A Reflective Note on Clinical Decision-Making and Outcome Management: Use of Evidence/Statistics to Support Clinical/Managerial Decisions

Nurses generate large data volumes but seem unaware that the information could support their decisions concerning patient intervention, ward administration, communication, and evaluation. Decisions can be classified as clinical, involving direct patient care and managerial. Clients' situations determine the nature of decisions which could evolve with continued care Clinical decisions require a higher level of cognitive thinking, nurse leaders cannot base their managerial decisions on intuition alone, rather, they gather, process, and prioritize critical patient information to choose, implement nursing action and evaluate results within available resources to solve client and institutional problems. Every piece of work conducted by a nurse is a source of information for present or future decisions. The process of client/nursing requires delegation; therefore, nurse managers must ensure the task is delegable for the particular patient or context, and that the right nurse with the requisite skill is given instruction/communication with the adequate resources to accomplish it. With the right knowledge, training and work culture, can become proficient in evidence-based practice and effectively utilize the tones of generated data in clinical decisions to improve patient outcomes.

Nurses generate large data volumes but seem unaware that the information generated could support their decisions concerning patient intervention, ward administration, communication, and evaluation. Nurses make accurate patient judgments under pressure and an average of one clinical decision every 30 seconds based on intuition, heuristics, rational, and or evidence-based. Considering that leadership decisions are often unstructured and require a higher level of cognitive thinking, nurse leaders cannot base their managerial decisions on intuition instead they gather, process, and prioritize critical patient information to choose, implement nursing action and evaluate results within available resources to solve client and institutional problems. Every piece of work done by a nurse is a source of information for present or future decisions (Goldsby et al., 2020; Levy-Malmberg et al., 2024; Prinsloo, 2024).

The Experience

I was impacted by my first encounter with the nursing director at my clinical placement area, expecting something similar or better at my alternate placement centre, but it turned out differently. She had been in that office for 11 months and appeared determined to sustain the wave of change she had started. The tool was the daily and weekly heads of unit/departmental reports and statistics with the statistics from the quality improvement unit; she also established the patient-focus rounds committee. Information gathering appeared crucial for her management style; this kept the leadership abreast of areas that needed prompt action, the cues were weighed, and the best alternative course of action was chosen. Data collected were used to support the request for more staff and resources to run the department and confirm the magnitude of work the nurses were doing. Clinical and managerial decisions were always backed by evidence (statistics) from the unit concerned. I was intrigued by the emphasis on the correctness of the statistics from the wards and quality improvement unit. Though the staff appeared apathetic and reluctant to produce timely statistics, the quality improvement unit always marshalled the reports. The same was not seen at the alternate placement area, I observed a disinclination to use evidence in decision-making, the leadership appeared uncoordinated/heavy-handy, yet it had positive patient outcomes. I wondered what the departmental decisions were based on and was shocked when the ward managers seemed not to have a schedule for briefing/report or used the nursing quality improvement unit. Many ward reports/notes have no ward statistics, so it became a near-impossible task when it was time for the ward managers to compile weekly/yearly statistics.  Can nurses function without meticulously kept records? 

Decision-Making

Decision-making can be defined as the process of selecting a course of action from choices that may have favourable or unfavourable future effects (Goldsby et al., 2020). Decisions can be classified as clinical, involving direct patient care and managerial; involving management of groups of patients at the unit and organizational level. Clients' situations determine the nature of decisions which could evolve with continued care. Data collection and gathering will be effective when the nurse concerned can make a clinical interpretation and evidence-based judgement on the patient's condition/problems. Decision-making by staff is often an iterative (repetitive) process requiring intuition and analysis, making sense of the data can be very challenging thus continuous education and simulation on this cannot be overemphasized (O’Connor et al., 2023; Regehr et al., 2022).

Looking back at the 2 organizations, where does the authority for decision-making stem from, and what organizational structure, culture and climate would support effective nurse and manager decisions? A review of the organizational chart of both organizations did not show where the decision-making influence lay but observing the way staff reacted to the mention of names it was obvious that one influence lies with the nursing leadership but the other control is with the medical head. The former is concerned about generating and managing patient data for present and future transformation while the latter is focused on providing immediate value and quality patient care. The patient acuity in both organizations appears similar but the intensity of nursing care is different. In the one, the managers are responsible for staffing and scheduling of patient acuity and nursing intensity while it was not the same in the latter organization. Decision-making about this task is imprecise and creates tension for the nurses, so they decide to avoid it; because the nurse who is experiencing stress and workload would not want to add the stress of keeping or sending statistics to the supervisor. Therefore, nurse leadership requires that the supervisor generates statistics to be sent to the office. 

What determines the quality of decisions/decision takers? 

Decisions taken concerning patient care are determined by factors such as health system guidelines, culture and policy. Individual personal factors like confidence and belief help to direct the decision-making approach. Qualities a good decision-taker must possess include objectivity, confidentiality, integrity, technical and reasoning skills, cognitive skills being able to overcome cognitive bias, and supporting decisions with evidence. Effective decision-takers must not rely on intuition alone but be able to back choices with evidence. Collective working in multidisciplinary teams can help generate collective or team indicators to measure success and success is measured by patient response to treatment and outcome (Báo et al., 2019; Daouk-Öyry et al., 2021).

The rapid nature of care and the variety of decisions nurses make can lead to safer care and sometimes leave out the evidence to support such decisions. Nurses appear not ready to practice based on evidence when they display a poor attitude to documentation data retrieval and fail to use the same in decision-making. The ability to enter data, retrieve information and use evidence to practice is imperative for obtaining up-to-date information regarding current practice. It is thus expedient to update nurses’ literary skills and give impetus to their decision-making abilities (Dagne & Beshah, 2021; Martin et al., 2022).

Evidence-based decision-making is the tool on which the nurse manager rests both clinical and managerial decisions and facilitates the use of scientific rather than local knowledge. Though none of the organizations has commenced electronic patient recording, the former appears to be prepared and transiting towards integrating technology and might be better prepared to go by the awareness created and staff involvement, it might require minimal effort when implementing electronic nursing management of patients. No matter how long it takes with resistance from nurses, the application of technology to nursing is inevitable, nurses need to be prepared to maximize the benefit of reduced workload and cost of care, reduced errors, better patient monitoring/mastery of the process and better data generation, sharing and improved decisional support (Clavijo-Chamorro et al., 2022; Dagne & Beshah, 2021).

Delegating Decision-Making in Nursing

Nurses or their managers cannot carry out patient care activities alone thus, the need to delegate responsibilities and decision-making. Delegating the act of decision-making is an avenue to develop the skills of subordinate staff while building superior-subordinate relationships. And because the delegated task is important, the superior must ensure the task is delegable for the particular patient or context, the right nurse with requisite skill is given instruction/communication as well as the adequate resources to accomplish it, thus should provide support and supervision as the case may be due to the varied training and experience of the staff (Crevacore et al., 2023; Walker et al., 2021; Ward & Morris, 2016).

Moreover, clinical nurses use different approaches or combination approaches in their daily patient care choices, this includes advocacy, assertiveness, bargaining, wide consultation and sometimes depending on past experiences. However novel situations with a different patient might be tasking on the novice nurse, making sense and use of collected data will depend on her clinical interpretation ability; self-awareness and cognitive knowledge are therefore essential in this wise. Keeping proper patient records creates room for reflection and can provide a platform for learning. Individuals who are often engaged in reflection and metacognition seem to make better choices regarding patient care (Cuyvers et al., 2024; El-Guindy et al., 2022).

Consequently, accountability, authority and autonomy are equally needful when delegating responsibility. When a superior officer delegates responsibility, authority to carry out the task must be given and the delegating officer, as well as the delegatee, held accountable and responsible for the completion of such task, which amounts to shared governance. Organizations set up a clinical governance structure to ensure clinicians take and share responsibility and accountability in reducing risk to the client while providing quality care. Implementing shared governance promotes staff engagement, accountability, and team spirit in organizations. I learnt that nurses who are conscious of the shared governance structure do not shift responsibility when there is an error, they are confident about the decisions they make and seem to be better at implementing evidence-based decisions and recommendations (Chipps et al., 2023; Jun et al., 2024; O’Grady & Clavelle, 2021).

Similarly, as nurses make multiple decisions within split seconds, every activity provides an opportunity for excellence, from handing over to serving medication, ward-round or prioritization of clients for surgery and report writing, nurses engage in planning and display leadership and unique knowledge. Only when these activities are well accounted for will they make the desired impact, owning responsibility for properly kept patient records and delegated tasks means taking part in a shared governance system. In the view of Copelli et al., (2017) clinical governance occurs even at the level of individual patient management. Excelling at the ward level implies that the nurse can efficiently function at the top leadership level. Clinical governance is not restricted to the top managers alone, it applies to persons who can make an informed uncoerced decision. Nurses with greater autonomy often produce better and more positive decisions and patient outcomes. Chances of error and failure to rescue are reduced consequently, organizations that restrict staff input and use of ideas are directly increasing the risk their patients are exposed to (Brennan & Wendt, 2021).

Knowledge Requirement for Evidence-Based Decision

Evidence exists to prove that education and training can improve staff critical thinking and decision-making abilities, prevent patient complications and hospital-acquired infections can be reduced, cost of treatment and days spent on admission could equally be halved (Ghodsi Astan et al., 2022; Jalalpour et al., 2021; Van Nguyen & Liu, 2021a). Nevertheless, where is the place of education where there is no mentoring or support of novice staff, where the nurse-to-patient ratio is very high, where there is no managerial support for initiative or motivation, and where one profession is prized over the other? 

The first thing is to take steps to improve the skill of the nurse, and knowledge to identify conditions under which to act. Nurse’s leaders can garner support for each other by mentoring, coaching and advocating for junior nurses, and creating an effective communication channel for them (Brennan & Wendt, 2021; Ghodsi Astan et al., 2022; James Makepeace, 2023).  The traditional method of staffing based on the number of beds and average daily census does not consider the acuity of the patient. This could affect the output of nurses as less attention is paid to less critical patients, and decisions are focused on those requiring intense nursing care. It is believed nurses should be balanced based on patient acuity, and competence and not on the patient number alone (Bartmess et al., 2021; Ingwell-Spolan, 2018; Mohamed & Al-Lawati, 2022).

Knowledge for an evidence-based decision can come through engagement in continuing education, retraining and practice. Any compromise in education will result in compromised patient care choices and outcomes. Life is about making choices, failure to make a learning and treatment choice is affirming wrong practice. Hence nurses should be exposed to orientation during employment to the expectations of the job as well as decisions they need to make and benefit from refresher courses depending on the demands of the unit. As the front-line managers are involved in data gathering, they should learn the art of cue collection and analysis as well as making a judgement from the cues so that they can be an appreciable improvement in the quality of data collection (Batran et al., 2022; Brennan & Wendt, 2021; Farokhzadian et al., 2021). 

Determinants Of Effective Decisions

The first requirement for effective decision-making is to identify the decision to be made and have the right information to make a choice. The process of information gathering and selection of alternatives might depend on the nurses’ experience, knowledge in that field, involvement of other professionals and willingness to share (interprofessional interdependencies). A second factor is valuing interprofessional interaction. Patients are usually not nursed in isolation; teamwork among the staff produces better results. The nurse can share experience and learn principles or methods of statistical analysis from the medical record personnel. When the nurse is sensitive to and values professional relationships, this can assist in making timely and stunning patient decisions, so it is essential to build trust and mutual respect in interprofessional relationships (Bornman & Louw, 2023; Folkman et al., 2019).

A third factor that determines the effectiveness of nurses’ decisions is the ability to communicate with peers, superiors and subordinates. The motivational language of leaders can augment staff judgement, communication is the life wire on which tasks can be allocated and completed, and the inability to communicate can affect delegation. It is necessary to assign tasks and get feedback, a manager who communicates displays better knowledge and grip of her unit, and a subordinate who communicates gets better supervision and can refine or get the best alternative and results, allowing the continuity of nursing care (Men et al., 2022; Walker et al., 2021). 

Fourthly, knowledge self-confidence and self-efficacy are required skills for clinical decisions. Where the nurse cannot display these skills, her ability to make significant choices or even identify valuable alternatives will be limited. Pramilaa R, (2018) study (2018) revealed that nurses generally have an average level of clinical decision-making skills. Does it mean they are not well taught? As knowledgeable professionals, it is essential to build on the self-confidence of the nurse in the face of competition in the health field. 

Additionally, patients are now more knowledgeable and demanding, education knowledge without self-assurance in practice will reduce the trust of the patient in the nurse. Implementing continuous professional development programmes, retraining, seminars and workshops alongside residency programmes is cable of improving the clinical decision-making and leadership skills of the nurse as well as causing better patient outcomes (Darawad et al., 2020; Mansour et al., 2020). 

Challenges Involved in Nurse Clinical Decisions

The complex environment in which nurses work calls for the application of critical thoughts to clinical decisions, nurses globally are taking up tasks that require higher-order thinking and rational consideration. Many times, nurses attend to difficult patients under time constraints in an unconducive environment yet come out with smarter judgment. What will become of this skill-based profession without intellectual managerial skills? A lack of or insufficient working tools, multiple manual entries in registers, excess workload and stress contribute to what reduces the quality of nurses’ clinical decisions. Howbeit, improperly kept records might carry similar grave consequences as a wrongly administered drug, the implication of wrong documentation and statistics has both immediate and long-term effect on decisions of the manager, organizational plan, staff and equipment purchase and service and patient service and outcome (Booth et al., 2021; Hanson & Haddad, 2024). On the other hand, nurses still have an inadequate perception of problem-solving and problem-solving/research skills. Nonetheless, education can provide the platform on which to carry out these duties, but it requires a committed reflective thinker, with a conscious effort to improve practice. Adequate training and support from both direct supervisors and the educational unit will build the confidence of the staff in making impactful decisions (Van Nguyen & Liu, 2021b; West et al., 2022).

Other challenges nurses face while being insightful and thoughtful in practice include colleagues who are resistant to change, an unsupportive work environment, and a bad leadership style of manager.  The nurse must not allow herself to be limited by these factors, one who has the interest of the patient and is willing to grow must make the sacrifice of being persistent yet gentle in her approach to allow others to see the light in her line of thinking and decisions (Hajizadeh et al., 2021). Furthermore, leadership style, organizational culture and climate can enhance or deteriorate the decision-making skill of the nurse, so that the staff would truly desire to work with the organization or just need a source of livelihood. The organization through her leadership can create an egalitarian society where every person’s contribution is recognized and supported. Generally, transactional leaders get along more with staff as with monetary rewards, although financial incentives are not the only way to motivate staff, enabling contribution, initiative development and ability to solve problems should be acknowledged as well (Olabode et al., n.d. 2023). 

Can the attitude of the leadership to use data with the introduction of artificial intelligence technology for clinical decisions positively affect those of her subordinates? The organisation's policies determine the level of involvement in the governance system and how staff decisions are viewed. Managers who are empowered will make better choices, thus creating an environment that supports junior workers in imbibing the skill and being a partaker in quality decisions that can produce quality outcomes. The way out is for nurse leaders to be non-partisan but committed to their work. Nurse leaders must utilize the legitimate, expert and referent authority/power accorded to their office to the benefit of their staff, patients, relatives and community (Chisengantambu-Winters et al., 2020; Farokhzadian et al., 2021; Ross et al., 2024; West et al., 2022). 

Managing a department is not about doing existing roles better but about seeing the managerial role differently, it is about supporting the activities and attitude by providing information, strategic thinking, and encouraging constructive behaviour of the team members. Though clinicians should be taking responsibility for actions and improvement of practices, managers should provide the needed support. knowledge and practice of supportive decisions is the prerequisite for the advancement of nursing, especially in developing nations. the conflict of promoting positive patient outcomes over nurses’ concerns or advocacy can be eliminated when nurses realise that advocating for better patient data gathering and statistics means promoting better nurses’ outcomes. it is important therefore to create a conducive environment to achieve this. 

Recommendations

The following recommendations can assist managers and subordinates in initiating decisions that will impact both patient outcomes and staff input: All nurses are managers in the making; for this to happen, there must be a conscientious effort to increase/improve the quality of work done. One measure is encouraging staff to reflect on their jobs for better results. Leaders must also adopt reflective practice and critical thinking to support every action and decision. Nurse leaders should Imbibe a collaborative and consultative attitude in decision-making. The position of nurse and manager comes with legitimate and expert power, no need to wait to be given authority to act, it is just part of the nursing responsibility. Leaders must be focused and non-partisan to effect the desired change in nursing. Leaders must give commensurate authority, and autonomy when delegating responsibility. Additionally, ensure basic rules of management are understandable by the leaders and the led. The staff must know precisely what to do, receive appropriate communication, and always give and get feedback for decisions. Nurses and managers need to be educated and practice the process of decision-making and use of data in nursing. There is a need to computerize and ease the process, thereby saving time for direct patient care activities. Staff training needs should be assessed to help make staff suited to their jobs and make jobs suited to them.