Point of care: Decision-making that works

Michael C. LaFerney | 12/19/2018

Effective leaders solicit input and listen.

Point of care: Decision-making that works
Leaders have to make decisions. They make better decisions if they ask for ideas, are open-minded, encourage critical thinking, avoid common pitfalls, and monitor the results.  

Marissa, nurse manager, has called a staff meeting to discuss a pressing issue on the unit—staffing levels for the evening shift. Two registered nurses and a licensed practical nurse (LPN) staff the 12-bed geripsychiatric unit’s day and evening shifts. Nurses assigned to the evening shift feel the workload is too heavy and is affecting morale, and patient care is suffering. As an authoritative leader—not authoritarian—Marissa values input from others. She knows people are more responsive when they’ve contributed to the decision-making process.

Decision-making involves evaluating and choosing among alternatives (King, 2016). Although Marissa has intuitive ideas on optimal staffing levels, she wants a more analytical and conscious appraisal of the issue. She also wants to avoid confirmation bias, which is the tendency to seek out and use information that supports one’s own ideas (King, 2016). So she’s open-minded and wants critical thinking.

Marissa embraces a divergent-thinking model, one that produces many solutions to a problem. Using a brainstorming approach, she asks her staff, “Which model do you think will best provide care for our patients, and how many staff members will we need to meet this goal?” She adds, “Any and all ideas will be considered.” Thus, she avoids fixation—using a prior strategy that fails to look at a problem through a new perspective (King, 2016).

The first step in the decision-making process is to define the problem (King, 2016). “Why not use the same staffing we have on days? It works for us,” says Jane, a day-shift nurse who has never done evenings. “We have to get patients up and dressed—ready for activities and appointments. The evening shift just has to get them to bed.”

Mark, who works evenings, counters: “The day shift also has the nurse manager and program director, a secretary, an activities person, and various therapists on the unit. Evenings, it’s just us.” He points out that ambulatory patients wander and must be watched. “Although the unit secretary stays until 6 p.m., the vast majority of new admissions come in the evening. It’s hard to get to our supper and breaks. Three nurses are not enough!” He has defined the problem well.

Step 2 is to develop good problem-solving strategies (King, 2016). The case has been made that the evening shift needs more than three nursing staff, but how many more? Heuristics are strategies that suggest a solution but don’t guarantee one.

“How about using an acuity tool?” Tameka asks. Mark agrees that might be helpful, but things occur during the evening shift that an acuity scale might not reflect, such as a fall or a resident-to-resident altercation.

Donna, who works nights, suggests adding a certified nurses aide (CNA) to the evening shift. “The cost is low, and the CNA can monitor patients, supervise patients in a general area, and assist with bedtime preparation. Adding a CNA would free up a lot of time for the nurses.” Other members of the staff agree that Donna has made a good suggestion that should be tried.

Step 3 is to evaluate solutions (King, 2016). Marissa will assign a CNA to evenings the next three weeks to see if there is evidence that the added person helps relieve the burden for the other staff members. She will consider several factors in evaluating the result: Did patient care improve (fewer falls and fewer medication errors, for example)? Did the added help enable nurses to consistently have time for supper? Is the admission process more efficient? If the evidence warrants, she will make the CNA a permanent evening position.

Additionally, Marissa will come by the unit and see how the shift is functioning. She is aware of social loafing (King, 2016), which is the tendency to exert less effort because of reduced accountability. Often, more gets done with less. Marissa cares about the staff, though, and wants to avoid burnout. So she will ask the evening supervisor to visit the unit more frequently. Social facilitation often improves productivity, and input from the supervisor can help determine if the additional staff person is aiding unit functionality.

Step 4 is to rethink the decision over time (King, 2016). Did adding the CNA help resolve the issue? If not, Marissa will explore whether replacing the CNA with an LPN might be more helpful. She will also be open to other suggestions, such as an evening activity person. As manager, she is aware of costs, but the welfare of patients and staff members is her primary concern.

Marissa is aware of the group polarization effect (King, 2016). She recognizes that involving staff members in this decision could lead to nurses on both day and evening shifts feeling they need more personnel, resulting in unit polarization. But she also believes it’s important to include both shifts in the process so they understand and approve of the decision. If anyone disagrees with the plan, she wants to know.

Marissa doesn’t want groupthink. Groupthink occurs when maintaining group harmony becomes more important than making the right decision (King, 2016). Group harmony is important, but as a good leader, Marissa knows it’s important to allow opposing views to be expressed. Different views can provide more insight, and not having the opportunity to express opinions can lead to resentment later.

The meeting adjourns with good feelings all around. The minority group (the evening shift) has gained approval from the majority, and all three shifts have acknowledged the evening shift issue, provided input, and approved the decision.

Michael C. LaFerney, PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.

King, L. A. (2016). Experience psychology. (3rd ed.). New York, NY: McGraw Hill Education.

  • fixation
  • decision-making
  • groupthink
  • group polarization effect
  • social facilitation
  • social loafing
  • heuristics
  • confirmation bias
  • LaFerney
  • Michael C. LaFerney
  • vol44-4
  • RNL
  • RNL Feature
  • Nurse Leader
  • ClinicalC
  • Nurse Faculty
  • Nursing Student
  • Nurse Researcher
  • Clinician
  • Educator
  • Nurse Educator
  • Nurse Clinician
  • Nursing Faculty
  • Nurse Researchers
  • Nursing Student
  • Global - Middle East
  • Global - Oceania
  • Global - Africa
  • Global - North America
  • Global - Latin America
  • Global - Europe
  • Global - Asia
  • Effective decision makers solicit input and listen.