Effective Decision-Making

Our healthcare systems continue to experience uncertainty, sparked by supply chain disruptions, staffing shortages and system mergers. The participation of stakeholders in shared decision-making continues to be critical to ensure we are making the most effective decisions that impact our practice, work environments, and the patients and families we care for.

Feedback from direct care nurses (DCNs) and nurse managers (NMs) at Zablocki VA Health Care System in Milwaukee, Wisconsin, in late 2020 after the first surge of the COVID-19 pandemic identified key barriers to more effective decision-making. Awareness and attention to these barriers has improved; however, as time passes and new challenges arise, the following barriers remain:

• Uncertainty – We don't always know what we don't know. How do we determine the facts to bring us to a shared understanding of the current situation to help determine an action plan?
• Rumors – Hearsay stems from uncertainty and lack of clear communication channels.
• Lack of input from subject matter experts and key stakeholders – specifically DCNs and NMs. The incident command structure used in times of crisis can be so streamlined that it may create a silo that separates decision-makers from key information.
• Stress – These continue to be really stressful times. When we're stressed and dealing with rapid, frequent or constant change, it can be difficult to stay focused and make evidence-based decisions.

For many of us, the COVID-19 pandemic – and tightening budgets that have impacted a range of resources since the pandemic – have forced us to return to the basics. Perhaps we can use this back-to-basics approach to implement more effective decision-making. The cornerstone of effective decision-making is really shared decision-making, meaning that all stakeholders need to bring their expertise to the discussion and hold each other accountable for ensuring these perspectives are considered in the final decision. Here are some strategies to consider:

Direct Care Nurses

• Continue using nursing's foundation for effective decision-making: The nursing process (Assess, Diagnose, Plan, Implement and Evaluate) applies to both clinical and workplace/policy decisions.
• Participate in shift huddles and daily huddles. These huddles are great places for sharing information to ensure everyone has the same data moving forward.
• Utilize unit- and facility-based nursing shared governance (NSG) structures. NSG gives us a framework to engage all nurses in decision-making. This framework includes evaluating information, determining what proposed changes may mean for care delivery, discussing how to implement changes, and supporting one another throughout the process.
• Engage in well-being activities for yourself and as a shift, unit or work group.

Nurse Managers/Leaders

• Routine rounding – Request staff input, acknowledging their expertise at the point of care. DCNs, including advanced practice registered nurses, are clinical subject matter experts.
• Ask three key questions when making decisions:
  • Have all perspectives been heard and considered?
  • Do we currently have all the information available to make the best decision?
  • How will we know the decision is the correct one? (i.e., outcome measures, timeline for evaluation)
• Participate in and support NSG processes, even if sometimes it means more frequent but brief meetings or fewer longer meetings. Meetings are where we have discussions and engage in effective decision-making.
• Clarify potential conflicting information between system, facility and unit levels.
• AACN's podcasts "Making Impactful and Lasting Changes in Your Unit" and "Tapping Strengths: Creating an Environment for Growth" provide additional strategies.

Organizational Leaders

• Engage stakeholders in decisions – especially those with expertise at the point of care. Including DCNs in effective decision-making improves the quality, safety and value of care.
• Use a formal process to obtain feedback from stakeholders to inform future decisions.
• Provide a clear mechanism for staff to provide input or ask for clarification from top leadership/incident command.
• Consider using this Team Resilience Checklist for activities to improve practice.

Example of how NMs from the step-down unit at our organization supported DCN participation in shared decision-making:

The NMs recognized that working traditional start times increased the probability of DCNs being pulled away from NSG meetings and project time into direct care. Shifting the start time two hours later (i.e., after usual shift start time) allowed DCNs to engage in professional activities to improve practice.

• The DCNs collaborated with NMs to determine start times and tours that supported the DCNs' work/life balance and met unit staffing needs.
• If the protected time plan failed one day, the NM worked with the DCN to identify alternative dates and times that same week or pay period.

This example demonstrates true collaboration between the DCNs and NMs to achieve the ideal outcome of effective decision-making – consensus.

What new strategies have you implemented to ensure all levels of nurses participate in effective decision-making? What common barriers did you overcome?

I would like to thank Michelle Kirkendoll, MSN, RN, and Courtney Wilson, MSN, RN, for their personal input for the example listed in this blog.