DECISION MAKING IN NURSING SERVICE DEPARTMENT

INTRODUCTION:

Decision-making is complex, congrutive process and is the art of all administrative and
managerial functions within the authority vested in the administrator or manager must take
decision for implementing plans of the organization to achieve its objectives. It is true that
Decision-making is also a part of everyday life However, making decision has been identified as
one of the primary responsibility of any nurse manager. In nursing Decision may involve
allocating resources, appointing people investing capital or introducing new things. Decision-
making is at core of all planned activity.

DEFINITIONS:

Decision-making may be defined as the process of choosing between alternatives to achieve a

goal. It is the last step in the process by which an individual chooses one alternative from several
to achieve a desired objective.

1) Haynes and Massie – “A decision is a course of action which is consciously chosen for
achieving a desired result.”

2) Trewatha and New port- “Decision-making involves the selection of a course of action
from among two or more possible alternatives in order to arrive at a solution for a given
problem.”

3) “Decision-making is an act of choice by which an individual or organization selects one

position or action from several alternatives.”

4) “Decision making is the study of identifying and choosing alternatives based on the
values and preferences of the decision maker.”

5) “Decision making is the process of sufficiently reducing uncertainty and doubt about
alternatives to allow a reasonable choice to be made from among them.”

CHIEF CHARACTERISTICS OF DECISION-MAKING:

Decision-making is the heart of all administrative and managerial functions. Within the authority
vested in the administrator or manager, he/she must take decision for implementing plans of the
organization to achieve its objectives.

I. It implies of choice choosing from among two or more alternative course of action.
 II. It is a continuous process that pervades all the organizational activities.

III. The process is human that is a kind of intellectual activity.

IV. The process of choice among two or more alternatives is aimed at a solution for a given
problem.

V. The Decision-making is not identical with problem solving.

TYPES OF DECISIONS:

Types
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Mecha Analyti Judgm Adapti

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1. CONSIDERED DECISIONS.

These are of great magnitude, requiring reflection of deep thought. They affect overall
operations, require data gathering and proceed from multiple alternatives. They also
require time for consultation with others and to reflect on implementation problems.

2. OPERATIONAL DECISIONS.

These are the decision that executives make practically every day as a routine either to
solve problems or to prevent them. They have immediate impact and ensure smooth flow
of operations.

3. UNCOMFORTABLE DECISIONS.
 These are the decisions that impinge on inter personal relationship with subordinates and
others and make the decision make uncomfortable. Also termed swallow – hard, decision
maker uncomfortable because of the certainty of decide by subordinates of such a
decision. The manager has to carry it out regardless.

4. HURRIED DECISIONS.

These are also the decisions mode during daily operations. They require quick thought.
The overriding factor being the pressure to make it quickly. At times, wrong precedents
are set by such decisions while responding to problem situations that required, quick
decisions. In the daily grind of the hospital routine, there is an inherent tendency to make
hurried decisions when actually there was a need for a considered or operational decision.

5. POLICY DECISIONS.

These decisions are taken by the management and they define in general objectives of the
industry. The supervision has no direct influence over these decisions.

6. ADMINISTRATIVE DECISION.

These decisions refer to the formulation of rules and procedures which translate the
policies into practical terms. Administrative decisions are taken by the departmental
heads and they provide guidelines for taking specific problem situations.

7. MANAGERIAL DECISION.

While the policies and procedures are aimed at providing solutions to all problem
situations which can be anticipated they cannot cover all the situations. Each level of
hierarchy has certain areas where the individual can exercise discretion. At this level the
supervisor has his flexibility of freedom to deal with certain problem situations in his
own way.

a. Mechanistic decision.

It is routine and repetitive in nature. It usually occurs in a situation involving a limited

number of decision variables where the outcome of each alternatives is know. Most
mechanistic decision solve problem by habitual responses, standard operating
procedures or routines. Tools used for this type of decision include charts list,
decision tree etc. this is usually daily routine and scheduled activities.

b. Analytical decision.

Involves a problem with a large number of decision variables, where the outcomes of
each decision alternates can be computed. The computational techniques used to find
optimal solutions includes linear programming, network analysis inventory recorder
 model, queuing theory, statistical analysis of so forth. This decision helps solve
complex problems.

c. Judgmental decision.

Involves a problem with a limited number of decision variables but the outcome of
decision alternatives are unknown. Good judgment is needed to increase the
probability of desired outcomes. These types of decisions are, useful in marketing,
investment and to solve personal problems.

d. Adaptive decision.

Involves a problem with a large number of decision variables, where outcomes are
not predictable, because of the complexity and uncertainty of such problems, decision
makings are not able to agree on their nature or on decision strategies. Such
structured problems usually require the contribution of many people with divers’
technical background. In such situation, strategies have to be frequently modified to
accommodate new development in technology and environment, e.g. research
findings.

DECISION MAKING MODELS:

A decision making model is a systematic means of arriving at a decision. It is a way

of organizing data with the purpose of presenting or displaying it to the decision
maker in such a way that is more obvious than simply making a list of the
alternatives.

Decision
making models

Normative Decision tree Descriptive Strategic

model model model model

Normative model
This model is least 200 years old. It is assumed to maximize satisfaction of fulfills the
“perfect knowledge assumption” that in any given situation calling for a decision, all
possible choices and the consequences and potential outcome of each are known. Several
steps are identified in this analytically precise model.

 Defines and analyze the problem

 Identify all available alternatives
 Evaluate the pros and cons of each alternative
 Select the alternatives that maximizes satisfaction
 Implement
 Follow up.

Decision tree model

Various adaptations of decision-tree analysis are found in the literature. The essential
elements described in 1960s are standard. All factors considered important to a decision
can be represented on a decision tree. “vroom” arranged answers to seven diagnostic
questions in the style used in management decision making models. The questions focus
on protecting quality and acceptance of the all decisions and deals with adequacy of
information, good congruence, structure of the problem acceptance by subordinates,
conflict, fairness, and priority for implementation. Magee & Brown depict decision tree a
starting with a basic problem and using branches to represent “event forks” & “action
forks” the number of branches at each fork corresponds to the number identified
alternatives. Every path through the tree corresponds to a possible sequence of actions
and events, each with its own distinct consequences probabilities of both positive and
negatives consequences of each action and events are estimated and recorded on the
appropriate branch. Additional options ( for example, delaying the decision) and
consequences of each action event sequence can be depicted on the decision tree.
Computer stimulations of decision tree are now available and can be adapted to a limited
number or a highly complex network of branches involved in the decision making
process. Normal analysis of the tree is conducted by computing predicted consequences
of all event forks (the right-hand edge of all tree) substituting that value for the actual
event fort of its consequences and selecting the action for with the best expected
consequences. Quantitative analysis in the form of all decision trees can be used for any
type problem but may be unnecessary in simple problem involving limited consequences.

Descriptive model:

Simon developed descriptive model based on the assumption that the decision maker is a
rational person looking for acceptable solutions based on known information. This model
allow for fact that many decisions are made with incomplete information because of time,
money, or personnel limitations. It also allows for the fact that people do not always
make the best choices. Simon wrote that few decisions would ever be made if people
always sought optimal solutions. Instead, he contended, people identify acceptable
alternatives. Following steps are followed in this model.

Establish an acceptable goal.

Define subjective perceptions of the problem

Identify acceptable alternatives

Evaluate each alternatives

Select an alternatives

Implement a decision

Follow up

The descriptive model may lend itself well to nurses faced with daily decision that must
be made rapidly and that will have significant consequences. Steps in the model are not
unlike those familiar in the nursing process although the sequencing is different. Reader
may readily identify conditions in their own environments similar to those described by
the Simon and see immediate application of this model. Lancaster and Lancaster
illustrated the use of this model for nursing administrators.

The strategic model

Strategic decision making usually relates to the long-term planning. As an example,

hospital merge, and nursing departments are affected. Among the decision that are made
are whether to hire one top manager or department head verses two or more, whether to
decentralize and eliminate the middle managers, and what operational strategies will
prevent duplication and maximize the use of scare resources and provide for their
efficient use. Nagelkerk and Henry used a model by Mintzberg, Raisinghani, and Theort
(the MRT model) to design and test the nature of strategic decision making that entails
substantial risk. They worked with chief nurse executives employed in 6 acute care
hospitals with 400 or more beds each. In applying this model, participant used mixed
scanning of general and specific information from subordinates to identify complex
problems. To develop potential solutions they gathered facts from hospital documents.
They made their selection of the best single solution by

• Screening solutions using predetermined criteria

• Identifying the costs and benefits as nearly as possible, and

 • Selecting the single best solution.

It was concluded that top manager makes these final choices using intuition, formal analysis of
knowledge of organizational politics. In making good choices, top manager do extensive
planning, communicating and politicking.

In this research project, successful strategies for decision making were reported as follows.

1) Building extensive networks of individuals and groups who would provide resources at
local, state and national levels.

2) Searching the nursing, hospital, and business literature.

3) Being knowledgeable and involve in the politics of one’s organization and professional
organization.

4) Communicating regularly and repeatedly about decision making activity to organization

members, especially those in the hospital’s dominant coalition usually the chief executive
officers, finance manager, and chief of the medical staff.

5) Directing most of their time and energy toward the accomplishment of their plans.

STEPS IN DECISION MAKING:

Decision making can be regarded as an outcome of mental processes (cognitive process) leading
to the selection of a course of action among several alternatives. Every decision making process
produces a final choice. The output can be an action or an opinion. Following steps are followed
in decision making.

1. Identify and diagnosing the problem

2. Analysis the problem
3. Search for alternatives
4. Evaluate the alternatives and select the alternatives
5. Choice the alternatives
6. Action
7. Feed back
 Identify
and
diagnosing
problem
Analysis
the
Feed back problem
STEPS IN

DECISION

MAKIN Search for

Action alternative
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Evaluate
the
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Choice the s and
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1. Identify and diagnosing the problem

If the problem identified and properly defined that indicate the problem is half solved.
The problem should be identified through observation of reflection.

Condition where problem exist:

I. Deviation from past experience. E.g. staff turnover is increasing.

II. Decision from the plan.
III. When other people brings the problem to the manager.
IV. When competitions outperform the manager organization. E.g. when two
hospitals are existing in the same place.
 Once problems are perceived it should be correctly diagnosed. If diagnoses miss lead that
will lead to a wrong decision. To avoid this there should be specific objective regarding
the subjective matter of decision. When problem comes up there should be some
symptoms and manager have to perceive it correctly and find out the cause. Identify the
reason, the gap and understand the problem in relation to the higher objections of the
organization.

2. Analysis the problem

Find out what information is needed and from where information is available. In order to
make a decision one should be aware of the problem therefore the managers should have
a questioning attitude what are the symptoms who is involved when and how of the
problem, when questions answered the manager can form his/her hypothesis.

3. Search for alternatives

Any problem we face there are several means by which it can be solved but all the ways
may not be equally satisfied. Since there are several ways the most suitable way have to
be found out. Decision maker must be aware of the limiting factors. Sources which help
to find out the alternative are

♣ Past experiences
♣ Consult others
♣ What other are packing
♣ Using creative techniques

4. Evaluate the alternatives and select the alternatives

From the alternatives available select few and go in detail about alternative. Each
alternative is evaluated regarding the contribution towards the problem. We must think at
the economy available while deciding alternatives.
5. Choice the alternatives
From the evaluation of pros and cons the best one that fits in to the organizational
objective is chosen. The alternative selected required to communicated to those members
of the organization who is concerned with it acceptance of the decision by group
members is always essential for its effective implementation.
6. Action
Once the alternatives are selected it is put in to action to make sure that specific objective
is attended.
7. Feed back
 The result is communicated and if the decision maker finds that it is deviated then go
through the same process or select another alternative and again go through the same
process.
EFFECTIVE DECISION:

The solution of the problem depends on the effectiveness of the decision and implementation.

Characteristics of effective decision:

1. Action oriented
2. Goal directed
3. Provide efficiency in implementation

1. Action oriented: relevant and in-accordance with the requirement decision is to be

effective it must be specify the action to be taken to achieve objectives.
2. Goal oriented: Organizations are goal directed. Therefore any decision taken should
be goal directed to unable organization to achieve the objectives.
3. Provide efficiency in implementation: possible factors not only in terms of internal
context but also external context so that the decision can be implemented properly

How to take effective decision:

1. Categorical interpretation: logical decision can be made if the real problem is

interpreted and identify with in depth study of observation. Many times symptoms of the
problem is taken in to consideration and also sometimes assumptions are made. To avoid
this decision maker must define the problem properly. It is often suggested that a problem
is half solved if it is identify properly.
2. Application of limiting factor: in choosing from the alternatives the manager recognizes
and solves those factors which are limiting and critical to attainment of desired
objectives, and select the most desirable alternatives. The manager must analyze the
complete external environment of the strength and weakness of the organization.
3. Adequate information: information is the life blood of an organization because all
decisions are based on this. More is that quantity of reliable information higher is the
validity of decision. Therefore every aspect of the decision should be backed by sound
and adequate proofs.
4. Considering other views: while making decision it is desirable to consider adequately
other view.

Decision making condition: there are three condition of decision making depending on this
information.

1. Certainty
2. Risk
3. Uncertainty
1. Certainty: if the manager knows exactly the outcomes there is certainty. The decision
will be accurate. These condition comes when future is very close and also if the manager
has made such decisions is earlier when he is sure of the situation he can also predict the
consequences. Many times we are not certain about the events especially when decision
involves future event.

2. Conditions of the risk: Most of the organizational decisions are made under conditions
of risk. Many times we do not have 100% information. In this manager uses probability
estimations. Probability can be defined as the percentage of a time a particular outcome
would occur if an action were to be repeated for a very large number. There are three
methods of probability

a. Appropriate probability

b. Empirical probability

c. Subject probability

a. Appropriate probability: it is obtained through inferences from assumed condition.

b. Empirical probability: it is based on records. Actual experience over a period of time

and computing the percentage of time each event has occurred. Here we record the real
experience and then comes to a percentage of it.

c. Subjective probability: it is based on managers own judgment and is used when he

doesn’t have sufficient data to calculate appropriate or empirical probability. This is
likely to be less exact.

Common difficulties in decision making:

1. Incomplete information

2. Ineffective communication

3. Incorrect timing

4. Unsupportive environment

5. Non acceptance by the subordinates.

 BIBLIOGRAPHY

1. Ann Gillies R.N.M.A Edn; Nursing management system approach; 3rd

Edition; published by W.B Sounder Company. 1994.

2. B.T Basavanthappa;Nursing administration; 1st Edition, Published by

Jaypee Brothers Medical Publishers.Pg.No. 58-70

Swansburg Russel C. and Swansburg Richard J. Introduction to

Management and Leadership for Nurse Managers. 3rd edition, Canda, Jones
and Bartlett; 2002: 179- 225.

3. B.M. Sakharkar “principles of hospital administration and planning” Jaypee

brothers India.

4. Ann.Marriener Nursing management and leadership 5th edi, Mosby: 1996

page 15-60.