Making Decisions and Solving Problems

This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented.

Objectives

• Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option.

• Evaluate the effect of faulty information gathering on a decision-making experience.

• Analyze the decision-making style of a nurse leader/manager.

• Critique resources on the Internet that focus on critical thinking, problem solving, and decision making.

The Challenge

Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California

Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures.

What do you think you would do if you were this nurse?

Introduction

Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results.

Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities.

Definitions

Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice.

Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives.

Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.”

Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically.

Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate.

The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others.

Decision Making

This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools.

The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps.

BOX 6-1 Decision-Making Format

Objective: _____________________________________

Options	Advantages	Disadvantages	Ranking

Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option.

Implementation plan: ______________________________________________________________________________

Evaluation plan: __________________________________________________________________________________

A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland:

One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.”

Decision Models

The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal?

If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known.

If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders.

Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue.

Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision.

For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs.

Decision-Making Styles

The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction.

Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions!

The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem.

Exercise 6-1

Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not?

Factors Affecting Decision Making

Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.)

Literature Perspective

Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions.

The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) (Tanner, 2006, p. 204):

1. Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand.

2. Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns.

3. Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit.

4. Nurses use a variety of reasoning patterns alone or in combination.

5. Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.

The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture.

The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan.

The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken.

Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences.

Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” (p. 210).