The clinical landscape of critical care: nurses' decision-making.
BACKGROUND
Many studies have tended to explore individual characteristics that impact on nurses' decision-making, despite significant acknowledgement that context is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment.


OBJECTIVE
To investigate environmental influences on nurses' real decisions in the critical care setting.


METHODS
Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis.


RESULTS
All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse.


CONCLUSIONS
Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses' decision-making in order to improve health care outcomes.
Bucknall
Tracey
T
Victorian Centre for Nursing Practice Research, School of Nursing, University of Melbourne, Carlton, Victoria, Australia. bucknall@unimelb.edu.au
D000328:Adult; D002983:Clinical Competence / Q000592:standards; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000451:nursing*; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009723:Nurse-Patient Relations; D009736:Nursing Process; D009741:Nursing Staff, Hospital