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Learning Objective #1: identify factors that affect clinical decision-making strategies used by nurses.

Learning Objective #2: discuss the impact of complexity on the clinical decision-making strategies used by nurses.

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This study examined the nature and types of direct and indirect patient care decisions that experienced Registered Nurses describe while interacting with patients, families, and other care providers who may be present in the environment, and the influence of environment on clinical decision-making. In describing routine versus complex decision-making, different patterns of interactions and different decision-making strategies emerged. Respondents managed information, knowledge, and time to achieve desired clinical outcomes, and used specific decision-making strategies in routine, complicated, or complex situations. Patterns of decision-making strategies for linear and non-linear decision-making were identified that could assist in developing educational activities, role expectations, and organizational support for Registered Nurses’ clinical decision-making. This naturalistic inquiry was conducted in a medical/telemetry nursing unit of a community based acute-care hospital. Thirty-six themes and five categories emerged from data analysis of respondent interviews, field notes, and artifacts. Several patterns emerged from the data that influenced the decision-making strategies used by the nurses, including four decision-making strategies. The decision-making strategy employed was influenced by the nature and types of patient care decisions; professional nurse practice environment; Registered Nurses’ professional nursing identity; social capital on the unit; knowledge management processes; time-space; relationships with health care providers and administrators outside the unit; and relationships with physicians. The Registered Nurse’s choice of a decision-making strategy was influenced by individual, organizational, and systems attributes, and was based on the Registered Nurse’s assessment of the uncertainty or complexity of the problem and expertise required to solve the problem. Four decision-making strategies identified and used by the nurses included: toleration, coordination, cooperation, and collaboration. Nurses did not identify collaboration as a decision-making strategy with physicians, and descriptions of cooperation often included conflict.