Running head: REFLECTION IN NURSING 1

Reflection in Nursing

Student’s Name

Institutional Affiliation
REFLECTION IN NURSING 2

Reflection in Nursing

Introduction

Decision making in nursing is a complex and multidimensional process that requires

significant analytical skills and capacity to develop and improve professional qualities (Bjork &

Hamilton, 2011). Decision making is a dynamic process and is considered to be the fundamental

role in the framework of nursing duties and responsibilities (Tiffen, Corbridge, & Slimmer,

2014). It is influenced not only by nurse’s personal intentions and consequent analysis, but also

by contextual factors and major attributes (Johansen & O’Brien, 2016). Decision making is

regarded as practical use of nursing competence, namely, skills, knowledge, visions. To be more

precise, decision making is always based on particular judgments and requires a selection of a

single course of action among alternative ones. Lamb and Sevdalis (2011) underline that proper

and effective decision making is a vitally important skill in the scope of nursing. The scholars

highlight that its nature is non-technical, and it goes beyond conventional clinical knowledge and

technical skills each nurse is required to have (Lamb & Sevdalis, 2011). As a result, outcomes of

nurse’s decision making are various and impact safety of patients, quality of provided care and

efficiency of overall healthcare treatment. Therefore, it is of ultimate significance to make

justified, healthy and proper decisions prioritizing health and wellbeing of the patients. Thorough

itemized analysis of prior decision making and qualitative enhancement is an essential

contribution to nursing competence and healthcare outcomes.

The present paper is dedicated to profound analysis of a sample decision making from

nursing practice and subsequent identification of areas for improvement. Context for the decision

making that will be discussed encompassed shortage of personnel and problems with

replacement of positions. Decisions made under such circumstances will be analyzed from
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different perspectives and discussed in accordance to contextual factors. Along with such, areas

for improvement, reasons for particular solutions and inferences for further professional activity

as a Nurse Manager will be made.

Recent Decision Making

My position is a Nurse Manager. My unit is a 23 bedded surgical unit. It is characterized

by excessively busy schedules for nurses as far as census of patient flow in the unit is always at a

high rate. Hence, the unit needs qualitative and proficient nurses to provide patients with

maximal care and support. The situation with shortage of unit personnel undermined the issue of

sufficient nursing care and provoked urgent need for proper replacement of the personnel.

Nonetheless, the process of replacement was postponed due to the following reasons:

international recruitment process was temporarily frozen since hospital corporate office managed

particular financial issues. Apparently, unit needed immediate effective decision, and the

responsibility for this decision was on me.

My decision and action plan was based on priorities of qualified care provision and safety

of patients who needed nursing assistance. First of all, I decided to communicate with Nurse

Managers from other units about cooperation. My unit needed help in personnel issues, and I

asked Nurse Managers to forward some of their nurses to my unit when the patient census was

not high or when it was possible due to available staff at the unit. Such a request was emailed to

the Nurse Managers from other units via my Nursing Director. It was a polite request for help,

and it was expected to be attended properly. Provided such help was granted at least occasionally,

my unit would benefit significantly from proficient and regular assistance of these nurses. It was

ultimately important to provide a solution with professional assistance, not a voluntary

participation or assistance of the staff with insufficient or irrelevant competence.

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My next step in decision making in the given context was based on use of overtimes. To

be more precise, I initiated covering my regular shifts with extra hours in order to manage

process of care provision and guide nurses from other units if necessary. I also suggested such an

option to nursing personnel, and received several volunteers for the next shift. I realize that the

unit needed immediate and at the same time effective solution to cover shortage gaps and

guarantee maximal efficiency of the unit and patients’ safety until the issue of replacement is

solved.

Outcomes of Recent Decision Making

My decision making in the crisis situation described above resulted in both positive and

negative outcomes. First of all, the solution with extra shifts covered personally by me and by

other nurses from my unit was successfully implemented. To be more precise, it was a

constructive solution since many nurses were concerned about extra income, and additional

working hours provided them with such an opportunity. Overtime strategy did not undermine the

level of quality of care provided by unit nurses. Safety of patients was not undermined also as far

as I developed a strict set of rules concerning overtime hours. These rules forbade extra working

hours which could harm health of the personnel or provoke their exhaustion.

The Nurse Managers from other units supported my request and provided me with extra

employees during the period between personnel shortage and replacement of positions. This

period was two months. The most complicated part of it was the first week since overtime hours

were not regular as well as staff support from other units. It was difficult to align effective,

timely working process with such essential changes and adjustments in the apparatus of the unit.

Nevertheless, it was not the only problem with the given solution. The first month overtime

shifts were covered properly and even enthusiastically, whereas the 2nd month revealed negative
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outcomes, namely, increased level of tiredness, decrease in efficiency, and several cases of

burnout. Nurses started complaining about lack of rest and social life, reduced interest to come to

work, and lower working potential. Extra income was not an argument for some of nurses, and it

became hard to find a volunteer for the next shift. A schedule was developed, but it was not an

impeccable solution since several nurses even started thinking about resigning from their

position because of evident burnout. Some of nurses also underlined that they felt they could not

provide sufficient care for patients while working overtime and it was the major reason of their

refusals to work extra time. The patients primarily evaluated nurses’ performance as satisfactory,

but there were three complaints about untimely performance. Feedback is a crucial factor during

such an analysis as far as it assists in profound comprehension of the whole process and

underlines major problematic issues that require improvement in the future (Dowding et al.,

2011).

There were also issues related to assistance of nurses provided by other departments. To

be more precise, such a support was not regular, and there were cases when the whole schedule

failed because of unexpectedly high census of patients in one of the units. Nonetheless, the

biggest problem was based on discontentment of the nurses from other units. Primarily, they

claimed that change of working place was a considerable stress. Moreover, several nurses

underlined that they failed their direct duties and responsibilities at their unit while performing in

my surgical unit. Adaptation in a new unit was had both for those nurses and for the ones who

work in my unit. There were several conflicts, but they did not interfere with the overall working

process. Nevertheless, performance of these nurses was proper, timely and effective. They

contributed to functioning of my unit significantly.

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The most serious negative aspects which potentially can emerge as a result of such a

decision making are such as hazard of staff fatigue and burnout which, consequently, may lead to

errors in performance, mistreatment, and undermine overall safety of the patients and efficiency

of healthcare process. As Thompson, Aitken, Doran, and Dowding (2013) underline, “Health

systems require nurses whose clinical judgements and decisions contribute to, not detract from,

the quality of health systems” (p. 1721). Hence, it is of ultimate importance to analyze each

aspect of my decision making process in order to be capable to focus more on quality, patient

safety and overall efficiency in development of solutions for crisis situations in the future. It is of

ultimate importance to expand my competence both in theory and in practice in order to enhance

decision making process and its outcomes (Foy et al., 2011). It is also crucially important to

choose proper sources of information (Marshall, West, & Aitken, 2011). Thompson and Stapley

(2011) underline that educational interventions contribute to effective and justified decision

making process which means that progress in this field depends on my willingness to progress

professionally. Along with such, Yang, Thompson, & Bland (2012) claim that clinical experience

is also vitally significant for further effective performance. Hence, the next section focuses on

reflection and thorough analysis of the recent decision making, its outcomes, and areas for

improvement in the future performance as a Nurse Manager.

Analysis of the Context

First of all, it is relevant to discuss the implications and particular aspects which have led

me to thorough and itemized analysis of the whole decision making process and motivated to

reflect on my decision making potential in order to improve it in the future. The experience of

decision making described above provoked different emotions in me. To be more precise, I

experienced a significant challenge during the first week of implementation of my decision.

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When the challenge was properly managed, and the whole process became properly organized

and enthusiastically performed by the personnel, I felt confidence in my solution, gratitude to the

colleagues for assistance and support in such a crisis situation. Along with such, I felt huge

responsibility for each healthcare outcome and care for every patient. I tried hard to control each

process and contribute to it as much as I could. Moreover, I felt professionally content since

performance of my ultimate duties revealed positive dynamics. Nonetheless, my feelings

changed during the 2nd month of performance according to my new plan. To be more precise, I

started realizing that my decision was rapidly formed and I did not take into consideration many

important factors which influenced the whole working process. I felt lack of proficiency and

justified judgment at that time. Furthermore, I felt that I needed advice of an expert. Apparently,

advice and other perspective would be a proper approach from the very beginning since I

focused my decision only on immediate solution of the problems that my unit faced, not

continuous one.

My first reaction was thorough reconsideration of each problematic issue that emerged in

the working process. I examined several alternative solutions that could improve the situation.

Moreover, I discussed the issue of concern with the Nurse Managers from other units who

supported me with extra nurses. Their perspectives differed considerably, but each of them

assisted me in understanding the key problems and drawbacks of my recent decision.

Nurses behaved properly, but several of them complained regularly and mentioned the

idea of resigning which was the most alarming aspect of the whole situation. On the other hand,

these complaints and excessive exhaustion of the nursing personnel was not reflected in their

performance. To be more precise, nurses provided excellent care and support for all the patients.

I believe it was harder for the nurses from other units, but they managed not to provoke conflicts
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and cooperate with other personnel. Therefore, I do not think the patients felt a considerable

difference in terms of quality and safety criteria of care process.

Nursing personnel expressed support and understanding during this hard period.

Complaints were justified since working hours were increased and personnel experienced huge

pressure because of the reorganization of the working process, re-scheduling that happened

often, and emergence of new nurses in the unit team. Furthermore, rules I initiated in order to

ensure maximal efficiency and order in the unit were strict and also contributed to overall

stressful environment. I believe that some of nurses had the aforementioned burnout and I realize

that this has happened under my management and is entirely my responsibility. Several conflicts

with patients are also incidents related to my recent decision making. I could not have prevented

these conflicts since they may take place even under regular scheduling. Nonetheless, I could

have done many things differently on the initial stage of my decision making. My reflection will

be discussed in the next section.

My Reflection

As I have already mentioned, I would have acted differently from the very beginning.

According to Bulman and Schutz (2004), reflection is a key to regular enhancement as a

professional in the scope of nursing. I am determined to reflect on each core stage of decision

making and discuss potential alternatives and improvements for each of them. Schon (1983) as

well as Richardson and Maltby (1985) support this stance.

First of all, I should have dedicated more time and thought to the initial stage of decision

making. To be more precise, I should not make such crucial decisions which will impact the

whole unit, both personnel and patients, on my own. The most optimal decision in that situation

would be to arrange a meeting with personnel of my unit prior to implementing any solution in
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practice, and discuss the whole crisis situation with them. It is apparent that decision making is

my responsibility, but such a discussion could contribute to in-depth insight into the core of the

problem as well as to understand possible ramifications of the chosen solution. Prior to making

any decision, it would be relevant to arrange a discussion with other Nurse Managers from units

I asked assistance from. While personnel of m unit could help me in understanding practical

aspects of implementation of adjustments, other Nurse Managers could contribute to the scope of

management and effective administration of available human resources. Moreover, some of them

can have had experience in dealing with staff shortage previously, which will be the most

significant contribution to decision making process. Finally, Nurse Managers could have helped

me with evaluation of potential advantages and risks of the chosen solution.

Second stage involves actual decision making process. Apparently, I would have had

several alternative solutions after discussion of the situation with the unit personnel and Nurse

Managers. Hence, it would be relevant to analyze them individually. To be more precise, a

strategy of mind mapping will help align, compare, and elaborate on alternative solutions. Mind

mapping would assist in understanding core resources, steps, and challenges of each particular

solution. Moreover, decision making in nursing aimed to mitigate a crisis situation needs to take

into account each detail and each aspect which may be omitted in general discussion. Mind

mapping vividly highlights each pro and con as well as contrasts different solutions.

Decision making is a complex process. According to Truglio-Londrigan and Lewenson

(n.d.), “decision making requires looking inward at one’s own self, then outward at the world

around them, and then back in again” (p. 2). As it is evident from my recent experience, I failed

to adhere to such a sequence. To be more precise, I focused on the most superficial solution that
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offered immediate and temporary responses to the imposed questions. My major concern was

time, whereas I should have focused on efficiency and quality of the decisions.

There are different models which guide a nurse in the course of decision making, and it

will be relevant to align and compare my recent decision making and proper process outlined by

Marquis and Huston (2015). For instance, the authors underline potential efficiency of the

managerial decision making, or rational decision making model (Marquis & Huston, 2015).

According to the aforementioned model, the following steps should have been taken: 1)

objectives are set in the initial stage of decision making process in order to ensure proper

comprehension of the final outcome and the gap between it and current situation; 2) the next step

involves searching and outlining alternative options which can solve the issue in question; 3) in-

depth insight in each of the identified options leads to comparison of each solution and its

potential outcomes – both pros and cons should be thoroughly considered; 4) the next stage

encompasses selection of the optimal solution; 5) consequently, the action plan is developed and

implemented; 6) finally, outcomes are evaluated. The present approach to decision making in

nursing reflects the core priorities and values a Nurse Manager should adhere to in order to result

in constructive decision making and solution of crisis situation. My vision was considerably

narrower and less focused on quality and continuity of the final outcomes.

Marquis and Huston (2015) also present a framework of the key elements which

contribute to effective and justified decision making in nursing. To be more precise, these

elements are such as clearly defined and set objectives of the decision making process; collection

of relevant and credible data; provision of sufficient time for decision making; consideration of

at least several alternatives; logical thinking without superficial inferences; and determination to

act (Marquis & Huston, 2015). Apparently, I lacked several key elements of effective decision
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making, namely, I hurried with the process of decision making, I was superficial in my

inferences, and there was a deficit of both properly set objectives and alternative options. The

major reason for such a behavior and irrelevant decision making process was my understanding

that the longer I think, the worse care the patients receive. Nevertheless, an extra day or two of

decision making could subsequently result in long-lasting constructive outcomes.

As Truglio-Londrigan and Lewenson (n.d.) highlight, “the way we make decisions is

influenced by many intra- and interpersonal characteristics like our style, our culture, where we

grew up, our education, our personality, and how we perceive the world” (p. 3). After my in-

depth insight into the aforementioned influential factors I realized that my recent decision

making was strongly impacted by my personality and my previous experience. To be more

precise, I observed vivid examples of excessively slow decision making of my colleagues which,

consequently, led to worse healthcare outcomes in patients and overall decrease in efficiency of

unit performance. As a result, I was determined to provide a solution to the given crisis situation

as soon as possible since those examples taught me that each minute is valuable for patients.

Nonetheless, I did not take into account that such an approach has two sides, and efficiency

should not be undermined for the sake of quick decision making.

My further progress in self-reflection on my recent decision making leads me to another

potential improvement which I should have undertaken. It would be relevant and wise to address

higher nursing management with the issue of concern. To be more precise, an alternative

solution, or, at least, a part of the solution of the crisis situation with staff shortage at my unit

may be as follows: permission should be asked in higher nursing management to initiate closure

of several beds in the unit. The aim of this measure is to align potential of the currently available

nursing personnel with the actual beds in order to guarantee maximally efficient performance and
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sufficient time necessary for proper care process for each patient. Along with such, nurses will

have regular schedules and the hazard of burnout will be eliminated. There is also an issue of

care provision that is a major responsibility and mission of our unit. This responsibility will not

be undermined since the patients need qualitative care. Quality is an ultimate priority in the

healthcare sector in general and in our unit in particular. The quantity of beds for closure can be

calculated taking into consideration the final number of nurses available and timeline of their

shifts.

It is also relevant to discuss the issue of timeline of working hours and shifts in the unit.

To be more precise, the usual practice in our unit is total care. It means that there are

approximately five patients per one nurse during each shift. As a result, I need to have five

nurses each shift so as they can cover 23 patients in the unit properly, timely, and effectively.

Nonetheless, total care is not the only option for efficient nursing performance. An alternative

solution that I should have taken into consideration initially is team nursing approach. Such a

choice means fewer nurses per each shift. According to Cioffi and Ferguson (2009), “the use of

team nursing is considered to provide patients with continuity of care by a team therefore

addressing the potential for fragmented care often resulting from more task oriented care

delivery models” (p. 2). In such a way, fewer nurses could provide more meaningful and focused

care for the patients in the unit and at the same time stay in similar terms of scheduling even after

staff shortage. The main task of nurses in case of team nursing approach is “to work

collaboratively and cooperatively with shared responsibility, and to some extent accountability,

for assessment, planning, delivery, and evaluation of patient care” (p. 2). It is a different

approach, but its benefits are significant, especially under the circumstances of personnel

shortage.
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Ferguson and Cioffi (2011) underline that team nursing is a key strategy that contributes

to both quality and safety of nursing care. Moreover, it is a proper choice when the unit has

junior nurses who need supervision, control and guidance in their performance. Mitchell et al.

(2012) supports the stance of the aforementioned scholars on effectiveness of team nursing and

focuses on necessary aspects of paradigm shift targeted to establish team-based patient care in

the unit. The researchers emphasize that this paradigm shift is possible due to “common

touchstone principles and values that can be measured, compared, learned, and replicated”

(Mitchell et al., 2012, p. 24). Such an alternative solution could have required additional time for

the changes and adaptation of nurses to them. Nonetheless, the expected efficiency of nursing

performance and possibility to provide healthcare to all 23 patients in the unit are a set objective,

and the efforts will be relevant in this case since such an approach provides continuity and

quality of patient care.

The issue of nursing retention forms a background for a dilemma in the current course of

time. Krsek (2011) highlights that nursing retention is a smart decision in terms of contemporary

economy as far as “The Nursing Turnover Cost Calculation Methodology shows that each nurse

that leaves his or her position costs the hospital approximately $88,000. Voluntary turnover

among first-year nurses is estimated at 27.1%.” Hence, financial loss is essential, whereas lack of

proficient nurses is a problematic issue in the healthcare sector, and turnover is considered to be

a serious threat. Kerffot (2015) provides more up-to-date and itemized data on the issue in

question: “According to the Journal of Nursing Administration, it costs roughly $82,000 to

replace a nurse. That cost covers vacancy, orientation and training, the lowered productivity of a

newly hired nurse, and advertising and recruiting.” At the same time, the author of the article

highlights that overtime hours and exhausting schedules are among the main reasons of nursing
REFLECTION IN NURSING 14

turnover (Kerffot, 2015). Hence, my recent decision making is apparently a destructive solution

that endangers nursing retention after nursing shortage ramifications. Heede et al. (2013) support

the aforementioned vision of nursing retention and emphasize that enhancement of working

conditions for nurses is an optimal response to the given problem.

Another important aspect that will be addressed in the present self-reflection relates to

cost cutting in terms of hiring new personnel. Our unit acquires new nurses via international

recruitment. Keogh (2014) claims that when a healthcare organization hires in such a way it may

be decoded as an issue of urgency and ultimate significance. On the other hand, such hiring

practices are often results of negative ramifications of shortages or turnovers. To be more

precise, units often try to cut costs in such a way, but fail to provide quality and safety for their

patients afterwards, and have to initiate hiring of new staff. Dwivedi (2013) confirms that

turnover rate is considerably high in the current course of time, especially among newly hired

nursing personnel. The scholar also adds such important factors as competitive salary, privileges,

and focuses attention on leaves, benefits and healthy working environment (Dwivedi, 2013).

Hence, I should have taken these factors in consideration during decision making process. To be

more precise, I should have understood potential implications of extra shifts and nurses’ burnout

not only on efficiency of performance and patient safety, but also on further willingness of nurses

to work as a part of our unit. Finally, cutting costs is not a major issue when overall potential of

the unit is questioned because of staff shortage. Expenses should be optimal, but quality should

remain the ultimate priority. One of the most important inferences that I have made during self-

reflection on the recent decision making is as follows: it is important to focus on long-lasting

effect of the selected solution and ensure that its ramifications will not destruct the whole system

in general. Another important insight relates to personnel, namely, it is of ultimate importance to

REFLECTION IN NURSING 15

take into account nurses when making a particular decision that will impact their performance,

duties and responsibilities. It is necessary to ensure that the selected solution will impact them as

positively and constructively as expected.

Having analyzed my recent decision making, it is relevant to identify main influential

factors which provoked such a quick and unjustified solution of the crisis situation. First, it was a

serious stressful situation to the whole unit in general and me in particular. I felt huge

responsibility and realized urgent need of optimal solution. Moreover, I was eager to save all the

beds in the unit so as to be capable to provide health care to as much patients as possible. Along

with such, I hoped for quick progress in the process of hiring new personnel to cover the

shortage gaps, and though about solution for several weeks, not a permanent one. I did not

expect the hiring process to be postponed for such a considerable period of time. Enthusiasm and

willingness to take extra shifts expressed by nurses increased my determination to implement

such a decision in practice. Furthermore, my aim was to provide maximal coverage of shift gaps

with qualified assistance of nursing personnel since help of volunteers would not be professional.

One more influential factor was my insufficient vision with which I set a short-termed target, not

a perspective aim.

Such an in-depth insight into my recent decision making has led to the final stage of self-

reflection, namely, transformative learning. Okuda and Fukada (2014) as well as Silvia, Valerio

and Lorenza (2013) highlight that transformative learning leads to changes in practice of nursing.

The most effective stage of reflection in this context was working with meaning. I understood

implicit reasons of ineffective and short-termed perspective and realized how to build a more

global vision for responsible and constructive decision making. According to Burns and Bulman

(2000), an expert evolves due to self-reflection, regular improvement of skills and knowledge as
REFLECTION IN NURSING 16

well as implementation of inferences based on the previous experience. Learning via experience

is constructive (Moon, 1999).

Conclusions

Thus, the course of self-reflection on my recent decision making resulted in

transformative learning and development of the framework of alternative options and potential

improvement if the process of decision making in the future. First, I should have discussed the

situation and potential solutions with the nursing personnel and colleagues. Second, I should

have set long-term perspective targets, not a short-term solution. Third, I should have analyzed

all the options and their long-term ramifications. Fourth, I should have taken into consideration

not only factual provision of care to all the patients, but also its quality, safety of patients and

care for proper working conditions for nursing personnel. Fifth, reduction of beds in the unit

should have been included in the list of alternatives according to the aforementioned priorities

and values.

I have also concluded that I lacked particular skills and approaches in the process of my

recent decision making. To be more precise, I should develop a capacity to cooperate with

colleagues. It will also be relevant to discuss dilemmas with more experienced colleagues.

Finally, a skill of analytical thinking as well as a skill of perspective planning will help me

manage the course of performance in the unit more constructively. I should learn how to set

long-term and clear targets and how to select the optimal solution from the list of alternative

options based on perspective for all the stakeholders of the situation.

This experience was valuable as far as it brought many constructive insights and

inferences. It helped me improve my managerial skills and enhance my model of decision

making. Along with such, I understood a power of team potential and will pay more attention to
REFLECTION IN NURSING 17

thoughts and stances of the personnel, not only to my personal judgment. Finally, I realized that

quality is always more important than quantity, especially in the healthcare sector.
REFLECTION IN NURSING 18

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