Clinical Decision-Making in Last Semester Senior Baccalaureate Nursing Students

Purpose: Clinical decision making (CDM) is an integral part of what nurses do. Yet, nursing literature reveals concerns about the lack of preparation of new graduates to engage in effective clinical decision making (Benner, Sutphen, Leonard & Day, 2010). How students make clinical decisions has been of interest for many years (Baxter & Rideout, 2006). One of the challenges plaguing nursing education today regarding CDM is the interchangeable use of terms that gives rise to lack of conceptual clarity. It is not uncommon to encounter terms such as critical thinking, clinical reasoning, clinical judgment, and clinical decision making (Tanner, 2006; Benner, Sutphen, Leonard & Day, 2010) when describing how students make clinical decisions. These terms are interconnected but are not the same thing. How students are taught to make decisions may be a critical factor contributing to their inability to meet clinician expectations. What remains unclear is the way in which nursing students perceive they learn to make clinical decisions. The nature of the decisions they make, whether analytical or intuitive, remains unknown but such information is critical to guide development and implementation of educational interventions that enhance student clinical decision-making. This study was conducted to better understand 1) how senior nursing students learn to make clinical decisions and 2) the nature of students’ decision making based on Hammond’s (1996) Cognitive Continuum Theory (CCT), the conceptual underpinnings for this study. Relationships between clinical decision making and age, program type, previous degree/s, previous healthcare experience, or minority status were examined.

Methods: Nursing students in their final semester participated in this embedded mixed methods study. Following a pilot study, quantitative data were collected from 168 students at 11 schools in 4 states in the United States. Twenty-eight of these students also participated in focus groups (qualitative data). Two instruments were used: a demographic data form, and the Nurse Decision Making Instrument-Revised 2014 (NDMI). The NDMI, based on Hammond’s (1996) CCT, is comprised of 24 items, and has 4 subscales reflective of decision making (Lauri & Salantera, 2002). Overall NDMI internal consistency for this study was 0.90.

Results: Six themes emerged from the focus group data: Partners in Learning, Finding One’s Voice, Becoming Confident, Multiple Sources of Learning, Patient-Centered Care, and The Turning Point. These six themes were interrelated, leading to a core concept of Coalescing for Action. Nature of the decisions made: Three quarters of the participants scored in the quasi-rational range, indicating they were flexible making decisions. There were no statistically significant relationships between clinical decision making and the predictor variables.

Conclusion: Based on Hammond’s CCT, the process of growing as a nursing student, through practice and experience requires time and systematic cognitive processing. As students recognized more cues, they were better positioned to make quicker decisions. Decision making is dependent on cognition, the cues recognized, and the task at hand. Curricular development and planning clinical experiences for students in regards to skills and complex patient care situations may greatly enhance decision making abilities. Limitations include a small sample size, homogeneous focus groups, and the inadvertent omission of gender on the demographic instrument. Longitudinal studies throughout nursing school and into practice may better inform clinical decision making abilities.