The decision making of heart failure specialist nurses in clinical practice.

J Clin Nurs. 2009 May; 18(9): 1313-24Dowding D, Spilsbury K, Thompson C, Brownlow R, Pattenden JAims and objectives. To explore decision processes and types of decisions made by heart failure specialist nurses. Background. Heart failure specialist nurses are key to the management of patients with heart failure in the community. In previous studies heart failure specialist nurses have reported difficulty in developing decision making skills. Cognitive continuum theory can be used to examine the relationship between decision tasks and the processes used by heart failure specialist nurses to make decisions. Design. A qualitative study using non-participant observation and semi-structured interviews. Methods. Six heart failure specialist nurses were observed while they carried out consultations with three patients each (n = 18). Twelve heart failure specialist nurses were interviewed about their decision making in practice. Data were analysed using thematic content analysis. Results. Two areas of decision making were identified by heart failure specialist nurses as key; pharmacological management and managing patients in the palliative phase of their condition. Pharmacological management decisions involved the trading off of risks and benefits of titrating medication, with nurses using internalised guidelines to inform their practice. In contrast, nurses relied on support from other health care professionals when making decisions about a patient's need for palliative care. Conclusions. Medication titration decisions have a mixture of intuition and analysis inducing features making them amenable to the use of decision tools. The timing of the need for palliative care is less predictable, suggesting an intuitive approach to decision making may be more appropriate. Relevance to clinical practice. There are several strategies that could be used to improve the match between the decisions that heart failure specialist nurses take and the decision processes they use. These include the development of more tailored decision support tools for medication titration decisions and the provision of structured decision aids for assessing patients' need for palliative care.