Do heart failure specialist nurses think differently when faced with 'hard' or 'easy' decisions: a judgement analysis

To unpack specialist heart failure nurses' decision-making and explore whether viewing a decision as 'hard' or 'easier' is associated with different decision-making characteristics.

Specialist heart failure nurses exemplify modern nursing roles. They face diagnostic, prognostic and treatment uncertainties of varying degrees of complexity in the choices they face. Nurses' cognitive handling of complexity is largely unknown.

Judgement analysis survey.

Judgement analysis with 29 nurses and two judgement tasks was undertaken. A drug titration decision (classed as 'easier' by nurses) was compared with a 'harder' palliative care referral choice. Measures of agreement between the nurses, the linearity and non-linearity in information processing by nurses and the degree of cognitive control exercised by them were explored. Differences between nurses with varying degrees of education were explored using paired t-testing. The relationship between experience and key measures was explored using bivariate correlations.

Nurses varied in their judgements and the weighting afforded to information. Self-reported decision difficulty was less important for cognitive handling of information and agreement between nurses than we predicted. Nurses had high degrees of cognitive control in the drug task and far less in the palliative referral condition. However, there was no change in the linear or non-linear processing of information of the two tasks. Education and clinical experience were not related to agreement or information processing.

Nurses' self-reported difficulty in decisions should not be relied upon as valid indicators of decisional complexity. The title 'specialist nurse' should not be assumed to equate by default with clinical expertise. Thinking in a more sophisticated way about the relationship between experience, uncertainty, decision structure and information available may help nurses make better choices.

Teaching nurses about what makes for hard and difficult decisions and increasing awareness of the decisions they make may lead to better quality choices. Practice developers should pay attention to the quality of clinical experience as well as the quantity when considering decision-making expertise.