EXPERIENCE BEFORE AND THROUGHOUT THE NURSING CAREER The clinical landscape of critical care: nurses’ decision-making Tracey Bucknall PhD BN ICUCert RN Associate Professor and Executive Director of the Victorian Centre for Nursing Practice Research, School of Nursing, University of Melbourne, Carlton, Victoria, Australia Submitted for publication 27 August 2002 Accepted for publication 18 February 2003 Correspondence: Tracey Bucknall, School of Nursing, University of Melbourne, Level 1, 723 Swanston Street, Carlton, Victoria 3053, Australia. E-mail: bucknall@unimelb.edu.au BUCKNALL T. (2003) BUCKNALL T. (2003) Journal of Advanced Nursing 43(3), 310–319 The clinical landscape of critical care: nurses’ decision-making Background. Many studies have tended to explore individual characteristics that impact on nurses’ decision-making, despite significant acknowledgement that con- text is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment. Aims. To investigate environmental influences on nurses’ real decisions in the critical care setting. Method. Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis. Results. All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse. Conclusions. Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses’ decision-making in order to improve health care outcomes. Keywords: clinical decision-making, critical care nurses, context, geographical landscape, decision-making influences Introduction Clinical environments are dynamic, complex and inherently stressful. Nurses must deal with increasing patient complex- ity, sophisticated technology and often declining resources. Despite decision-making being a crucial part of the critical care nurse’s role, there are few empirical studies that address the situational effects consistently found in critical care settings. Much of the earlier decision-making research is based on rationalist approaches such as information process- ing and decision analysis. These studies often used highly controlled decision tasks that did not incorporate conditions such as stress and personal interactions which are frequently encountered in clinical settings. More recently, there has been a swing towards interpretive approaches to explore decision- making in the real world, but these studies are usually restricted to one specific unit and lack generalizability (Bucknall 1996). Nevertheless, Hamm (1988) argued that the two approaches are part of a continuum, with rationalist approaches suited to structured problems at one end and intuitive approaches suited to unstructured problems at the opposite end. However, in spite of concern about theor- etical approaches, their remains a major gap in the literature on the influence of the clinical environment on nurses’ 310 Ó 2003 Blackwell Publishing Ltd