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Home care nurses' inferences and decisions
Home Care Nurses' Inferences and Decisions Eileen S. O'Neill
The types of inferences and decisions made by home health nurses were explored in this study. One hundred patient care records representing 10 home care nurses' primary clients were examined. Two main types of decisions were identified: (1) autonomous with the subcategories of self-directed and consultative and (2) collaborative. Less experienced nurses recorded the most decisions and relied on collaborative decision making more often. Implications include the need for increased autonomy in decision making for home care nurses and the necessity for decision supports for novice nurses.
Copyright © 1997 by W.B. Saunders Company
S NURSES ATTEMPT to improve their decision-making skills, few guidelines are available to assist them. The underlying problems continue to be the unclear explanation of decisionmaking and confusion regarding how factors in nursing practice influence the process. Deliberations involved in making clinical decisions have been described from two perspectives: the analytic, studying alternatives rationally and selecting the best alternative; and the intuitive, knowing without the conscious use of reasoning (Paul, 1993). Although both modes may be complimentary, it is unlikely that they exist simultaneously. The current view is that the type of thinking used must reflect the characteristics of the decision situation and the knowledge of the decision maker. However, the types of judgments required of nurses in different practice settings have not been described. Thus, without understanding the nature of these judgments, methods to improve the decisionmaking process cannot be developed. Therefore, the present exploratory study was designed to add another dimension to the knowledge of clinical decision making by exploring inferences and decisions recorded in patient care records. The investigator examined the inferences and decisions recorded by a select group of nurses employed by an urban home care agengy. A clinical inference was defined as a determination of the patient's health status (Kelly, 1966) and a clinical decision as a determination of therapeutic action. The study also was designed to explore the relationship between home care experience and decisions. The two main questions addressed were: (a) What were the types of inferences and decisions recorded by home care nurses? (b) Did experience
A
Applied Nursing Research, Vo]. 10, No. 1 (February), 1997: pp 33-38
in home care affect the types of inferences and decisions that nurses record? BACKGROUND
Clinical decision making varies among nurses, decision characteristics, and contexts (Grier, 1984). Most investigators have focused on the ability and experience of the clinician, which show the importance of knowledge in decision making (Benbasset & Bachar-Bassan, 1984; Coughlin & Patel, 1987; Del Bueno, 1990). Elstein, Shulman, and Sprafka (1978) found that decision-making ability depended in part on the available knowledge relative to a specific patient problem. White, Native, Kobert, and Engberg (1992) came to a similar conclusion in a study of nurse practitioners. They observed that all subjects collected the same information, but those who failed to reach the correct diagnosis did not understand the meaning of the data. Patterns of decision making change as experience-based knowledge increases (Benner, 1984; Benner & Tanner, 1987; Dela Cruz, 1994). Schimidt, Norman, and Bochizen (1990) described "illness scripts" developed by experienced physicians from repeated exposure to patients. New
From the College of Nursing, Universiiy of Massachusetts Dartmouth, North Dartmouth, MA. Eileen S. O'Neill PhD, RN: Associate Professor. Supported by the Massachusetts Association of Colleges of Nursing and the University of Massachusetts Dartmouth Foundation. Address reprint requests to Eileen S. O'Neill PhD, RN, College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA 0274Z Copyright © 1997 by W.B. Saunders Company 0897-1897/97/1001-000555.00/0
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EILEEN S. O'NEILL
patient problems were matched to scripts or patterns in memory to determine diagnosis and treatment. Benner and Tanner (1987) identified pattern recognition, a similar phenomenon, that expert acute care nurses relied on to make clinical judgments. Experienced home care nurses also described using a pattern-matching process in clinical judgment (Stulginsky, 1993). In addition to familiarity with a specific problem, the difficulty of the problem can also account for variability in decision making. Corcoran's study (1986) of hospice nurses treating chronic pain found the degree of complexity of the decision evoked different approaches to decision making. Hughes and Young (1990) also reported that surgical nurses' decisions departed from the normative model as the problem became more difficult. Using a grounded theory approach, Dela Cruz (1994) described variations in decision-making styles of home care nurses depending on the clinical problem. O'Neill (1994a, 1994b) discovered that nurses used different heuristics or "rules of thumb" as the problem became more complex. When viewed together, this research indicates that different problems elicit different strategies. When nurses recognize the problem along with the appropriate solutions, pattern recognition may be central. Other strategies are employed when the problem or the solution becomes complex and ill defined (Dela "Cruz, 1994; Getzels, 1982). Factors such as the level of patient acuity and time available for decision making, may also require different processes (Henry, 1991; Stein, 1991). Additionally, clinical settings dictate the choices available to nurses. For example, the solitary practice of home care nurses and the scrutiny by insurance reimbursers undoubtedly influence the options. The implication that various problem categories require certain strategies cannot be studied without designating the problems nurses repeatedly confront in specific practice arenas. Furthermore, methods to improve clinical decision making cannot be devised without identifying categories of nurses' decisions (Fonteyn, 1991).
METHODS Setting and Sample The setting for the study was a large home care agency, which served approximately 45,000 patients in 1994. The agency employed 47 registered
nurses, 37 full time, and 10 per diem. Ten full-time nurses with home care experience ranging from 1 to 7 years were selected. Four of the nurses had 1 year experience, two had 3 years, and the remaining four nurses had 7 years. These three groups represented novice, competent, and expert practice levels as described by Benner (1984). Then, 10 patient care records from each of the nurses' primary case load were randomly chosen by the nursing supervisor for a total of 100 discharged records. The appropriate institutional review boards approved the study. Anonymity and confidentiality for both nurses and patients were maintained by using code numbers on all data collection and analysis materials.
Procedure Both descriptive and quantitative content analyses were used (Crabtree & Miller, 1993; Morgan, 1993). A template approach, as described by Crabtree and Miller (1993), guided the data collection and the qualitative analysis. The initial template or coding guide was developed from several sources that included a previous study conducted by the author (O'Neill, 1996), existing knowledge regarding nurses' decisions, and a pilot study of nurses' recorded decisions. The coding guide contained definitions and key phrases to be used in identifying inferences and decisions. It was pretested using data from 20 patient care records not selected for the main study. Initial definitions were retained, but key phrases were added to the coding guide after pretesting. During analysis, the coding guide was expanded and modified as new categories and subcategories emerged (Miles & Huberman, 1984). Data collection took place over a 3-month period.
Coding Reliability The investigator or research assistant examined each record. The entries that indicated a determination of the patient's health status or reflected a decision to take action were recorded on a data collection tool. Both coders underwent training in the use of the coding guide. Interrater reliability based on 10 patient care records was 0.85, whereas intrarater reliability was 0.95 for the investigator and 0.90 for the research assistant (Waltz, Strickland, & Lenz, 1991). Both coders were unaware of the experience level of the sample during data
HOME CARE NURSES' INFERENCES AND DECISIONS
collection and during the initial analysis phase of the study. FINDINGS Clinical Inferences
As stated previously, a nursing inference was defined as a determination of the patient's health status (Kelly, 1966). A total of 803 inference statements were identified in the 100 patient care records. An average of five admission diagnostic statements were documented in each record. Novice nurses recorded the highest number of admission diagnoses (X = 5.4) and experienced nurses the least (X = 4.2). Novices also recorded the highest number of inferences in the narrative notes (X = 3.06 vs. 2.75). These statements ranged from changes based on the assessment of health problems, (status of wounds), to the description of patient responses (pain), to the evaluation of interventions (health teaching). Samples of documented inferences included: "No improvement in leg ulcer," "Patient in no acute distress. Suffering from hot, humid weather"; "Patient caimot be taught procedure because of decreased intelligence." Although traditional "nursing diagnosis" language appeared in the admission notes, these descriptors were not apparent in the ongoing narrative record. Home care nurses in the study also diagnosed disease states. Nurses, particularly those most experienced, identified medical problems such as urinary tract infections and congestive heart failure based on patient symptoms. They also diagnosed potentially life-threatening situations that required immediate action. Conditions such as deep vein thrombosis, transient ischemic attack, and myocardial infarction were recorded. For biomedical inferences, nurses communicated the uncertainty of the situation by a question mark before the diagnostic statement. As one nurse recorded: "Noted positive Homan's sign. Patient admits to sharp pain from fight toes up and behind right patella. Slight edema noted.. ? Deep vein thrombosis." Decisions
A nursing decision was defined as a determination of a therapeutic action. Three hundred and eighty-four decisions were identified in the 100 patient care records. Decisions were classified in two categories: (a) autonomous (n = 272; 71%), with two subcategories, self-directed (n = 185;
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48%) and consultative (n = 87; 23%); and (b) collaborative (n = 112; 29%). Autonomous Decisions Autonomous decisions were defined as independent determinations of action. Identified were two subtypes, self-directed and consultative. Selfdirected decisions consisted of treatment choices made and performed by the primary nurse. The majority involved coordinating and managing patient care. The need for a different level of care, such as increased nursing visits or for specialized care such as a social worker, physical therapist, or physician represented frequent management decisions. Other services coordinated by the nurse involved home health aides to assist with personal care and transportation. Nurses often discussed the case management decisions with the patient and family prior to calling on other professionals. Following are examples of these notes: "Call to M.D. office. Made aware patient is dependent on oxygen. Informed them oxygen will only last up to 2 hours. Office promises to make patient a priority. Will be treated and released on time"; "refer to social worker for psychosocial assessment; assist with financial problems and family coping." Decisions related to symptom control and alleviation also were common. Frequently cited were choices regarding pain management, wound care, and activity intolerance. One nurse wrote the following: "Patient on duragesic complaining of constipation. Current medication not helping. Advised Colace 2 tabs daily, increase fluids and fiber in diet." The second subcategory of autonomous decisions, consultative decisions, comprised 23% (n = 87) of the sample. These decisions also appeared to be independent in nature because the nurse determined the appropriate treatment or intervention. The nurses sought approval from the physician, however, to implement these decisions. Physicians rejected only 2 of the 87 accepted decisions. Examples of these notes follow: "Telephone call to MD: Discussed using Elavil for pain"; "Patient weak: T 101. Patient states he is not eating, drinking poorly. Lung sounds diminished. AP 160 irregular. Very pale. Appears dehydrated. Call to M.D. Agreed to send patient to the Emergency Room for possible admission"; "Call to M.D. Requested okay to use Senekot BID and Ducolax tab. 1-3 to manage bowel patterns."
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Collaborative Decisions Collaborative decisions were characterized as partnerships with another health professional, usually the physician, to determine the best course of action. In these cases, the nurse recognized a patient problem and sought help. Twenty-nine percent (n = 112) of the 384 decisions were classified as collaborative. In 90% (n = 101), the nurse conferred with the physician to determine the appropriate intervention. Excerpts from recordings follow: "Call to M.D. to inform of reddening around ulcer with no improvement. Requested a change in treatment"; "Call to M.D. questioning need to increase insulin orders." For the remaining 10% (n = 11) of decisions in this category, nurses conferred with other nurse specialists, such as psychiatric or oncology nurses. In these peer-assisted decisions, the home health nurse diagnosed a problem and discussed alternative interventions with other nurses. One nurse documented this: " - - C a l l to oncology nurse. Discussed client hallucinating, unsafe situation. Questioned what has been done in past with this type of problem." A small number of collaborative decisions (n = 5) resulted from patient center conferences to explore options for patients with complex problems. One such note stated the following: "Case conference with physician, social worker, home health aide, and nurse. Patient's wound is much worse. Son is only care-taker and is noncompliant. Does not keep Mother dry or give medications properly. Explored options for care. Decided to discuss nursing home placement with mother and son." When the data were examined to determine the impact of experience on the types of inferences and decisions recorded, the findings indicated that novice nurses recorded the most inferences and expert nurses the least. The only discernible difference between experienced and inexperienced nurses was the number of potential admission diagnoses. Inexperienced nurses identified more possible problems such as "potential for infection" and "potential for ineffective coping" on the patient's admission. Autonomous decisions were documented in approximately equal numbers regardless of the nurse's experience. Novice nurses, however, reported more collaborative decisions than experts. The analysis revealed that these nurses relied on the physician to determine
EILEEN S. O'NEILL
interventions regarding wound management and bowel care. Novices often reported changes in the patient's status to the physician and sought directions on how to proceed. More experienced nurses addressed these problems without help. DISCUSSION AND IMPLICATIONS
Patient care records revealed a large number and range of inferences and decisions by home care nurses. Although nursing diagnosis language was used to identify patient problems on admission, inferences in the narrative record did not reflect this terminology. Zink (1994) also found home care nurses did not alter "case opening" diagnostic statements. Nurses in the present study used a hybrid form of language that combined traditional biomedical language and humanistic terminology. This finding may imply that "nursing diagnosis" language does not reflect the way nurses think about patient problems, or perhaps the diagnostic classification system was not useful in monitoring patient progress. Nevertheless, common clinical labels and descriptions are essential for thinking, communicating, and accountability. They also influence decisions regarding appropriate treatment. In home care nursing, where several nurses may visit the patient over a period of time without contact with one other, identifying patient problems is crucial. Rather than debating the form that language should take, continued studies investigating how nurses actually perceive patient problems as well as the rich language in use might foster clearer communication. Approximately 70% of the decisions identified in this study were independently determined actions. In over one third, however, nurses sought permission to go forward from a physician. The records indicated that this consumed a substantial amount of nurses' time and in several instances, the primary physician could not be reached. In these situations, the nurse had to summarize the patient's history and problems to a substitute physician not familiar with the case. This practice does not support efficient and cost-containing patient care. The use of protocols for symptom management decisions such as constipation might alleviate the problem. Also, home care agencies might consider employing advanced practice nurses with prescriptive rights. Primary nurses could then consult with them for treatment of common, recurring health
HOME CARE NURSES' INFERENCES AND DECISIONS
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problems such as pain, bowel and bladder difficulties, and wound care. Not only could nurses' time (and therefore, money) be saved, but patients would benefit from more timely attention to their needs. The uncertainty of novice nurses identified in previous studies was evident in their increased number of consultative decisions in areas of symptom management (Corcoran, 1986; O'Neill, 1994b). These nurses do not have sufficient knowledge or experience to deal with patient problems and possible interventions. In addition, methods are lacking that might prepare them to function in the solitary, independent environment of home care. Specific classroom instruction in case management, collaboration, symptom alleviation, decision making, and health teaching could build the knowledge base needed for decision making. Supports such as consulting and mentoring from experienced nurses would not only decrease reliance on the physician but increase the novice's knowledge hastening the development of expertise in these decisions (Corcoran, Narayan, & Moreland, 1988). Also, as common recurring decisions are identified, seminars for nurses at all levels to actively examine their thinking will improve decision making (Mattingly & Fleming, 1994). The findings in this study are restricted to the use of one agency and by the small sample size. Also, the use of patient care records limits the results because they do not contain all the clinical judgments of nurses. Although "chart talk" (Mattingly & Fleming, 1994) reflects only the most salient decisions, home care records nonetheless do provide a rich source of previously ignored decision information.
CONCLUSIONS
This study highlighted the broad range of inferences and decisions made by a selected group of home care nurses. Recorded inferences included both biomedical and nursing diagnoses, although biomedical diagnoses predominated after the nurses initial assessment. Three types of decisions were identified in this study, providing a beginning framework of home care nurses' decisions. The majority of decisions focused on case management and symptom alleviation. Seventy percent of nurse decisions were independently derived, but about one quarter of these decisions required physician approval for implementation. More timely health care could result if experienced nurses had access to protocols and health professionals with prescriptive rights to perform their prescribed treatment. Novice nurses would also benefit from decision supports in the form of protocols, but they need additional guidance in determining the most appropriate decisions. Approximately one third of the nurses' decisions were collaborative, pointing to the need for skills in communication and negotiation. Finally, examination of the type of decision making developed in this study is intended to be a beginning list of clinical judgments made by home care nurses. Further validation, expansion, and refinement are expected as nurses study and describe clinical decisions. With further investigation, the information can be used by educators and managers to prepare nurses for home care. Knowing the types of judgments and decisions encountered in practice can also help nurses reflect on their modes of thinking and improve their decision skills.
REFERENCES Benbasset, J., & Bachar-Bassan, E. (1984). A comparison of initial diagnostic hypotheses of medical students and interns. Journal of Medical Education, 59, 951-956. Benner, RE. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Benner, RE., & Tanner, C.A. (1987). How expert nurses use intuition. American Journal of Nursing, 87, 23-31. Corcoran, S.A. (1986). Task complexity and nursing expertise as factors in decision making. Nursing Research, 35, 107-112. Corcoran, S.A., Narayan, S., & Moreland, H. (1988). "Thinking aloud" as a strategy to improve clinical decision making. Heart and Lung, l 7, 463-468. Coughlin, L., & Patel, V. (1987). Processing of critical information by physicians and medical students. Journal of Medical Education, 62, 818-828.
Crabtree, B.E, & Miller, W.L. (1993). A template approach to text analysis: Developing and using codebooks, In B.E Crabtree & W.L. Miller (Eds.), Doing qualitative research (pp 93-109) Newbury Park, CA: Sage. Del Bueno, D.J. (1990). Experience, education and nurses' ability to make clinical judgments. Nursing andHealth Care, 11, 290-294. Dela Cruz, EA. (1994). Clinical decision-making styles of home healthcare nurses. Image: The Journal of Nursing Scholarship, 26, 222-226. Elstein, A.S., Shulman, L.S., & Sprafka, S.A. (1978). Medical problem solving: An analysis of clinical reasoning. Cambridge: Harvard University Press. Fonteyn, M. (t 991). Implications of clinical reasoning studies for critical care nursing. Focus on Critical Care, 18, 322-327.
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Getzels, J.W. (1982). The problem of the problem. In R. Hogarth (Ed.), New directions for methodology of social and behavioral science: Question framing and response consistency (pp. 37-49). San Francisco: Jossey-Bass. Grier, M.R. (1984). Information processing in nursing practice. In H.H. Werley & J.J. Fitzpatrick (Eds.), Annual review of nursing research (Vol. 2) (pp. 265-287). New York: Springer Publishing. Henry, S.B. ( 1991 ). Effect of level of patient acuity on clinical decision making of critical nurses with varying levels of knowledge and experience. Heart & Lung, 20, 478-485. Hughes, K.K., & Young, W.B. (1990). The relationship between task complexity and decision-making consistency. Research in Nursing & Health, 13, 189-197. Kelly, K.J. (1966). Clinical inference in Nursing: A nurse's viewpoint. Nursing Research, 15, 23-26. Mattingly, C,, & Fleming M.E (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: Davis. Miles, M.B., & Huberrnan, A.M. (1984). Quanlitative data analysis: A source book of new methods. Beverly Hills, CA: Sage. Morgan, D.L. (1993). Qualitative content analysis: A guide to paths not taken. Qualitative Health Research, 3, 112-121. O'Neill, E.S. (1996) The clinical decision making of home health nurses, Home Health Care Nurse 14, 363-368. O'Neill, E.S. (1994a). Home health nurses use of base rate
EILEEN S. O'NEILL
data in diagnostic reasoning. Advances in Nursing Science, 17(2), 75-83. O'Neill, E.S. (1994b). The use of similarity in the clinical inferencing tasks of community health nurses. Scholarly Inquiry for Nursing Practice, 8, 261-271. Paul, R. (1993). Critical thinking. Santa Rosa, CA, Foundation for Critical Thinking. Schmidt, H.G., Norman, G.R., & Bochizen, H.R (1990). A cognitive perspective in medical expertise: Theory and implications. Academic Medicine, 65, 611-621. Stein, H.E (1991). The role of nonbiomedical parameters in clinical decision making: An ethnographic approach. Qualitative Health Research, 1, 3-26. Stulginsky, M.M. (1993). Nurses home health experience. Part II: The unique demands of home visits. Nursing and Health Care, 14, 476-485. Waltz, C.E, Strickland, O.L., & Lenz, E.R. (1991). Measurement in nursing research (2nd ed.). Philadelphia: Davis. White, J.E., Nativo, D.G., Kobert, S.N., & Engberg, S.J. (1992). Content and process in clinical decision-making by nurse practitioners. Image: The Journal of Nursing Scholarship, 24, 153-158. Zink, M.R. (1994). Nursing diagnoses in home care: Audit tool development. Journal of Community Health Nursing, 11, 51-58.
The types of inferences and decisions made by home health nurses were explored in this study. One hundred patient care records representing 10 home care nurses' primary clients were examined. Two main types of decisions were identified: (1) autonomous with the subcategories of self-directed and consultative and (2) collaborative. Less experienced nurses recorded the most decisions and relied on collaborative decision making more often. Implications include the need for increased autonomy in decision making for home care nurses and the necessity for decision supports for novice nurses.
Copyright © 1997 by W.B. Saunders Company
S NURSES ATTEMPT to improve their decision-making skills, few guidelines are available to assist them. The underlying problems continue to be the unclear explanation of decisionmaking and confusion regarding how factors in nursing practice influence the process. Deliberations involved in making clinical decisions have been described from two perspectives: the analytic, studying alternatives rationally and selecting the best alternative; and the intuitive, knowing without the conscious use of reasoning (Paul, 1993). Although both modes may be complimentary, it is unlikely that they exist simultaneously. The current view is that the type of thinking used must reflect the characteristics of the decision situation and the knowledge of the decision maker. However, the types of judgments required of nurses in different practice settings have not been described. Thus, without understanding the nature of these judgments, methods to improve the decisionmaking process cannot be developed. Therefore, the present exploratory study was designed to add another dimension to the knowledge of clinical decision making by exploring inferences and decisions recorded in patient care records. The investigator examined the inferences and decisions recorded by a select group of nurses employed by an urban home care agengy. A clinical inference was defined as a determination of the patient's health status (Kelly, 1966) and a clinical decision as a determination of therapeutic action. The study also was designed to explore the relationship between home care experience and decisions. The two main questions addressed were: (a) What were the types of inferences and decisions recorded by home care nurses? (b) Did experience
A
Applied Nursing Research, Vo]. 10, No. 1 (February), 1997: pp 33-38
in home care affect the types of inferences and decisions that nurses record? BACKGROUND
Clinical decision making varies among nurses, decision characteristics, and contexts (Grier, 1984). Most investigators have focused on the ability and experience of the clinician, which show the importance of knowledge in decision making (Benbasset & Bachar-Bassan, 1984; Coughlin & Patel, 1987; Del Bueno, 1990). Elstein, Shulman, and Sprafka (1978) found that decision-making ability depended in part on the available knowledge relative to a specific patient problem. White, Native, Kobert, and Engberg (1992) came to a similar conclusion in a study of nurse practitioners. They observed that all subjects collected the same information, but those who failed to reach the correct diagnosis did not understand the meaning of the data. Patterns of decision making change as experience-based knowledge increases (Benner, 1984; Benner & Tanner, 1987; Dela Cruz, 1994). Schimidt, Norman, and Bochizen (1990) described "illness scripts" developed by experienced physicians from repeated exposure to patients. New
From the College of Nursing, Universiiy of Massachusetts Dartmouth, North Dartmouth, MA. Eileen S. O'Neill PhD, RN: Associate Professor. Supported by the Massachusetts Association of Colleges of Nursing and the University of Massachusetts Dartmouth Foundation. Address reprint requests to Eileen S. O'Neill PhD, RN, College of Nursing, University of Massachusetts Dartmouth, North Dartmouth, MA 0274Z Copyright © 1997 by W.B. Saunders Company 0897-1897/97/1001-000555.00/0
33
34
EILEEN S. O'NEILL
patient problems were matched to scripts or patterns in memory to determine diagnosis and treatment. Benner and Tanner (1987) identified pattern recognition, a similar phenomenon, that expert acute care nurses relied on to make clinical judgments. Experienced home care nurses also described using a pattern-matching process in clinical judgment (Stulginsky, 1993). In addition to familiarity with a specific problem, the difficulty of the problem can also account for variability in decision making. Corcoran's study (1986) of hospice nurses treating chronic pain found the degree of complexity of the decision evoked different approaches to decision making. Hughes and Young (1990) also reported that surgical nurses' decisions departed from the normative model as the problem became more difficult. Using a grounded theory approach, Dela Cruz (1994) described variations in decision-making styles of home care nurses depending on the clinical problem. O'Neill (1994a, 1994b) discovered that nurses used different heuristics or "rules of thumb" as the problem became more complex. When viewed together, this research indicates that different problems elicit different strategies. When nurses recognize the problem along with the appropriate solutions, pattern recognition may be central. Other strategies are employed when the problem or the solution becomes complex and ill defined (Dela "Cruz, 1994; Getzels, 1982). Factors such as the level of patient acuity and time available for decision making, may also require different processes (Henry, 1991; Stein, 1991). Additionally, clinical settings dictate the choices available to nurses. For example, the solitary practice of home care nurses and the scrutiny by insurance reimbursers undoubtedly influence the options. The implication that various problem categories require certain strategies cannot be studied without designating the problems nurses repeatedly confront in specific practice arenas. Furthermore, methods to improve clinical decision making cannot be devised without identifying categories of nurses' decisions (Fonteyn, 1991).
METHODS Setting and Sample The setting for the study was a large home care agency, which served approximately 45,000 patients in 1994. The agency employed 47 registered
nurses, 37 full time, and 10 per diem. Ten full-time nurses with home care experience ranging from 1 to 7 years were selected. Four of the nurses had 1 year experience, two had 3 years, and the remaining four nurses had 7 years. These three groups represented novice, competent, and expert practice levels as described by Benner (1984). Then, 10 patient care records from each of the nurses' primary case load were randomly chosen by the nursing supervisor for a total of 100 discharged records. The appropriate institutional review boards approved the study. Anonymity and confidentiality for both nurses and patients were maintained by using code numbers on all data collection and analysis materials.
Procedure Both descriptive and quantitative content analyses were used (Crabtree & Miller, 1993; Morgan, 1993). A template approach, as described by Crabtree and Miller (1993), guided the data collection and the qualitative analysis. The initial template or coding guide was developed from several sources that included a previous study conducted by the author (O'Neill, 1996), existing knowledge regarding nurses' decisions, and a pilot study of nurses' recorded decisions. The coding guide contained definitions and key phrases to be used in identifying inferences and decisions. It was pretested using data from 20 patient care records not selected for the main study. Initial definitions were retained, but key phrases were added to the coding guide after pretesting. During analysis, the coding guide was expanded and modified as new categories and subcategories emerged (Miles & Huberman, 1984). Data collection took place over a 3-month period.
Coding Reliability The investigator or research assistant examined each record. The entries that indicated a determination of the patient's health status or reflected a decision to take action were recorded on a data collection tool. Both coders underwent training in the use of the coding guide. Interrater reliability based on 10 patient care records was 0.85, whereas intrarater reliability was 0.95 for the investigator and 0.90 for the research assistant (Waltz, Strickland, & Lenz, 1991). Both coders were unaware of the experience level of the sample during data
HOME CARE NURSES' INFERENCES AND DECISIONS
collection and during the initial analysis phase of the study. FINDINGS Clinical Inferences
As stated previously, a nursing inference was defined as a determination of the patient's health status (Kelly, 1966). A total of 803 inference statements were identified in the 100 patient care records. An average of five admission diagnostic statements were documented in each record. Novice nurses recorded the highest number of admission diagnoses (X = 5.4) and experienced nurses the least (X = 4.2). Novices also recorded the highest number of inferences in the narrative notes (X = 3.06 vs. 2.75). These statements ranged from changes based on the assessment of health problems, (status of wounds), to the description of patient responses (pain), to the evaluation of interventions (health teaching). Samples of documented inferences included: "No improvement in leg ulcer," "Patient in no acute distress. Suffering from hot, humid weather"; "Patient caimot be taught procedure because of decreased intelligence." Although traditional "nursing diagnosis" language appeared in the admission notes, these descriptors were not apparent in the ongoing narrative record. Home care nurses in the study also diagnosed disease states. Nurses, particularly those most experienced, identified medical problems such as urinary tract infections and congestive heart failure based on patient symptoms. They also diagnosed potentially life-threatening situations that required immediate action. Conditions such as deep vein thrombosis, transient ischemic attack, and myocardial infarction were recorded. For biomedical inferences, nurses communicated the uncertainty of the situation by a question mark before the diagnostic statement. As one nurse recorded: "Noted positive Homan's sign. Patient admits to sharp pain from fight toes up and behind right patella. Slight edema noted.. ? Deep vein thrombosis." Decisions
A nursing decision was defined as a determination of a therapeutic action. Three hundred and eighty-four decisions were identified in the 100 patient care records. Decisions were classified in two categories: (a) autonomous (n = 272; 71%), with two subcategories, self-directed (n = 185;
35
48%) and consultative (n = 87; 23%); and (b) collaborative (n = 112; 29%). Autonomous Decisions Autonomous decisions were defined as independent determinations of action. Identified were two subtypes, self-directed and consultative. Selfdirected decisions consisted of treatment choices made and performed by the primary nurse. The majority involved coordinating and managing patient care. The need for a different level of care, such as increased nursing visits or for specialized care such as a social worker, physical therapist, or physician represented frequent management decisions. Other services coordinated by the nurse involved home health aides to assist with personal care and transportation. Nurses often discussed the case management decisions with the patient and family prior to calling on other professionals. Following are examples of these notes: "Call to M.D. office. Made aware patient is dependent on oxygen. Informed them oxygen will only last up to 2 hours. Office promises to make patient a priority. Will be treated and released on time"; "refer to social worker for psychosocial assessment; assist with financial problems and family coping." Decisions related to symptom control and alleviation also were common. Frequently cited were choices regarding pain management, wound care, and activity intolerance. One nurse wrote the following: "Patient on duragesic complaining of constipation. Current medication not helping. Advised Colace 2 tabs daily, increase fluids and fiber in diet." The second subcategory of autonomous decisions, consultative decisions, comprised 23% (n = 87) of the sample. These decisions also appeared to be independent in nature because the nurse determined the appropriate treatment or intervention. The nurses sought approval from the physician, however, to implement these decisions. Physicians rejected only 2 of the 87 accepted decisions. Examples of these notes follow: "Telephone call to MD: Discussed using Elavil for pain"; "Patient weak: T 101. Patient states he is not eating, drinking poorly. Lung sounds diminished. AP 160 irregular. Very pale. Appears dehydrated. Call to M.D. Agreed to send patient to the Emergency Room for possible admission"; "Call to M.D. Requested okay to use Senekot BID and Ducolax tab. 1-3 to manage bowel patterns."
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Collaborative Decisions Collaborative decisions were characterized as partnerships with another health professional, usually the physician, to determine the best course of action. In these cases, the nurse recognized a patient problem and sought help. Twenty-nine percent (n = 112) of the 384 decisions were classified as collaborative. In 90% (n = 101), the nurse conferred with the physician to determine the appropriate intervention. Excerpts from recordings follow: "Call to M.D. to inform of reddening around ulcer with no improvement. Requested a change in treatment"; "Call to M.D. questioning need to increase insulin orders." For the remaining 10% (n = 11) of decisions in this category, nurses conferred with other nurse specialists, such as psychiatric or oncology nurses. In these peer-assisted decisions, the home health nurse diagnosed a problem and discussed alternative interventions with other nurses. One nurse documented this: " - - C a l l to oncology nurse. Discussed client hallucinating, unsafe situation. Questioned what has been done in past with this type of problem." A small number of collaborative decisions (n = 5) resulted from patient center conferences to explore options for patients with complex problems. One such note stated the following: "Case conference with physician, social worker, home health aide, and nurse. Patient's wound is much worse. Son is only care-taker and is noncompliant. Does not keep Mother dry or give medications properly. Explored options for care. Decided to discuss nursing home placement with mother and son." When the data were examined to determine the impact of experience on the types of inferences and decisions recorded, the findings indicated that novice nurses recorded the most inferences and expert nurses the least. The only discernible difference between experienced and inexperienced nurses was the number of potential admission diagnoses. Inexperienced nurses identified more possible problems such as "potential for infection" and "potential for ineffective coping" on the patient's admission. Autonomous decisions were documented in approximately equal numbers regardless of the nurse's experience. Novice nurses, however, reported more collaborative decisions than experts. The analysis revealed that these nurses relied on the physician to determine
EILEEN S. O'NEILL
interventions regarding wound management and bowel care. Novices often reported changes in the patient's status to the physician and sought directions on how to proceed. More experienced nurses addressed these problems without help. DISCUSSION AND IMPLICATIONS
Patient care records revealed a large number and range of inferences and decisions by home care nurses. Although nursing diagnosis language was used to identify patient problems on admission, inferences in the narrative record did not reflect this terminology. Zink (1994) also found home care nurses did not alter "case opening" diagnostic statements. Nurses in the present study used a hybrid form of language that combined traditional biomedical language and humanistic terminology. This finding may imply that "nursing diagnosis" language does not reflect the way nurses think about patient problems, or perhaps the diagnostic classification system was not useful in monitoring patient progress. Nevertheless, common clinical labels and descriptions are essential for thinking, communicating, and accountability. They also influence decisions regarding appropriate treatment. In home care nursing, where several nurses may visit the patient over a period of time without contact with one other, identifying patient problems is crucial. Rather than debating the form that language should take, continued studies investigating how nurses actually perceive patient problems as well as the rich language in use might foster clearer communication. Approximately 70% of the decisions identified in this study were independently determined actions. In over one third, however, nurses sought permission to go forward from a physician. The records indicated that this consumed a substantial amount of nurses' time and in several instances, the primary physician could not be reached. In these situations, the nurse had to summarize the patient's history and problems to a substitute physician not familiar with the case. This practice does not support efficient and cost-containing patient care. The use of protocols for symptom management decisions such as constipation might alleviate the problem. Also, home care agencies might consider employing advanced practice nurses with prescriptive rights. Primary nurses could then consult with them for treatment of common, recurring health
HOME CARE NURSES' INFERENCES AND DECISIONS
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problems such as pain, bowel and bladder difficulties, and wound care. Not only could nurses' time (and therefore, money) be saved, but patients would benefit from more timely attention to their needs. The uncertainty of novice nurses identified in previous studies was evident in their increased number of consultative decisions in areas of symptom management (Corcoran, 1986; O'Neill, 1994b). These nurses do not have sufficient knowledge or experience to deal with patient problems and possible interventions. In addition, methods are lacking that might prepare them to function in the solitary, independent environment of home care. Specific classroom instruction in case management, collaboration, symptom alleviation, decision making, and health teaching could build the knowledge base needed for decision making. Supports such as consulting and mentoring from experienced nurses would not only decrease reliance on the physician but increase the novice's knowledge hastening the development of expertise in these decisions (Corcoran, Narayan, & Moreland, 1988). Also, as common recurring decisions are identified, seminars for nurses at all levels to actively examine their thinking will improve decision making (Mattingly & Fleming, 1994). The findings in this study are restricted to the use of one agency and by the small sample size. Also, the use of patient care records limits the results because they do not contain all the clinical judgments of nurses. Although "chart talk" (Mattingly & Fleming, 1994) reflects only the most salient decisions, home care records nonetheless do provide a rich source of previously ignored decision information.
CONCLUSIONS
This study highlighted the broad range of inferences and decisions made by a selected group of home care nurses. Recorded inferences included both biomedical and nursing diagnoses, although biomedical diagnoses predominated after the nurses initial assessment. Three types of decisions were identified in this study, providing a beginning framework of home care nurses' decisions. The majority of decisions focused on case management and symptom alleviation. Seventy percent of nurse decisions were independently derived, but about one quarter of these decisions required physician approval for implementation. More timely health care could result if experienced nurses had access to protocols and health professionals with prescriptive rights to perform their prescribed treatment. Novice nurses would also benefit from decision supports in the form of protocols, but they need additional guidance in determining the most appropriate decisions. Approximately one third of the nurses' decisions were collaborative, pointing to the need for skills in communication and negotiation. Finally, examination of the type of decision making developed in this study is intended to be a beginning list of clinical judgments made by home care nurses. Further validation, expansion, and refinement are expected as nurses study and describe clinical decisions. With further investigation, the information can be used by educators and managers to prepare nurses for home care. Knowing the types of judgments and decisions encountered in practice can also help nurses reflect on their modes of thinking and improve their decision skills.
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