Dissertations / Theses on the topic 'Emergency nursing Decision making'

Clinical decision making is an integral, multifaceted phenomenon fundamental to nursing practice. The domain of flight nursing practice is unique in terms of knowledge, structure, clinical presentations and environment. The uniqueness and diversity of patient scenarios and the advanced practice level of the flight nurse role blend to provide a potential rollercoaster flight mission. At the time this research was conducted nursing standards to guide clinical decision making were being developed. Medically orientated clinical guidelines were in place, but they were designed to highlight a specific, well defined clinical scenario or skill. It has been argued that guidelines for nursing practice do not always parallel the complex clinical situations in which advanced practitioners may find themselves (Malone, 1992b). Flight Nurse Specialists (FNSs) with greater than two years flight nursing experience employed by the Royal Flying Doctor Service (RFDS) - Western Operations were interviewed regarding their experiences of clinical decision making in emergency situations. Using a phenomenological methodology, indepth interviews were audiotaped and transcribed. The interviews were analysed using the method described by Colaizzi (1978). Data was described and interpreted, common themes were extrapolated and analysed. A Gestalt of Knowing was identified by the interconnection and interrelationships of the extrapolated themes. The three themes are: Ways of Knowing the Patient, Context of Knowing and Reflective Practice. Ways of Knowing the Patient is constructed with the sub-themes intuitive knowing, experiential knowing and objective knowing. The second theme, Context of Knowing, is made up of the sub-themes aviation environment, non or minimised involvement in triage, knowing co11eagues, solo practitioner, experiential level and practice guidelines. Self-critique and change in practice formed the theme Reflective Practice. Findings provide a significant contribution to the knowledge of clinical decision making in nursing and to the practice of flight nursing in the Western Australian context. Several recommendations arose from the findings in relation to further research, policy making, standards development and practice developments. Further research is needed into the themes and sub-themes. FNSs need to be allowed to undertake the role of triage for those flights that they will undertake as the solo health professional. The development of standards for flight nursing would benefit from the consideration of the findings of this study and other qualitative studies of clinical decision making. Reflective practice should be considered as a mechanism for not only evaluating practice but as a mechanism for identifying stressful events.

Thesis (Ph. D.)--Georgia State University, 2008.
Title from file title page. Cecelia Gatson Grindel, committee chair; Anne Koci, Annette Bairan, committee members. Electronic text (144 p. : ill.) : digital, PDF file. Description based on contents viewed July 10, 2008. Includes bibliographical references (p. 82-86).

This ethnographic study provides insight and understanding, which is needed to educate and support the Triage Nursing role in Australian Emergency Departments (EDs). The triage role has emerged to address issues in providing efficient emergency care. However, Triage Nurses and educators have found the role challenging and not well understood. Method: Sampling was done first by developing a profile of 900 nurses who undertake the triage role in 50 NSW EDs through survey techniques. Purposive sampling was then done with data collected from participant observation in four metropolitan EDs (Level 4 and 6), observations and interviews with 10 Triage Nurses and the maintenance of a record of secondary data sources. Analysis used standard content and thematic analysis techniques. Findings: An ED culture is reflected in a standard geography of care and embedded beliefs and rituals that sustain a cadence of care. Triage Nurses to accomplish their role and maintain this rhythm of care used three processes: gatekeeping, timekeeping and decision-making. When patient overcrowding occurred the three processes enabled Triage Nurses to implement a range of practices to restore the cadence of care to which they were culturally oriented. Conclusion: The findings provide a framework that offers new ways of considering triage nursing practice, educational programs, policy development and future research.

The purpose of this study was to explore the relationship between nurses' use of intuition, years of worked nursing experience, and nurses' perceived ethical decision making ability. Additionally, recognizing the relationship between the intuitive/experiential and the analytic/rational systems, this research extended beyond the intuitive/experiential system capturing analytic/rational thought. A sample of 182 nurses from the Emergency Nurses Association (ENA) was recruited for this investigation. A nonexperimental, correlational research design was used to examine the relationship between the variables. Intuition was measured using the Experiential scale of the Rational-Experiential Inventory (REI) and analytic/rational was measured using Rationality scale of the REI. Perceived ethical decision making ability was measured with the Clinical Decision Making in Nursing Scale (CDMNS) applied to an ethical dilemma within the participants own practice. Cognitive-Experiential Self-Theory (CEST) provided the theoretical framework for this study. According to CEST, information is processed by two independent, interactive conceptual systems; a preconscious intuitive/experiential system and a conscious analytic/rational system. These are thought to function parallel from yet interactively with each other. One-way ANOVAs, independent sample t-tests, Pearson's r correlation, and multiple regressions analysis provided the statistical methods used to answer nine research questions. A significant relationship was found between intuition and perceived ethical decision making (r = .252, p = .001). This contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions.

Thesis advisor: Dorothy A. Jones
Thesis advisor: Pamela J. Grace
The purpose of the study was to explore the relationship between multiple variables within a model of critical thinking and moral reasoning that support and refine the elements that significantly correlate with accuracy and clinical decision-making. Background: Research to date has identified multiple factors that are integral to clinical decision-making. The interplay among suggested elements within the decision making process particular to the nurse, the patient, and the environment remain unknown. Determining the clinical usefulness and predictive capacity of an integrated ethically driven environmental model of decision making (IEDEM-CD) in emergency settings in facilitating accuracy in problem identification is critical to initial interventions and safe, cost effective, quality patient care outcomes. Extending the literature of accuracy and clinical decision making can inform utilization, determination of staffing ratios, and the development of evidence driven care models. Methodology: The study used a quantitative descriptive correlational design to examine the relationships between multiple variables within the IEDEM-CD model. A purposive sample of emergency nurses was recruited to participate in the study resulting in a sample size of 200, calculated to yield a power of 0.80, significance of .05, and a moderate effect size. The dependent variable, accuracy in clinical decision-making, was measured by scores on clinical vignettes. The independent variables of moral reasoning, perceived environment of care, age, gender, certification in emergency nursing, educational level, and years of experience in emergency nursing, were measures by the Defining Issues Test, version 2, the Revised Professional Practice Environment scale, and a demographic survey. These instruments were identified to test and refine the elements within the IEDEM-CD model. Data collection occurred via internet survey over a one month period. Rest's Defining Issues Test, version 2 (DIT-2), the Revised Professional Practice Environment tool (RPPE), clinical vignettes as well as a demographic survey were made available as an internet survey package using Qualtrics TM. Data from each participant was scored and entered into a PASW database. The analysis plan included bivariate correlation analysis using Pearson's product-moment correlation coefficients followed by chi square and multiple linear regression analysis. Findings: The elements as identified in the IEDEM-CD model supported moral reasoning and environment of care as factors significantly affecting accuracy in decision-making. Findings reported that in complex clinical situations, higher levels of moral reasoning significantly affected accuracy in problem identification. Attributes of the environment of care including teamwork, communication about patients, and control over practice also significantly affected nurses' critical cue recognition and selection of appropriate interventions. Study results supported the conceptualization of the IEDEM-CD model and its usefulness as a framework for predicting clinical decision making accuracy for emergency nurses in practice, with further implications in education, research and policy
Thesis (PhD) — Boston College, 2011
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. ED triage is a rather unexplored area in the Swedish health care system. This thesis contributes to our understanding of this complex nursing task. The main focus of this study has been on the organisation, performance, and decision making in Swedish ED triage. Specific aims were to describe the Swedish ED triage context, describe and compare registered nurses’ (RNs) allocation of acuity ratings, use of thinking strategies and the way they structure the ED triage process.

In this descriptive, comparative, and correlative research project quantitative and qualitative data were collected using telephone interviews, patient scenarios and think aloud method. Both convenience and purposeful sampling were used when identifying the participating 69 nurse managers and 423 RNs from various types of hospital-based EDs throughout the country.

The results showed national variation, both in the way triage was organised and in the way it was conducted. From an organisational perspective, the variation emerged in several areas: the use of various triageurs, designated triage nurses, and triage scales. Variation was also noted in the accuracy and concordance of allocated acuity ratings. Statistical methods provided limited explanations for these variations, suggesting that RNs’ clinical experience might have some affect on the RNs’ triage accuracy. The project identified several thinking strategies used by the RNs, indicating that the RNs, amongst other things, searched for additional information, generated hypotheses about the fictitious patients and provided explanations for the interventions chosen. The RNs formed relationships between their interventions and the fictitious patients’ symptoms. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences.

The findings in this dissertation indicate that the way a patient is triaged, and by whom, depends upon the particular organisation of the ED. Moreover, the large variation in RNs triage accuracy and the inter-rater agreement and concordance of the allocated acuity ratings suggest that the acuity rating allocated to a patient may vary considerably, depending on who does the allocation. That neither clinical experience nor the RNs’ decision-making processes alone can explain the variations in the RNs triage accuracy indicates that accuracy might be influenced by individual and contextual factors. Future studies investigating triage accuracy are recommended to be carried out in natural settings.

In conclusion, Swedish ED triage is permeated by diversity, both in its organisation and in its performance. The reasons for these variations are not well understood.

A Classificação de Risco foi implantada nos serviços de urgência com a finalidade de priorizar o atendimento, considerando a gravidade da situação clínica e a necessidade de cuidados imediatos dos usuários. No entanto, há dificuldades em relação ao desenvolvimento desta atividade pelo enfermeiro. Assim, o objetivo do estudo é avaliar a Classificação de Risco nos serviços de urgência na perspectiva dos enfermeiros. Para atingir essa finalidade foi realizado estudo exploratório, quantitativo, de mensuração de opinião, por meio da técnica Delphi. Foram realizadas três rodadas de aplicação de questionários interativos, que circularam entre os participantes até obtenção de consenso. Para a composição do painel dos especialistas foi utilizada a técnica de bola de neve. Os dados foram coletados por meio de questionário inserido na plataforma eletrônica SurveyMonkey®, de acesso on-line, e foram submetidos a tratamento estatístico. Foi estipulado como consenso o percentual acima ou igual a 70% das respostas. Os resultados obtidos indicaram que a Classificação de Risco é um dispositivo orientador de fluxo de usuários e de priorização da gravidade clínica, contribuindo para a diminuição do tempo de espera dos pacientes em condições clínicas graves e permitindo a redução de agravos e sequelas de pacientes urgentes. Além disso, os participantes concordaram que a classificação de risco organiza o trabalho dos enfermeiros e do serviço de urgência. A avaliação do estado clínico por meio do desenvolvimento da escuta qualificada às queixas dos usuários foi identificada como uma das ações dos enfermeiros na classificação de risco, sendo que a autonomia no exercício dessa atividade foi considerada como uma das potencialidades. Quanto à formação necessária para a realização da classificação de risco, foi indicado o conhecimento clínico como base para a tomada de decisão na priorização do atendimento ao paciente. A experiência profissional em classificação de risco foi também identificada para o julgamento da prioridade de atendimento do paciente e a capacidade intuitiva foi apontada como facilitadora. Para isso, os enfermeiros necessitam de habilidades de comunicação e de enfrentamento dos conflitos com os usuários. Dentre as fragilidades, houve consenso de discordância de que o ambiente da classificação de risco seja capaz de promover o acolhimento do paciente e de favorecer a privacidade. Foi considerado que o dimensionamento do número de enfermeiros por turno de trabalho não é suficiente para a realização da classificação de risco nos serviços de urgência, de forma que a demanda excessiva de usuários e o número inadequado de profissionais podem expor os enfermeiros da classificação de risco à elevada carga de trabalho. Também houve consenso de discordância quanto à disponibilização de capacitações periódicas aos enfermeiros sobre a utilização dos protocolos/escalas de classificação de risco. Quanto à fragilidade de ações dos enfermeiros na classificação de risco, foi indicada a falta de reavaliação da condição clínica do paciente durante o período de tempo de espera pelo atendimento, o que pode gerar agravamento da condição clínica do paciente e prejuízos ao exercício profissional do enfermeiro. Conclui-se que os enfermeiros representam suporte profissional, cognitivo e emocional na Classificação de Risco. Os resultados sinalizam que a qualificação permite que os enfermeiros continuem atuando na avaliação e classificação do risco nos serviços de urgência e permanecerão realizando essa atividade no futuro.
The Risk Classification was deployed in emergency services in order to prioritize care, considering the severity of clinical status and need immediate attention from users. However, there are difficulties regarding the development of this activity by nurses. The objective of the study is to evaluate the triage performed at emergency services, from the nurses‘ perspective. To achieve this purpose was conducted exploratory study, quantitative measurement of opinion by the Delphi technique. The subjects answered interactive questionnaires, which circulated among the participants for three rounds, until reaching consensus. The board of experts was composed using the snowball method. Data were collected using a questionnaire available on SurveyMonkey®,an online electronic platform, and submitted to statistical analysis. It was established that consensus would be reached when 70% or more answers were equal. The findings show that triage is a tool that guides patient flow and rates clinical severity, thus contributing to reducing the waiting time for patients in severe clinical conditions, and permitting to reduce complications and sequels in emergency patients. Furthermore, the participants agreed that triage organizes the work of nurses and the emergency service. It was identified that the evaluation of the clinical condition by carefully listening to the patient‘s complaints was one of the actions that nurses used to classify the risk, and that the autonomy of this activity was considered one of its strengths. As to the necessary training to conducttriage, it was indicated that clinical knowledge should be the foundation for making decisions when establishing priorities in patient care. Professional experience was also considered important in triage to judge the priority of patient care, and intuition was pointed out as a facilitator. Nurses, therefore, must have communication skills as well as coping skills to deal with the patients‘ conflicts. Among the weaknesses, there was consensus of the disagreement that the triage environment promotes patient embracement and offers privacy. It was considered that nurse staffing per working shift is insufficient to perform triage at emergency services, in a way that the excessive demand of patients and the insufficient number of professionals can expose triage nurses to high work overload. There was also consensus regarding the disagreement of the availability of periodic training for nurses on how to use triage protocols/scales. Regarding the weaknessof the triage nurses‘ practice, it was indicated there was a lack of reevaluations of the patient‘s clinical condition during the waiting time, which could worsen the patient‘s clinical condition and harm the nurses‘ practice. In conclusion, nurses represent professional, cognitive and emotional support to triage. The findings indicate that qualification allows nurses to continue conducting triage at emergency services and will continue performing this activity in the future.
La clasificación de riesgo se desplegó en los servicios de emergencia con el fin de priorizar la atención, teniendo en cuenta la gravedad de la situación clínica y la necesidad de atención inmediata por parte de los usuarios. Sin embargo, existen dificultades en relación con el desarrollo de esta actividad por las enfermeras. El objetivo del estudio es evaluar la clasificación de riesgo los servicios de emergencia desde la perspectiva de las enfermeras. Para lograr este propósito se realizó un estudio exploratorio, la medición cuantitativa de la opinión por la técnica Delphi. Se realizaron tres rondas de aplicación de cuestionarios interactivos, que circularon entre los participantes hasta obtenerse consenso. Para conformar el panel de especialistas se utilizó la técnica de la bola de nieve. Datos recolectados mediante cuestionario ingresado en plataforma informática SurveyMonkey®, disponible online, sometidos a tratamiento estadístico. Fue estipulado como consenso un porcentaje igual o superior al 70% de respuestas. Los resultados obtenidos indicaron que la Clasificación de Riesgo es un dispositivo orientador de flujo de usuarios y de priorización de gravedad clínica, contribuyendo a disminuir el tiempo de espera de pacientes en condiciones clínicas graves y permitiendo la reducción de agravamientos y secuelas en pacientes de urgencia. Además, los participantes concordaron en que la clasificación de riesgo organiza el trabajo de los enfermeros y del servicio de urgencias. La evaluación del estado clínico mediante el desarrollo de escucha calificada de quejas de pacientes fue señalada como una de las acciones de enfermería en la clasificación de riesgo, considerándose la autonomía en el ejercicio de la actividad como una de las potencialidades. Respecto a la formación necesaria para realización de clasificación de riesgo, se indicó el conocimiento clínico como base para toma de decisiones en priorización de atención del paciente. La experiencia profesional en clasificación de riesgo fue también mencionada para determinar la prioridad de atención del paciente, la capacidad intuitiva resultó señalada como facilitadora. Para ello, los enfermeros necesitan poseer habilidades comunicacionales y de enfrentamiento a los conflictos de los pacientes. Entre las fragilidades, hubo consenso de discordancia sobre que el ámbito de clasificación de riesgo sea capaz de promover la recepción del paciente y favorecer su privacidad. Se consideró que el dimensionamiento numerario de enfermeros por turno laboral es insuficiente para la realización de clasificación de riesgo en los servicios de urgencias, dado que la demanda excesiva de pacientes y la escasez de exponen a los enfermeros de clasificación de riesgo a una carga laboral elevada. También hubo consenso de discordancia respecto a la disponibilización de capacitación periódica para los enfermeros sobre la utilización de protocolos/escalas de clasificación de riesgo. Acerca de la fragilidad de acciones de los enfermeros en la clasificación de riesgo, se indicó la falta de reevaluación de la condición clínica del paciente durante el tiempo de espera previo a la atención, lo cual puede agravar la condición clínica del mismo y perjudicar el ejercicio profesional del enfermero. Se concluye en que los enfermeros representan soporte profesional, cognitivo y emocional en la Clasificación de Riesgo. Los resultados señalan que la calificación permite que los enfermeros continúen actuando en la evaluación y clasificación del riesgo en los servicios de urgencias, y continuarán realizando dicha actividad en el futuro.

The aim of this thesis was to examine the cognitive processes through which experienced Offshore Installation Managers (OIMs) make decisions during emergencies, and to determine whether they use a naturalistic or normative decision making strategy. That is, do they recognise the emergency as familiar and base decisions on condition-action rules serially generated (naturalistic), or do they need to concurrently compare and contrast options before selecting the best possible (normative). Emphasis was on the individual OIM's understanding of an emergency and the meaning he attached to the information or events taking place. The method employed to achieve this objective, was a Cognitive Task Analysis (CTA) based on triangulation principles, i.e. using multiple methods to examine the same research question and so enhance reliability and validity. The main findings of this thesis were: • Decision making in Safety Case (1992) identified offshore installation emergencies is primarily based on condition-action rules, or rule-based according to Rasmussen's (1983) model, not Standard Operating Procedures. • Decisions are serially generated. There is no evidence of option comparison. • The environment severely limits the number of options available to the OIM. • Decisions are predominantly made when one element of the present status of the incident changes. • Tactical decisions account for approximately 54% and operational decisions for 46% of the decisions made. • Nearly 50% of the decisions taken are instigated by other team members. • The majority of the time (86.8%) is spent on situation assessment. • The OIMs' situation awareness is limited to a maximum of eight interdependent problem categories. • Situation awareness comprises approximately four categories at any one point. • Risk and time pressure are the two major factors contributing to incident assessment. • There are individual differences in decision making style and situation awareness.

The two studies described here address the question of how District Nurses determine patients' nursing problems and plan care. The theoretical framework for the investigation is derived from Information Processing Theory. A process tracing methodology was used to capture the content of District Nurses' thinking during an assessment visit to a newly referred patient. Data was collected in the natural setting to ensure ecological validity. The assessment visits were tape recorded and immediately following the visit a stimulated recall session was conducted in which the nurse was asked to describe her thinking during the assessment, prompted by the tape recording. This session was itself tape-recorded. Thus two verbal protocols were elicited for each assessment: a visit protocol and a recall protocol. Data were analysed by content analysis. The verbal protocols were assessed to ensure that they met the criteria for validity and reliability of the coding schedules was established using two measures or interrater reliability. The first study sought evidence of hypothetico-deductive reasoning by nurses and describes the type of decisions made by nurses. Although evidence of hypothesis generation and testing was found, nurses' knowledge was found to determine how they interpreted data initially and what data they sought. It was therefore concluded that a model of diagnostic reasoning that focused on cognitive processes alone was insufficient to explain the dynamics of clinical problem solving. The second study, therefore, sought to establish the structure and content of District Nurses knowledge and the cognitive processes they used during an assessment. The results suggest that nurses attend to both clinical and personal phenomena in order to make a judgement about the state of the patient and that their knowledge is organised internally as schema. This provides an explanation of how nurses recognise salient information and determine what further data is required. Four key cognitive activities were identified: search, inference, action and plan. The study concludes by drawing a line of reasoning to show how nurses integrate knowledge and reasoning processes to accomplish clinical problem solving.

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.

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Bachelors
Nursing
Nursing

Thesis (Ph. D.)--University of Florida, 2000.
Title from first page of PDF file. Document formatted into pages; contains xi, 133 p.; also includes graphics. Vita. Includes bibliographical references (p. 100-131).

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

This thesis sets out to examine decision making in emergencies by industrial on-scene incident commanders.  The aim was to develop a better understanding of decision making strategies used in hazardous, dynamic situations, with ill-defined problems and complex organisational issues.  The project was set in the UK nuclear power generation industry.  The focus was on the role of the Access Controller (AC), who, as the operational level decision maker in a nuclear emergency response organisation (ERO), is particularly crucial when effective decisions must be made that may affect the potential escalation of the situation. The Naturalistic Decision Making (NDM) approach (Zsambok and Klein, 1997), which focuses on the context of the decision making environment, expertise, and the holistic decision making process, provided the theoretical framework for the thesis.  Within this framework, the model of Decision Making Under Stress (DMUS) developed by Stokes, Kemper and Kite (1997) in the aviation domain was tested in this nuclear setting.  The thesis consisted of five studies conducted with participants from various fixed nuclear installations throughout the UK, culminating in the development of a computer-based decision making task. The main findings of the thesis were that the majority of AC decisions are rule-based (80%). Written procedures did not appear to enhance decision making in emergencies, but prior experience of making a particular emergency decision was found to assist more competent decision making.  Duration of experience in the AC role was not in itself a good indicator of decision making expertise, which was found to be dependent on a corpus of problem solving strategies from normal operational role, along with recognition of critical cues (situation awareness) and recall of a schema or script stored in LTM. The conclusions presented in this thesis, for both the role of AC specifically and a nuclear ERO in general, should go some way towards improved understanding of decision making in complex, hazardous environments.  Moreover, these results may generalise to other industries and organisations where effective decision making during emergency response is essential.

Emergency call takers listen to callers expressing mundane errands, but also to callers who describe severe accidents, agony and deaths. The emergency setting is further complicated by having to perform triage under time-pressure, but without possibilities of seeing the patient. The setting rests on an imperative of speedy management—there are few or no possibilities to postpone or reconsider decisions. At the same time, the mode of communication (telephone) may cause overflow or insufficient information, resulting in an uncertain and ambiguous decision setting. A focal point for the organization is therefore the individual capability of conducting triage. However, call takers are also helped by organizational routines, which are manifested in decision support systems, in order to navigate this uncertain and ambiguous setting. Taken together, the emergency setting brings a tension to the fore—how does this emotional setting, with features of vivid and interruptive experiences that possibly detour normative decisions, interact with routines that are supposed to provide for both stability and that recurrent decisions can be made under similar conditions? Drawing on the fields of psychology, decision making, organization theory and communication theory the tension is investigated by a series of four studies. The first study is a field study of the emotional landscape of emergency call taking. Emergency call takers rated callers’ emotional expressions in authentic emergency calls, the level of intensity and expressed need for help. The second study is an experiment, using a speech sample from authentic emergency calls in order to find out whether expressed emotion and intensity contribute to perceived need for help. The third study focuses on management strategies of call takers. More specifically, how do emergency call takers manage double-faced emotional management—i.e., their own and the caller’s emotions—simultaneously? The fourth study focuses on how call takers make decisions, more specifically how call takers use intuitive and emotional capabilities to complement or challenge rational aspects of the decision support systems. The studies reveal that certain emotions occur more often than others and that the level of intensity of expression contributes to perceived help need. Call takers have also developed specific emotional management strategies in order to cope with both callers’ and their own emotions. Finally, call takers were found to use rational and formal routines as well as non-formal, intuitive and emotionally based individual routines in order to derive their decisions. These findings are put into organizational context in terms of implications for emergency call taking. Limitations to the development of situation-specific expertise and obstacles for organizational learning are identified. Also, emergency call taking would benefit from drawing on knowledge found outside of the medical domain. However, the most important finding is that interpretation of emotional expressions in callers’ voices can trigger modifications of the triage routine in use.

Disp. June 12

Modern Matrons are at the vanguard of both care delivery and the NHS reforms and have an important role in the modernisation of, and future delivery of healthcare. An important contextual feature of their role and a concept that has been widely embraced by the National Health Service, is that of decentralized decision making. Unlike clinical decision making which has been extensively studied, there is little in the healthcare literature regarding leadership and management decision making or the concept of decentralised decision making. In order to maximise the effectiveness of the Modern Matron role, it is important that we gain a thorough understanding of how they make leadership and management decisions, the reality of the term decentralized decision making for them and an insight into their abilities and needs in regards to this essential skill.

A descriptive study was conducted to explore the relationship among three measures of decision making capacity: (1) clinicians' opinions, (2) Pfeiffer's (1975) SPMSQ, and (3) a developmental instrument by Fitten et al. (1990) designed to measure patient clinical decision making ability. Another purpose of the study was to replicate portions of the work by Fitten et al. (1990). A convenience sample of 41 patients, four physicians, and three nurse practitioners was studied. Quantitative research techniques were employed for data collection and analysis. Significant correlations were found among all measurements of decision making capacity indicating that the developmental instrument appears to be a valid method of determining decision making capacity according to results obtained for convergent validity. The findings of this study support those reported by Fitten et al. (1990).

This dissertation presents a comprehensive qualitative study of the decision-making aspects of emergency department (ED) triage at a large urban Trauma I hospital in the Southeast. Specifically, this study addresses the following research questions: (1) What do triage nurses perceive as the primary role of the triage process? (2) How do triage nurses interpret patient performances? These questions are explored through illuminating the intricacies of triage decision-making by the use of semi-structured interviews and observations. The findings of this study indicate: (1) a better understanding of the triage decision- making process yielding more practical insights related to the informal, emergent, and often improvisational ways patients are received, categorized, and treated was needed, and (2) providing a clearer understanding of the processes involved in sorting patients may provide much-needed insight regarding clinical concerns and/or issues regarding patient categorization, adverse clinical events, and excessive patient wait times. These findings are of particular importance due to the widespread overuse of EDs for nonemergent care. Essentially, EDs are designed for patients to visit due to an alteration in their physical and/or mental state. Once a patient enters the ED, a medical professional is tasked with the responsibility of interpreting the physical and/or mental state of the patient, which is generally achieved by interpreting the patient story - the precipitating event that brought them into the ED. What this study contributes to the literature is a deeper understanding of the communicative processes that ED triage nurses leverage to make sense of patient stories.

During their clinical practicum, nursing students are involved in making decisions about the care for their patient or group of patients. The purpose of this study was to ascertain nursing students' perceptions of the variety and magnitude of factors that influence them as they are making decisions about patient care. For the study a nonexperimental approach utlizing a cross-sectional descriptive design was used. Thirty-three second year and thirty-one third year nursing students from a diploma nursing school responded to a questionnaire designed to reflect perceived domains of influence in thier clinical decision making. A subset of 18 subjects were interviewed. Some of the major findings include: 1) More second year than third year students perceived stress as a factor affecting their clinical decision making. Third year students most often mentioned the instructor-student relationship as a source of stress. Second year students most often referred to their workload and fatigue as contributing to their stress. 2) More third year than second year students preceived decision making theory and the nursing process to be an influencing factor in decision making. 3) Previous life and health-related work experience was indicated to be an influencing factor in clinical decision making more often by second year students than by third year students. 4) When asked to choose and rank five from a list of sixteen influencing factors in clinical decision making, the combined group chose the following in order; knowledge of patients and their condition, level of self confidence, knowledge of nursing proces, relationship with instructor, previous nursing experience, and previous life experience. 5) In the interviews the two most frequently mentioned guiding forces in decision making were: (a)what they (the student) or someone close to them would want and (b)patient preference. The study encourages nursing instructors to be cognizant of the variety of forces impacting student decision making in the clinical setting. It also suggests that students who are encouraged to incorporate their personal reality in an atmosphere that provides some latitude in decision making will be more likely to assume decision-making responsibility.
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The Institute of Medicine identified that 98,000 deaths occur in hospitals each year due to poor decision-making. The need for better understanding of decision-making in patient care is evident. The purpose of this study is to explore nurses' perceptions of clinical decision-making for a patient who experienced a clinical event. The overarching framework for this research is the Effective Nurse to Nurse Communication framework which uses clinical events, or sudden changes in patient condition, to explore nurse communication between nurses who respond to a clinical event and nurses who receive report from the responding nurse about the clinical event. Naturalistic Decision Making is the framework used to explore the decision-making factors used by experienced decision makers in real world conditions. These frameworks provided the basis for data collection, interview question development, and facilitated data analysis. Twenty nurses in an urban acute care hospital were interviewed at their workplace about a patient who had experienced a sudden change in condition in the previous 24 hours. These interviews were transcribed and analyzed using content analysis. Categories that emerged were: Awareness of Patient Status, Nursing Roles (outside of specific patient care), Goals, Education / Certification / Hospital Training to support decision-making, Experience and Decision-Making, Time Pressure, Teamwork / Support from Staff, Resources, Following Established Routine. Patient Education, and Consideration of Options to Meet Goals. Further analysis indicates that elements of decision-making differ between responding and receiving nurses and based on experience level of the nurse. Strengths, limitations, and suggestions for future research are presented.

In a descriptive study, Lutzen's Moral Sensitivity Questionnaire (MSQ) was used to describe nurse case managers' perception of ethical decision making. Both community-based and hospital-based case managers responded. Research questions addressed (a) relationship between respondent's age and patient autonomy and between length of experience as case manager and benevolence; and (b) difference in conflict in ethical decision-making by level of education and difference in rules in ethical decision-making by type of setting. No significant correlations were found between the respondent age and patient autonomy nor between the respondents' length of experience as case manager and benevolence. There was a statistically significant difference in perception of conflict by educational level. Difference in rules in ethical decision making by type of setting approached statistical significance.

The present and categorical correspondence between how students approach their learning and the way such approaches impact on the acquisition and augmentation of clinical decision-making skills is neither well understood, nor yet clearly established, in nurse education research. To address this gap, this study investigated the approaches to learning and the clinical decision-making of adult nursing students in their final year of training on two separate campuses of a central London university. Approaches to Learning Theory, promulgated by Martin and Sӓljö in 1976, and subsequently expanded and updated by Entwistle and colleagues, provided a theoretical lens and explanatory framework for this study. Acknowledging that the Approaches to Learning Theory adopts a hierarchy of three domains of approach, surface, strategic, and deep, it is argued that students’ clinical decisionmaking should be improved by changing their predominant approach to learning from the surface or strategic to the deep approach. To test this hypothesis, a research intervention was implemented for a purposive sample of participants who adopted either the surface or strategic approach to learning. Consistent with the underpinning principles of the deep approach to learning, the intervention focused on enhancing engagement with learning, problem-solving, and critical thinking skills. A second survey of approaches to learning and clinical decision-making was administered after the intervention, and semi-structured interviews were conducted to further corroborate the statistical findings. Instruments for data collection comprised the Approaches to Study Skills Inventory for Students, known as the ASSIST (Tait et al, 1998), Jenkins’ (1985) Clinical Decision-making Nursing Scale (CDMNS), and a short demographic questionnaire designed by the researcher. This research found that by altering the learning approach, consequent on the researchintervention, the adoption of the deep approach to learning enhanced clinical decision-making. Post-intervention findings revealed a strong positive correlation between the deep approach and clinical decision-making. Participants’ disposition for the surface approach also decreased significantly. Male participants indicated an affinity for the deep approach in comparison to female students who predominantly adopted the strategic approach. The study concluded that by cultivating students’ deeper engagement, underpinned by the intention to seek meaning and understand their learning, clinical decision-making was improved.

Concerns have been well documented about deteriorating patients being missed and that care has not been of a sufficient standard to maintain their safety. This 'failure to rescue' remains despite changes in training and critical care experts working with ward staff. little is known about what influences decision-making at the point a patient deteriorates and prior to referring on to an expert. The aim of this study was to understand how nurses reach their clinical decisions while caring for a deteriorating patient and to identify the contextual factors that influence that decision-making process. Using grounded theory methodology the study comprised fieldwork, semi-structured interviews and a focus group; participants were 22 nurses and 2 physiotherapists working in general medical and surgical wards. A pragmatist philosophical tradition informing symbolic interaction guided the interpretive analytical framework of the study. The simultaneous collection, memoing, dimensional analysis of the data and constant comparison of the findings with the body of literature, built an emerging theory of clinical reasoning in acute care situations. Findings suggested that acute care nurses practice in one of 3 modes. They are: • 'Ward routine', where normal ward work takes place and nurses use protocols to deliver care. • 'Crescendo of care' where searching, information gathering, checking findings and efforts to gain control over the clinical situation took place. Nurses' reasoning in this mode was abductive and focused on building a believable case prior to referral. • 'Management of crisis' where the nurse was sure of their concerns, made the referral and continues to seek to confirm concerns. Through the three modes nurses reasoned and made sense of the clinical information they picked up. They spent lime marshalling this data until it served them a believable credible case with which to refer to another professional. This involved negotiating and bargaining to elicit action. The goals in these actions and interactions were to keep the patient and themselves safe. This was underpinned and motivated by their personal and professional beliefs. Throughout the whole decision-making process nurses accounted for every decision and judgement they made until they were convinced and confident in what they believed was happening. Then they made a referral to a more senior professional. This was conceptualised as the theory of mind accounting in clinical reasoning 'Which emerged as the explanation for how nurses clinically reason and make decisions when caring for a patient whose condition is declining. The emerging theory offers an alternative explanation of the way nurses assess and intervene when concerned about a patient. This is significant because timely accurate decision-making is fundamental to providing quality care.

Current trends in participative democracy suggest that the use of stakeholder involvement in decision making will increase in the next decade and beyond. The evolution towards stakeholder involvement is driven mainly by stakeholders’ expectation to participate in decision making on issues that affect them. The current view of international radiation protection organisations is that the stakeholders have a right to participate in decision making, but the changes to the current system of radiation protection decision making will only occur slowly through build up of positive experiences and appreciation of benefits provided by stakeholder involvement.The benefits of stakeholder involvement have already been observed in decision making in issues ranging from new nuclear build to dealing with radiological emergencies, but unsuccessful stakeholder involvement programmes have also been observed. In order to integrate stakeholder involvement further into radiation protection decision making it is important to incorporate and implement lessons learnt from both successful and unsuccessful stakeholder programmes, and understand when stakeholder involvement can be applied. My research into clearance of low radioactivity materials shows that stakeholder involvement can be applied in planned exposure situations as defined by the International Commission on Radiological Protection (ICRP). Involvement of stakeholders in planned exposure situation decision making should, however, be limited to issues with high level of reputation risk or wide ranging impacts of multiple stakeholder groups.To assess whether stakeholder involvement can be applied in the other exposure situations defined by the ICRP as emergency and existing exposure situations, the other part of my research focused on radiological emergencies. The research demonstrated that stakeholder aided decision making already has a place in solving cooperative problems of emergency management, but there is still further scope to apply stakeholder involvement in coordination of emergency management. The research shows that there is scope to integrate stakeholder involvement further into radiation protection decision making, but this must be done in a planned and organised manner.

Thesis (M.S.)--Medical College of Ohio, 2005.
"In partial fulfillment of the requirements for the degree of Master of Science in Nursing." Major advisor: Joanne Ehrmin. Includes abstract. Document formatted into pages: ii, 63 p. Title from title page of PDF document. Bibliography: pages 59-61.

This study, conducted as a needs assessment, was guided by O'Connor's Decision Support Framework (DSF). The DSF describes a process of providing to both parents and practitioners decision support by identifying the sub-optimal determinants of the decision. The objectives of the study were to describe the decision making needs of parents making choices about neonatal male circumcision and the needs of prenatal instructors who inform parents about options. The study design was across-sectional survey of 88 mothers and 67 fathers and 10 prenatal instructors. Structured questionnaires were used, eliciting variables based on the DSF, such as: the perception of the decision; perception of others regarding the decision; resources to make the decision; and participant characteristics. Although all instructors stated that circumcision was discussed, the content of the discussion varied according to the instructor's experience and perception of the decision. Most instructors (9/10) believed parents lacked both information about options and chances of the benefits and risks. Few of the instructors (2/10) saw their role as instrumental in the decision. (Abstract shortened by UMI.)

Thesis (Ph. D.)--School of Nursing. University of Missouri--Kansas City, 2006.
"A dissertation in nursing." Advisor: Thad Wilson. Typescript. Vita. Title from "catalog record" of the print edition Description based on contents viewed Jan. 29, 2007. Includes bibliographical references (leaves 213-230). Online version of the print edition.

This dissertation focuses on (river) forecasting, but also includes a study on stormwater treatment. Using forecasts for decision-making is complicated by their inherent uncertainty. An interview-based study qualitatively and a survey empirically investigate forecast use in emergency management. Emergency managers perceive uncertainty as a given rather than as a problem. To cope with the uncertainty, decision-makers gather as much information as possible; forecasts are only one piece of information among many. For decision-making, emergency managers say that they rely more on radar than on river forecasting. However, forecasts play an important role in communication with the public, because they are the official interpretation of the situation. Emergency managers can add a lot of value to those forecasts by combining them with local knowledge, but might not do so because of accountability concerns. Forecasts must have value to emergency managers, because those with more work experience rely more on them than those without. Another study further develops the application of quantile regression to generate probabilistic river forecasts. Compared to existing research, this study includes a larger number of river gages; includes more independent variables; and studies longer lead times. Additionally, it is the first to apply this method to the U.S. American context. It was found that the model has to be customized for each river gage for extremely high event thresholds. For other thresholds and across lead times, a one-size-fits-all model suffices. The model performance is robust to the size of the training dataset, but depends on the year, the river gage, lead time and event threshold that are being forecast. An additional study considers the robustness of stormwater management to the amount of runoff. Impervious surfaces, such as roads and parking lots, can increase the amount of runoff and lead to more pollution reaching streams, rivers, and lakes. Best Management Practices (BMPs) reduce the peak discharge into the storm sewer system and remove pollutants such as sediments, phosphorus and nitrogen from the stormwater runoff. Empirically, it is found that BMP effectiveness decreases sooner, steeper and deeper with increasing sizes of storm events than assumed in current computer models.

Робота публікується згідно наказу ректора від 21.01.2020 р. №008/од "Про перевірку кваліфікаційних робіт на академічний плагіат 2019-2020р.р. навчальному році" . Керівник проекту: професор, д.т.н. Шмельова Тетяна Федорівна
Air navigation system can be considered as a complex system with multiple composite parts or subsystems that constantly interact with each other, e.g.: – Airspace users (AU); – Air navigation service providers (ANSP); – Airports; – Network Manager (NM). Due to growing demand in air transportation, the complexity of the systems and load on it increases constantly. However, at the same time, the requirements for the level of safety, security remains the same. In order to meet the required levels of safety, there is a need for supporting systems that would support operators (e.g. flight crew, air traffic controller, etc.) of air navigation systems in making decision in day-to-day operations. That’s why the decision support systems became widely used in the air navigation systems to support the human operators. They are aimed at helping and supporting decision making processes or human operators in air transportation sphere and allow them to select the best decision in conditions of limited time or uncertainty. The wide introduction of decision support systems in air navigation will contribute to the optimisation of human operator work which will lead to an increase in operational efficiency and safety. One of the components that negatively contribute to the safety of flights are human errors that could lead to emergency situations and later on to incidents or accidents. The emergency situation of low oil pressure is a serious issue for both flight crew and air traffic controller and possess a threat to the flight safety due to its nature. It can lead to serious incidents and accidents and due to the type of the issue it is close to impossible to eliminate it. However, it is possible to provide all necessary means to support decision making of a human operator (e.g. air traffic controller) to ensure that correct and safe decisions are taken by the operator to resolve an emergency situation.

A descriptive correlational design based on an adapted model of Donabedian’s Structure, Process, Outcome model and Benner’s Novice to Expert theory was used to examine the clinical decision-making of nurses regarding elder abuse. The relationship of the nurses applied knowledge (assessment cues) of elder abuse; demographic questions (e.g. years of experience as a Registered Nurse (RN) and their clinical level of practice status), the use of intuition in nursing practice; and clinical decision outcomes (interventions) for patients in cases of suspected elder abuse was examined. A convenience sample of RNs who worked in the emergency department (ED) in three acute care hospitals, in southeastern United States were asked to complete questionnaires on education about elder abuse, their intuition use, demographic information, applied knowledge of elder abuse, and clinical decision outcomes for suspected elder abuse. The majority of the nurses had participated in the clinical level of practice status program.The convenience sample of 84 RNs consisted of 68 females (81%) and 16 males (19%). The average age of the respondents was 41.43 years. The mean number of years worked as a RN was 13.87 years. Multiple regression results indicated an overall model of two predictors (RNs applied knowledge (assessment cues) and years worked as a RN) significantly predicted clinical decision outcomes (interventions). The model accounted for 25.1% variance in clinical decision outcomes. The t-test revealed there was no difference (applied knowledge (assessment cues) of elder abuse, intuition use in nursing, years working as a RN, clinical level of practice status, and clinical decision outcomes (interventions)) between RNs who received elder abuse education at orientation and those who did not receive the education. The study results suggest that years of working as a nurse supported elder abuse recognition and intervention. The clinical level of practice status of nurses was found not to be a sensitive indicator. Elder abuse education during orientation varied between the hospital settings. The results indicate the educational need for nurses regarding suspected elder abuse.

Ethical decision-making is an integral aspect of gerontic nurses' experiences of caring for nursing home residents and their families. This thesis examines the author's journey into the life-worlds of nine registered nurses working in an Australian nursing home to explore how they manage the ethical problems they encounter in their everyday experience of nursing home life. As a result of interviews, the study revealed that nurses utilized an approach to ethical decision-making not previously described.This approach was identified as being professional, familial, collegial and reciprocal in nature. As an approach to ethical decision-making, respectful relationships is a potential tool for nurses coping with the ethical problems that are an every-day aspect of their professional lives in a nursing home. Respectful relationships can guide nurses' ethical decision-making as they strive to do the right thing

Inadequate and inconsistent nursing practices related to pain management are a significant problem facing stakeholders in the health care industry. The purpose of the research study was twofold: (a) to explore the processes used by registered nurses’ for clinical decision making regarding pain management in the acute care setting and (b) to develop a substantive theory using grounded theory by examining the emergent data from the perceptions of as many as 20 registered nurses. The study explored registered nurses’ perceptions of the process of clinical decision-making in pain management within the context of social norms of nursing care and the setting in which practice takes place. The exploration of the complex dynamics of clinical decision-making in pain management was guided by the principles of classic grounded theory. Fourteen registered nurses (n=14) participated in an interview process and provided their perceptions of the clinical decision-making process in pain management. Through an inductive iterative process of constant comparative analysis, patterns of conceptual relationships were revealed closing the theory-practice gap in the literature for the substantive problem of inadequate pain management and the process of clinical decision-making in pain management. The substantive theory that emerged from the data is facilitating shared understanding: registered nurses partnering through relating, referring, advocating, and bargaining with the patient, and members of the health care team to make patient-centered clinical decisions in pain management.

Thesis (Ph.D.)--Industrial and Systems Engineering, Georgia Institute of Technology, 2009.
Committee Chair: Stasko, John; Committee Member: Abowd, Gregory; Committee Member: Cross, Stephen; Committee Member: Czerwinski, Mary; Committee Member: Vidakovic, Brani

Thesis advisor: Sr. Callista Roy
Social Cognition and the Impact of Race and Ethnicity on Clinical Decision Making Most literature reflects the persistent existence of unequal treatment in the care provided to ethnic and racial minorities. Comparatively little about ethnic bias in the literature goes beyond the retrospective study as the most frequently encountered method of inquiry. Access to providers and the ability to pay only provide partial explanation in the known data. A more controversial hypothesis is the one offered in this dissertation. This qualitative research explored the cognitive processes of ethnic bias as a phenomenon in clinical decision making. The method was a simulation that captured events as they occurred with a sample of nurse participants. The racial and ethnically related cognitive content of participants was evoked through the interactive process of playing a board game. Immediately following that activity, a video vignette of an ambiguous pain management situation involving an African American male was viewed by each nurse who was then asked to make a "treat" or "not treat" clinical decision. The dialogues during playing of the board game in addition to the rationale for the treatment decision provided data for analysis. Content analysis is the primary approach for using the data to answer the research question. Themes of latent and manifest content were described for those who made the decision to treat and those who decided not to treat
Thesis (PhD) — Boston College, 2012
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

The Canadian Nursing Association promotes the use of evidence-based decision-making (EBDM) as a component of quality nursing care. A shift to a population health approach encourages public participation in health-related decision-making. Public health nurses (PHNs) participate in joint health-related decision-making with community partners. The purpose of this exploratory and descriptive study was to gain an in-depth understanding of EBDM from the perspective of the PHN. The meaning of EBDM, the perceived barriers and facilitators of using evidence, and the role of the PHN in bringing evidence to the joint decision-making process that they share with community partners was explored. A qualitative methodology known as ethnography was used and data were collected from two sources: observations at team meetings and semi-structured interviews with PHNs. Analysis of the data led to the identification of three sub-themes: holistically knowing the community, bridging 'evidence' to context, and actively managing information. All three sub-themes contribute to the main theme: the PHNs' role in fostering collaborative 'evidence-based' decision-making in the community. The PHNs' holistic view of evidence, which includes hard and soft data, contextual data and professional experience, is discussed. Basic steps in a shared EBDM process are described and dimensions of the context in which PHNs practice are explored. Implications for education, practice, research, and policy are discussed.