, reading and integrating evidence regarding SDM are critical for nursing staff in charge of SDM.

As interviewee J said,

... Because we need to look for information to support our talk regarding SDM-related content, we must have the ability to read papers and then explain empirical concepts to the patient or family. Therefore, nursing staff must have the ability to construct empirical evidence.

Editing media regarding SDM

Auxiliary tools, including patient decision aids (PDAs), are often required to enhance the understanding of patients and their family members regarding information provided during the SDM process. PDAs are structured tools, such as brochures and interactive online applications, that can aggregate available evidence related to a given decision and help patients clarify the relevant value of the decision [ 25 ]. Because the younger generation of Taiwan is not fluent in Taiwanese, it is necessary to have Taiwanese commentary videos available, particularly for older patients. However, all nursing staff are currently in charge of developing models and videos with limited funding.

One of the nursing staff who worked on editing, dubbing, quick response (QR) coding, and other related tasks said, “... Making PDAs, such as videos, QR codes, and Google Forms, is not difficult for the nursing staff because this is what they usually do... ”

Some nursing staff also obtain resources to assist their own production of animations. Interviewee A stated, “... when we are required to make SDM films, especially if we need an animation, we ask for the assistance of experts. The hospital has a unit that is involved in producing animations. ”

Trigger discussion and coordination

The SDM process should involve the entire medical team. However, promoting SDM without the approval and participation of other medical staff in addition to the concerted efforts of nursing staff is challenging. This theme consisted of the following categories: forming a co-operative SDM team and trigger and coordination regarding SDM.

Forming a co-operative SDM team

SDM is a comprehensive concept based on the values and autonomy of patients, family members, doctors, and nursing staff. Because most decisions are related to medical treatment, doctors are the leaders of these decisions. However, some doctors have still not established the concept or habit of SDM.

As interviewee H said,

... not every doctor has the knowledge or [has come to a] consensus regarding SDM. So, doctors may not use PDAs to explain the decision-making process to an individual patient, or doctors...do not use it in a way that the patient can understand, and whether they enter the spirit of SDM is doubtful.

The success of SDM depends on constructing a favorable relationship during a clinical encounter that involves sharing information and supporting patients to deliberate and express their preferences and views during the SDM process.

After participating in SDM with a doctor who agreed with the concept of SDM, interviewee A said,

When promoting SDM, nursing staff co-operate with the chief doctor who supports SDM and influence other doctors through the chief doctor. Because the topic of SDM may be more strongly related to patient treatment, doctors and nursing staff should have a tacit understanding with each other [that] can help promote SDM.

Interviewee C mentioned, “ Doctors are the main characters in promoting SDM and nursing staff assist doctors. ”

Trigger and coordination regarding SDM

The majority of interviewees believed that most problems related to SDM involved medical decisions. Therefore, the final decision makers are doctors, patients, and their family members. Nurses act as a communication bridge in the process. Nurses are required to communicate information to patients and their family members in an easy-to-understand manner after discussion with the doctor. In particular, the communication skills of nurses are most crucial when SDM must be implemented within a short time and when family members are under extreme pressure to discuss and make decisions in that limited amount of time, especially when the patient is critically ill.

As stated by interviewee B,

When the patient or family members need to make a medical decision, I listen to their opinions first before searching for information. Sometimes, the attending physician does not have much time at the bedside, so I go over the analysis with the patient. If the patient says that he or she does not know which medical decision to make, I search for information again and discuss with the doctor again. [To participate in] SDM...[one] needs to have the ability to communicate...

Handling advances and retreats during the communication process is essential. As interviewee F mentioned, “ Nursing staff should properly guide the patient and family to speak and communicate on the topic of SDM...to resonate with family members...then family members would be willing to talk. The talking skills and an ability to guide the talk are quite important. ”

In addition to conveying decision-related empirical information, nurses should guide and coordinate the concepts and expectations of both doctors and patients most of the time. Interviewee J indicated,

During the SDM process, nursing staff need to coordinate or even connect with [people]. Like holding a family forum in the ward, the nursing staff should understand what content is unclear to family members and ask the doctor to explain. Also, the nursing staff should remind the family what they need to consider.

The promotion of SDM should be based on a satisfactory nurse–patient relationship. In particular, when communicating with older patients, the ability to speak Taiwanese and other languages is essential. As interviewee B stated, “ Some elderly patients do not want young nursing staff to take care of them. They think that the scattered [Taiwanese] speaking...will affect the information they receive. ”

Respect of sociocultural factors

The interviewees frequently noted that SDM requires patients and their family members to fully understand and consider what they want before making a decision. However, evidence suggests that people are influenced by their cultural background when making decisions regarding their health. This theme includes the following categories: patients’ values with respect to their cultural background, and the cultural differences of patients and families.

Patients’ values with respect to their cultural background

Cultural values influence the way in which people conduct themselves in the health care system and give patients a set of ethical priorities when making decisions regarding their diagnosis and treatment. Nurses should be patient and listen to the expectations of patients and their family members during the SDM process. To fully respect patients’ cultural values, nurses should respect the decision-making process they adopt even if it is collectivist and not based on equality within the family.

As stated by interviewee B, “ SDM needs to consider the experience and values of the patient. ”

In Taiwan, because of traditional cultural pressure, patients are more likely to play a silent role in the decision-making process.

Interviewee K mentioned that “ [There is a] need to understand the true thoughts of the patient. The patient will not immediately tell you what they are thinking...it takes a little bit of patience to listen. ”

Cultural differences of patients and families

The family is crucial to patients in many aspects regardless of their cultural background. Moreover, the level of dominance of the family can vary when a patient is involved in making crucial decisions. In some non-Western societies, the family plays a dominant role in decision making.

Interviewee C, who encountered a family member who refused to sign a “do not resuscitate” (DNR) form, said the following:

The family members insist on their opinions and feel that they are not [displaying] filial piety if they sign the DNR. This [reflects] the personal values and background of the family member. The nursing staff can only directly explain to family members again…[and] respect the opinions of the family members in the end .

Nursing staff must have the cultural sensitivity to demonstrate appropriate empathy and listening skills. In addition, nurses should be respectful of the wishes of family members even if they differ from those of the patient. Nursing staff must act as the spokesperson for the patient. Interviewee D said the following:

The nursing staff should let the family members know the thoughts and wishes of the patient. When the patient has signed a consent or intention letter, the nursing staff should convey the patient’s wishes to the family members and doctors instead of agreeing with the final decision of the family members, with the decision being against the patient’s wishes.

This study explored the experiences of clinical nurses participating in SDM. Studies have found that the SDM process is complicated for clinical nurses. The findings of this study yielded three themes of clinical nurses’ experiences in the SDM process: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors.

Clinical decisions can be relatively simple (such as those involving general clinical treatment) or complex (such as those involving cancer treatment); be discrete (such as those involving the birth method) or involve continuous care management (such as when formulating chronic disease treatment and care plans); and can involve multiple stakeholders (such as the professional care team and caregivers of the patient) [ 26 ]. All interviewees in this study indicated that knowledge regarding SDM is extremely crucial in the SDM process. In addition, clinical nursing staff should understand professional concepts related to SDM. Our results are in accordance with those reported by Friesen-Storms et al. [ 9 ], who indicated that nursing staff having knowledge regarding SDM, skills, and a positive attitude can facilitate the SDM process. Moreover, our interviewees believed that they should first establish and be familiarized with the SDM concept, agree with it, and then be willing to implement it before conducting SDM. This result supports the finding of Mathijssen et al. [ 7 ], who indicated that improving medical professionals’ understanding of the SDM concept is the crucial first step for enhancing the implementation of SDM in clinical practice.

The interviewees in this study considered reading and integrating evidence and editing media regarding SDM to be critical abilities for implementing SDM continually. This result is in accordance with that reported by Tones et al. [ 27 ]; they found that when providing patients with various educational and interventional measures for effectively implementing SDM, it is necessary to collate the relevant literature and evidence and discuss the priorities of various behavioral changes with the patient and their family members in a language that they can easily understand. Subsequently, individualized patient health education aids can be developed to provide patient-centered and evidence-based health education to the patient and their family. Several studies have shown that nursing staff form the majority of a medical care team and are the team’s key members. To help patients make choices, nursing staff should not only use research evidence but also interpret that evidence or provide recommendations to meet the requirements of the patients in the SDM process. Therefore, nurses must be able to search for and integrate empirical data as well as understand basic concepts and principles related to SDM [ 9 , 12 ]. The results of the present study revealed that nursing staff could help patients understand the disease, clinical progress, and treatment options by using information software during the implementation of SDM. Therefore, the nursing staff believed that having the basic ability to edit media was indispensable. This result is in accordance with that reported by Friesen-Storms et al. [ 9 ], who found that providing nursing staff with SDM training, such as training in media editing and the creation of PDAs, and guidance in developing a patient-centered attitude could significantly improve the implementation of SDM by nursing staff.

SDM is a framework in which health professionals and patients co-operate to make decisions during implementation of a series of medical procedures [ 28 ]. Satisfactory clinical communication skills are crucial in nursing staff for establishing effective SDM [ 9 ]. The participants in this study all agreed on the importance of trigger discussion and coordination. The final decision makers in SDM are doctors, patients, and family members. However, nurses still account for the majority of medical care professionals [ 9 , 12 ]. The interviewees in this study indicated that the attending physician sometimes did not have sufficient time to participate at the bedside while performing clinical SDM, thus limiting the implementation of SDM. This finding is similar to that of an Asian study conducted by Lin et al. [ 29 ], who reported that most patients felt that health professionals, even if they agreed to implement SDM, had limited resources available to provide adequate information or support to patients in making decisions. This result is in accordance with that of Mathijssen et al. [ 7 ], who determined that time limitation was an issue for during implementation of SDM in clinics. In addition, the present finding indicated that nursing staff play the crucial role of a communication bridge in the implementation of SDM.

The interviewees indicated that promoting SDM without the approval and participation of the decision-making leader (doctor) is challenging. This is another crucial finding of the present study. Therefore, forming a co-operative SDM team is an essential factor for promoting SDM. This result is in agreement with those of several studies. Hofstede et al. [ 30 ] conducted a study on SDM for patients with rheumatology and indicated that although the medical staff all had the same knowledge, attitude, and experiences regarding SDM in rheumatology, lack of co-operation between professional groups was an essential obstacle to implementation of SDM. Patients may receive conflicting information from different medical professionals. Therefore, SDM requires effective communication between medical professionals to provide structured information to patients [ 7 ]. Our interviewees indicated that the theme of SDM was related to the treatment of the patient, doctors played a primary role in implementing SDM, and nursing staff assisted doctors in promoting SDM. These findings are similar to those of other studies [ 7 , 29 ]. Mathijssen et al. [ 7 ] investigated the SDM-related knowledge, attitude, and experiences of 147 medical staff and revealed that under SDM, decisions regarding diagnostic tests were based on doctors’ input because making decisions regarding patients’ disease treatment and diagnosis was not the task or responsibility of nursing staff. Lin et al. [ 29 ] investigated patients’ perspectives on SDM in Taiwan; they discovered that patients had a desire to be involved and felt that adequate information exchange would be a necessary step toward collaboration or sharing treatment-related decisions with clinicians. Most clinics have used interprofessional practice to improve the quality of care in recent years. Therefore, the subject of co-operation among interprofessional teams for the implementation of SDM has also been valued. Dawn and Legare [ 31 ] indicated that oncology nursing staff were the key members of interprofessional practice in terms of exerting influence, particularly when patients had to make a decision regarding prevention, screening, or treatment options during the SDM process. The importance of the role of nursing staff in SDM could also be observed in interprofessional practice.

In Taiwan, because of traditional cultural pressure, patients are more likely to play a silent role in the decision-making process than in other countries. Lin et al. [ 29 ] reported that in submissive Asian cultures, SDM implementation can be more challenging. The importance of nurses’ respect of sociocultural factors during the SDM process was a crucial finding of this study. Crucial to SDM implementation is the effective participation of patients. Because different patients have different backgrounds, characteristics, and value preferences, patients may make various choices and value judgments when it comes to clinical decisions [ 32 ]. Several studies have shown that the cultural factors of patients should be considered when performing SDM [ 18 , 29 , 33 , 34 ]. Patients have independent autonomic and informed rights as well as the right to insist on care and choose their treatment plan. Unlike other medical care measures that can directly improve the symptoms of patients through care behavior, SDM may exert a positive effect on the future medical treatment of patients, ultimately leading to better health outcomes [ 35 ]. The present study indicated that nursing staff should listen to the requirements of patients and their family members who expect SDM, and patients and their family members should fully consider what they want before making a decision. When we understand this culture, the results of the study will become clear because they reflect the traditional means of decision making. This result is in accordance with that of Mathijssen et al. [ 7 ], who found that understanding the willingness and degree to which patients wish to participate in decision making is crucial for medical professionals. Sims-Gould and Martin-Matthews [ 36 ] postulated that working with patients and their family members in an interconnected, bidirectional manner and recognizing and supporting cultural ideas, values, and beliefs can help the patients and family members in becoming co-producers in health and thus aid the implementation of SDM. Thus, these findings indicated that respect and cultural sensitivity are crucial factors in the SDM process.

Because the participants in this study were chosen from nursing staff in a medical center in northern Taiwan, the results cannot be applied to all nursing staff. In addition, the self-responses of medical and nursing staff regarding their attitude and experiences related to SDM (such as “In what situation do you think it is suitable to use SDM?”) may have been affected by their definition of SDM. Moreover, nursing staff with a positive attitude toward SDM may have been more inclined to participate in this study. Therefore, the probability of bias in sample selection cannot be ruled out. Future studies should expand their sample sources to explore the SDM experiences of multiple nursing staff members and thus provide a more complete reference base for relevant patient care.

This study explored the experiences of clinical nursing staff participating in SDM by conducting in-depth interviews. The results yielded three themes of the implementation of the SDM process for clinical nurses: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors. The promotion of SDM can help nursing staff more deeply explore the thoughts and expectations of patients and their family members as well as confirm the direction of care.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding authors on reasonable request.

Abbreviations

Shared Decision Making

Do Not Resuscitate

Patient Decision Aids

Interprofessional practice

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Acknowledgements

The authors would like to thank the nurses who participated in this study.

The Ministry of Science and Technology of Taiwan for funding [grant numbers: MOST 107-2511-H-227-003 -

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Pao-Yu Wang

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Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, R.O.C.

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CFF: Concept/design, data collection, data analysis/ interpretation, drafting article, critical revision of article, and writing - original draft. WPU: Concept/design, data collection, data analysis/ interpretation, and critical revision of article. LYH: resources, project administration, critical revision of article, and data curation. LSC: resources, project administration, and critical revision of article. WHY: resources, project administration, and critical revision of article. LMH: Concept/design, data collection, data analysis/interpretation, drafting article, and critical revision of article. All authors contributed to writing, revising, and approved the final manuscript.

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Shared clinical decision-making experiences in nursing: A qualitative study*, * Interview guide *.

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Clinical Reasoning and Decision-Making in Nursing

Introduction, critical thinking, clinical judgment, and clinical reasoning.

Then only characteristic that can identify a professional nurse is cognitive rather than using the psychomotor ability (Simmons, 2010). Clinical nursing practice requires a practitioner to make a sound judgment and critical decision in responding and recognizing patient sign and symptoms promptly to enhance patient outcome. Clinical errors and bad judgment in decision-making may have an adverse health effect on the patient; therefore, clinical reasoning skills play a pivotal role in the clinical judgment of a patient.

In decision- making, nurses can assess alternative and make a right decision basing on watching, evaluating, recognizing, and using clinical reasoning. Through patient assessment data, nurses can understand and make a proper decision about patient problem and treatment. The nurse’s decision bases on clinical judgment or nursing diagnosis.

Critical thinking skills are vital for a professional nurse; they help in examining the underlying assumption and question the validity of the situation or problem in a patient. However, critical thinking itself is not sufficient for the nurse who has to decide on how to act in a specific case to avoid harming the patient. Critical thinking generates new good health ideas for nurses to use in caring for a patient.

1. Alfaro-Lefevre, R. (2015). Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: APractical Approach. Elsevier Health Sciences.

2. Simmons, B. (2010). Clinical reasoning: concept analysis. Journal of Advanced Nursing, 66(5), 1151-1158.

3. Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38(1), 34-36.

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How to Write a Nursing Reflective Essay as a BSN Nursing Student

• November 29, 2023

Welcome to NursingWriters.net, your go-to resource for expert information and guidance on writing nursing essays. In this article, we will provide you, as a BSN nursing student , with a comprehensive guide on how to write a compelling nursing reflective essay. Reflective essays are a personal reflection on your experiences in the nursing profession, and we are here to help you navigate this writing challenge.

As a busy nursing student, we understand that you may have limited time to spare. That’s where NursingWriters.net comes in, empowering you to excel in your BSN program by providing expert guidance on different writing and comprehension challenges you may face. Let’s dive into the world of nursing reflective essays and discover how you can effectively express your thoughts and insights.

Key Takeaways:

• Reflective essays allow nursing students to reflect on their experiences and personal growth in the profession.
• A nursing reflective essay is different from a personal statement, focusing on self-reflection rather than academic achievements.
• Key elements to include in a nursing reflective essay are the inciting incident, personal reflections, vivid details, and actions taken.
• The introduction should grab the reader’s attention and provide a clear thesis statement.
• The body paragraphs should delve into the writer’s reflections and emotions with specific examples and anecdotes.

What Is a Reflective Essay in Nursing?

A reflective essay in nursing is a powerful tool that allows nursing students to analyze their experiences, emotions, and actions related to their nursing practice. It provides an opportunity for self-reflection, critical thinking, and personal growth. Reflective writing can help nurses develop a deeper understanding of their own practice, improve patient care, and enhance their professional development.

Reflective essays in nursing differ from personal statements in that they focus on specific experiences and their impact on the writer’s growth and development. These essays require the writer to critically reflect on their actions, emotions, and thoughts, and identify ways to improve their practice. By examining their experiences and applying reflective frameworks, nursing students can gain valuable insights into their strengths, weaknesses, and areas for growth.

When writing a reflective essay in nursing , it is important to follow a structured approach. This includes describing the incident or experience, analyzing personal thoughts and feelings, exploring the actions taken, and reflecting on the outcomes and implications. By structuring the essay effectively, nursing students can communicate their reflections in a clear and organized manner.

Key Elements to Include in a Nursing Reflective Essay

When writing a nursing reflective essay, it is important to include key elements that will make your essay comprehensive and impactful. These elements will help you convey your thoughts and experiences clearly, allowing the reader to gain a deeper understanding of your reflections on nursing practice.

Inciting Incident or Event

The first key element to include in your nursing reflective essay is the inciting incident or event. This is the moment or experience that triggered your reflection and made a significant impact on your practice. It could be a challenging patient encounter, an ethical dilemma, or a personal realization. By describing this event in detail, you set the stage for your reflective journey.

Personal Reflections

Your nursing reflective essay should also include personal reflections on the experience. This is where you delve into your thoughts, feelings, and emotions related to the inciting incident. Reflect on how the event made you feel, what you learned from it, and how it has influenced your growth as a nursing professional. Be honest and vulnerable in your reflections, as this will allow the reader to connect with your experience on a deeper level.

Vivid Setting and Descriptive Details

To create a vivid and engaging narrative, include specific details that paint a picture of the setting and the people involved. Describe the physical environment, the interactions between healthcare professionals and patients, and any other relevant details that contribute to the overall context of the experience. This will help the reader visualize the situation and understand the complexities of the event.

Actions Taken

Finally, it is important to describe the actions you took in response to the inciting incident. Discuss how you applied your nursing knowledge and skills to address the challenges or opportunities presented by the event. Reflect on the effectiveness of your actions and whether there were any areas for improvement. This demonstrates your ability to critically analyze your own practice and make informed decisions.

By including these key elements in your nursing reflective essay, you can create a comprehensive and impactful piece of writing that showcases your growth and development as a nursing professional.

How to Write the Introduction of a Nursing Reflective Essay

The introduction of a nursing reflective essay plays a crucial role in capturing the reader’s attention and setting the tone for the entire essay. It should provide a concise overview of the main points that will be discussed and create a sense of curiosity and engagement. Here are some tips to help you write an effective introduction for your nursing reflective essay:

• Start with an intriguing opening line: Begin your introduction with a captivating statement or anecdote that relates to the topic of your essay. This will grab the reader’s attention and make them eager to continue reading.
• Provide context and background information: Give a brief overview of the event or experience that you will be reflecting on in your essay. This will help the reader understand the context and significance of your reflections.
• Present a clear thesis statement: Your thesis statement should clearly state the main purpose of your essay and the specific points or themes that you will be exploring. This will give the reader a preview of what to expect in the body of the essay.

By following these tips, you can craft an introduction that captivates the reader and sets the stage for a compelling nursing reflective essay.

“As I walked into the busy hospital ward on my first day of clinical rotation, I couldn’t help but feel a mix of excitement and nervousness. Little did I know that this experience would become a pivotal moment in my nursing journey, shaping my understanding of empathy, communication, and patient-centered care. In this reflective essay, I will delve into the details of this encounter and explore the personal and professional growth that resulted from it.”

With an attention-grabbing opening, providing context, and presenting a clear thesis statement, your introduction will set the stage for a compelling nursing reflective essay that captures the reader’s attention and lays the foundation for your reflections.

Nursing Reflection Essay Tips and Examples

Writing a nursing reflective essay requires careful consideration and thoughtful analysis. Here are some tips to help you craft an impactful and meaningful reflection essay as a BSN nursing student . Additionally, we will provide examples to illustrate how these tips can be applied.

Tips for Writing a Nursing Reflection Essay:

• Start by choosing a specific experience or event that had a significant impact on your nursing practice. This could be a challenging patient encounter, a critical incident, or a personal realization that transformed your perspective.
• Reflect on the experience and consider how it affected your emotions, thoughts, and actions. What did you learn from the experience? How has it shaped your growth as a nursing professional?
• Focus on the key aspects of the experience that were particularly impactful or meaningful to you. Avoid including unnecessary details or deviating from the main message of your reflection.
• Use specific examples, anecdotes, or patient scenarios to support your reflections. This will make your essay more engaging and relatable to the reader.
• Consider the ethical implications of the experience and reflect on how it has influenced your approach to patient care and decision-making.
• End your essay with a reflection on the implications of your learning for future nursing practice. How will you apply the lessons learned to provide better care and improve patient outcomes?

Now, let’s take a look at two examples of nursing reflective essays to further illustrate these tips:

“During my clinical rotation in the Intensive Care Unit (ICU), I encountered a complex patient case that challenged my critical thinking skills and decision-making abilities. The patient was a middle-aged woman who had undergone a complicated surgery and experienced numerous post-operative complications. This experience taught me the importance of collaboration within the healthcare team and the significance of advocating for the patient’s best interests…”

“One of the most significant experiences during my nursing education was my time spent in the pediatric oncology unit. Witnessing the resilience and bravery of children facing life-threatening illnesses had a profound impact on my perspective as a nurse. It taught me the importance of providing holistic care, not only addressing physical needs but also supporting emotional well-being and promoting a positive environment for healing…”

These examples demonstrate how personal reflections, specific details, and professional insights can be incorporated to create a compelling nursing reflective essay. Remember to structure your essay in a clear and organized manner, ensuring that your reflections flow logically and coherently.

By following these tips and utilizing examples, you can create a compelling nursing reflective essay that showcases your growth and development as a nursing professional.

How to Conclude a Nursing Reflective Essay

The conclusion of a nursing reflective essay serves as the final reflection on the writer’s growth and learning from the experience. It is an essential part of the essay that summarizes the main points discussed and leaves a lasting impression on the reader. The reflective essay conclusion should bring closure to the essay by restating the thesis statement and highlighting the key takeaways from the essay.

To write a strong and impactful conclusion, start by restating the thesis statement in a clear and concise manner. This reminds the reader of the main focus of the essay and reinforces its significance. Next, summarize the key points discussed in the body paragraphs, highlighting the most important insights and reflections. This helps to reinforce the main ideas and ensures that they are not overlooked in the final reflection.

In addition to summarizing the main points, a thought-provoking statement or future outlook can be included to provide a sense of closure and leave the reader with something to ponder. This can be a reflection on how the experience has influenced the writer’s future practice or a call to action for continued personal and professional growth. By ending the essay on a strong and meaningful note, the conclusion enhances the overall impact of the nursing reflective essay.

A well-crafted conclusion is essential for a nursing reflective essay as it reinforces the main ideas, leaves a lasting impression on the reader, and provides a sense of closure. By following these tips, nursing students can create a powerful and impactful conclusion that enhances the overall effectiveness of their reflective essays.

Tips for Writing a Nursing Reflective Essay

Writing a nursing reflective essay can be a challenging task, but with the right approach, it can also be a rewarding experience. Here are some helpful tips and strategies to guide nursing students in their essay writing process:

• Start early: Give yourself plenty of time to brainstorm ideas, reflect on your experiences, and write and revise your essay. Starting early will help you avoid last-minute stress and allow for a more thoughtful and polished essay.
• Conduct thorough self-reflection: Before you begin writing, take the time to reflect on your experiences and emotions related to your nursing practice. Consider how these experiences have shaped your growth and development as a nurse, and what lessons you have learned along the way.
• Organize your thoughts and ideas: Create an outline or a rough structure for your essay to ensure a logical flow of ideas. Group similar thoughts and reflections together to create cohesive paragraphs, and use headings or subheadings to further organize your essay.
• Seek feedback: Share your essay with trusted peers or instructors and ask for their feedback. They can offer valuable insights, provide constructive criticism, and help you refine your essay to make it stronger and more impactful.

Additionally, it is important to pay attention to the technical aspects of your essay:

• Grammar and spelling: Proofread your essay carefully to ensure it is free of any grammatical or spelling errors. Use grammar and spell-check tools, and consider asking someone else to review your essay for a fresh perspective.
• Coherent writing style: Use clear and concise language to convey your thoughts and reflections. Avoid excessive jargon or technical terms, and focus on communicating your ideas effectively.
• Formatting guidelines: Follow any formatting guidelines provided by your instructor or institution. Pay attention to font style, size, spacing, and citation style if required.

By following these tips and strategies, nursing students can approach their reflective essay writing with confidence and produce compelling and insightful essays that showcase their growth and development in the nursing profession.

Reflective Tools and Models for Nursing Reflective Essays

Reflective tools and models can provide structure and guidance for nursing students when writing reflective essays. These tools help organize thoughts and experiences, allowing for a more comprehensive and meaningful reflection. By utilizing reflection models , nursing students can enhance their reflective writing skills and deepen their understanding of their own growth and development as healthcare professionals.

Gibbs’ Reflective Model

“Reflective practice is both an art and a science that requires ongoing commitment and practice.” – Gibbs

Gibbs’ Reflective Model is a widely used reflection framework in nursing. It consists of six stages: description, feelings, evaluation, analysis, conclusion, and action plan. This model encourages a structured approach to reflection, allowing the writer to systematically explore their thoughts and emotions, analyze the situation, and identify areas for improvement or further development.

Dewey’s Reflective Thinking Model

“We do not learn from experience, we learn from reflecting on experience.” – Dewey

Dewey’s Reflective Thinking Model focuses on the importance of reflection as a tool for learning and growth. It emphasizes the need to actively engage with experiences, thoughts, and emotions, and to critically evaluate them in order to gain deeper insights and understanding. This model encourages nursing students to think analytically and develop a continuous learning mindset.

Kolb Reflective Model

“Knowledge results from the combination of grasping experience and transforming it.” – Kolb

The Kolb Reflective Model is based on the concept of experiential learning. It consists of four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation. This model encourages nursing students to engage in a cyclical process of learning, where they actively participate in experiences, reflect on them, conceptualize their insights, and apply their learning in real-life situations.

Schön Reflective Model

“Reflection-in-action is the heart of the learning process.” – Schön

Schön Reflective Model emphasizes the importance of reflection in the midst of action. It focuses on the ability to think and adapt in real-time, making decisions based on professional knowledge and experiences. This model encourages nursing students to develop a reflective mindset that allows them to learn and grow while actively engaging in their practice.

Benefits of Reflective Writing in Nursing

Reflective writing plays a crucial role in nursing practice, offering numerous benefits for nursing students and professionals alike. By engaging in reflective writing, nurses can enhance their self-awareness, develop their critical thinking skills, and gain a deeper understanding of patient experiences. This section will explore the advantages of reflective writing in nursing and its significance in healthcare.

Enhanced Self-Awareness

Reflective writing fosters self-reflection, allowing nurses to examine their thoughts, emotions, and actions in various clinical situations. Through this process, they gain a deeper understanding of their strengths, weaknesses, and areas for improvement. This heightened self-awareness enables nurses to provide more effective and compassionate patient care, fostering a patient-centered approach.

Improved Critical Thinking

Reflective writing encourages nurses to think critically about their experiences and the impact of their actions. It requires them to analyze and evaluate the effectiveness of their decision-making and problem-solving skills. By reflecting on past experiences, nurses can identify areas where they can enhance their clinical practice and make informed decisions based on evidence and best practices.

Increased Empathy and Understanding

Through reflective writing, nurses develop a deeper empathy and understanding of patient experiences. By reflecting on their interactions with patients, nurses can recognize the emotions, fears, and challenges faced by individuals in their care. This increased empathy enables nurses to provide more holistic and patient-centered care, improving the overall healthcare experience for patients.

Continuous Professional Development

Reflective writing is an essential tool for nurses’ continuous professional development. It allows them to document their growth, learning, and achievements throughout their nursing career. By regularly engaging in reflective writing, nurses can identify areas for further development, set goals for improvement, and ensure they are providing the best possible care to their patients.

Overall, reflective writing in nursing is a powerful tool that empowers nurses to enhance their self-awareness, critical thinking skills, and empathy. By engaging in this practice, nurses can continuously improve their clinical practice, provide high-quality patient care, and contribute to the ongoing development of the nursing profession.

Nursing Reflective Essay Examples

Looking for inspiration for your nursing reflective essay? Here are some examples that showcase different experiences, reflections, and growth in the nursing profession.

These examples demonstrate how nursing reflective essays can provide valuable insights into personal experiences, reflections, and professional growth. They serve as excellent references to help nursing students develop their own reflective writing skills and gain a deeper understanding of the nursing profession.

Writing a Nursing Reflective Essay for Nursing School Application

A nursing reflective essay can be a powerful tool for nursing school applications. It allows applicants to showcase their self-awareness, critical thinking skills, and passion for the nursing profession. When writing a nursing reflective essay for a nursing school application, there are a few key tips to keep in mind.

Reflect on your passion for nursing

Start by reflecting on what drew you to the nursing profession and why you are passionate about it. Consider your personal experiences, such as volunteering or shadowing healthcare professionals, and how they have shaped your desire to become a nurse. Highlight your commitment to providing compassionate and quality patient care.

Share personal experiences in healthcare settings

Provide specific examples of your experiences in healthcare settings, such as clinical rotations or internships. Reflect on the challenges you faced, the lessons you learned, and how those experiences have impacted your growth and development as a future nurse. Discuss any significant interactions with patients, healthcare teams, or mentors that have shaped your understanding of the nursing profession.

Align with the nursing school’s values and mission

Research the nursing school’s values, mission, and educational philosophy. Ensure that your reflective essay aligns with these principles and demonstrates your commitment to the school’s mission. Use the nursing school’s prompts or essay questions as a guide to structure your essay and address the specific criteria they are looking for in applicants.

By following these tips, you can write a compelling nursing reflective essay that effectively conveys your passion for nursing, showcases your experiences, and aligns with the nursing school’s values. Remember to proofread your essay carefully for grammar and spelling errors and seek feedback from mentors or trusted individuals in the nursing profession to ensure your essay is clear, concise, and impactful.

(Table) Tips for Writing a Nursing Reflective Essay for Nursing School Application

Writing a nursing reflective essay can be a transformative experience for BSN nursing students. It allows them to gain valuable insight into their own growth and development as future healthcare professionals. Throughout this comprehensive guide, we have provided expert information and guidance on how to write a compelling nursing reflective essay.

By understanding the purpose of a reflective essay and the key elements to include, nursing students can effectively showcase their personal experiences and reflections. Incorporating reflection models such as Gibbs’ Reflective Model or Kolb Reflective Model can also provide structure and depth to their essays.

At NursingWriters.net, we are dedicated to empowering busy nurses and providing them with the tools they need to excel in their BSN programs. Whether it’s writing a reflective essay or any other writing challenge, we are here to support and guide nursing students towards success.

What is a nursing reflective essay?

A nursing reflective essay is a personal essay where the writer reflects on their own experiences and how those experiences have shaped their growth and development in the nursing profession.

How is a reflective essay in nursing different from a personal statement?

While a reflective essay in nursing focuses on the writer’s personal experiences and reflections, a personal statement is more of a formal document that highlights the writer’s qualifications, achievements, and future goals in the nursing profession.

What are the key elements to include in a nursing reflective essay?

The key elements to include in a nursing reflective essay are the inciting incident or event, personal reflections on the experience, specific details to create a vivid setting, and a description of the actions taken by the writer. It is important to avoid including academic details and excessive focus on emotions.

How should I write the introduction of a nursing reflective essay?

To write an engaging and informative introduction for a nursing reflective essay, you can grab the reader’s attention with an intriguing opening line, provide context and background information, and present a clear thesis statement. Focus on the specific event or experience that will be the main focus of the essay.

How should I structure the body paragraphs of a nursing reflective essay?

The body paragraphs of a nursing reflective essay should have a clear structure. Use the first paragraph to present the thesis statement and provide background information on the event. Use subsequent paragraphs to explore your reflections, emotions, and actions taken. Use specific examples and anecdotes to make the essay more engaging.

How should I conclude a nursing reflective essay?

To write a strong conclusion for a nursing reflective essay, you can summarize the main points discussed in the essay, provide a final reflection on your growth and learning from the experience, restate the thesis statement, and leave the reader with a thought-provoking statement or future outlook.

What are some tips for writing a nursing reflective essay?

Some tips for writing a nursing reflective essay include starting early, conducting thorough self-reflection, organizing your thoughts and ideas, and seeking feedback from peers or instructors. Pay attention to proper grammar and spelling, coherent writing style, and adhere to any formatting guidelines provided.

How can reflective tools and models help with nursing reflective essays?

Reflective tools and models provide structure and guidance for nursing students when writing reflective essays. Models such as Gibbs’ Reflective Model, Dewey’s Reflective Thinking Model, Kolb Reflective Model, and Schön Reflective Model can be used as frameworks for organizing thoughts and experiences in a nursing reflective essay.

What are the benefits of reflective writing in nursing?

Reflective writing in nursing offers benefits such as enhanced self-awareness, improved critical thinking skills, increased empathy and understanding of patient experiences, and continuous professional development. It promotes lifelong learning and helps improve patient care.

Where can I find nursing reflective essay examples?

You can find nursing reflective essay examples that showcase different experiences, reflections, and growth. These examples incorporate personal reflections, specific details, and professional insights into nursing practice. They demonstrate the diversity of topics and experiences that can be explored in nursing reflective essays.

How can I write a nursing reflective essay for nursing school applications?

To write a nursing reflective essay for nursing school applications, reflect on your passion for nursing, personal experiences in healthcare settings, and future goals in the nursing profession. Address specific prompts and align the content with the nursing school’s values and mission.

How can writing a nursing reflective essay benefit BSN nursing students?

Writing a nursing reflective essay allows BSN nursing students to gain insight into their own growth and development as future healthcare professionals. It helps improve critical thinking skills, self-awareness, and understanding of patient experiences. It also promotes continuous professional development.

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Clinical Decision-Making in Nursing Practice

August 29, 2023

View all blog posts under Articles | View all blog posts under Doctor of Nursing Practice

Clinical decision-making is one of the most important skills that nurses bring to the profession. When nurses have the authority to make evidence-based care decisions that follow best practices, a host of benefits accrue. Patients have better outcomes, nurses have higher job satisfaction, and hospitals benefit by improving their patient care metrics and reducing their risk profile.

Therefore, nursing education coursework and practicums should teach both critical thinking and clinical decision-making in order to prepare nurses for their role as leaders in patient care quality.

What Is Clinical Decision-Making in Nursing?

Nurses are the experts in patient care. They have a more in-depth understanding of a patient’s current condition than doctors and hospital administrators do. They’re the first to recognize that a patient is in pain or that a patient’s condition is deteriorating. That’s why nurses need to be problem-solvers and decision-makers with regard to patient outcomes.

Clinical decision-making in nursing is an active approach to assessing a patient’s condition and basing care decisions on the evidence. It’s a collaborative approach, with a team of health care providers weighing in and determining the best course of action. Clinical decision-making also includes patients and families in the process, which recognizes patients as their own best advocates and experts on their physical and mental health needs.

Critical thinking skills, teamwork, communication, collaboration, and knowledge of best practices are all essential parts of the clinical decision-making process. Nurses, colleagues, and patients keep the lines of communication open, make sure that everyone is on the same page with regard to decisions, and follow the evidence when caring for patients.

Examples of clinical decision-making by nurses include the following:

COVID-19 Interventions

During the pandemic, the health of hospitalized patients infected with COVID-19 could deteriorate quickly. Experienced nurses combined their knowledge of patient care and their analysis of COVID-19 patients whom they’d already treated to identify patients who were in the most danger of requiring rapid response. Nurses often followed their intuition and experience rather than relying on rules-based decision-making, allowing them to respond to complex and rapidly changing information more quickly.

Catheter-Associated Infections

Boston Medical Center identified Foley catheters as the source of 9% of hospital-acquired infections in its patients, according to a BMJ Open Quality article. The medical center set up a task force, including nurse managers, nurse educators, urologists, and other stakeholders. This team identified the issues and created education programs to prevent infections. The initiative resulted in an 83% reduction in catheter-caused infections between 2013 and 2017.

Patient Falls

Falls are a common source of inpatient injuries. In a 2021 study published in the Journal of Medical Internet Research, researchers analyzed the effectiveness of a data analytics tool for preventing falls among elderly and other patients. The data showed that use of the data analytics tool increased nurses’ awareness of fall risk and decreased the number of falls overall. Studies such as these become part of the evidence that support clinical decision-making.

Why Should We Care About Clinical Decision-Making?

Clinical decision-making has a number of advantages for hospitals, patients, and nurses. At its core, the process is rooted in science and the scientific method (hypothesis, test, repeat). It allows nurses to use all of their clinical experience, education, and professional knowledge of patient care, rather than following a set workflow or checklist. Nurses are clinicians; therefore, they should make clinical decisions. Health care organizations that support nursing judgment and critical thinking benefit in the following ways:

Patient Outcomes

The above examples show how clinical decision-making can improve patient outcomes. Nurses assess their patients, work with their colleagues, communicate with patients and their families, and identify patient health requirements. They can base their decisions on research and data. They can use critical thinking skills to identify when a patient’s treatment needs to be adjusted. The research increasingly shows that clinical decision-making by nurses can improve quality of care and patient satisfaction.

Hospital Advantages

As health care payment models move from fee-for-service reimbursement models to value-based care, patient outcome metrics have become more important. That’s because hospitals and doctors will soon largely be reimbursed based on the quality of the care they provide rather than by procedure. Medicare is using data such as hospital-acquired infections, falls, and readmissions to penalize hospitals. As a result, allowing nurses to use their clinical judgment can help boost hospital revenues.

Job Satisfaction

The nursing shortage has worsened under pressure from COVID-19. Nurses report that when their employers give them authority to make clinical decisions, they are more likely to be satisfied in their jobs. They may be less susceptible to burnout and more likely to stay in the profession. When employers treat nurses as clinicians, they are more likely to retain staff, which can help stem the nationwide nursing shortage that the health care system faces.

Multidisciplinary Care

By its nature, clinical decision-making is a multidisciplinary process. Health care providers can apply it at the patient level, because it accounts for the views of all professionals involved in a patient’s care plan. It also applies at the organizational level, as leaders can incorporate the knowledge and experience of all clinical and administrative staff members when making operational decisions.

Coordinated Care

The coordinated care pathway is a hallmark of clinical decision-making at the patient level. It connects health care providers (doctors, nurses, and support staff) and makes sure that everyone communicates through transition points, such as when patients are handed off to specialists or other care teams or throughout the length of their medical condition.

Organizational Decision-Making

At the organizational level, nurses, nurse managers, physicians, administrators, and chief nursing and chief medical executives are part of the decision process. This was found to be especially effective during the pandemic. According to the American Association of Critical Care Nurses, direct care nurses, nurse leaders, and organizational leaders came together to support clinical care best practices at all levels, starting with the nursing process (assess, diagnose, plan, and evaluate).

A Comprehensive Nursing Education for Your Future

The future of nursing is in the hands of clinicians who are just now coming into the workforce. This is a time of great change in health care. Hawai‘i Pacific University’s online Bachelor of Science in Nursing to Doctor of Nursing Practice program prepares nurses to excel in this new world with a curriculum that supports clinical decision-making and critical thinking. Take the first step into your future today.

Recommended Reading:

The Importance of a Nurse’s Role in Patient Safety

What Is Evidence-Based Practice in Nursing?

Nursing Advocacy: The Role of Nurses Advocating for Patients

Agency for Healthcare Research and Quality, "Chapter 2. What Is Care Coordination?"

American Association of Critical-Care Nurses, Effective Decision Making

American Association of Critical-Care Nurses, "Effective Decision-Making During the Pandemic"

American Association of Nursing Colleges, "Hospitals Innovate Amid Dire Nursing Shortages"

BMC Nursing, "Shared Clinical Decision-Making Experiences in Nursing: A Qualitative Study"

BMJ Open Quality , "Catheter-Associated Urinary Tract Infection Reduction in Critical Care Units: A Bundled Care Model"

JMIR Publications, "Clinical Impact of an Analytic Tool for Predicting the Fall Risk in Inpatients: Controlled Interrupted Time Series"

Nursing-Writing, "Clinical Decision Making in Nursing Scenarios"

PLoS One , "Identifying Factors That Nurses Consider in the Decision-Making Process Related to Patient Care During the COVID-19 Pandemic"

RN.org, "Critical Thinking in Nursing: Decision-Making and Problem-Solving"

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• decision making
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Nurses have probably always known that their decisions have important implications for patient outcomes. Increasingly, however, they are being cast in the role of active decision makers in healthcare by policy makers and other members of the healthcare team. In the UK, for example, the Chief Nursing Officer recently outlined 10 key tasks for nurses as part of the National Health Service’s modernisation agenda and the breaking down of artificial boundaries between medicine and nursing. 1 As well, nurses are expected to access, appraise, and incorporate research evidence into their professional judgment and clinical decision making. 2 This active engagement with research evidence is the focus of this paper. We will explore why it is necessary to consider the clinical decision making context when examining the ways in which nurses engage with research based information. We will also consider the relation between the accessibility and usefulness of information from different sources and the decisions to which such information is applied. Finally, we will argue that if we are to encourage nurses to actively engage with research evidence during clinical decision making, we need to better understand the relation between the decisions that nurses make and the knowledge that informs them.

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Decision-Making Process in Nursing Essay

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Introduction

Health policy, regulatory requirements, accreditation, health care financing.

Nurse managers must make daily decisions that affect their staff members’ working circumstances, the standard of patient care, patient outcomes, and the hospital’s reputation. Bikker and Bekooij (2021) state that to assess and successfully meet the demands of all parties, a manager must be familiar with all organizational elements, medical and healthcare information, and related specifics. It is the responsibility of the nurse manager to ensure that a hospital carries out its nursing function with maximum efficiency and effectiveness. However, several external factors impact the job of a nursing manager and the decision-making process. I interviewed a nurse manager from a nearby medical facility to understand how external influences affect how well she does her tasks. In particular, highlighted the impact of health policy, regulatory requirements, accreditation, and healthcare finance in the interview as external factors that affect decision-making.

Health policy is fundamentally adaptable and flexible since its main objective is to ensure that the population receives the highest possible standard of care and treatment. However, decisions that impact these problems are made by considering both the data provided by doctors and nurses and the statistics of people’s requests (Bikker & Bekooij, 2021). As a result, to develop an effective policy, medical staff participation and suggestions are required.

In the interview, Mrs. Jensen sees that for her decisions to have a positive effect, she must effectively manage policy difficulties. For instance, she emphasizes the importance of mentoring her staff members to enhance their expertise by applying evidence-based procedures. The policy aids in raising staff morale and developing their ideas for providing services. Additionally, research on firms that support nurses’ engagement has produced comparable effects since nurses frequently show notable improvements in their job due to employee initiatives. Because the current policy compels managers to make choices that could improve it, nurses’ decisions and health care policy consequently influence one another.

Health regulations and standards are required to make nursing decision-making easier and to lessen the possibility of malpractice and medical errors. In addition, nursing may be directly impacted by laws and policies of the federal, state, and local governments. Bikker and Bekooij (2021) state that the functions and responsibilities of regulatory authorities should be clearly defined as healthcare access changes and safety concerns develop. Mrs. Jensen acknowledges that the regulatory landscape may hinder or frustrate the provision of nursing services. Since it is equally important for nurses to display sympathy and adhere to formal standards, the rules remarkably impact decision-making. A nurse manager must, therefore, occasionally depart from the norm. The nursing manager uses an instance from her practice as an example when she permitted her subordinate to finish the shift earlier to assist her son’s academic performance. She was aware that the nurse was required at work but that her son’s health would impact the nurse’s disposition and the caliber of her work. She had to permit her to depart despite breaking the local and organizational norms.

Accreditation standards significantly impact any healthcare facility’s nurse administration. A hospital’s ability to provide certain services is defined by its accreditation requirements, which are directly related to better patient outcomes. Traczynski and Udalova (2018) state that to ensure a healthcare facility complies with the most recent standards of patient care; the accreditation authorities monitor the delivery of nursing services. Despite being authorized to provide a limited number of services, Mrs. Jensen’s institution needs to work harder to broaden its scope. Without the required accreditation she cannot be able to apply for funds, permissions, or increased hospital charges. Additionally, no adjustment demanded by one of the accrediting bodies may put the nurse manager under more stress and burden.

For many states, funding medical organizations are challenging because the budget is constrained, and the demands of this sector keep expanding. According to Taylor (2017), the effectiveness and efficiency of patient care services, as well as the results, have a significant impact on healthcare funding. However, some hospitals need more resources to expand and raise the level of care. They must rely on insufficient internal funding and seek additional funding from outside sources, such as sponsorships, grants, and healthcare institutions. Mrs. Jensen acknowledges that she must operate within a limited budget that must be carefully stretched to accommodate all requests. The financing issue has a bigger impact than the other aspects of research. The nursing manager is responsible for budget management and financial choices, many of which impact the hospital’s organizational structure.

Mrs. Jensen’s interview provides evidence that outside pressures impact nurse management. The interview’s main objective was to determine how decision-making is affected by health policy, legal requirements, accreditation, and financing for healthcare. Health financing has the biggest impact as it is frequently constrained and unable to meet all requirements. Decisions are influenced equally by health regulations, accreditation standards, and health policies, but still all decisions made by the nurse manager are distinctive. To implement the best solution, the administrator must understand and manage the influence of all aspects.

Bikker, J. A., & Bekooij, J. (2021). Market Forces in Healthcare Insurance: The Impact of Healthcare Reform on Regulated Competition Revisited . De Nederlandsche Bank Working Paper No. 705, SSRN Electronic Journal . Web.

Taylor, D. W. (2017). Rethinking the financing of healthcare in Canada . Healthcare Management Forum , 29 (6), 260–263. Web.

Traczynski, J., & Udalova, V. (2018). Nurse practitioner independence, health care utilization, and health outcomes . Journal of Health Economics , 58 , 90–109. Web.

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IvyPanda. (2023, December 15). Decision-Making Process in Nursing. https://ivypanda.com/essays/decision-making-process-in-nursing/

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1. IvyPanda . "Decision-Making Process in Nursing." December 15, 2023. https://ivypanda.com/essays/decision-making-process-in-nursing/.

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Shared decision making: why the slow progress? An essay by Neal Maskrey

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• Neal Maskrey , honorary professor, evidence informed decision making
• Keele University, Staffordshire
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After more than 40 years of research and policy endorsement, adoption of shared decision making into routine practice has been remarkably slow. Neal Maskrey blames a lack of focus on doctors’ broader communication skills

Shared decision making occurs when clinicians and patients work together to select tests, treatments, management, or support packages, based on clinical evidence and patients’ informed preferences. It involves providing evidence based information about options, outcomes, and uncertainties, together with counselling and a system for recording and implementing patients’ informed preferences. 1

Shared decision making has its roots in the ethical principles underpinning clinical practice. In the UK it is included in the NHS Constitution and is a requirement of the doctors’ regulator the General Medical Council (GMC), and it is recommended as usual practice by NHS England and in guidelines by the National Institute for Health and Care Excellence.

Every year from 2009, the healthcare services regulator the Care Quality Commission has asked hospital inpatients whether they were involved as much as they wanted to be in decisions about their care and treatment. 2 In 2018 just over 50% of 75 000 respondents answered, “Yes, definitely,” and the pace of any progress seems glacial: about 25% of patients agreed when the CQC asked whether doctors had talked in front of them as if they weren’t there.

Recent Canadian observations of paediatric ear, nose, and throat consultations showed that only half of items that were listed as elements of shared decision making in a validated 12 item scale were present in over 90% of consultations. 3 Clinicians were not observed assessing the patient’s preferred approach to receiving information to assist in decision making.

And, given the need identified by the late geriatrician Kate Granger for healthcare professionals to say, “Hello, my name is . . .” at the …

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Clinical Decision making and the Nursing Process

Info: 1334 words (5 pages) Nursing Essay Published: 11th Feb 2020

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