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Background: Nurses’ clinical decisions are important for maintaining the quality of nursing care and for preventing medical errors. Furthermore, in medical settings where treatment is being given on a continuous basis, it is extremely important how clinical decisions by nurses are communicated to nursing teams who support patients 24 hours a day. Nurses’ decisions are shared with the team through methods such as record making and oral communication. However, varying levels of competence exist among nurses, and not all communications can be publicly and explicitly confirmed. Accordingly, in such situations it is assumed that outstanding nurses use their ingenuity to communicate clinical decisions to nurses within the team so that important clinical decisions can be faithfully shared. These are experienced daily by nurses, and shedding light on these daily experiences can help to integrate practical nursing knowledge in the area of clinical judgments in decision-making in nursing teams.
Compared to international standards in leading countries, the ratio of nurses to patients in Japan is extremely low. New standards for nurse allocation were established in 2006, but there are still particularities, the nurse to patient ratio during night shifts has remained at about 1 to 20. On the other hand, the mean length of inpatient stay has decreased in recent years; specifically by more than half over 20 years, from 20 days down to 10. Until now, it was possible for nurses to understand the situation of patients even when nurses were few in number, due to the extremely long period of stay, but this is now very difficult. Attrition rates of nurses in Japan have always been high, and there are big gaps in nurses’ skills and experience, including the issue of a lack of nurses in their 30s. The number of nursing assistants is being increased, but in nursing education and in nurses’ beliefs, it remains the case that the daily help for patients is perceived as work for nurses to do directly. In Japan, the difficulties of training new nurses and the decline of clinical decision-making abilities of nursing teams are critical issues. This study offers insights into ways in which expert nurses in Japan are striving to support medical treatment and nursing.
Methods: Participants were expert nurses who were directly engaged in patient care and who belonged to nursing teams working on a shift system. Data were collected through semi-structured interviews. In the interviews, nurses were asked to speak about how they would communicate important clinical decisions to other nurses in their team when making such decisions when providing nursing care by looking at specific nursing case examples. Analysis involved transcribing interviews verbatim, coding the actions taken by expert nurses when communicating to other nurses, and categorizing codes by examining similarities and differences. The study was approved by the ethical review board of Kyoto Tachibana University.
Results: Interviews with 8 nurses from 3 hospitals were analyzed. Mean duration of interviews was 75 minutes. The mean length of nursing experience of the analyzed participants was 20 years. All nurses had work experience in at least 3 wards and half held positions of rank equivalent to deputy head nurse.
From the data, a total of 27 codes were obtained as actions taken by nurses when communicating to team members. These codes were subsequently condensed into 6 categories. Specifically, these categories were:
“Avoid proceeding on decisions made by oneself or one other single person”, for example, ‘I informally consult others orally about my decision’ or ‘I check many times as we go along rather than making a final single decision’; “Integrate each individual staff’s actual practice as it is”, for example, ‘I watch carefully what happens when someone else makes a decision different from mine’ or ‘I anticipate doctors’ ideas and actions when communicating nurses’ decisions’; “Proceed in accordance with the decisions of superior nurses”, for example, ‘I actively seek the decisions of superior nurses’ or ‘I make an effort to go and confirm things face-to-face with superior nurses rather than relying on written records’; “Take experts’ decisions as opportunities to learn”, for example, ‘I show my decisions as examples for other nurses’ or ‘I communicate in consultation with predetermined people to make it easier to consult’; “Create an environment in which the observations and awareness of new nurses are respected”, for example, ‘I try to make it possible for new nurses to express their intuitive ideas without hesitation’ or ‘I get nurses of lower rank to just communicate the facts of what they have observed to reduce the burden of decision-making’; “Support the desire to cooperate with each other”, for example, ‘I place myself between new and veteran nurses and interpret and communicate what both sides are saying’ or ‘Through communication, we share the situation of the patient and the suffering involved in medical treatment’. The interpretation drawn was that at the core of these categories is “maintaining harmony in the nursing team in order to maintain better care”.
Discussion: Expert nurses used a wide variety of methods to communicate their own decisions to other nurses while taking into consideration the competence and position of each individual nurse. In concrete terms, expert nurses respected the position of each nurse, and created a space in which each nurse could participate naturally by distinguishing each stage of the judgment process from observation to practice, employing various methods to maintain team harmony. It seems that expert nurses do not merely communicate the results of decisions, but place emphasis on ensuring that each nurse is involved in the decision-making process. Also, it seems that expert nurses do not just communicate the decision content based on knowledge and information, but also take into account others’ emotions when communicating.
In a shift system, it is not possible for nurses to directly cover gaps in competence among nurses in charge of other shifts at care settings, and thus nurses in charge of each shift are required to maintain some tension and autonomy. In order to connect decisions made to actual care in practice implemented by nurses in charge to the maximum extent, expert nurses encourage deep understanding that enables other nurses to take action enthusiastically. However, this remains at the individual level of effort made by expert nurses, and organizationally is an insecure nursing practice.