Module 2: Decision-Making Models, Tools, and Styles in Healthcare and Nursing

Lesson Objectives

Overview

Module 2 is divided into three Lessons. The first two Lessons will discuss decision-making: models and tools, values, the concepts of delegation and assignment, and workflow including nursing care delivery models. Lesson 2 will delve further into decision making, looking at teams and conflict. The potential impact of power and politics on decision-making and conflict will be addressed. Lesson 3 will look at accountability in general, and then accountability in healthcare and nursing with an emphasis on financial and performance accountability.

Lesson Objectives

On completion of this lesson, you should be able to:

1. Discuss the pros and cons of various decision-making models
2. List and highlight the positives and drawbacks of a variety of decision making tools
3. Identify some of the styles of management decision-making
4. Define and give examples of “values”
5. Talk about the concepts of “delegation” and “assignment” as it pertains to nursing care delivery.
6. Describe reporting structures that enhance the management of workflow
7. Outline some of the traditional and contemporary nursing care delivery models

Decision-Making

Decision-making is an every-moment function for the nurse. Whether it concerns a client’s care on the shift you are just starting or a decision about which new graduate to hire after interviews, decisions are part of the nurse’s work life. The nurse (staff, manager or leader) may choose to delegate or assign responsibilities to other staff – but those are still decisions. No matter the type of decision to be made, a process is followed. In this Lesson, different models and tools for decision-making will be presented, as well as the “styles” of decision-making. Because there are a number of structures that are directly affected by decisions, concepts such as reporting structures, inter-professional teams, and nursing care delivery models will be highlighted. Factors concerned with delegation of work and how to communicate will be noted as well.

Decision-Making Models

“A good plan, executed now, is better than a perfect plan next week”  

There are many decision-making models, of which a few are particularly applicable to health care:

1. Rational Decision-Making – provides a structured and organized approach to making a rationale decision. Flow charts are an example of a tool used with the rational decisionmaking process. It is assumed that the person making the decisions can determine the best course of action through logical thinking. A series of steps begins with the identification of a problem or opportunity, through the preparation of all potential solutions and their consequences, ending with actions to be taken based on the decisions made. Bad decisions are usually a result of inadequate preparation of the stakeholders in the process, and spending sufficient time to generate a range of possible solutions.
2. Decision-Making Based on Patterns and Cues – this decision-making process relies on experience and expertise to recognize and correctly ‘translate’ a series of cues and patterns of information into a decision (or series of decisions). Patricia Benner (1984) used this model as the basis of her work in her book: “From Novice to Expert”. She describes nursing skills as experiences through which the nurse moves. There are five (5) levels of “knowing” (knowledge): novice, beginner, competent, proficient, and expert. “These five levels reflect movement from reliance on past abstract principles to the use of past concrete experience as paradigms and change in perception of situation as a complete whole in which certain parts are relevant”. Current Nursing, 2013 Dr. Gary Klein’s research on decision-making suggested that people actually use an intuitive approach 90% of the time. His recognition primed decision-making model describes that in any situation there are cues or hints that enable people to recognize patterns. With more experience, the more patterns that can be recognized (Decision-making confidence.com)
3. Innovative Decision-Making – “Thinking outside the box” describes this decision-making approach. As environments change, innovative decision-making is critical for health care organizations to find new and fresh approaches to care of their clients. Brainstorming is a process by which everyone is encouraged to think of possible solutions to the problem/opportunity, without making judgments about the idea (i.e. shooting it down). It is important that those participating in the brainstorming do so as a group, rather than as individuals trying to ‘out-do’ each other. In the latter situation, the process of generating new ideas can become competitive and unpleasant (more discussion in Lesson 3.1 on motivation and performance). The leader must ensure that the group members are recognized and rewarded for their work as a group rather than as individuals.

Values and Decision-Making

Values represent what is important to a person or to an organization. Values help to determine priorities and should be at the centre around which decisions are made. Thus, an organization’s, mission, vision and values need to be consistent and reflective of each other. Can you think of a situation where the values identified by your work situation have been translated into actions and situations where you do not believe the values have been upheld? There are many “values” to which an organization can espouse such as respect, collaboration, equality, family orientedness, professionalism, teamwork; the list is extensive. Two values held particularly dear by Canadians are equality and transparency:

• Equity – Some consider equity to mean that everyone shares equally, while other feel it should be based on who contributes more or has a greater need. Regardless of how “equity” is defined, communication regarding the decision-making process is paramount, particularly if those affected cannot or are not involved in the decision process. As long as people believe the decision to be fair (equitable), then those involved will be satisfied.
• Transparency – Being open about the decision-making process and the outcome is considered transparency. Canadians believe there should be transparency in both public (government) and private (businesses) establishments. However, the actions associated with transparency may be difficult to uphold related to privacy concerns, or that there are delays in providing information to interested parties. Again, communication of as much of the actions and decision-making processes as possible will assist with the concept of transparency.

Styles of Management Decision-Making

Autocratic – A decision is made (and implemented) without input from those about whom the decision may affect. Emergency situations are an example of when an autocratic decision style may be acceptable.

Decision-Making

Consultative – The leader or manager consults those who are going to be affected by the decision, but that same manager/leader ultimately makes the decision. Employees will feel involved and should increase the chances of acceptance of the decision.

Participatory – where the decision is shared between the manager/leader and the staff. However, the degree to which the staff is ‘allowed’ to participate can vary greatly.

Collaborative – when a group rather than an individual makes a decision. The group members are involved in the decision process, but the decision is based on a majority decision, rather than 100 percent agreement. (Democratic vote)

• Consensus Decision-Making: is a type of collaborative decision-making where the group members make a decision and there is general agreement with the decision made. It is not 100% agreement. Efforts are made to work through opposing views in an attempt to reduce the degree of opposition or polarization.

Decision-Making Tools

While there are many decision-making techniques and tools, the processes usually focus on the same key principles of figuring out that a decision needs to be made, researching and considering all the options, making the decision, and then reviewing the decision once it is made to ensure it solves the problem (Brooks, 2014). Decision-making tools can help with the decision process by organizing thoughts in a logical sequence or helping to clarify the decision that best “fits” the problem, but they do not make the decision; they are assistants (tools) only.

Decision Tree – a graph or model that looks like a tree-like structure. The “branches” show the possible outcomes of any one of a number of possible decisions drawn in a logical flow.

Decision Matrix – used to evaluate all options of a decision. A table is created with all the options in the first column, and all the factors that affect the decision in the first row. Users then score each option and weigh which factors are of more importance. A final score is tallied to reveal which option is best.

Pareto Analysis – or the Pareto Principle is a technique used when a large number of decisions need to be made. This process helps to prioritize the decisions that may make the greatest overall impact. It is proposed that 80% of results come from 20% of the efforts. I am sure you have heard the saying that 80% of problems comes from 20% of the employees? (the percentages are not exact)

SWOT Analysis – Strengths, Weaknesses, Opportunities, and Threats. To undertake a SWOT analysis, the group members assess internal factors – the strengths and weaknesses of their organization, and the external factors that are the opportunities and threats to their organization.

Cost-Benefit Analysis – used to weigh all the financial ramifications of each possible alternative (both the benefits and the costs). The option chosen is the one that makes the most economic sense.

Decision-Making Models

Multivoting – used when there are multiple people involved in making a decision. This process helps to reduce a large list of options to a smaller number, and then eventually to a final decision.

A difficult problem with multiple causes (some of which may not be known) is because of incomplete, contradictory and changing requirements. “Wicked” problems are symptoms of other problems. Churchman (1967) labeled this situation and looked to a systems approach to try to solve it. However, because the dynamics of an organization are fluid, “fixing” or changing one part of the system usually results in a domino effect upon other parts of the system that had previously been assessed as satisfactory; or, more problems are identified as solutions are trialed.

The Nurse Manager experiences this dilemma on a frequent basis as she tries to problem-solve a situation on her/his unit, for example, needing a new type of pressure-reduction mattress.

However, as s/he explores the purchase (s/he has the money), purchasing, quality improvement, risk management, other Managers and their units, other disciplines, skin care experts, need and wish to get involved. The list goes on of the number of other factors who need to be considered in trying to obtain better mattresses!

Strategic Planning - is the process of determining long-term plans. The strategic plan documents the decisions made during the planning process and generally includes the organization’s Mission statement (description of focus or purpose), Vision statement (description of where the organization would like to be in the future), values, goals and objectives, and how these can be attained (Gaudine & Lamb, 2015, p. 136-137). Using a tool such as the SWOT analysis may help in identifying the elements that should be part of a strategic plan. Strategic plans used to be developed for a five-year period, but now, due to the rapid pace of change in health care environments (and not just health care), strategic plans are often based on a three year cycle.

Delegation and Assignment

“Delegation is a complex skill that requires knowledge, the ability to work well with others on a team, and communication skills” (Gaudine & Lamb, 2015, p. 142). Delegation occurs in all aspects of patient care – from the nurse delegating to an unregulated health care provider, to the physician delegating a function to a Registered Nurse (CRNNS, 2012). Nurses are required to both delegate and assign, but often are reluctant to do so, perhaps feeling that they are not prepared or experienced enough to do so, or fearing ramifications if something goes wrong (Sullivan, 2018). As well as an understanding of the nursing practice act in the nurse’s province or territory, how and whether a task or procedure is delegated will also rely upon the relationship of the ‘delegator’ to the ‘delegatee’. Is there a trust relationship? How was the request communicated and how did the person receiving the request respond? Another factor that must be considered is the chain of command as to who is allowed to delegate what to whom, and again, how is the

Values and Decision-Making

request communicated? As we know there remains significant sensitivity between and among RNs, LPNs, regarding seniority and delegation. Note the seven themes identified on p. 142 of your text regarding barriers to RNs and unlicensed assistive personnel. Can you relate to any of these themes in your work environment?

Management of Workflow

How work is completed including its organization and delegation are based on decisions for which the manager is accountable. There are several reporting structures by which work can be accomplished. A job description details the functions of a particular position and for what a person is accountable for undertaking and completing. The job description also identifies to whom the person reports as well as who might report to that person, including delegation. If well written, it can provide role clarity; without it role confusion can occur causing stress and frustration regarding who is responsible and accountable for what activities and functions. Another factor that must be considered is the management style of the manager. If s/he is one who must be constantly overseeing the work of others (for which she has already delegated and established clear job descriptions), s/he could be considered a micromanager. Conversely, a macro-manager manages aspects of the system to enable goals and objectives to be completed.

Reporting Structures

• Centralized and Decentralized Structures – decisions are made at the very top in centralized structures with those beneath carrying out the activities to complete the identified tasks. Most staff would not feel like they were part of the decision-making processes, but from the senior administrative perspective, they would know and control how the organization works. In a decentralized structure managers and staff at the lower levels are given authority to make decisions. In this manner, decisions can be made at the point of need, rather than having to take problems “up the chain-of-command” for action.
• Flat and Tall Structures – a flat organization has few “layers” of management between front line and senior management which should keep everyone more closely connected and up to date re: communications. Conversely, a tall organization has more layers, but there is more opportunity for career advancement. At a tertiary hospital in Nova Scotia, front-line managers were reduced by approximately 25-30% in the 1990’s as a cost saving strategy. Unfortunately, it soon became apparent that the manager’s spans of control were so great that s/he lost the day-to-day connections with the staff reporting to her/him. The result was much reduced morale, higher sick time, and lack of timely problem-solving among other drawbacks. The majority of these positions have now been re-introduced.
• Shared Governance – with the downsizing of managers front line staff were saddled with heavier responsibilities and decreasing morale. To improve their working conditions and encourage and retain nurses and new graduates, the concept of shared governance was introduced. It refers to shared decision-making among a variety of roles and allows all nurses within an organization to be involved in decision-making related to their professional practice. However there are large challenges to implementing and maintaining this form of governance including managers now working in a supportive role to the staff (finding out information for them), rather than controlling and directing. The sheer size of some organizations and staff thoroughly understanding their scopes of practice and the boundaries around where they have the mandate to make decisions are issues of concern with shared governance.

• Program Management – a way of organizing health care organizations by groups of patients (Ambulatory Care, Geriatric Assessment, Respirology) versus by professional discipline (physiotherapists, dieticians, etc.). All the disciplines in a Program report to an operational or program manager (who may or may not be of the same profession), for their work within the program. Simultaneously, the staff person will report to a professional practice manager regarding issues to do with their profession. It was thought that program management would enhance inter-professional* care, thereby reducing overlap and repetition. On the downside, disciplines may feel that they are losing the connectivity to their own profession who understanding their particular professional practice issues. It is difficult for a program staff member to discuss a professional issue with her/his manager if she is not of the same discipline. In fact, the word “nurse” is removed from the program manager’s title, even though a majority of program managers are nurses! (*Inter-professional care are those teams where not all members need to be involved in the care of the patient and family after the initial assessment. In multidiscipline teams, all members are involved.)

• Horizontal and Vertical Integration – across Canada amalgamation of facilities in urban centres and facilities in both urban and rural settings have undergone amalgamation to reduce service overlap and repetition and thus save money (at least that is the theory!) This integration is called Horizontal integration. Vertical integration means that an organization becomes larger through joining with other organizations that complement the services they provide, such as community health centres or long term care centres.

Nursing Care Delivery Models

A critical and significant issue challenging nursing today is the way in which nursing care is delivered. The essence of providing nursing care revolves around the work environment and culture, the type of nursing care delivery system, and staffing and scheduling practices. Pressures from many sources—all centered on an overall expectation to reduce the cost of care, enhance efficiency, and maintain quality—affect the organization of nursing care. Nurse Managers are often challenged by the push to replace professional RN staff with less-skilled workers. They also still brush up against the view that “a nurse, is a nurse, is a nurse”. Research (as mentioned earlier in this course) is substantiating that more registered nurses are associated with improved patient outcomes, but there is virtually no research on LPN/RPN practice and outcomes, nor on models of care delivery.

The purpose of a nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to a specified group of patients. The delivery of care includes assessing care needs, formulating a plan of care, implementing the plan, and evaluating the patient’s responses to interventions. There are a variety of delivery modes including: case method, functional method, team nursing, primary nursing, nursing care management, and client-focused care. Also, read the “Leading Health Care Example” on page 150 of your text that describes a new nursing care delivery model developed by the nurses at the Ottawa hospital.

Traditional

• Total care/Case method: one nurse assumes complete responsibility for the client’s care.
• Functional: each aspect of the client’s care is assigned to a particular nurse (e.g., medication nurse, wound nurse, etc.)
• Team: a group of staff (registered nurse, licensed practical nurse, etc.) is assigned as a group to care for clients.
• Primary Nursing care: a registered nurse is responsible for a particular client’s care 24 hours a day.

Contemporary

• Case management: a clinical system of health care delivery that organizes and sequences care at the client-provider level to achieve cost control and optimal outcomes.
• Client-focused care: tasks are unit-based and organized to meet the needs of the client.
• Product line management: a product line manager (who may or may not be a nurse) is responsible for directing the care of particular types of clients; any number of clinical areas /services are combined to provide a “distinct product line”.

How important is a particular model of care delivery in your practice setting? What model of care is used in your practice setting? Think about your practice setting and reflect upon the pros and cons of the method of nursing care currently in place.

Are you having difficulty deciding which model of nursing care delivery is best? You are not alone. The nursing literature describes the advantages and disadvantages of various models but no one model of care delivery has been identified as ideal in all situations. In today's environment, there is room for creativity and innovation in designing the model that will work best for an individual unit. The report commissioned by the Canadian Nurses Association (2012) entitled “Evidence to Inform Staff Mix Decision-Making: A Focused Literature Review”, provides a comparison of various models used in Canadian health care – past and emerging (p. 8-10). Patient care delivery models (PCDMs) are sometimes called “systems of care delivery” or “patient-focused” or “patient-centred care”. The stated goals of PCDMs include improved interdisciplinary teamwork and bringing care closer to the patient. PCDMs are defined as work of RNs, other levels of nursing personnel, and some other health care providers through role and task design and the allocation of work activities and responsibilities. PCDM were introduced in the late 1980s and early 1990s, often in parallel with organization restructuring, downsizing, and quality improvement initiatives. During the period between 1992 and 2002, the numbers of RNs employed in staff nurse positions fluctuated in response to the elimination of positions through organizational restructuring activities, often described as patient-centred, or patient-focused, or for the purposes of quality improvement. The number of employed RNs did not keep pace with population growth during this period. Have you witnessed this in your work setting? If so, what do you think are the implications of this decrease for nurses and quality care?

It can be difficult for managers to be transparent in situations where privacy is required, such as issues related to staff or patients. Or, managers may delay providing information because the information isn’t yet finalized. What do you believe are the appropriate boundaries of transparency? What is fair and unfair?