The Decision Making Process Applied to the World of Nursing and Health Care

The steps of the decision making process are as follows:

            1.  Identify the Problem

2.  Identify Decision Criteria

3.  Allocating Weights to Criteria

4.  Developing Alternatives

5.  Analyzing Alternatives

6.  Select Alternative

7.  Implement Alternative

8.  Evaluate Decision Effectiveness

So does this transfer to the realm of nursing and, if so, how?  Well the answer is yes.  The decision making/problem solving process can be viewed in the following problem addressed by a nurse manager using the American Nurses Association (ANA) standards to analyze the problem.

1. Identify a management problem.  A management problem is the lack of consistent and accurate monitoring of daily weights for congestive heart failure patients admitted to the inpatient cardiac stepdown unit.
2. Write a problem statement.  Daily weights are a tool for monitoring hypervolemia in heart failure patients.  Daily weights are monitored every morning, obtained by night shift nursing and nurse assistant staff, as a tool for physician monitoring of fluid volume status.  Daily weights are repeatedly not being collected or inaccurately documented for heart failure patients on the unit.  Consistent and accurate daily weights while inpatient offers patient reinforcement regarding the importance of continuing this activity at home after discharge.   
3. Use the ANA standards to analyze this problem.

• Standard 1
• Assessment (What data would you collect?)
• Use of evidence based practice is a core competency for nursing management and professional nursing practice (Roussel, 2013, p.26).  Focusing on evidenced based practice to support the importance of the practice of daily weights, I would collect data related to the importance of accurate fluid management strategies in heart failure patients. 
• According to Albert (2012), the “assessment of hypervolemia is important, because freedom from hypervolemia after hospitalization has been associated with improvement in long term clinical outcomes” (p.23).  Albert (2012) also listed the five signs of hypervolemia as orthopnea, peripheral edema, weight gain, need to increase diuretic dose, and jugular venous distension (p.23).  To promote the best possible outcomes for our patients, accurate daily weights must be collected and documented daily as ordered by the physician and per our unit protocol.  This not only allows for more accurate monitoring during the patient’s hospitalization, it promotes the completion of daily weights post discharge.  As Medicare reimbursement dollars decrease for HF readmissions, health care providers must provide patients with every possible tool to adequately manage their chronic health condition effectively upon discharge.    
• Standard 2
• Diagnosis the cause of the problem (Explain variables that impact the problem)
• The cause of the problem is the inconsistency of nurse versus nurse assistant weighing patients.  A knowledge gap has also been identified.  Some nurse assistants were found to be unaware of the importance of daily weights for disease management.  A knowledge gap was also identified related to the understanding of the importance of comparing the morning’s weight against that of the previous day for accuracy and evaluate if a recheck is necessary. 
• The practice had been that only patients with heart failure or as ordered by physician were weighed every day.  This lead to confusion and the increase occurence of missing patients who were ordered to be weighed daily.  Also, many nurses on the unit viewed daily weights as a “CNA responsibility” and did not follow up with the results of the daily weights.   
• Standard 3
• Identify outcomes (How does this problem impact staff and other departments?)
• This problem impacts the patient, nursing staff, physicians, and health care organization.  The patient is impacted by not receiving the best possible and recommended care.  Nursing staff are affected by not adequately completing physician orders.  Physicians are impacted, as they cannot accurately judge the fluid volume status of the heart failure patient without accurate and consistent weights obtained per orders. 
• The organization is impacted greatly by this problem.  Not only is weighing patients per orders the best practice for the patient, it is in the best interest of the organization.  By promoting healthy behaviors and educating patients, the organization promotes healthy behaviors after discharge.  Healthy behaviors and disease management behaviors improve patient health and decrease the rate of a hospital readmission.  Reimbursement for hospital readmissions for heart failure patients is decreased.  This cost becomes a responsibility of that health care organization.  For the financial wellbeing of the organization, hospital readmissions need to be prevented however possible.
• Standard 4
• Planning (Develop a plan to address the problem)
• As a manager, I want to promote staff involvement and buy in for change on the unit.  Therefore, this problem was brought to the attention of the Unit Based Committee.  As a committee made of frontline nursing staff on the unit, it is a great opportunity to give them the autonomy to initiate a change.  The UBC reviewed the problem and discussed potential plans to improve the problem under the guidance of management. 
• The UBC developed a plan for improvement of daily weights.  Daily weights accuracy and consistency will be improved if all patients are weighed.  This will decrease the “skipping” of patients needing to be weighed.  Improved communication will be promoted between nurse and CNA.  The nurse and CNAs will distinguish who will weigh each patient to ensure the weights are completed in a timely fashion.  Nurses will be re-educated regarding the importance of daily weights and monitoring the weight entered in the chart for accuracy.  CNA education will take place to educate regarding what amount of weight change must be reported to the nurse as well as what changes in weight mean.
• Standard 5
• Implementation (Develop an implementation plan)
• The implementation plan will begin at the next unit staff meeting.  At the monthly unit staff meeting, a representative from UBC will be present to “roll out” the change to the staff with the support of management.  The UBC and management will provide staff with evidence supporting the importance of accurate daily weights.  Feedback will be encouraged and appreciated to improve staff buy in to the change.
• CNA education regarding daily weights will be conducted yearly at CNA skills day as well as immediately via email, at monthly CNA meeting, and at the monthly staff meeting. 
• The unit clerical for each shift will be responsible for checking for incomplete daily weights and reporting findings to the charge nurse. 
• Standard 6
• Evaluation (Develop an evaluation plan)
• The evaluation of the plan will be done daily by the unit clerical (who reports findings to charge nurse) checking for incomplete weights.  Evaluation of the plan will also be done through promotion of frontline staff feedback regarding perceived efficacy of plan.   Lastly, chart reviews offer a concrete form of evaluation.  Daily weights are documented on the vital signs flow sheet in the electronic chart.  Daily chart reviews will be reported to the charge nurse.  A designated UBC member will also review charts weekly and report discrepancies to management. 

So as you can see, the world of nursing closely relates to the world of business.  The ANA standards of problem analyzing is very similar to the steps of the decision making process listed.  The steps of the decision making process can be found in the steps of ANA problem analysis.

References

Albert, N. M. (2012). Fluid Management Strategies in Heart Failure. Critical Care Nurse, 32(2),

20-33.

Roussel L 2013 Management and leadership for nurse administratorsRoussel, L. (Ed.). (2013). Management and leadership for nurse administrators (6th ed.). Burlington, MA: Jones & Bartlett Learning.