Aims: To explore nurses' perspectives regarding the decision-making processes that lead to missed nursing care and to identify the personal and contextual attributes involved in these processes.
Design: A qualitative study was undertaken between April - October 2018.
Methods: A total of 28 registered nurses working in different wards in hospital settings participated in nine focus groups with semi-structured interviews. An interview guide encouraged nurses to share perceptions of missed care and the personal and contextual attributes shaping their decision-making.
Results: Content analysis revealed three themes related to nurses' decision-making processes for whether to omit or delay care. First, nurses emphasized the role of nurses' agency, suggesting explicit or implicit rationing of care, regardless of scarce resources. Second, nurses distinguished between two modes of thinking that they labelled "automated thinking," activated in routine situations and "effortful thinking," initiated in more novel situations. Finally, nurses identified situational factors triggering fluctuations in their awareness such as task type, difficult patients and the presence of relatives and the head nurse.
Conclusions: Nurses are aware of the processes guiding a decision to omit or delay care. They pointed to patient, nurse and ward conditions that serve as cues in their decision whether to miss care. Identifying these cues supports Hammond's cognitive continuum theory of decision-making and may serve in the development of training programmes for nurses aimed at limiting the phenomenon.
Impact: The study addressed missed nursing care through a decision-making lens. The findings pointed to nurses' agency as shaping decisions about whether to miss care and identified the personal and contextual cues that guide nurses' decisions. These findings call for organizational training programmes encouraging nurses to identify barriers and facilitators of missed nursing care and how to overcome them.
目的: 本研究旨在探讨护士对导致护理缺失的决策过程的看法,并确定这类过程中所涉及的个人和环境属性。 设计: 2018年4月至2018年10月期间展开了定性研究。 方法: 共有28名来自医院不同病房的注册护士参与了9个焦点小组的半结构式访谈。根据访谈指南,鼓励护士分享关于护理缺失的看法,以及影响其决策的个人属性和环境属性。 结果: 内容分析显示,有三项主题与护士是否作出省略或延迟护理的决策过程有关。首先,护士们强调了护士代理人的作用,提出不管资源是否稀缺,都要明示或暗示进行护理资源配给。其次,护士区分了两种思维模式,她们将其称为“自动思维”,在常规情况下激活,而“努力思维”则在其他新情况下激活。最后,护士确定了引发其意识波动的情境因素,譬如任务类型、困难患者、亲属和护士长在场。 结论: 护士了解促使作出省略或延迟护理的决策的过程。护士表示,患者、护士和病房的状况是她们决定是否作出护理缺失的依据。这些依据的识别支持Hammond的决策认知续线理论,并可用于制定旨在限制这一现象的护士培训方案。 影响: 本研究从决策角度探讨了护理缺失问题。研究结果表明,护士的代理人决定了是否省略护理,并确定了促使护士作出决策的个人和环境依据。根据这些研究结果,需开展组织培训方案,鼓励护士查明护理缺失的障碍和促成因素,以及如何克服这些障碍。.
Keywords: care left undone; decision-making; focus groups; missed nursing care; nurses; rationing nursing care.
© 2020 John Wiley & Sons Ltd.