Toward understanding nurses' decisions whether to miss care: A discrete choice experiment

Abstract

Background: Studies of missed nursing care suggest that it results from ward-level, patient-related, and task-type factors, while nurses' decision-making style was scarcely studied. Studying the effect of nurses' decision-preference structures, namely a pattern of joint ward and patient factors, on missed care may also contribute to understanding the phenomenon.

Objectives: To examine the relationships between decision-preference structures and missed care and the moderating effects of decision-making styles and task type in these links.

Design: A discrete choice experiment with a between- and within-participants design.

Participants: A sample of 387 registered nurses working in acute medical surgical wards in Israel.

Methods: Based on the protocol for discrete choice experiments, a survey was developed to assess the decision-preference structure, considering five factors: overload, presence of head nurse, clinical complexity, difficult patient, and presence of relatives. Participants were randomly assigned to four task-type conditions and completed a survey regarding their task. Decision-making style was assessed using a validated questionnaire.

Results: Extensive workload (b = -0.46; p = 0.001), difficult patient (b = -0.20; p = 0.001), and patient clinical complexity (b = -0.10; p = 0.006) were negatively linked to the probability of missed care. The interaction between workload and task type (b = 0.252; p = 0.017) indicated that the probability of missed care under extensive compared with regular workload was lowest for developing a discharge plan and highest for providing emotional support. The interaction of patient complexity and task type (b = 0.230; p = 0.013) indicated that the probability of missed care in developing a discharge plan and medication administration was lower for patients having high compared with low clinical complexity. The interaction between difficult patient and task type (b = -0.219; p = 0.044) indicated that the probability of missed care in emotional support, developing a discharge plan, and patient's mobility was lower for difficult than for non-difficult patients. Finally, the interaction between workload and decision-making style (b = -0.48; p = 0.001) indicated that the probability of missed care under heavy compared with regular workloads was lower for the dual-preference or the dominantly intuitive styles.

Conclusions: This design enabled examining the prioritizing processes nurses use when deciding about whether to miss care. The likelihood of missing more in structured tasks is lower under a heavy overload and when patients appear difficult or clinically complex. Dual-preference styles or dominantly intuitive styles are more suitable for the routine high workload.

Keywords: Decision-making style; Discrete choice experiment; Missed nursing care; Nurses; Situational factors; Task type.