A Study of Participative Decision Making and Hospital Staff Nurses

by

Judith Anne Glennie

Submitted in partial fulfillment of the requirements for the degree of Master of Nursing

Dalhousie University Halifax, Nova Scotia October, 1996

Q

Copyright by Judith AM

Glemie 1996

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Canada

DEDICATION To

Mother SyLvia Power,

my first nursing mentor, for

her unwavering commitment to caring.

Table of Contents

..........................

v

..............................

ix

Tableofcontents

Abstract

.......................... x CHAPTIER 1: Introduction . . . . . . . . . . . . . . . . . . . . . . 1 CnAPTER II: Literature Review . . . . . . . . . . . . . . . . . . . 4 ûrganizational Participation . . . . . . . . . . . . . . . . . 4 Nursing-Related Participation Literature . . . . . . . . . . . 5 Antecedents of Decision Making . . . . . . . . . . . . . . . . 6 Cognitive Processes . . . . . . . . . . . . . . . . . . . 6 Preferences . . . . . . . . . . . . . . . . . . . . . . . 9 Education and Experience . . . . . . . . . . . . . . . . 14 DecisionTypes . . . . . . . . . . . . . . . . . . . . - 1 6 Practice Setting . . . . . . . . . . . . . . . . . . . . 17 . . . . . . . . . . . . . . . . . . . . . . . . -18 CRAPTER III: Theoretical Franework . . . . . . . . . . . . . . . . . 20 Congruence . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Research Questions . . . . . . . . . . . . . . . . . . . . . . 22 CHAPTEIC IV: Methodology . . . . . . . . . . . . . . . . . . . . . . 23 Research Instrument . . . . . . . . . . . . . . . . . . . . . . 23 Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . 25 Acknowledgements

Analysis of the Findings

. . . . . . . . . . . . . . . . . . . 26

. . . . . . . . . . . . . . . . . . . . . . . . . . 26 CHAPTER F: Findings . . . . . . . . . . . . . . . . . . . . . . . . 28 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . 28 Ethical Concerns

Study Population

. . . . . . . . . . . . . . . . . . . . . . . 28

Decision Making Equilibrium/Saturation/Deprivation Clinical Decisions UnitDecisions Hospital-Wide Decisions Strategic Decisions

.........

31

. . . . . . . . . . . . . . . . . . . . . . 32 . . . . . . . . . . . . . . . . . . . . . . . -33 . . . . . . . . . . . . . . . . . . . . 34 . . . . . . . . . . . . . . . . . . . . . . 34 Overall Frequencies of Subscales . . . . . . . . . . . . . . . . . . 35 Clinical Decisions . . . . . . . . . . . . . . . . . . . . . . 35 Currently Makes Decision . . . . . . . . . . . . . . . . 37 Should Make Decision . . . . . . . . . . . . . . . . . . 37

UnitDecisions . . . . . . . . . . . . . . . . . . . . . . . - 3 7 Currently Makes Decision . . . . . . . . . . . . . . . . 38 Should Make Decision . . . . . . . . . . . . . . . . . . 38 Hospital-Wide Decisions . . . . . . . . . . . . . . . . . . . . 39 Currently Makes Decision . . . . . . . . . . . . . . . . 39 Should Make Decision . - . . . . . . . . . . . . . . . . 40 Strategic Decisions . . . . . . . . . . . . . . . . . . . . . . 40 Currently Makes Decision . . . . . . . . . . . . . . . . 40 Should Make Decision 41

.................. Responses to Individual Questions in Each Subscale . . . . . . . . . 41 Clinical Decisions . . . . . . . . . . . . . . . . . . . . . . 41 Currently Makes Decision . . . . . . . . . . . . . . . . 43 Shouid Make Decision . . . . . . . . . . . . . . . . . . 43 Unit Decisions . . . . . . . . . . Currently Makes Decision . . Should Make Decision . . . . Hospital-Wide Decisions . . . . . . Currently Makes Decision . . Should Make Decision . . . . Strategic Decisions . . . . . . . . Currently Makes Decision . . Should Make Decision . . . . CHAPTER VI : Discussion

. . . . . . . . . . . . . . . . . . . . . . . 48 . . . . . . . . . . . . . . . . . . . . 48 . . . . . . . . . . . . . . . . . . . . 49 . . . . . . . . . . . . . . . . . . . . 50 . . . . . . . . . . . . . . . . . . . -52 . . . . . . . . . . . . . . . . . . . . 53

Participants . . . . . Decisional Preferences DecisionMakers . . . . DeliverySysteat . . . . Conclusions . . . . . .

. . . . . . . . . . . . 56 Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . 57 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . 58

CHAPTEIR VII: Limitations and Recommendations

Research Education

Appendix B

. . . . . . . . . . . . . . . . . . . . . . . . 58 . . . . . . . . . . . . . . . . . . . . . . . . 59

.............................

73

AppendUcF AppendixG

References

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

vii

List of Tables

.

Table 1

Table 2 . Table 3 .

.

Table 4

Table 5 -

.

. . . . . . . . . . . . . 28 Years Worked as a Nurse . . . . . . . . . . . . . . . . . 29 Primary Area of Practice . . . . . . . . . . . . . . . . 29 Shift Assignment . . . . . . . - . . . . . . . . . . . . 30 Unit Assignment . . . . , . . . . . . . O . . . . . . . 30 . Staff Nurse:

Nursing Education

Percent of Staff Nurse Responses Categorized into Decisional States for Clinical Decisions . . . .

. . . . 33

Table 7.

Percent of S t a f f Nurse Responses Categorized into Decisional States for Unit Decisions . . . . . .

. . . . 34

Table 8 .

Percent of Staff Nurse Responses Categorized into Decisional States for Hospital-Wide Decisions

Table 9 .

Percent of Staff Nurse Responses Categorized into Decisional States for Strategic Decisions

Table 10.

Number of Times a Response Category was Selected for Clinical Subscale: Frequencies and Percentages . . .

. . 36

Number of Times a Response Category was Selected for Unit Subscaïe: Frequencies and Percentages . . . . .

..

Number of Times a Response Category was Selected for Hospital-Wide Subscale: Frequencies and Percentages

. . 39

Table 6

Table 11 . Table 12

.

Table 13 .

, . . . . . 34

. . . . . . . . 35

Number of Times a Response Category was Selected for Strategic Subscale: Frequencies and Percentages

38

. . . . 40

viii

Abstract

This study focuses on hospital staff nurse preferences for participation in decision making, the congruence betweea desired and actual participation and the relative influence of personal and

organizational variables. Cher the last decade, studies of nursing by governments, nursing organizations and hospital associations have recommended increasing nursing participation in hospital and patient care decisions both to improve patient outcornes and to better meet the

professional role expectations of nurses. While much has been written which supports the move toward participative structures and shared

governance models, there is l i t t l e empirical evidence to support the changes.

This study was designed to examine staff nurses' current and desired participation in four discrete decision areas: clinical/patient care,

unit, hospitd-wide and strategic, and to consider the influence

of age, nursing educational preparation and nursing delivery system on the differences between expectations and experience. A 50 item, forced

choice questionnaire was administered to 139 staff nurses from a variety

of rural and urban hospitals in an Atlantic province in Canada. The study found that staff nurses wish to be involved in decision making across al1 four decision areas.

It was further determined that

nurses participate in fewer decisions than desired. There was

some

evidence that the congruence between preferred and actual decision W n g was related to nursing delivery system. The demographic

variables of age, education and experience did not contribute to explaining the variance,

Acknowledgements 1 wish to acknowledge the people who have provided assistance and

support to me throughout this research and during the course of my graduate studies.

Professor Mona June Horrocks, m y thesis advisor, has

been my continuing link with the graduate program over the years and has been tremendously supportive and encouraging. 1 have appreciated that she has always demonstrated an interest in my ideas and continually pushed me to challenge assunptions about nursing work.

1 am grateful to the members of my thesis committee: Dr. Beth

Gilbert provided a significant amount of practical assistance with research methodology and it was a most beneficial experience and great

privilege to work w i t h Beth and her colleagues in the development of the questionnaire used for this study. Dr. Aïexander Wilson, a member of

this team was an invaluable resource for data analysis. Andrea Gunter was a tremendous help with the data. 1 am very appreciative that Brenda Montgomery was willing to share her nursing expertise on this committee

and graciously travelled to meetings from some distance.

This study would not have been possible without my wonderful nursing colleagues around the province who took the t h e to complete the questiomaire and offer suggestions. I am appreciative of

my

classmates

and other faculty in the Master of Nursing Program for their encouragement. 1 am indebted to Vivienne Stevenson who assisted in the preparation of this manuscript and numerous others during my course of study.

Lastly, I want to thank my family: my husband Ray, our three sons Andrew, Philip and Joseph and my mother Sylvia for their patience and

encouragement. They continue to sustain and inspire me.

CHAPTERI

Introduction Hospitals are experiencing unprecedented change driven in part by societal evolution frm an industrial age to an era of information

technology. As changes occur in patient care delivery systems, govemance structures and career opportunities for nurses, it is

necessary to have information which will help direct and evaluate these

changes. One of the ways through which nursing can be an effective partner in h e a l t h care reform is to clearly state the requirements for providing appropriate nursing.

The expansion and specialization of the nursing role in response to the increasing complexity of technical treatments and patient problems has resulted in the need for an eobanced knowledge base for the

decisions and subsequent actions for which nurses are held increasingly legally accountable.

Baccalaureate education has been widely accepted

as the means t o achieve the required knowledge.

One of the central goals of professional nursing is for greater autonomy and responsibility for decision making.

Hospitals, the lasgest

employer of nurses, continue to be organized as bureaucratic hierarchies where nurses have little control over their practice conditions. This

restrictive environment is increasingly problematic as nurses and nursing education programs promote professional role expectations. ûver the last decade studies of nursing by governments, nursing

organizations and hospital associations have recommended increasing nusing participation in hospital and patient care decisions (Applied Management Consultants, 1988; Canadian Nurses & Canadian Hospital

2

Association, 1990; Prescott, Demis & Jacox, 1987). Their direction is in response to two related issues:

1.

The need to hprove the quality

of nursing workiife and 2. The desire to improve patient outcomes and control costs. Appropriate utilization of the nursing resource is consistently cited as a way to achieve botb ends. The societal significance of a stable, satisfied nursing resource is great when viewed in the context of shrinking health care budgets and hospital populations w h i c h are older and sicker and require expert care.

Staff nurse participation in decision m a k i n g while widefy advocated, has received little systematic investigation. In some jurisdictions, hospitals are implementing decentralized decision methods commonly referred to as Shared Governance (Porter-ûlGrady, 1989) with little understanding about the specific decisions over which nurses desire increased control or the importance of these decisions to their practice. Nursing is not an homogenous group either in tems of education or

practice. Diploma programs offered by hospitais and community colleges and university baccalaureate programs provide several pathways to

attaining the status of nurse. As well, a variety of organizatioml structures in the workplace are assumed to exert different influences on the way in which nursing is practiced. Both factors contribute to an

experience of nursing where the reality is often inconsistent w i t b the expectation. There is a growing perception that the "fit" between expectation and experience (Argyris, 1972) or stated negatively, the

discrepancy between current and desired participation, may be of greater significance than absolute rates of participation (klutto & Vredenburgh,

1977; McClure, 1984). Conceptually, participative decision making (PDM) is defined as "efforts by leaders to ensure that al1 parties for whom a decision is relevant have an opportunity to influence the decision'* (House & Baetz, 1979).

The value orientation or underlying assuenption

in this study is that participative decision making is useful because the worker has valluable knowledge that can result in effective decision outcomes and that formalized PDM can make conflicting expectations more apparent, allowing negotiation of resolutions.

The purpose of this study is to examine the kinds of decisions in which nurses wish to participate, the preferred method of participation, the discrepancy between desired and actwl participation and the effects

of education, experience and delivery system on desired and experienced participation.

This nursing study will contribute important information

to an evolving body of knowledge on nursing autonoiny through which

nursing can attain sufficient "controls over the nurse-patient encounter

to deliver its o m unique product, full nursing care" (Bates, 1975).

CHAPTER II* Literature Review Decision making as a nursing phenornenon has not been systematicaily or thoroughly investigated. Consequently, incomplete understanding limits the use of existing knowledge as a basis for describing and ultimately prescribing nursing practice. The riterature

is presented in two parts. First, the evolution of participative (PDM) decision making as a labor process, generaily in the workforce and specifically in nursing, is examined to provide an organizational context for the study- Then, research related to the personal and organizational antecedents of PDM is reviewed to situate this study.

Ornanizational Participation Participation in organizational decision making, conceived broadly, is a long standing area of research in the field of management and a central theme of emerging nursing research (Brennan & McHugh, 1988; Curry, Wakefield, Price, Muller & McCloskey, 1995; Kusserow,

1988). The evolution of the study of employee participation in the twentieth century workplace has paralleled changing societal and managerial values.

In the early twentieth century the schwl of

scientific management founded by Frederick Taylor advocated principles

of task management, systmatization and routination of work to produce efficiency (Taylor, 1911). Taylor's

system

advocated shifting the

decision making responsibility for doing a job from workers to management. As employees lacked opportunities to use their knowledge and develop new skills and abilities, employee dissatisfaction, often in the foms of high turnover, absenteeisis and unionism, began to

characterize the work environaient (Adams, 1983). In the early 1930's concern over the effects of job fragmentation on job performance lead to the human relations movement.

Human

relations research supported participatory management styles and led to a focus on the interpersonal as well as the technical aspects of work. By the early 1950's the work of motivation and needs theorists

like A.H. E6aslow (1943) began to influence research on workplace management. Studies increasingly examined negative effects of the

deskilling processes of the early century. By the 1960's management philosophy began to emphasize the importance of worker participation in

decision making. This shift in philosophy was built on evidence that job enrichment with its attendant increase in autonomy and responsibility leads to organizational commitment and job satisfaction (Krahn & Lowe, 1988).

Current management thought and the trend in industry toward the philosophy of Continuous Quality Improvement is based largely on concepts of decentralization and empfoyee participation in decision making (Casalou, 1991). Working in this new paradigin it is no longer

assumed that there is a tradeoff between efficiency and effectiveness

(Counte, 1992). Management research supports flattening the traditional management hierarchy so that managers support employees who are assumed to have important knowledge and skills to control work processes

(Shorteil, 1982). Nursina-Related Particimtion Literature

The available nursing research literature is consistent in reporting a direct positive relationship between participative decision

6 making and job satisfaction (Blegan, 1993).

Weisman, et al. (1981)in a

survey of nursing staff (n=1,259) found that autonomy in decision making

was the strongest predictor of job satisfaction and negatively related to intent to leave. Similar findings were reported by Curry, et al. (1985).

Numerous articles in the nursing literature advocate PDM by

staff nurses.

However, the importance placed on participative decision

making in the nursing literature has been chailenged. In a recent article, Schwartz (1990)analyzed two papers which described the same study on nurse absenteeism. One version (Barhyte, Counte & Christman,

1987) in a nursing journal reported lower absenteeism as a direct consequence of increased PDM. Another account published in a hospital journal (Comte, Barhyte & Christman, 1987) reported that increased PDM

had insignificant effects on absenteeism. Schwartz (1990)suggests that those who read nursing journals are developing impressions about the

merits of PDM that may be incongruent with impressions gained from hospitai literature. Clearly. more study is needed concerning the effects or outcomes of participation in decision making. Antecedents of Decision Making Comitive orocesses.

Central to understanding the process of participation in hospital decisions is the explication of the nature of decision making in

nursing. Reviews of research related to the cognitive processes

involved in clinical decision making support the premise that it is a cornplex process dependent i n part on the characteristics of the person

making the decision (Grier, 1984; Tanner, 1986). Jones (1988) traces

the development of three approaches being used to explain the cognitive

7

processes utilized in decision making about patient care.

These are the

decision analysis, information processing and hypotheses generating/testing models. The latter has been popular in medical

literature (Kassirer & Gorry, 1978). Jones (1988) credits its acceptance by its ''justification that clinical judgements cannot be reduced to simple quantifiable rules of procedure but is rather a matter

of detecting subtle pattern matches and weighting of cuntentious cues and explanations" (p.188). Tanner, et al. (1987)attempted to determine

the generalizability of this model to nursing practice.

Using verbal

responses to videotaped vignettes the authors described the cognitive

strategies used by nursing studeats and practicing nurses.

Their

findings suggest that the reasoning process in decision making by nurses

can be described by the general model developed from studies of physicians.

Research devoted to studying the differences between novice and expert nurses provides strong evidence that expert nurses utilize different thought processes when making clinical decisions (Berner, 1984; Broderick & Ammentorp, 1979; Corcoran, 1986). This stems from the

greater efficiency at seeing the whole picture in contrast to the

novice, who unable to "chunk" information, processes data in isolated segments.

The exploration of intuition, an important phenomenon influencing decision making has been the focus of a number of researcb studies. Rew

and Barrow (1987) traced the concept through an analysis of the American Journal of Nursing between t900 and 1985 (n=14,971)and concluded that the study of intuition as an essential component of cornplex decision

making has been historicdly neglected by the nursing discipline. Rew (1988) interviewed fifty-six nurses in critical care and

home care

settings in an effort to explore how nurses in clinical practice experience intuition in the steps of the nursing process. Thematic analysis of the interviews contributed to a definition of the concept of

intuition as "knowledge that is received in an immediate way, perceived as a whole, and not arrived at through a conscious linear, analytic process" (p.152) and provided evidence that nurses recognize intuition as a component of clinid practice in making decisions and taking

action. The nature (Agan, 1987; Berner, 1984) and role of intuition in expert

clinical judgements has been documented. Berner and Tanner

(1987)identified twenty-one expert nurses and combined interview and observation techniques to recomend that intuition be more accurately

termed "skilled pattern recognition" ( p . 3 0 ) .

Pyles and Stern (1983)

found that nurses in critical care units used a combination of intuition

and logic (the Nursing Gestalt), involving both sensory and conceptual acts as the basis for decisions related to whether or not a patient was

developing cardiogenic shock.

Their researcb additionally supports the

proposition that rnentoring plays an important role in teacbing neophyte nurses to be capable decision makers.

A recurrent theme

in these and

other studies is that intuition, a complex phenornenon based on knowledge

and experience, continues to be undervalued in nursing work.

The significance of the body of research related to cognitive processes is that it supports the premise that making decisions about patient care is a complex process which is influenced by personal and

organizational factors.

Preferences, Two studies purported to investigate the relevance of nurses' attitudes about decision making for predicting actual decision making practices (Joseph, 1985; Joseph, Matrone

&

Osborne, 1988). In the first

study, Joseph investigated the influence of self-concept, sex-role stereotype, diploma vs. baccalaureate education and years of experience.

In a sample of eighty-five nurses working in two large metropolitan hospitals the author administered the Joseph Decision-Making Tool

(m)

to measure attitudes regarding decision making in the clinical medicalsurgical area.

The tool consists of twenty scenarios in which the

subject is asked to make a decision regarding a patient problem. Selfconcept was measured by the Bem Sex Role Inventory Scaïe.

A

step-wise

multiple regression procedure was used to determine which of the

variables had the greatest effect on nurses' attitudes toward decision making. Although the study met with limited success in determining the

predictive ability and relative importance of each variable (the variables in question accounted for only 20% of the total variance), one finding was significant. Approximately sixty percent of respondents

indicated that nurses should make decisions based on outcomes as well as process. Joseph cites supporthg findings (Joseph, 1982) obtained

during pilot testing of the Joseph Decision Making Tool.

In the second study the authors investigated three variables influencing actual decision making practices of staff nurses. They had previously identified (1) perceptions of collaborative relationships, (2) attitudes towards decision making and (3) type of unit from "in

10

depth" interviews with staff nurses. Using the JDMT (ra.79) and a

multiple regression procedure, they found that attitudes, or expectation for decision making, (explained by 1/3 of the variance) were the best predicators of decision making. Conceptually similar to attitudes about decision making are

nurses' preferences for making decisions. In a recent study the impact

of individuai preferences for autonomous decision making on job satisfaction was examined in a group of hospital nurses (Dwyer, Schwartz &

Fox, 1992). A Likert scale developed by the authors attempted to

measure the degree of involvement nurses preferred on f o u domains identified as SCHIEDULE, PRûCESS, UNIT and PATIENT. Preference for decision m a k i n g was measured as an individual-differences construct

along a continuum front high autonomy to manager/policy control. The

authors found that overall the direction and magnitude of the relationships between autonomy over decisions (measured as clinical ladder steps) and satisfaction (measured with single item FACES scale) was a

positive one for work processes. As preference for decision

making increased so did job satisfaction. For decisions related to

management of the nursing unit the relationship was maintained for nurses with high preferences for decision rnaking.

Conversely, those

with low preferences for decision making had lowered job satisfaction as autonomy increased. These findings supported the authors' hypothesis

that individual preferences for autonomy moderate the relationship between clinical ladder step and job satisfaction. However, this relationship was not maintained for decisions related to discharging patients when a subjective measure of perceived control (Dwyer &

11

Ganster's 22 item scale) was used instead of clinid ladder step. A t

higher levels of perceived autonomy nurses with a high preference for determining when patients are discharged were less satisfied with their

work and with their jobs overail than those w i t h lower prefereoces in that area. The authors suggest that a l e nurses report high levels of decisional control over other areas, they are not permitted to determine when patients are discharged in the practice setting. They conclude that when nurses desire but are not permitted t o have decisional

authority the level of satisfaction is negatively affected. One of the implications of the study is

mat decision making authority needs to be

clarified for specific decisions. Citing the compelling argument to measure specific decisions i n which hospitai staff nurses desire tu be involved and to what level, Blegen, Goode, Johnson, Maas, Chen and Moorhead (1993)administered

questionnaires to 600 staff nurses working in small, medium and large hospitals in Iowa using a stratified, multi-stage random procedure.

From Iists supplied by the hospitals of nurses working at hast 5016 time, subjects were randomly chusen to complete a questionnaire

developed by the authors coataining 21 patient care and 21 unit

operation decisions. Desired level of involvement in decision making was measured on a five point Likert scale reflecting (1) no authority

and accountability; (2) assume authority and accountability when asked; (3) share authority and accountability with others and participate in group decisions; (4) consullt with others and then make decisions;

(5) fui1 independent authority and accountability. Perceived actual involvement and the extent to whicb respondents wanted greater

involvement were measured by general questions for each of the two groups of decision areas (patient and unit).

The study resuits indicated that staff nurses preferred a higher level of autonomy in patient care decisions than in unit decisions.

Staff nurses agreed on the desired level of authority and accountability

for more than half of the decisions they were asked to rate. Of these, independent authority was desired for 1 1 of 21 patient care activities

and 4 unit decisions. The nurses agreed that 25 of the 42 decisions should be made by nurses either individually or as a working group. Questions related to perceived and preferred autonomy indicated that nurses

believed that they had more autonomy over patient care than unit

decisions: and desired more involvement in both areas. A subset of head nurses, as well as staff nurses with baccalaureate degrees and those indicating involvement in professional organizations had higher

preferences for decision making than other staff nurses.

Decisions for which nurses wanted independence concerned patient teaching, pain management, preventing complications, cfarifying and advancing orders, scheduling and discussing the plan of care with the patient, consulting with other providers and arranging daily assignments and schedules. Nurses preferred to work as a group to determine policies, procedures, unit goals, job descriptions, and performance and quality assurance standards. The authors conclude that their evidence

provides initial support for the transfer of a set of specific decisions to staff nurses. The researchers noted that the majority of staff nurses wanted little to no involvement for ordering diagnostic tests, planning yearly budgets and selecting new staff.

In a study designed to

evaluate

the impact of staff nurse

participation in decision making on job satisfaction and organizational

c-itment

Kreitzer (19%) œeasured congruence between preferred and

actual levels of involvement in decision making. Participation in seven clinicaf and ten administrative decision areas was measured using a five point Likert scale which encompassed never involved to always involved.

ûverall, eighty-nine percent (89%) of staff nurses were categorized as being deprived in clinicai decision areas and 99.1% were

administratively deprived. Of the 750 respondents only 15 ( 3 X ) were found to be decisionally saturated or participate in more decisions than

preferred. There was some evidence that the variable "years of nurse experience" was inversely related to administrative decisionaï deprivation (nurses with less than five years experience had highest levels of administrative decisional deprivation). There was no evidence

that nurses who were less experienced suffered greater deprivation in clinical decision

areas.

These last two findings may suggest that

recent graduates feel a greater competence for, and therefore desire, administrative decision autonomy in nursing units where typically administrative decisions are centralized with management. Despite the fact that the demographic variables included in the study did not

capture differences in reported degree of decisional deprivation there was some variability in nurses' reçponses. The author suggests that other variables such as marital status, number of dependent children and

structural variables of the unit may be significant.

Harrison and Roth (1987) examined pceferences for decision &ng within a group of chief nursing officers in randomly selected

14

multihospital systems- Actual and preferred degree of involvement in

decision making was measured for eleven decision areas sub-categorized

as hospital or administrative and nursing operation. Again, the

preferred degree of involvement i n both areas was significantly greater than the perceived actual degree.

There was a significant positive

relationçhip in this study between age and experience and preference for decision making ushg Pearson's product moment correlations. Multihospital size was inversely related to actual involvement in decision making in nursing operations. Education and emerience,

In the literature there is a confluence of opinion that education and experience are important antecedents of decision making. Four

studies investigated the effects of knowIedge, experience, stress, role modelling and values. frcnn the literature.

The factors considered were initially derived

Ba-

and Bourbonnais'

( 1992)

study and two

replications (Bourbonnais & Baumann, 1985; Thompson 8 Sutton, 1985) utilized case studies and semi-structured interviews to analyze nurses' rapid decision making in critical and coronary care units.

In the

fourth study, Pardue (1987) investigated the differences in critical thinking ability and decision making skills among experienced associate

degree, diploma, baccalaureate and masters-prepared nurses (n=121). While nurses with masters and baccalaureate degrees obtained the highest scores i n critical thinking ability, there were no significant

differences among the groups related to perceived decision making skills.

A i l subjects in each study ranked experience followed by

howledge as the most significant factors influencing their decisions.

15

Prescott, Demis and Jacox (1987), as part of a larger study on

nursing turnover, conducted a qualitative analysis of nurse

participation in clinical decision making. A random sample of interviews from 150 staff nurses, 68 head nurses, 49 supervisors and I l 1 physicians from six large U.S. cities provided the study data. Education and experience were considered, by the researchers, to be characteristics potentially affecting clinical decision making.

There

was agreement among the nurses interviewed regarding the positive

influence of experience on decision making.

Knowledge of patient

problems and related alternative courses of action, as well as the

ability to effectively participate on the health care team, were cited as the consequences of experience. Education emerged as an ambiguous factor.

mile

nursing supervisors felt that nurses with B.S.N.

preparation contributed more effectively to decisions, staff nurses felt that they were under utilized, wasting much t h e and effort in seeking

physician approval. Studies of the problem of turnover in nussing suggest that it is greater for recent graduates (Cronin-Stubbs, 1977; McCloskey, 1975). Wolf (1981) cites wealistic job expectations as a major variable in

the early resignations. Green's (1988) work suggests that new nurses face a dilemma of role adjustment as they move from the professional

orientations of nursing education programs modelled by faculty in a highly controlled environment, to work-related models whese bureaucratie values exist to a greates degree than professional and service-oriented values. Currently, in preparation for a future requirement of

16

baccalaureate preparation as the minimum education standard for e n t r y to practice, many students are choosing to study at university Baccalaureate programs rather than at hospitals or comunity colleges. Additionally, many practicing diplwa nurses are returning to university to acquire nursing baccalaureate. The literature on nursing curricula suggests that baccalaureate fosters greater ski11 development in

leadership, decision making, autonomy and collaboration with other professionals on a collegial basis, the hailmarks of a profession (Kramer, 1981; Hover, 1975; Bullough & Sparks, 1975). Corwin (1961)

found that baccalaureate graduates held professional role conceptions more frequently than did diploma graduates who had greater bureaucratie

and service orientations with primary loyalties to administration, ûnly one study provided empirical evidence of the relationship between PDM and nursing education level (Blegen, et al., 1993). The determination of whether and how BNs have heightened expectations for decision making

has serious human resource implications. Decision t m s .

The literature reveals inconsistent findings concerning the types of decisions made by staff nurses in the practice setting. Some studies (Baumann & Bourbomais, 1982; Joseph, Matrone & Osborne, 1988) found

that nurses were naking decisions commonïy thought to be within the realm of medicine.

In contrast Prescott, Demis and Jacox (1987) found

nurses' participation in decision making focused largely on the early stages of collecting information, identifying problms and giving information/maiUng suggestions to physicians.

Therefore, pbysicians

were retaining control over most patient care decisions even those

considered witbin nursing's professional domain.

In a recent study Cassin (1993)determined that nurses' representation in decision making has been "transfomeci by managerial regimes into accounting records which allow for broad-based

participation in decision making on terms other than nursing" (p.113). Cassin refers to the "objective" staffing measurement systems (workload measurement/patient classification) which are part of a comprehensive management effort to improve nursing productivity. Cassin's work converges with that of Campbell who has studied the effects of the application of industrial techniques in the context of funding restraint in health care institutions to argue that these managerial methods

systematically devalue nurses' knowledge and displace professional judgement in favour of the "routinization" of nursing decisions (1987). Managerial methods for measuring workloôd are being used to nom nursing decisions in relation to patient care

away

from traditional interests of

care. Campbell (1992)asserts that even tighter control of nursing decision making w i l l result from computerized decision systems. Practice settinq.

The type of nursing unit has been identified as a factor affecting nurses' decisional authority. Prescott, Demis and Jacox's (1987) interviews with 150 staff nurses opined that small, specialized and critical care units facilitated greater nursing involvement in clinical decisions. However, Joseph, Matrone and Osborne (1988) found that, while nurses from critical care units seemed to report more decision making, no significant differences were found when actual practices were

compared with a general medical-surgical group.

It is noteworthy that

18

this study was conducted in an institution where a primary nursing mode1 was

well-established. Prescott, Demis and Jacox (1987)found also that

primary nursing care was consistently cited by nurses and physicians as a facilitator of decision maklng for nurses. They suggest that this is due in part to greater nurse/physician collaboration. The significance

of the collaborative relationships is reported by Knaus, Draper, Wagner and Zimmerman (1984)who found that effective communication between

nurses and physicians and the nurses' authority to make decisions positively correlated with lower mortality rates in intensive care nits. Znherent in the few studies that did examine practice setting is

the assumption that staff nurse roles are interchangeable with little acknowledgement that nursing decisions may vary across worksite, clinical area of practice or unit assignment. Schwirian (1981) criticizes investigators for studies which treat nurses like "interchangeable checkers." S

m

.

The evolution in management philosophy over the last century has significantly influenced workplace practice. Organizational structures

are moving away from hierarchical formlations to those characterized by

worker participation at al1 levels of the organization. Current management models are based on the philosophy that worker participation not only secures organizational commitment but also improves quality as

well as cost outcomes.

The nursing literature on mlM is scat. What is known is that nurses expect or prefer greater participation in decisions than

19

currently exists.

They employ cognitive processes which support cmplex

decision making and are increasingly supporteci by baccalaureate preparation. What has not been studied with any precision are the specific decisions and the method and degree of participation important to the practice of nursing.. Finally, the impact of education,

experience. practice setting and nursing delivery methods on expectations for PDM is unclear.

This study will address these issues.

CHAPTER III Theoretical Framework The theoreticai framework is a blend of constructs developed by

Nightingale (1982)who focuses on four dimensions for examining PDM within an organization and Alutto and Belasco (1972) hose work supports the premise that al1 individuals are not equally desirous of participation and that the critical variable is not the absolute rate of participation, but rather the congruence between the desired and experienced rates of participation in an organizational setting.

Nightingale's framework is based on a (1979) study of ten organizations where participation was forsialized and ten which were formally non-participative. Nightingale found significant differences

in values, beliefs, attitudes and the use of problem-solving approaches to resolving conflict. In the participative organizations, employees

used more problem-solving, were more optimistic and more collaborative.

ûperationaily Nightingale evaluates four dimensions of participation in an organization: 1.

The level in the hierarchy for which PDM is important.

This study examines P M among clinical staff nurses. They are closest to patients and are considered to be at the first level of the patient care hietarchy. 2.

The kinds of decisions in which emdoyees ~artici~ate.

This study builds on the work of Gilbert, et al. (1992)who developed instrument which examines participation in clinical, administrative and strategic decision areas. Derived fron the work of Benner (1984) clinical decisions are classified as diagnostic and monitoring

activities, intervention and treatment regimes, decisions in rapidly changing and emergency situations. and coaching, teaching and helping.

Administrative decisions may be unit or hospital-wide and relate to the day-to-&y

operations of a hospital. Strategic decisions are

cbaracterized as those involving significant impact for the organization

in terms of allocation of resources and longorange planning. 3.

The derrree of w t i c i w t i o n in decisions.

Nightingale used an eight point Likert scale to measure participation on a continuum from low to high participation. The instrument chosen for this study involves a forced choice among options progressing front most to hast input in the decision making process. 4.

The method bv which em~lovees~artici~ate.

Participation may be direct or indirect via a committee or another individual. Connruence

AZutto and Belasco (1972) conceptualize decisional participation as the difference between the number of decisions in which an individuai wishes to participate and the actual rate of participation. In a study

of faculty ( ~ 4 5 4employed ) in two school districts the authors proposed that decisional participation can be evaluated d o n g a continuum characterized by three conditions: 1.

decisional deprivation - a c t d participation in fewer

decisions than desired. 2.

decisional equilibrium

- actual participation in as many

decisions as required. 3

decisional saturation - actual participation in a greater

number of decisions than desired.

Two subsequent studies (Alutto & Acito, 1974; Alutto &

Vredenburgh, 1977) supporteci the utility of the model.

The 1977 study

evaluated the relationship between PDM and role conflict and organizational commitment among nurses (n=174) in two urban hospitals. As

with previous studies decisional deprivation was reported for a

majority of participants.

Staff nurses are not a homogenous group and may have varying preferences for involvement in decision making.

Variables of age, type

of nursing education, years and type of experience, practice setting and patient assignment methods may contribute to differences in the types of decisions in which nurses wish to participate, the degree of participation desired and the "fit" between expectations and experience. Research Questions 1.

To what extent is there congruence between staff nurses

actual vs. preferred levels of PDM? 2

What are staff nurses' preferences for PDM in clinical

(patient care), administrative (unit and hospital operations), and strategic decision areas (long-range organizational planning)? Are demographic factors such as age, education and years of experience

related to decisional preferences? 3.

What is the relationship between staff nurse level of PDM

and type of nursing delivery system?

CHAPTERXV

Methodology Research Instrument Gilbert, et d.'s (1992)scale for rneasuring preferences for participative decision making, the Participative Decision Making Scale for Nurses (PDMSN) was used for this study (Appendix A).

It is a paper

and pencil, self-administered report which consists of 50 items divided into four subscales: 20 in a Clinical subscale, 10 in a Unit subscale,

10 in a Hospital-Wide subscale and 10 in a Strategic subscale. Items on

the Clinical subscale correspond to clinical decisions identified by Berner (1984). On the other subscales, participants are asked to

respond to a series of items representing unit, hospital-wide and strategic decisions. The focus of the PDMSN items is on issues that involve staff nurses working in a hospital.

To complete the

questionnaire respondents answering the clinical subscale are asked who should make the decision for example, to undertake specific procedures

such as inserting intravenous lines and changing the frequency of

treatments. Response options range from "me" (high PDM) to "physician alone" (low PDM).

For the other subscales there are f i v e response

options.

Separate scores are calculated for each of the four subscales. For each subscale a total score is computed by adding the values of the response options selected. On the clinical subscale the minimum score

is 20 and the maximum score is 80. In this section option 1 is assigned a value of 1 (complete decision authority), options 2 and 3 a value of 2

(direct involvement), options 4 and 5 a value of 3 (indirect

24

involvement), and options 6 and 7 a value of 4 (no involvement). For

each of the other subscales the minimum score is 10 and the maximum score 50. For al1 subscales a high total score indicates preferences

for high levels of PDMFor the purposes of this study, the response scale has been adapted. with the authors' permission, to measure the discrepancy between desired and actual PDEi (Appendix B).

Respondents were asked to

mark an S in the response scale box which corresponds to the person or persons they believe shoutd d e the decision and a C where they believe

the decision is currently made. For each of the items in the four subscales a difference score

will be calculated (present involvement

- preferred

involvement or C-S).

Negative scores (participation in fewer decisions than desired) reflect

decisional deprivation. Zero scores indicate equilibrium, or the perception that decisions are being made by the rigfit person(s).

Positive scores indicate decisional saturation (greater involvement than desired in decisions). Data was summarized for eacb of the subscales.

The choice of the instrument is based on a riumber of considerations. Previous work has measured preference for PDM using a dictomous yes/no format (Alutto & Acito, 1974; Alutto & Belasco, 1972); Alutto & Vredenburgh, 19771, or a Likert scale (Dwyer, Schwartz & Fox,

1992; Joseph, 1982; Kreitzer, 1990; Prescott, Dennis & Jacox, 1987). It is anticipated that the use of a forced choice response scale will quantify more precisely the nature of a decision involvement and lead to studies testing

the outcomes of specific decisions.

The instrument has been refined as a result of psychometric

25

testing over the last several years and achieves acceptable reliability (internai consistency of subscales yield alpha coefficients ranging from -78 to . 8 9 ) and construct validity (Gilbert, P i k e , Wilson, Chalykoff,

Pauley, Ellis & Filthaut, 1992). To date, the PDMNS has been used with

nurses gradwting from diploma, associate degree and baccaiaureate programs. This study is an opportunity to test the instrument with a

population of practicing nurses. Additionally, it allowed the researcher to participate in a multidisciplinary study of decision making in nursing with the expectation of ongoing work in this area.

Subiects Demographic variables including age, gender, marital status, ages of dependents, source of initial nursing education, pst-basic education, years of RN experience, area of practice and unit assignment

method were measured by single item questions attached to the questionnaire.

The accessible popdation for this study consisted of Registered Nurses employed as staff nurses in English speaking bospitals in an atlantic province in Canada. The sample was 400 s t a f f nurses employed on a full time basis i n the hospital sector. Using a randomization

procedure, names were computer generated from an 8,000 -ber registration database through the Nurses Association of the province (Appendix C ) .

Geographic location, area of practice and length of

employment were not controlled in the selectioa.

Data Collection

The questionnaire was mailed by the researcher to al1 nurses from the computer-generated list. Envelopes containing a cover letter

26

explaining the purpose of the study and a copy of the instrument were sent to the home addresses of potential respondents (see Appendix A ) . Participation in the study was voluntary and respondents were assured of the anonymity of their responses. Questionnaires were coded and follow-up letters were sent to al1 non-respondents two w e e k s following the deadline. Analysis of the Findinns

Scoring and interpretation of the PDSMN occurred as previously described. Means and standard deviations were computed for each of the subscales. The statistical anaiysis of responses consisted of a MANOVA procedure with subsections of the questionnaire and congruence between

preferred and actual PDM as dependent variables. Independent variables are age, education, experience and nursing delivery system. Other demographic variables such as unit type and number of dependents will be retained for future analyses. Ethical Concerns Permission was obtained from the authors for the adaptation a d use of the instrument, the PDMSN (Appendix B).

Additionally, assistance

was provided by the Nurses Association of the province to identify and

supply labels for subjects (Appendix C).

The participants in the study were advised of the purposes of the study and how they were selected. They were requested not to sign the questionnaire to assure anonymity. It was emphasized that participation was voluntary but that

their contribution was important. Nurses were

assured that there would be no reference to names in any published work and that oniy aggregate responses w d d be shared or published. They

27

were given the opportunity to request a

suonnary

of the findings through

a mail back mechanian including a stamped envelope addressed to the

researcher.

Thirty-five nurses requested copies.

CzWPmRV

Findings Data Collection

Of the 600 questionnaires distributed, 142 were retuîned for an overall respoase rate of 35%.

Of the 142 respondents, 139 were staff

nurses employed i n the hospital.

The remainder ( ~ 3 were ) nurses

employed in management positions.

As the present study focused only on

staff nurses, the final sample included 139 Registered Nurses. Studv Powlation

The majority of nurses responding to the questionnaire were employed on a full time basis (n=133) with 6 reporting part t h e status. Similarly, 131 respondents were female (98.6%) and 6 were male ( 4 . 3 % ) .

The ages of the participants ranged frm 26 to 63 with a mean age of 4 0 . 3 y e a r s .

Tables 1 through 5 provide additional d e t a i l regarding

the demographic characteristics of the respondents included i n the As Table 1 indicates, approximately one third of the nurses

study.

(30.9%) have received baccalaureate degrees while two thirds are diploma program graduates.

Table 1.

S t d f Nurse:

Nursing Education

Program Source Baccalaureate Degree in Nursing Diploma in Nursing Msters in Nursing

Number

Percent (%)

43

95

30.9 68.4

139

100%

1 Total

.7

The number of years worked as a nurse ranged from 5 to 39 years with the mean being 16.8 years.

As Table 2 reflects, al1 of the

respondents had worked as a nurse for 5 or more years and 71% for more

than 10 years.

Table 2.

None had worked less than five years.

Years Worked as a Nurse --

Number

Number of Years Worked

< 5 years 5-10 years 11-16 years > 16 years Not Identified

O

Total

41 24 67 7 139

Percent (Z)

O 28.5 17.3 48.2 5.0 f 00%

Tables 3, 4 and 5 illustrate the location of pricPary area of practice, the distribution of primary shift assignment and the unit assignment among the staff nurses.

The largest proportion of staff

nurses work primarily in the medical surgical (31.6%) and critical care areas (33.1%). Approximately

hâlf (47.5%) of the staff rotate s h i f t s

with the majority (51.8%) working 12 hour shifts. The type of unit assignment is split among three major categories of primary nursing ( 3 2 . 4 % ) , team nursing (25.2%) and case assignment (21.6%),

Table 3.

Pr-

Area

of Practice

Patient Care Unit Type

Number

46

Critical Care Medical/Surgical Paediatrics/Obstetricç Ambulatory Rehabil itation Other Not Identified

44 12 7

9 19

Total

2 139

Percent ( % ) 33.1 31.6

8,6 5.0 6.5 13.7 1.4

100Z

Table 4 S M f t Assignment Shif t Assignaient

Nwaber

Percent ( X )

39 2 6 66 26 -

28.1

L

1

MostLy Days Mostly Eveniags Mostly Nights Rotating Not 1deÏÏtified

Total

I

8 bour s h i f t s 12 bour shifts

.

139

45

72

Missing Cases Total

Table 5.

1.4 4 3 47.5

22 -

139

Unit Assignnrent

Nureber

Assiment Method Primary Nursing Case Management

Team Nursing (Task Assignment ) Case Assignment (Patients Assigned by Shift) Not Identified

Total

Percent (Z)

44 3 35

32.4

30

21 -6

2.2 25.2

24 139

One hundred and thirty-one respondents answered the question regarding the size of the hospital of employment.

Of these 30% (n=39)

indicated a hospital of less than 100 beds, 28% (n=37) reported hospital

size of 100-3ûû beds and 42% (n=55) worked i n hospitals with greater than 300 beds.

In

summary,

the mean age of the respondents w a s 40.3 years.

The

majority (68.4%) were diploma prepared nurses who worked i n al1 types of

patient care units and al1 s h i f t s .

Approximately one third came from

mail hospitals, another third from medium hospitals, while 42% worked

in larger, urban hospitals.

Nurses with Baccalaureate degrees were

employed across al1 practice areas but with relatively fewer BNs (n=8 or

31 2016) in &ler

hospitals. The -le

consisted entirely of nurses with

greater than five years of nursing experience . Aithough the results should be viewed as exploratory, overall they present a clear pattern:

Respondents to the questionnaire (staff

nurses) indicated that staff nurses should have more involvement in decisioa making thao currently exists.

This pattern occurs on al1 four

subscales, to varying degrees. The pattern is clearest for the subscale measuring strategic decision making and most variable (but with a strong pattern) on the subscale measuring clinical decision making.

The data can be anaiyzed and presented in various ways.

In t h i s

paper the data based on the concepts of decision making equilibrium,

deprivation and saturation will be addressed first. The following

section defines these concepts and uses them to examine decision making

for each of the four subscdes. Decision W n g Equilibrium/Saturation/Deprivation Decision making equilibrium occurs for respondents who indicate

that the person or group who currently makes a specific decision, sbould make the decision.

Zn other words, for a given question, equilibrium

occurs if the respondent places the C (who gsrrently makes the decision)

and the S (who &ould

make the decision) in the same box of the response

category on the questionnaire.

Decision making deprivation occurs when

the respondent states that staff nurses should have more involvement in decision making than currently exists. Saturation occurs when the respondent indicates that staff nurses currently have more involvement

in decision making than should be the case.

Following is an examination

of decision making equilibrium, deprivation and saturation for each of

the four subscales. Clinical Decisions Generally speaking, respondents indicate a state of decision

making equilibrium for clinical decisions.

For the majority of

questions, a majority of respondents indicated equilibrium.

In other

words, respondents believe that the person(s) who should make a

particular decision, does.

However, it is important to note that it is

not an overwhelming majority of respondents who indicate decision making

equilibrium. A sizeable percentage of respondents indicate decision making deprivation; they believe staff nurses shodd have more

involvement in decision making than currently exists. exception of three notable questions, only a d respondents indicate decision making saturation.

Finally, with the

l percentage of

In other words,

respondents do not believe that staff nurses have too much involvement

in decision making.

The percentage of responses falling into the

decisional deprivation, equilibrium and saturation categories for each item are identified in Table 6.

Table 6. Percent of S t a f f Nurse Responses Categorized into Decisional States for Clinical Decisions

Request coosultation with specialists

(MD) Start necessary procedures Send patients to instructional classes Request conrmLtation w i t h allied health workers Change frequency of treatments Place patient on special status Order routine lab tests Tell family of change in patient's condition Place patient on monitoring devices Request consultation with clinicaf. nurse specialist Stop treatments Start stress management techniques Discharge a patient Answer patient's questions on medical treatment Decide on tube feeding schedule Give over-the-counter medication w i thout order Change diet Decide on strategies for pain control Change frequency of vital signs Obtain patient's understanding of illness Unit Decisions Uniformly, respondents indicated a state of decision making deprivation for unit decisions. Deprivation (as detemined by the higher percentage o f people indicating deprivation for each of the

questions) is greater for unit d e c i s i o n s than for clinical. 7).

(See Table

Table 7.

Percent of Staff Nurse Responses Categorized into Decisional States for Unit Decisions

Quality assurance program for unit L e m of shift Number of part-the positions on unit Number of nurses needed per shift Calling in addltionai staff Unit rutes Topics for insemice education New staff orientation program Unit physical design find and quality of supplies kept on

unit Hospital-Wide Decisions

ûverwiielmingly, respondents indicate a state of decision making deprivation for hospital-wide decisions.

Decision making equilibrium is

indicated in only one instance. Decision making saturation is virtually nonexistent. Table 8.

(See Table 8 , )

Percent of Staff Nurse Responses mtegorized into Decisional States for Hospi tal-Wide Decisions

Conceptual mode1 for care Pay scales Clinical advancement criteria Dress requirements Research proposal evaluation Purchase of new products Safety requirements Safety education needs Policy in use and control of medlcat ion Goals/objectives of nursing department

Strategic Decisions

The respondents clearly indicate a state of decision making

35

deprivation for strategic decisions. For nine out of ten questions, more than 50% of respondents indicated a state of decision making deprivation. The remaining question, at 48% was close to an indication

of deprivation. Sone respondents indicated a state of decision making equilibrium. Decision making saturation is nonexistent. Table 9.

Percent of Staff Nurse Responsses Categorized into Decisional States for Stra tegic Decisions

Mission Statement of the hospital 42. Philosophy followed by hospital 43. Hospital's g o a l s and objectives

41.

44. Bed closures 45. Hospital expansion ( physical ) 46. New patient semices 47. Controversial health care issues 48. Allocation of expensive services 49, Technological changes 50. Budget allocation Overall Frequencies of Subscales

The preceding section examined whether respondents want more involvement in decision making, less involvement in decision making, or the status quo. The general finding was the nurses would like more

involvenent in decision making. The data does not indicate where respondents believe the level of decision making currently cests or

where respondents believe it should rest. This s e c t i o n will examine who the respondents indicate is currentlv making the decision and who the

respondents indicate s h o d d be making the decision for each subscale.

Clinical Decisions

The response categories for the clinical decision making subscale are as follows:

.

Me Me in consultation w i t h nurse manager Me in consultation with physician Nurse Manager after consulting me Physician after consuiting me. Nurse manager alone Physician alone.

1 2. 3. 4. 5.

6. 7.

The frequency of selecting a response category w a s found by adding together the number of times a response category was chosen for

Since there are twenty questions in the clinical

questions 1 t o 20.

subscale, and there are 139 respondents, the maximum number of possible

responses is 20 x 139 = 2,780.

The percentage of times a response

category was selected was also calculated.

Table 10 shows the frequency that respondents selected a particular response category and the percentage of respondents that

selected a response category.

Numoer of Times a Response Category w s Selected for C l i n i d Subscale : Frequencies and Percen tages

Table 10.

D

PART A

Appendür D describes the data i n graph

~

O

N

O

P

~

~

- (fLINICAL

NORSE MANAGER ALONE PHYSICIAN ALONE

35 1047

237

Currentlv makes decision.

In response to the question "who currently makes the decision", it is clear that "physician alonef' (category 7 ) was selected most frequently by respondents. An examination of Table 10 shows that "physician alone" was selected 1,047 times or 43%of the tirne.

The

second most frequently selected response was "me1' (category 1 ) , with 529

or 22% of responses.

In summary, the respondents indicate that either

the physician alone or the staff nurse alone are currently making most of the decisions

.

Should make decision.

The response category "me in consultation with physician" (category 3 ) was chosen most frequently in response to the question "who

should make the decision".

An examination of

selected 784 times or 33%of the time.

Table 10 shows that it was

The second most frequently

selected response was "me" (category l ) , with 699 responses or 29% of the responses. The third most frequently chosen response was "physician after consulting me".

It was selected 349 times.

This constituted 15%

of the responses .

Unit Decisions

The response categories for the questions in the subscale measuring unit decisions are as follows: 1.

2. 3. 4. 5.

Senior management (which includes Director of Nursing) Nurse manager Nurse manager after informal discussion with nursing staff A cornmittee elected by staff nurses Staff nurses on the unit.

Frequencies were found by adding together the number of times a

response category was chosen for questions 21 to 30. The percentage was

38 calculated by taking the overall frequency and dividing it by the total

number of responses. Taole I I .

Number of Times a Response CÎtegory was Selected for Unit Subscale: Frequencies and Percentages

SENIOR MANAGIGMENT

477

39

37

3

NURSE MANAGER

463

173

36

14

NURSE MANAGER AFTER DISCUSSION WITE STAFF

202

493

16

39

33

194

3

125

371

10

A

COMMITTEE E L E O BY STAFF NURSES

STAFF MIRSES

15

'

29

Currentlv makes decision. Table 11 shows that the most frequently selected response to the question "who currently makes the decision'' is "senior management" (category 1 ) .

It was selected 477 times or 37% of the time. The second

most frequently selected response was nurse manager (category 2 ) .

This

w a s selected 463 times or 36% of the tirne (see aleo Appendix D).

Should make decision. In response to the question "who should make the decision". category 3 (nurse manager after discussion with staff) was chosen most

frequently. Table 1 1 shows that it was selected 493 times or 36% of the time.

The second most frequently selected response was category 1

(staff nurses).

This was selected 371 times or 29% of the time.

In summary, the respondents indicate that unit decisions are currently made by senior management and the nurse manager and the

respondents believe that decisions should be made by the nurse manager

after informal discussion with staff nurses.

Hospital-Wide Decisions

The response categories f o r the questions ieasuring hospital-wide decisions are as follows: 1. 2. 3

.

4.

S t a f f nurses A cornittee on which nurses have a representative Nurse managers Senior management (which includes Director of Nursing).

Frequencies were found by adding together the number of times a response category was chosen for questions 31 to 40. Frequencies and percentages are presented in Table 12. Table 12. Nmber of Times a Response Category was Selected for &spi tal-Vide Subscale r Freguencies and Percen tages

SENIOR MANAGEMENT

1

477

1

39

NURSE MANAGER

1

463

1

173

NURSE MANAGER AFTER DISCUSSION WlTH STAE'J?

202

493

ELECTED BY STAFF NURSES

33

1 94

725

1371

A C~~

STAFF NURSES

1

Pr

37

1

3

36

1

14

3

11

10

1

29

Currentl~makes decision.

In response to the question "who currently d e s the decision", respondents selected "senior management" (category 4) most frequently.

Table 12 shows that "senior management" was selected 477 times or 37% of

the t h e .

This was followed closely by "nurse managers &ter discussion

with staff" at 463 times or 36% of choices (see Appendix D).

Should make decision.

In response to the question "who should make the decision", respondents sefected "nurse manager after discussion with staff" (category 3) most frequently. Table 12 shows that category 3 was selected 493 times or 39% of the the.

For this category 90 choices ( 6 , 4 % ) of respondents indicated that they did not know who currently d e s decisions for this category.

Strate~icDecisions

Strategic decisions were measured by questions 41 to 5 0 .

The

response categories for these questions are as follows: 1. 2.

3. 4.

Staff nurses A committee on which staff nurses have a representative Nurse managers Senior management and/or Board of Directors.

Table 13. Nimber of Times a Respoose Category was Selected for Stra tegic Subscale : Frequencies and Percen tages

Currentlv d e s decision.

In response

t o the question "who currently makes the decision" it

is clear that respondents selected "senior management and/or board of directors" (category 4 ) most frequently. Table 13 shows that t h i s

41

response was selected 1,017 times or 76% of the time (see Appendix D).

Should make decision.

In response to the question "who should make the decision" respondents selected "a committee on which staff nurses have a

representative" (category 2) most frequently. Table 13 shows this

response was selected 702 times or 52% of the tirne. Having examined the overall responses for each subscale,

individual questions within the subscales will be examined in order to see which questions are consistent with the overall pattern and which

questions diverge from the overall pattern. Responses to Individual Questions in Each Subscale

In the first part of the findings section, gaps between current and desired involvement in decision making were discussed. The next

s e c t i o n discussed overall response categories that were selected.

Following is an examination of individual questions where there were large discrepancies in order to determine in a more precise fashion who

the respondents indicate are currently making t h e decision and who the

respondents indicate should b e making the decision. Clinical Decisions As indicated by Table 6, question

5 (change frequency of

treatments) had the lowest equilibrium score (40%of respondents indicated equilibrium) and the highest deprivation score (58% of

respondents indicated decision making deprivation).

An examination of

Appendix E shows that the most frequentfy chosen response for "who

currently makes the decision'' was "physician alone" and the most

frequently chosen response for "who should make the decision" was "me in

consultation with physicianl'. Questions 7 (order routine lab tests), 17 (change diet) and 18 (decide pain control strategies) a l s o had low equilibrium scores and high deprivation.

Less than 45% of respondents indicated decision

making equilibrium for these questions.

For d l questions, the most

frequently chosen response "who cwrently &es

"physician alone".

the decision" was

The most frequently cbosen response for " h o should

make the decision" was "me in consultation with physician" for question

18 and "me" for questions 7 and 17 (see Appendix E).

The responses to questions 8, 14 and 20 differ markedly from the responses to al1 the other questions i n Part A.

These questions are (8)

"tell family of change in patient's condition", (14) "answer patient's questions on medical conditions1', and (20) "obtain patient's

understanding of illness".

A l 1 three questions relate to Berner's

"coaching, teaching and helping" role.

The responses indicate the only

occurrences of decision making saturation that exceed one or two percent

for the entire questionnaire. For question 8 (19% indicated saturation), the most frequently chosen response for "who currently &es

the decision" was "physician alone". The most frequently chosen

response for "who sbould make the decisim" was l'me ic cms-dtation with

physician".

The response to questions 14 and 20 is more confusing. The

most frequently chosen response t o "who currently &es

the decision" is

"me", which was also the most frequently chosen response to "who shouid

make the decision".

This question must be explored further.

In the context of the number of nurses indicating decision saturation for these questions, it would appear that many of the nurses

43 who currently make these decisions wish the decision responsibility to

be elsewhere, while sme of those nurses who do not perceive that they

make the decision, wish to. Currentl~&es

decision.

The pattern identified by l w k i n g at questions individually, is

similar to the pattern identified by looking at overall response categories. The most frequently chosen response for fourteen out of twenty questions was "physician alone".

These were questions 1, 3, 4,

5, 6, 7, 8, 11. 13, 15, 16. 17, 18, and 19 (see Appendix E).

For one

question (2) the most frequently chosen response was "me in consultation

with physician".

For three questions (9, 14 and 20) the most frequently

chosen response was "meft, in other words the staff nurse makes the decision. Should make decision.

The most frequently chosen response for eight out of twenty questions was "me in consultation with physician" (1, 2. 4, 5, 6. 8. 11,

and 18).

An equal number of respondents chose "me" ( 3 , 7, 9, 14, 16,

17, 19, and 20).

Question 13 (discharge a patient) was the only

question where the most frequently chosen response was "physician aftec

consulting me".

However, it is important to note that 48% of

respondents still indicated decision making deprivation for this

question. Unit Decisions

Questions 24 (number of nurses needed per s h i f t ) and 29 (unit physical design) had the lowest equilibrium scores (19%) and the highest deprivation scores (81%). Appendix E shows that the most frequently

44

selected response for "who currently d e s the decisions was "senior management" and the most frequently selected f o r "wbo should make the decision" was "nurse manager after informa1 discussion with nursing staff1'. Currentlv makes decision.

The pattern identified by looking at questions individually is similar to the pattern presented when looking at ovecall response categories. However, an examination of individual questions shows that for six questions out of ten the most frequently selected response category was "senior management" and for four questions out of ten the

most frequently selected response was "nurse manager". Should make decision.

For seven out of ten questions the most frequently chosen response was "nurse manager &ter

informal discussion with nursing staff".

Questions 22 (length of s h i f t ) , 25 (calling i n additional staff) and 27

(topics f o r inservice education) deviated from the pattern.

For these,

the most frequently selected response was "staff nurses on the unit".

Hospital-Wide Decisions Questions 31 (conceptual or theoretical models which would direct

the care of patient) and 33 (clinical advancement criteria) had the lowest equilibrim scores (25%) and the highest deprivation scores

(75%). An examination of the responses to these questions shows that the most frequently chosen response "to who currently makes the decisions" was "senior management".

The most frequently chosen response

to "who should make the decision" was "a committee on which staff nurses have a representative.

Currentlv d e s decision.

The most frequently chosen response for six out of ten questions was "senior management".

For question 32 (pay scales) +he most

frequently chosen response was "a committee on which nurses have a representative". Presumably, tbis committee is a bargainhg cornittee.

Of note,

only

thirty-five nurses responded to question 35 (research

proposal evaluation).

They selected "1 don't h o w " for bot6 who

'kurrently" and "should" make the decision.

Should make decision.

The

most frequently chosen response

for nine out of ten questions

was "a committee on which staff nurses have a representative".

For

question 35 (research proposa1 evaluation) this was the next most

frequent response after "1 don't knowf'. Strateaic Decisions

Question 47 (controversial health case issues, e.g. abortion, "no code standards") had the lowest equilibrium score (23%) and the highest deprivation score (77%). Appendix E shows tbat the most frequently selected response for "who currently makes the decision" was "senior

management" and the most frequently selected response for "wbo should make the decision"

was "a committee on which staff nurses have a

representative". Currentlv makes decision.

The pattern is clear for strategic decisions. For ten out of ten questions the most frequently chosen response was "senior management and/or board of directors".

46

Should make decision.

Again the pattern is char. For ten out of ten questions the most frequently chosen response was "a committee on whicb staff nurses have a representative"

.

Impact of Demographic Variables on Congruence Between Actual and Preferred Levels of Involvement in Decision W n g As proposed, a Multiple Anaiysis of Variance procedure (MANOVA),

was used in an attempt to measure the relationships of the independent

variables of age, education (dipl-

vs. baccalaureate), years of

nursing experience and nursing delivery system on the congruence between actual and preferred decision making for each of the subscales. The MANOVA failed to detect differences based on the independent variables.

This was a methodological problem resulting from the data.

For each

respondent, the computer program counted only those questionnaires for which the data was complete.

In other words, any questionnaire for

which there was any missing respoose was dropped from the analysis

yielding a small sample size. In a further attempt to statistically capture the impact of independent variables, paired t-tests were performed with subscale

difference scores and the independent variables. None of the tests achieved statistical significance although there was some evidence that years of experience was inversely related to Hospital and Strategic decision areas at a .O5 level of significance. An examination

of frequencies using cross tabulations of delivery

system and congruence proved to be most promising and offered same indication that Primary Nursing (delivery system) and hospital size (over 300 beds) were related to higher levels of decision making

equilibriun for clinical decisions (see Appendix F). Conclusion

The overall pattern is clear: The staff nurses who responded to the questionnaire indicate that staff nurses s h o d d have more involvement in decision making than currently exists.

Decision making

saturation is virtually non-existent, vrith the exception of three questions, and decision making deprivation is significant on al1 four subscales. Generaily, respondents indicate that currently the decision

makers are physicians and senior management and that nurses should be involved in a consultative process in the decision.

The pattern is clearest for strategic and hospital-wide decisions. While the pattern is present for clinical and unit decisions, there are a significant number of responses distributed throughout the various categories of the response scale. While the analysis failed to explain

the differences based on the independent variables, it would be important to study these and other variables in future research.

Finally, as previously noted, the data does not provide an exphnation as to wby respondents aaswered as they did- Possible explmations will be detailed in the discussion chapter- An

understanding of the reasons behind the respondents' answers is important for guiding follow-up action, particularly for decisions where

saturation is indicated, To understand the reasons for the cesponses would require further investigation.

CHAPTERVI

Discussion The findings of this study support contemparary nursing literature on participation in decision making. The vast majority of nurses in this study indicated some degree of decisionaî deprivation across al1 decision areas studied. An extremely smail number of nurses are decisionally saturated, or participate in more decisions than is their preference. Furthemore, the degree of deprivation is consistent across the demographic variables of age, nursing education program and years of experience in nursing. The significance of these findings will be

discussed in this chapter. Partici~ants None of the nurses responding to the questionnaire reported less

than five years of nursing experience. This finding may be explained in

different ways- The current job market is such that graduating nurses wait several years before finding f u l l time employment. So, since the questionnaire was sent to fui1 time nurses, a very small number of nurses with fewer than five years of experience

may

have received it. A

less optimistic exphnation might be that newer nurses are frustrated with the workplace, finding expectations for practice irrelevant in the context of the reality i n which nurses are struggling against increasing workloads. Placed in this context, the study might not be viewed as meaningful by newer nurses who are trying to cope. The notion of

nurses' frustration with stressful workplaces may also be related to the overall low response rate.

Decisional Preferences

Nurses who responded to the questionnaire indicate that staff nurses

value involvement in decision making and should have greater

involvement than currently exists.

The pattern is clearest for

strategic, hospital-wide and unit decisions. While the pattern is present for clinical decisions, there are a significant number of responses distributed throughout the categories of the response scale.

The desire for greater involvement in decisions is consistent with

the earlier cited findings by Blegan. et al. (1993).

As

well, in both

studies nurses claimed greater participation in patient care than in

unit decisions. Decision making saturation is virtually nonexistent. However,

three questions were noteworthy for the degree of saturation reached; these were the onfy questions where saturation was greater than 10%

throughout the entire questionnaire and for two of the questions where saturation wceeded deprivation. Al1 of the questions were from the Clinicat subscale and related to providing patients and families with information regarding the patient's illness and treatment. This finding

is consistent with recent research by Kennard, et al. (1996)who noted that only 50% of nurses in their study reported educating their patients about the treatment plan chosen or discussing treatment options with

their patients.

Fewer still (17%) discussed prognosis.

Respondents may have reported decision making saturation for a variety of reasons. These might include the belief that they do not

have the appropriate training fur the task, that they do not have adequate information or t h e to h d e the situation properly, or that

physician and/or institutionaï support for nucsing involvement in these instances is lacking. This finding has inportant implications for

nursing education and administration and therefore this is an area warranting further investigation. Providing information to patients and

their families is a nwsing responsibility. The Canadian Nurses Association, in the Code for Nurses states:

Nurses seek to involve individuals receiving care, and families when appropriate, in health care decisiondiaking. Nurses provide the information and support required so that individuals, t o the degree possible, are able to act on their own behalf in meeting their health care needs. Another possible exphnation for levels of saturation around this decision area, and one which seems plausible given that this was an area

where many nurses also wished more involvement, relates to perceptions. GeneralLy, nurses underestimate the significance of the teaching and

information provided to patients during the processes of care (Kennard,

et al., f 9 9 6 ) , tending to report only formal, structured teaching sessions as valid examples of such activity.

Decision Makers Generally, respondents indicate that currently the decision &ers

are physicians and senior management and that nurses should be involved in a consultative process in the decisions across decision categories.

This finding supports the move in many jurisdictions toward shared governance models and interdisciplinary practice, both of which involve

staff nurses to a greater extent in decision making processes.

One courd anticipate the potential benefits to patients from increased staff nurse authority and accountability relative to clinical practice. Nursing is a clinically-based profession and as such, staff

51

nurses are educated to be competent practitioners.

Sirnilarly, greater

staff nurse involvement in determinhg the working environment and t h e opportunity to contribute nursing expertise to a broader range of health care decisions should yield positive outcomes for

h e a i t h care system.

both nurses and the

Further research should be directed toward

measuring the outcomes of increased participation and the costs of

involvement. Data from this study suggest that the involvement desired by staff nurses for administrative decisions could be largely achieved through a more consultative leadership.

For Unit decisions, nurses believe that

decision authority should be transferred from Senior Management to Unit Managers who accordingly should consult informally with staff nurses on

the unit. For Hospital-Wide and S t r a t e g i c decisions respondents wish to have staff nurses participate through committee structures. Neither condition implies diverting nursing t h e away from the bedside toward greater administrative activity. An organization culture in which

participation is valued and actively supported might achieve many of the d i r e c t i o n s indicated in t h i s study.

Data related to Clinical decisions suggests that i n order to meet nurses' expectations some of the decision making authority should be

shifted from physicians tu staff nurses. This would involve negotiatioa between the disciplines of nursing and medicine. The emergence of shared care models and interdisciplinary practice may provide the

stimulus for change in this direction. As previously noted, isuproved collaborative practice among disciplines, particularly those of medicine and nursing, has positive outcomes for patients. The degree of

52 equilibrium reported for clinical decisions suggests that there may be more cooperation among disciplines than is generally acknowledged. Del ivem Svstem Primary Nursing elicited higher than average equilibrium scores

for clinical decisions.

The Primary Nursing Model is one in which

nurses have accountability in a broader range of decisions for selected

patients for the duration of their hospital stays. This is in contrast to the Case Assigniaent Model, in which patients are assigned by shift, or Team Nursing through which nurses perform tasks grouped according to

specific functions. Data from this study indicates that Case Management, the model emerging in many jurisdictions in Canada and the United States has not

yet been introduced to the areas surveyed for this study. The administration of the questionnaire used for this study in areas where Case Management is practiced s h o d d yield important information

concerning this model.

In contrast to Primary Nursing, which relies

heavily on al1 R.N. staff, Case Management allows for the introduction of non-professional staff for functions which are administered by the nursing case manager.

The application of the equilibrium scale could

yield important information regarding nurses' experience of participation.

For example, in the absence of appropriate

collaboration, one might anticipate higher levels of decision saturation when there are fewer professional colleagues with whom to confer. Conversely, with appropriate support, Case Management may b e the vehicle

for the increased participation desired by staff nurses. An important finding was that staff nurses d i d not view Unit

53

Managers as currently involved in clinical decisions, nor was it their

preference to further involve t6em in the process. This might suggest that nursing has moved away from the tradition of Head Nurse/Unit Ffanager as the ciinical expert on the unit toward a manageriai mode1 of nurse administrator. This finding has significance for nursing in tems

of selection and education of Unit Managers. It is important to know what value staff nurses place on the nursing expertise

of managers. One

could anticipate the substitution of managers from other disciplines for

nurses in administrative positions as has occurred in some jurisdictions

if nurses are not clear regarding this issue. The administration of PDMSN to a group of nursing managers and comparing responses with those

of staff nurses should provide useful direction. Conclusions

This study supports the implementation of shared govername models for staff nurses working in hospitaf settings. The nurses i n this study clearly s t a t e the wish to be involved in administrative decisions

affecting the health care environment. Their direction is to move

decisions directly affecting them closer to staff nurses by transferring sets of decisions d o m the hierarchy to the unit level. A consultative Unit Manager is the person to whom they would assign decision accountability. Staff nurses wish to be involved in decisions which affect the larger organization. Given the choices allowed by the study

questionnaire, staff nurses s t a t e their preference for involvement through staff nurse participation on decision making committees.

Nurses also desire greater consultation concerning patient care

decisions. The mechanisms for achieving this are not as easily identified from the study data. Research concerning Nursing Delivery Systems may provide

direction. What is clear, is that nurses view

physicians as making many of the patient care decisions without involving them in any consultation. Previous work with physicians would

support this perception. Meaningful interdisciplinary practice will necessitate resolving issues around accountability for decisions. Finally, perhaps the most significant outcome of this study, is the evidence of the value wbich nurses place on collaboration. Indeed, one could view many of the findings from this study in the context of an understanding of nursing knowledge as interpretive knowledge, which is socially constructed and informed through a variety of collaborations with others. Through their responses, nurses have supported the use of participation frameworks for examining nurses' preferences for decision making

.

A further

limitation of this study is that the q u e s t i o ~ a i r e

obtained information about staff nurse participation indirectly, through eliciting perceptions of both preferred and actual levels of participation in decisions. To the extent that perceptions equate with

actual behavior, this study is valid. A mechanism through which to

measure decision making directly would be desirable. This study was designed to focus on the impact of age, education, years of experience and nursing delivery system on the congruence

between actual and preferred decision making for four decision areas.

The study is limiteci by the inability to statistically demonstrate relationships or discount ttheir existence. Some of the difficulty

55 arises front the methodological problems discussed previously.

In

addition, there are a number of potentiaily important variables sucb as role obligations, leadership characteristics, organization culture,

management philosophy and structural variables such as patient care unit size that might be determinants of participation.

CHAPTER V I 1 Limitations and Recommendations

The purpose of this study was to examine the decisional preferences of staff nurses and to evaluate the impact of age, educational preparation, years of experience and nursing delivery system

on the difference between expectation and experience in decision making. While the study was designed as exptoratory, there are several limitations related to the sample selection process that may have had an impact on both the findings of the study and the generalizability of results. Sample

The sample that this study was based on w a s r a n d d y selected and respondents were representative of a variety of hospital sizes and work

units. However, the low response rate (n=139/40 or 35%) could indicate that staff nurses who participated in the study may have differed in some way from those who declined to participate. This notion is supported by the apparent enthusiasm of some of the nurses who responded. Thirty-one nurses, after completing the questionnaire which took at least thirty minutes, continued to mite coments in the space provided at the end of the instrument (Appendix G). As well, I recorded eleven long-distance telephone calls from nurses around the province who

expressed interest in the study and cailed primarily to determine whether they could still complete the questionnaire after having missed

the deadline. Unifomly, they expressed their excitement concerning the outcornes of the study. It may be tbat the timing of this study, during a time of low morale and task-oriented perceptions of nursing

57

inadvertently "selected out" those who believed in decision making. Three of the respondents (who were not included in the -le) indicated that they held management positions, yet completed the questionnaire. Through the computer selection procedure, questionnaires may have been inappropriately sent to other nurses who were not employed

in staff positions. This would have affected the response rate. Questionnaire

In the context of the number of nurses participating, many omitted answers throughout the questionnaire. On examination, there is no

obvious pattern to suggest the reason for this finding. It may be that

the questionnaire, which unlike many Likert models requires a specific choice for each question, took too long to complete and therefore questions requiring deliberation were omitted. This would not explain why some respondents omitted demographic information such as shift

assignment. That twenty-four nurses did not indicate assignment method may

be that there is lack of clarify around these nursing models. These

are concepts which should be better defined for future participants. Clarity of the questions was an issue reported by several of the respondents, particularly foc the clinical subscale, which may have influenced the choice of decision maker. The words "request consultation with" in questions 1 , 4 and 10 could be interpreted to mean that the staff nurse was requesting that sumeone else consult with

specialists, etc. or that the staff nurse consult the specialist

directly. Similarly, by not stating specifically what the nurse is consulting about, the question is open to interpretation. During questionnaire development 1 administered the instrument to

58

five masters-prepared nurses. They did not have difficulty with the clarity of the questions, although they ciid comment that the forced-

choice response scale was difficult for some questions. It would be

appropriate to further refine the questions, especially for the clinical subscale, by consiking a group of staff nurses.

Recommendations Research

.

Studies examining the role of nurses in decision making are relatively recent.

As such, most

have focused on describing the

decision involvement of nurses. If nurses and funders are to value the contribution of professional nursing, attention to the outcomes of

increased participation is needed, both in tems of patient outcomes and nursing s a t i s f a c t i o n . Subsequent analyses of data generated by this study will examine

the relationship of nurses' experience of decision making with a measure

of self-efficacy. Additionally, the study data will be s k e d with other researchers who are using the PDEiSN questionnaire in an effort to develop both the instrument and a larger database of information.

Other variables which account for nurses' experiences of decisional deprivation are important to the development of nursing knowledge in t h i s area.

This study has been limited to one rnethodology,

the use of a questionnaire, to gather information about nursing decision making. Future studies should consider the combined use of interviews,

participant observation and case study approacbes. The richness of the nursing knowledge which is applied to decision making must be known and

valued if society is to sustain and enhance the humanistic nature of

professional nursing practice.

Research also needb to be conducted regarding the quality of

decisions and outcomes for patients when nurses have greater involvement

in clinicai decisions. Areas to consider include patient satisfaction, coordination of care, length of stay and clinical outcome indicatots. While this study found no differences in preferences for involvement in decision making based on nurses' education or experience, it is important to continue to evaluate the differences in the quality of decisions based on these factors.

Education. The data from this study indicate that nurses continue to be underutilized, wasting much t h e and energy seeking physician approval. Collaboration seems to be a central issue and nurses and physicians have a responsibility to address it. Educational environments in which

health disciplines share resources provide fertile ground for studies on collaboration, as well as the best opportunity for interdisciplinary understanding and mutual support so that the "cooperative agenda for medicine and nursing" may finally be realized (Mechanic & Aiken, 1982).

Schools of nursing ensure that students have the

pathophysiological and psychosocial bases for patient care and the

clinical decision making ability to apply that knowledge. Competent nurses require education in conflict resolution and strategies for

collaboration so that rather than focus on competition arising from areas of shared medical and nursing domains, attention can be shifted

toward determining what knowledge, ski11 and decisional authority is needed to appropriately meet patients' needs.

60

While t h i s research focused on nurses working in hospitals, the study findings have implications for nurses in other types of environments.

Clearly, much more research is required in order t o

understand staff nurse participation in decisions, the impacts of participation on patients and nursing, and the mechanisms for the aliment of decision making expectations and experience.

As is

frequently the case, this study raised more questions than it answered.

170 Meadowbank Avenue, Saint John, N.B. E2K 2L8

Dear Nursing Colleague: My naeie is Judy Glemie and 1 am a nurse enrolled in the Master of Nursing program at Dalhousie University. tbesis resaarC0 d e d s Kit6 the very iPportant topic of tbe involvement of staff nurses in decision rakiag, As changes occur in patient care delivery systems, career opportunities and governance structures, it is necessary to have information whicb will help direct and evaluate these changes.

The questionnaire, developed by researchers at the University of New Brunswick examines four levels of decision making and assesses: the level of involvement you currently have in decisions, the level you think you should have and the methods by which you would like to participate. Your name was selected as a potential participant, with the assistance o f the Nurses Association of New Brunswick as one of four hundred names randomly selected by cornputer from a list of nurses working in full-time staff nurse positions in the province. Participation is voluntary and yon are assured anonymity and confidentiality. The questionnaires are coded and you are requested not to sign them. No individual or institutional names will be associated with the completed questionnaires, and data will be reported only as group data.

The success of the study depends on the response rate. 1 hope that you will take some time from your busy schedule to complete the questionnaire and return il; in the enclosed, stamped, self-addressed envelope. Completion time is approximately 30 minutes. Your participation is valued and 1 believe you will find completing the questionnaire interesting. If you have any questions about the study or would like additional information about it, please do not hesitate to contact me at the address above or at (506)634-1763. Please return the completed questionnaire by (date)

.

Judith A. Glemie, Mkster of Nursing Candidate, Dalhousie University.

NURSING DECISION MAKING QUESTIONNAIRE' 1. For cncli qiicstloii: a) Plncc a C in the box on the rcsponsc scnle wlilch corresponds to the person or petsons who -Y m&c tlic dccision.

b) Placc ;ui in tlic box on tl~crcsponsc sailc whlch comsponds to thc person or persons who SHOULD make the dccision. Imagine tl~crearc no existing mles, pmcedures, or hospital poiicics about wlio m;ikcs declsions. 2. b c h question should liavc C niid oiiq S rcsponse. T'î~cy m y or may not be in the s m e box. No question slioiild Iinve morc tlinn one S and one C. Altliougli you mny be tempted to rcspond witli morc i1i:in oiic C or o i ~ cS, plcnsc do do so. Simply sclccr the best answcr bnscd on your tnost coiiunoii cxlwricncc 111 yoiir ciirrent pnctlcc settliig.

Rciponrc 1

Qucrllon C

Rctporuc )

Rciponrc 4

Rciporuc 5

s

C

Qucrllon A

QucaUon 8

Rcsponw 2

c

s

c,s

3. If you work on a unit for whicli n question does not apply, plcase put n/û under thc 'othcr" column, 4. Althou& YOW idcd mswer to a qiiestion mny not be providcd, we cncoumpe you to selcct what YOU considcr to bc tlic bcst answer from the responsc scnle. Howevcr, Y you wlsh to give an answçr thnt 1s not provldcd hi tlic rcspoiise scnlc, wtiic your snswcr under the "otlicr" column. Plcasc be as clcnr as possible.

5. Tiierc are no 'rlght" mswers otlicr thnn your honcst rcsponse.

L

C = w h m decision isYmade S = where decision SHOULD be made

Evcry ciirrcncly ~ .scrvhq an o i i n l t - 1 o . d cornmIticc? 1 2 3 Yu ' No Don't Know

b) Eno, wodd you bc wüLtng ta sah on a u n i t - I d comrnftt& 1

2

3

Yu

No

Don't f f i o w

t a) Ait p u -tfy 1

Ya

saPing on a hospitai-wi& c o d t c t c Z 3 No Don't Know 2

b) if no, wouùi you & w i i b g to scmc on a hospicai-wi& c a d 1

2

3

Ya

No

Don't Know

3, a) A r c p u c~rrtotlyscrvfng on a s ~ t c g f g p c 1

Ya '

2

3

No

Dan't Know

cmnd-

b) ft no,wonld you kw i U g to mo n 2 strattgic pfa.riiing cornmitceci f 2 3 Yu No Don't Know

4. a] Do you thtnk nurses should be rtphscntcd at the Board ofD k c m r s mcetiugs? 1 2 3 Ya No Don'~f i o w

b) If)'a, speci€ywho you think should hprtsent n u s u ac Board meetings.

P l t u c mswcr thc foiionring quutfons by cirdlng thc most appmpriatc numbcr on t!ic ruponsc s c a k providcd:

Page Ftw

Nuolng Ihclrfon M , h gQuuztonnaire

BASIC hZïRSiNG EDUCATION: Diplamr

,

Ba--e .*tm

Degrcc

-

T h a d you for compIaing thk questioxuzih~

Please retumit in the m=uinet dircrikd by the admhhtntor.

Your comments concemhg any aspect of the questionnaire are welcome on this page.

Comments:

170 Meadowbank Avenue Saint John, N.B.

E X

SC8

Dear Nursing Colleague:

Earlier this month 1 sent you a questionnaire entitled " h r s i n g Decision lkkiag Questionnaire''. A t that t h e 1 asked you to participate in a study which 1 am conducting for my Master of Nursing thesis on staff nurse decision making.

It is now two weeks past the suggested deadline for completion and I am sending this letter to al1 of the nurses who received questionnaires to encourage completion of the questionnaire if you have not done so

already .

1 feel that t h i s is an important and timely study. Your input is valued. If you wish to receive a summary of the results phase indicate below and return, separately frm the questionnaire, in the enclosed. self-addressed envelope.

If you have questions about the study or questionnaire, please do not hesitate to get i n touch with me at the above address or at (506)634-1763. Additionally. you may wish to get in touch with my Thesis Advisor, Professor M.J. Horrock, at Dalhousie University, Faculty of Nursing, at (902)494-2535. Thank you for your i n t e r e s t and cooperation.

Sincerely, Judith A. Glemie, R.N. Master of Nursing Candidate.

I wish to see a summary of the results Name : Mailing Address:

73

UNIVERSITY O F

N E W BRUNSWICK

Posï Office Box 5050

/

Saint lohn, N.B.

/

Canada

Faculty of Business

(506)648-5570

Appendix B

November 26, 1993

As was discussed ac our m e t ~ gIasc Monday. bis lerrer p n r s you permission ro use die Parücipcive Decision Making Scde for &-unes for dao coUeccion for your blaster's Tinesis. AU mernbers of the research team who designed die insuurnent are in -emenL These people are G e d d u i e ChalykoE,

Beth Gilbert, EiIeen Pike and Alexander WilsonBesc wishes for the veedy cornpleuon of your thesis.

Bech Gilberc, PbD. Rofessor, Facdcy of Business

EL

lurses Lssociation of llew Brunswick

,'Association ies infirmières t infirmiers :uNouveau-

I&ck

File: 90.12 Judith Glennie 170 M e a d o w b d Avenue Saint John, NB. E2.K 2L8 Dear Judy;

In follow up to o u r recent conversation, this letter ie to CO* that the Association can provide you with a random sample of 400 staff nurses employed on a Full time basia in t h e hospita1 setting. As discussed, the hospital setting would include the Extra Mural Hospita. Please let m e know when you require this information and if 1can be of further assistance to you in this regard. Sincerely,

OVERALL FREQUENCIES BY CATEGORY

PART A CLMICALDEClSIONS lYllO CURItENTLY h1AKiS TllE SIIOULD hlAKE TllE DECISION (S) TO:

oecisiaiu (CIAND WIO

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1, Rqucsi consultaiion wiih zpccialireû physicians (e.g., Psychioinsi, Nciunlngisi)?

2. Sm ncccsrnry procedures (cg,, s u a IV, d n w blood)?

3. Scnû paiicnis IO insuuclional classa (c.g., diabclic and w d i x carc)?

4. Rup~csiconoulwiion wiih alllcd hcalih workcrs (c.g., socid war);cn, rcspiniory ihcrapisr)?

5, Chsngc ficqucncy of uauncnu (tg., drcsring changes)?

6. Plxc p h i on s ~ c i a stil~us l (cg., suicide nsk)?

7. Order rociiinc lob iuu (c.g., urinalysis)?

9, Plxc a paticni on monitoring dtviccs (cg., cardia monitor)?

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Appendix

F

ûverall Equilibriw/Deprivation/Saturation Questions 1-20

Primary Nursing Equilibrium/Deprivation/Saturation Questions 1-20

More than UIO Beds Equilibrium/~privation/SatwationQuestions 9-20

review, although I don't feel it reflects al1 issues especiaily for smaller hospitals. Nurses roles shouid be more consistent. 1 found some of the questions difficult to answer. Covered a very broad scopeStaff nurses should play more of a role in decision making. Management should accept nurses wbo wish to participate, rather than select who they wish to special committees. There is too mch control by Management in some instances. They (Management) have a tendency to overfook the reat issues, sometimes, rather than try to solve them. Staff nurses have a better understanding of the needs of the patient and these are the people who we should be concemed about- 1 feel our role as nurses has changed drasticaily over the years, and sometimes we get lost in m c h paper work, and meeting of schedules, and forget what the real task at hand reaZly is. What happened to the friendly chat to the patient, to make them feel at ease? 1 feel this was a go& project, and 1 am happy to have the opportunity to submit some concerns and ideas. A gwd

Enjoyed filling this questionnaire.

It is short and to the point. Hope

it helps you!

A little more clarity with the initial instruction, L e . that the response scale is me or me with the Dr etc. Why w a s psychiatric nursing left out of the general patient care areas? Many of the situations listed dealt wlth med/surg nursing, as 1 work in psychiatry. 1 found rnyself hesitating to answer after trying to apply a similar type of situation in a psychiatric setting. 1 hope my responses will still be u s e f u l . Good luck with the research! Good Luck! 1 have answered these questions t a the best of my ability. 1 worked several years full-time in a mal1 hospital and was away from active nursing for close to 2 years due to health reasons. I am in a change now - part t h e and a &y clinic. My answers are based on my previous experience I personally feel that the "team" of health professionals should be involved in decision making for the best outcome. 1 bave often had the misfortune of working with family physicians who do not listen to the caregivers. Unfortunately it is the patient who suffers, as precious time is often lost in diagnosis or start of effective treatment. I am sure this also affects our budget. (1 should clarify that not al1 physicians fa11 into this category.) Maybe more effort needs to be put towards the role of the medical team through educatioo of al1 health professionals. Good luck with your study.

.

Comments Explanations Clinical Decisions - Nurses need more say in care. Example: Skin Care W e need to get a Doctor's order for Ihles Paste. Pharmacy took it off stock cart so we have to m i t sometimes a fui1 day before it is dispensed . Unit Decisions - Info not shared in a timely fashion. Impact of staff nurse not valued. Nurse managers side with top management more than they concem themselves with nurses viewpoint. Morale is at an al1 t h e low, work stress is climbing and at the last staff meeting we were told to stop complaining! Fiscal restraints play a great part in decision making. Hospital Wide - ûnly part time nurses serve on committees as management will not free up f u l l time nurses ( L e . replace night shifts so full time nurse couid attend cornittee meetings). Nurses with a few months experience are chosen over long time employees. Of the full time nurses who do seme - they are usuafly %and chosen" by nurse managers. Strategic Decisions - Regionalization and introduction of program management has been thrust upon us with limited explanation. 1 do feel the Senior management has the responsibility to oversee changes within the system but feel frtxstrated that they are so dominated with fiscal concern and productivity with little or no regard to the caring component. Seldom is there any positive feedback for staff nurses! 1 feel that nurses need to play an important role in upcoming health care changes and decisions. Often when asked, staff nurses may have the most insight and practical decision making skills in which the health care dollars could be best saved or utilized.

Sorry for the delay! Because many of these questions did not apply to the very small hospital where 1 work 1 found them difficult to answer.

The questionnaire is very precise, and most health care areas/issues have been covered quite thoroughly. On policy/procedure issues, as staff nurses our roles are somewhat Iimited in our building. Almost al1 decisions are made by senior management. On a &y to day basis, however, our roles are much more clearly defined. In a primary nursing facility (which we hope it will stay, but due to budgetary restraints may not be here for much longer), we have a much broader range of responsibilities for the total care of the clients. Fortunately (or unfortunately, depending on your point of view), our nurse manager is seldom present in our unit, and plays only a small part in how our duties are carried out. And, also very fortunately, for the most part our physicians consider us an integral and very essential part of the health care team. They ask for, and welcome, any input from us in patient care decisions, and value highly our knowledge and expertiseWe are very lucky in that respect on our unit; others around us are not so fortunate. That is partially due to the fault of the physicians,

partially that of the individuai nurses involved. Perhaps some assertive training courses would be a welcome addition to the orientation progras? Also, our nurse manager always seems to volunteer our unit for trials: new equipment, new procedures, etc., and in that respect also we play an important role in the use of new methods in our facility, since we have discussions on the feasibility (or non) of same. Decision making is invaluable in raising the self-esteem of an individual, and when too many decisions are made by people not affected by day to &y working situations, that self esteem, as you know, reaches al1 time lows, Good h c k on your thesis, Judy. 1 can only imagine the many hours of toi1 you have put forward already. I ' m not supposed to sign this, but I 'm sure you know from whom it cornes. 1 have recently resigned from my nursing position but have answered this questionnaire from the perspective of my most recent position. W e have not started working with nurse managers

- We are still with

Head

Nurses. 1 found that 1 did not know s m e of the answers to your questions and in numerous others found no answer suitable. 1 feel at times staff nurses are being left out of important decisions that are being made regarding very important issues in al1 aspects of their working environment. This includes the new renovations and changing roles and services provided in the hospital where 1 currently work, The decisions are being made by the senior management and corporate levels where staff nurses could provide very valuabfe information. We need more input into our working environment at the unit level as well. Staff nurses should be able to participate at the cornittee levels where these decisions are made.

I was particularly interested in Part F as it niade me admit t o that I am not happy in nursing as a career any longer. 1 have nurse for almost 10 years and am increasingly discouraged with health care system. Xt has taken the "care" out of h e d t h . 1 do not wish to pursue a career that is no longer fulfilling. not have the medical field 1 hope, but may start aty career in directly outside of the goverment.

myself been a our 1 will a new

1 work in an Emergency dept. so a Doctor is present 24 hours a &y. We are expected to do certain tasks prior to the doctor seeing the patient. Judy: I was on vacation and didn't receive your questionnaire until the f i r s t week of August. Sorry 1 am late in returning it. 1 hope it can still be used in your research. Good Luck!

Consultation with a psychologist should be available for stress control and other problems, without a doctors' orders.

- Unable to ?

accurately answer many questions because answers did not capture current work situation.

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Feel t h a t i n many ways my personal thoughts on decision making have moved these processes on my unit ahead of our t h e . Nurses encowaged (at unit level) to fully participate BOWEVER nursing potential for autonomy and its decision making remains badly hampered by senior nursiag and hospital administration decision making. Staff nurses need to learn how to maice many decisions outside of the

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realrn of 'bedside nursing' - senior nurses are needed to be role models and ri& takers + not outdated authoritarians. As nurse managers/leaders - we can o n i y achieve nursiag's goals - if we move w i t b and not anainst staff nurses!

1 apologize for my lack of knowledge re strategic decisionmaking at my hospital. As a mother with 3 snaall c h i l e e n , I love my work but have little extra t h e for the added laiowledge and participation on cornittees- Our staff works well w i t h the pediatricians on our unit on a daily basis. The decision-making w i t h GP's is o f t e n done more by them initially as they don't work with us as much and therefore, don't rely on our assessments as often. Which is probably true in many specialized areas. This vas tough. A lot of "gray" areas were involved. 1 hope it has helped your research.

Since it may have affected my responses, you shoufd be aware that 1 am currently an 11-7 Nursing Supervisor. I attempted to answer the questions in a manner reflective of when I worked as a staff nurse, but since entering Management it is possible some of my ideas and actions have changed accordingly. 1 wish you well on your thesis. thorougb - and should provide al1 the research needed. 1 hope you send final results to al1 participants. Th;tnks. Seems

Thank you for the opportunity to participate. 1 would love to see the resul ts It was frustrating having to make some choices I did (for lack of the anmer 1 wanted to pick) and 1 would have liked to be able to mite lengthy comments so that 1 could explain my choices.

.

Some of t h e questions were not applicable to my unit; some questions 1 did not quite understand but answered to the best of my ability- 1 am sorry to be so late as 1 recognize it is important to do this E n d of questionnaire for ongoing education. My apologies. Generally, a very interesting and timelv research. Questions in Part B (Unit Decisions) are difficult in m y situation as our D.O.N. and Nurse Manager are the same person with our 12-hour shift nurse being the Resource person in her absence. Le., when I indicated Nurse Manager or DON the answer couid go under either section. Thanks for this opportunity to participate.

The unit in which 1 work is a new unit - myself the primary care giver after 3 years I have 1/2 time assistant.

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The past year have finally had on site physician cover. Hence, have had a great deal of decision making opportunities, so the questionnaire had areas where it was difficult to give a straight answer. An interesting experience - helped me to clarify and focus of how decisions are made at my hospital and unit. Many thanks.

my

perception

With my work in Extra Mural Hospital, my work experience has increased greatly and 1 feel like my work is really helping others. 1. The box type print is easier to read than the calligraphy style print on questionnaire. 2. The t h e of year and the t h e allowable for completing this questionnaire may limit the nmber of returned questionnaires; perhaps 2-3 weeks allowance next the. (If 1 had been on holidays, 1 would have missed your deadline.) Good luck!

Good questionnaire. Not intimidating or degrading in any marner. Took about 30 minutes to complete. Thanks.

I would be interested in leaning of the results from your research. Working in the Extra Mural Hospital setting is quite different from the structured hospital setting. The nurse is alone in the home and consultation by phone as well as having to make decisions in emergency situations is different. Your categories under clinical decisions allow for a fair degree of flexibility however when forced to identify one category, 1 feel the validity of my response is at times compromised, Many of the decisions related to patient care on the unit 1 work in are made by the multidisciplinary team. It is not one discipline scoring points by making decisions in collaboration with another. Each has a say. Many decisions are reached by consensus. You seem to be attempting to compartmentalize aspects of what is a far more complex process by your

response scale through this questionnaire. My brief experience in ER would have brought out a greater need for nurses making decisions that are currently made by physicians. An empowered team of nurses could expedite many patient visits.

You are to be commended highly for the effort and research done in the development of this excellent questionnaire. My congratulations to each of you.

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