Decision Making and Communication : Aspects of Nursing Competence

Abstract: The overall aim of this thesis is to understand the conditions and prerequisites of nurses’ decision making on nursing measures and their communication in multiparty talk, activities nurses manage in their work. By analysing both environmental elements in nursing practice and how experienced nurses manage decision-making processes, the intention has been to understand how nurses’ competence occurs and is expressed in nursing practice. A specific problem concerns the attention given to the patients’ right to participate in co-operative care planning meetings when decisions are made about their further care and how the conditions for patient involvement and influence become visible in multiparty talk.In the theoretical framework, it is argued that competence generally speaking concerns the individual’s potential capacity for action in relation to a certain task, situation and context. The expectations as regards nursing competence at work are expressed in work regulations and recommendations; however, the content of nursing education and practice constitutes powerful institutional frames, influencing how nurses are able to perform their tasks. The individual’s cognitive ability, the context-specific and collaborative knowledge, can be seen as additionally elements of nursing competence.The thesis is based on two different datasets which have generated four sub-studies. Studies I and II focus on the nurses’ decision-making process and the influence of the simultaneous presence of environmental elements. The empirical data consist of 30 hours of participant observation and inter-views with 6 experienced nurses at three different wards. Studies III and IV concern nurses involve-ment in a dynamic communicative process with co-workers, patients and, at times, their relatives including data from audio-recordings of 14 co-operative care planning sessions concerning stroke survivors.Throughout the four studies, a gap is visible between nurses’ decision making and communication in practice and the expectations of how nurses should manage these activities related to work regulations and the goals formulated in the nursing educational programs. How nurses make their decisions depends on their competence, the complexity of the task and how much they involve themselves in talk with others. The medical perspective dominates when nurses give priority to what should and can be done in nursing activities. As regards patients’ participation in co-operative care planning meetings, the professionals dominate the discourse space. The nurses never openly invited the patients to elicit their own perspective of their illness or care planning. The nurses mostly suggest-ed opinions or asked the patients to confirm these opinions. There is, however a hidden power agenda when patients and relatives try to reach a desired decision. The same phenomenon may occur when patients are in alliances with health care professionals. The above-mentioned issues are discussed in the light of nursing competence and the need for nurses to discuss what it means to be a nurse in relation to institutional frames of power relationships. If the official regulations and recommendations are to be satisfied, there is an urgent need for increased collaboration between nurses, the health care system and the nursing education programs.