Reflect on current gaps or opportunities for enhanced services within your healthcare organization.

Heliyon 6 (2020) e03128

Contents lists available at ScienceDirect

Heliyon

journal homepage: www.cell.com/heliyon

Research article

Developing a decision-making dependency (DMD) model for nurse managers

Christine Chisengantambu-Winters a, Guy M. Robinson b,*, Nina Evans c

a School of Nursing and Midwifery, Australian Catholic University, North Sydney, New South Wales 2060, Australia b School of Geography, Environment and Population, University of Adelaide, Adelaide, South Australia 5005, Australia c School of Information Technology and Mathematical Sciences, University of South Australia, Mawson Lakes, South Australia 5095, Australia

A R T I C L E I N F O

Keywords: Health sciences Nursing Social sciences Management Human resource management Nurse managers Decision making Management Dependency factors

* Corresponding author. E-mail address: [email protected] (

https://doi.org/10.1016/j.heliyon.2019.e03128 Received 5 June 2019; Received in revised form 5 2405-8440/© 2019 Published by Elsevier Ltd. This

A B S T R A C T

Decision making is an inherent, complex and vital component of the work of managers. Its importance and role in operationalizing the activities of an organisation are well-evidenced in management literature. Yet, there is a dearth of literature about the processes used by nurse managers to make decisions. The principal aim of this paper is to identify the different types of decisions made by nurse managers and explore the related decision-making processes. A ‘dependency model’ is proposed, which illustrates the factors affecting the art of decision making. Structured interviews were conducted to identify types of decisions made by nurse managers in different health- care settings and the factors underpinning these decisions. The research focused on an intensive study of a small group of nurse managers working in rural and regional health institutions in South Australia. The sample included nurse unit managers, after-hours coordinators and directors of nursing. Hermeneutic principles and interpretive research were used to conduct interviews with nurse managers who make numerous and varied types of decisions, though often without following a step-by-step approach. The study identified dependency factors that influence how decisions are made, and developed a model based on eight key variables: (1) the situation to be addressed; (2) the time period in which the decision has to be made; (3) required inputs from colleagues; (4) complexity of the task and the environment, (5) the duration and time it takes to make a decision, (6) availability of resources, (7) the decision-making environment, and (8) personal characteristics. These eight variables are interrelated and have both direct and indirect impacts on how decisions are made. Nurse managers make pragmatic decisions reflecting the complexity of their roles and responsibilities. Awareness of the factors on which decisions depend helps understanding of how they navigate through decision-making processes. The findings are presented as a model that can be used to support decision making by nurse managers in various health settings.

1. Introduction

1.1. Decision-making

Decisions are made at different levels in an organisation involving single individuals or groups. This complex cognitive human activity has small-scale impacts, applying to an individual, or they can affect the operation of a large corporation, a community or wider society (Goodwin and Wright, 2014). The consequential impact can also have limiting or progressive effects, and temporary or permanent impacts on individuals, organisations, groups and communities. Decision making is multi-faceted to the extent that there are numerous factors that influence how decisions are made (Ford and Gioia, 2000; Wu et al., 2016). Decision making is a

G.M. Robinson).

November 2019; Accepted 23 De is an open access article under t

vital component of human and management activity, yet its processes are often obscured and not easily explained. Knowing which factors can mitigate the process of decision making is vital to expediating decision-making processes. More importantly, knowing which factors need to be considered when making decisions is pivotal to the overall process of decision making.

When making a decision, there is a conscious choice to behave or to think in a certain way. It entails reaching a conclusion and making a choice or selection of the best alternative from a set of possibilities of a group of two or more possibilities (Al-Tarawneh, 2012; Jonassen, 2005; Nibbelink and Brewer, 2018) to solve a problem according to the de- mands of the situation (van Knippenberg et al., 2015) and the opportu- nities that exist (Hunink et al., 2014). Hence, Tannenbaum (1950 p. 23)

cember 2019 he CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

C. Chisengantambu-Winters et al. Heliyon 6 (2020) e03128

states that “to decide”means “to cut off”, meaning that a decision implies taking one course of action from a set of alternatives. Decision making also involves undertaking a series of steps that often begins with an identified stimulus, a need or a thought, and results in a commitment to action (Goetsch and Davis, 2014; Simon, 1977). It is a sequence of ac- tivities that involves gathering, interpreting and exchanging information, creating and identifying alternative courses of action, and then choosing among alternatives (Thompson, 2018, p.166). In summary, a decision is a conclusion arrived at after careful consideration of the alternatives; it is the final product of a specific mental and cognitive process of an indi- vidual's choice leading to the selection of a course of action (Kennerley and Mason, 2008, p.7).

The complex processes involved in decision making are not always readily understood (Bojadziev and Bojadziev, 2014). This may be espe- cially so in the health sector, where technological advances are driving changes to policy and regulations while making new demands on the workforce. Arguably, even though decision making has been extensively discussed in management literature, arguably, the process of decision making remains quite difficult to determine and understand, and with little critical focus in health-care institutions (Hunink et al., 2014; Saaty and Vargas, 2013). This is surprising given that decison making is a vital activity having both direct and indirect impacts on patient well-being.

Nurse managers, who occupy the role of middle-level management within the health system (McSherry et al., 2012; Merrill, 2015; Skytt et al., 2008), make decisions that impact on care providers' activities within clinical and critical-care settings (Majid et al., 2011; Standing, 2014). Decision making by nurse managers is one component of a com- plex, multi-responsibility position, which demands execution of varied decisions to address the variety of situations in the clinical area. These decisions can be simple or complex (Lake, 2007), often with major im- pacts on patient care and helping to shape how hospitals and other health-care facilities function (Thompson and Yang, 2009). The abilities of managers to develop good decisions may be affected by various impacting personal and situational factors, including policy standards, knowledge, skills, protocols and the heath-care environment (Ejimabo, 2015).

Within the health sector, decision-making processes present a major challenge. To ensure that institutions meet their prime care-provision outcomes, there is an increasingly recognized need for the develop- ment of improved approaches to aid decision making within the sector, including by nurse managers (Reid and Weller, 2010). It is therefore important to understand more about the process of decision making, including factors affecting how decisions are made. In this paper we refer to these as dependency factors and we examine how nurse managers make decisions, drawing upon interviews and close observation of a small sample of nurse managers in South Australia. Dependency factors emerge from this analysis and are combined in a simple conceptual decision-making dependency (DMD) model, which we suggest can be used to help formulate better decisions and as part of nurse-mangers' training to recognise the principal variables affecting their key decisions.

1.2. Management and decision making

In any organisation, managers oversee day-to-day operations and manage organisational affairs by directing activities through manage- ment processes of recruitment, selection, job description, organising, planning, training, marketing, and policy application that permeate through managerial activities (Schermerhorn et al., 2014). Without managers the organisation's activities would be chaotic. Organisations therefore need managers to steer their activities through challenges and uncertainties, and to provide direction and meaning to their activities. Management is a series of decision-making processes, with decision making located at the heart of executive activity (Anderson et al., 2015). It is a practice that blends a good deal of craft (experience) with a certain amount of art (insight) and some science (analysis) (Mintzberg, 2003, p.1).

2

Effective management requires managers to develop strong decision- making abilities by applying good judgement and having an insight to any given situation because what ever a manager does, s/he does through making decisions (Bloom et al., 2012; Weiss et al., 2019). Thus, ‘good’ decision making is the fundamental hallmark of a professional manager's skills, functioning and effectiveness (Lunenburg, 2011). Good judgement and insight underlie the decision-making process (Bouyssou et al., 2013). To be good decision makers, managers should have critical thinking skills and be able to respond quickly to situations. They must also reflect and identify areas needing improvement (Liebler and McConnell, 2016).

Successful outcomes from decisions taken depend largely on the fine balance between the manager making the decisions and the environment in which a decision is made. Good knowledge of a given situation by a manager acts as a platform for the decision-making process and offers a position fromwhich to defend actions taken. In general, decision making, among other qualities and functions of a manager, presents ongoing demands. In this regard, a manager must have the necessary tools and processes to allow them to make good decisions and solve problems (Beck and Harter, 2014). This is especially true in situations where de- cisions may have major consequences for human health and well-being, as is the case in the health-care sector.

1.3. Decision making within the health-care sector

Health-care institutions are dynamic, challenging, complex in nature, and established to save lives and improve the wellbeing of patients. Managing such an environment is a difficult, nuanced business, which requires various tacit understandings that can only be gained in context (Mintzberg, 2003). Decision making within the health sector is undeni- ably becoming more complex, because of the ever-changing trends, policies and increased technological advances in medicine underpinned by increases in patients' knowledge and awareness of their rights. This all adds to growing complexity regarding how measures that support de- livery of care should be structured and delivered (Effken et al., 2010; Huston, 2008; Santana et al., 2018).

High quality, sound decision making is one of the major elements and essence of good management and leadership in health-care institutions (Bender, 2016). Decisions impacting on life and the wellbeing of patients have a different type of weight attached to them as compared with the types of decisions made in other fields and organisations. The ultimate intention of a decision in a health-care context is to maximize outcomes to patients by way of effective service provision that delivers positive results. In addition, decisions in health-care settings must be made in a way that is consistent with professional expectations and demands made by the medical profession. These decisions can be ethically and morally challenging because they directly and indirectly involve human life and wellbeing. Undoubtedly, decisions made in the clinical environment contribute significantly to the patients' experience as well as enabling the efficient, effective and efficacious use of finite human resources to meet care demand and improve service delivery. The consequences of poor or inefficient decision-making processes can easily be manifested by de- cisions that are ineffective and consequently adversely affect perfor- mance and care delivery.

2. Materials and methods

2.1. Research approach

The researchers employed a qualitative phenomenological approach using hermeneutics to investigate the subjective perspective of in- dividuals' (nurse managers') experiences (Balls, 2009). Hermeneutics describes and interprets human experience, “seeks meanings that are embedded in everyday occurrences” (Reiners, 2012, p.1) and draws upon prior knowledge of situations encountered by the subjects. Hence, based on the hermeneutic interpretive process developed by Heidegger (Mackey, 2005; Miles et al., 2013; Reiners, 2012), the researchers sought

C. Chisengantambu-Winters et al. Heliyon 6 (2020) e03128

to understand the world of nurse managers and draw meaning from narrative accounts they provided (Holloway and Galvin, 2016; Wang and Geale, 2015). The aim was to describe the nurse managers' experiences and their influence on individuals' decision making. This approach required examining, reflecting, analysing and interpreting ‘texts’ (the experiences) to discover their meaning regarding decision making (Sloan and Bowe, 2014). Permission to conduct the study was obtained from the Human Research Ethics Committee, University of South Australia.

The research took place in rural and regional health-care facilities in South Australia. While the findings can be applied broadly to facilities elsewhere, including those in urban and metropolitan settings, it should be noted that specific demands are often placed upon health-care staff working in rural and regional areas. For example, different skills and role expectations may exist between workers in regional and metropolitan settings in essentially similar positions. Managers in regional areas practice in an environment often affected by diminished human and material resources compared with their urban counterparts (Mlcek, 2005). The under-supply of health professionals in regional Australia has resulted in less health expenditure than with fee-for-service funding ar- rangements. This reflects the distinctive social, economic and de- mographic characteristics of rural areas that contribute to lack of support and networking due to physical and professional distance from other peers (Bourke et al., 2012).

2.2. Sampling

This paper describes part of a broader investigation of the role of nurse mangers in rural and regional health-care facilities in South Australia (Chisengantambu, 2015; Chisengantambu et al., 2017). Mixed method sampling was used to obtain rich data (Palinkas et al., 2015). Simple random sampling gave every regional and rural health institution in the state an equal chance to be involved in the study, selecting randomly from the eight regions of South Australia and a list of the hospitals and health-care facilities in each region. Letters were sent to health institutions requesting their participation in the research and stating the study aims and purpose. Having selected facilities, purposive sampling (Robinson, 1998, p.29) was then used to select individual nurse managers who occupied a range of different nurse manager positions, including nurse unit managers (NUM), after-hours coordinators (AHC), residential care managers (RCM), clinical nurse consultants (CNC) and directors of nursing (DON). This meant that the sample composition included nurse managers working in different capacities and types of facilities, which provided diverse experiences and world-views. Informed consent was obtained from participants, who could ask questions and clarify points that were unclear. Participants were assured of confiden- tiality, with pseudonyms used in this account to guarantee anonymity.

2.3. Data collection and analysis

Data were collected using a mixed approach, consisting of face-to-face interviews, direct participant observations by the first author, and review of documents. This approach ensured that the collected data captured the detailed, rich and complex experiences of the participants, enabling clearer understanding of what and how decision making occurred in the various health settings.

Interviews were conducted with nurse managers using a semi- structured data collecting tool, comprising mainly open-ended, semi- structured and contrasting questions to elicit opinions and perceptions of nurse managers. As per the Heideggerian approach, participants were encouraged to engage and to self-reflect during the process of data collection in order to help elaborate and explain their experiences. In- terviews were recorded with the participants' permission and transcribed for analysis. Although interviews are the focus of this paper, the findings also reflect observation of the interviewees in the workplace by the lead author and consideration of management documents.

3

Data were analysed using a data management tool, NVivo qualitative software, employing a coding system from which it is possible to create reports, queries and charts. Themes and patterns were identified in the data, providing new insights into nurses' experiences (Hila and Alabri, 2013) by using the software to recognise themes linked to the textual descriptions of the participants' experiences. This helped identify views and feelings associated with the experiences of decision making. Four processes were used when analysing data:

a) organisation (achieved through coding); b) summarisation and categorising; c) identification of patterns and themes; and d) linking themes and drawing a relationship between themes and ideas.

Use of NVivo as a method of data management in this fashion is endorsed by King (2004, p. 263) who argues that it is invaluable in helping to index segments of text to particular themes, to link research notes to coding, and to perform complex search and retrieve operations, which can aid the researcher in examining possible relationships be- tween the themes.

Using NVivo, inductive analysis was applied to derive concepts and themes, through interpretations made from the transcribed data, thereby allowing theory to emerge from the data rather than starting with theory and endeavouring to test hypotheses (Thomas, 2006). During the process of data interpretation, quotes were used to highlight the views being expressed. Data saturation was reached when no new themes or new thematic information were being attained or adding to the overall ex- periences of the nurses. This occurred with a sample size of fifteen: 14 women and one man.

3. Results

3.1. Types of decision made

Decisions vary in relation to their scope, purpose, the nature of their inputs and outcomes, and by virtue of their specific requirements, pro- cedure or structure. Exploring how decisions are made helps to elucidate the time spent on decision making and the role and type of activities carried out, which in turn impacts how decisions are made. For example, one participant said “80–90% of the time the situation dictates to us what we should do and what type of decision we have to make” (Molly). Deducing from the participants' responses, the researchers identified the following categories of decisions the nurse managers made:

� Sporadic and unplanned decisions: These were made ‘on the spot’ without much planning;

� Planned decisions: These had been thought through and careful consideration had been given to their implementation;

� Information-supported decisions: Decisions that were made after certain information had been clarified with colleagues or senior managers, e.g., information concerning the purchase of equipment;

� Participative decisions: Decisions that were made collectively, i.e. through a meeting or networking groups. These are also consultative in nature with other people being consulted before a decision is made;

� Formal and bureaucratic management decisions: Decisions made at executive level and handed down to subordinates (including nurse managers) by senior management. These types of decisions are usu- ally non-negotiable, and the staff must abide by them.

The nurse mangers also recognized that the types of decisions made in health-care facilities are influenced by the level at which the decisions are made. Hence, they distinguished between executive, managerial and clinical decisions, as indicated in Figure 1.

The responses obtained in interviews revealed that decision making by the nurse managers was neither streamlined nor confined to specific rationalized processes; that is, no pre-determined or set processes were

Figure 1. Types of decision made in health-care facilities.

C. Chisengantambu-Winters et al. Heliyon 6 (2020) e03128

followed when making decisions. Indeed, the nurses found it difficult to clearly articulate how they made decisions, especially as this varied with each situation. For instance, some decisions were well-planned and well- executed while some decisions were made ‘on the spot’ and ‘on the run’. Answers to the question, “How do you make decisions?” were varied, consistent with the complex nature of decision making. One nurse queried, “How are we supposed to make decisions? We make decisions like anybody else. I make a decision as I would make a decision at home; but the scenario and the situation at work are different to that at home” (Cathy).

Only some of the participants followed a recognisable decision- making pattern, as shown by the quotes presented in Table 1. Re- sponses to the question about how nurse managers made decisions included phrases such as ‘normal’, ‘nothing particular’, ‘like anybody else’, ‘chaotic at times’, ‘confusing’, ‘not sure’, ‘lack of clarity’, ‘the blind leading the blind’, ‘we have to do what we have to do’, ‘we do not usually have a choice’ and ‘we have to oblige to the situation’.

Table 1. Decision-making: Quotes from nurse managers.

“I would not say there is a system or a pattern, but I would say that I tend to use some strategies more commonly than others” (Sue). “There is a system which I have developed but it is hard to put this into words” (Daisy). “The nature of the situations determines how the decision is made” (Jaylee). “We do everything to make sure that the care of the patient is not compromised. They say the customer is always right and in this case the patient is always right. I do not necessarily have to agree with what they are saying, but I have to be professional about it and how I handle the situation. I also use the same strategy with the staff when they sometimes make demands that are not possible at the time” (Theresa). “The nature of the situation influenced how the decision was made. In some situations, you may have time to consult other people, but when it comes to a patient's condition, sometimes you just have to make a solo decision, especially when you work at night and there are no other senior nurses around” (Danny). “There is no clear-cut procedure that I use, but I guess I follow the usual process of referring to policies and procedure manuals, consulting with other staff, nurse managers and my supervisors” (Sue). “Most of the time, I think the idea through in my head and then implement the idea and if there is time, I can ring other people. There are times when you are thinking on your feet and you go ahead and implement the idea, then after you implement the idea you say, ‘whoops!’ I wish I had consulted other people first” (Cassie)

Source: First author's interviews with sample nurse managers.

4

Nurse managers tended to use a “search and find” approach to look for relevant information, clues or ideas before making a decision. How- ever, when participants were asked to elucidate the process they used when making decisions, they responded as shown in Ta