1. Introduction

Nursing administration is shaped by the organizational, professional, and regulatory frameworks within which nurses must operate. The nurse administrator is responsible for a group of health care personnel who must interdependently relate to a large, continually growing, and incredibly complex system. Therefore, a challenge that besets nursing management points at developing the capacity of nurse executives to apply critical thinking in making decisions and establishing priorities in the clinical setting [1]. Furthermore, Thompson posited that the impact of technological expansion and the increased acuity level of patients, combined with consumer demand for accountability and responsibility had fuelled the shift of the nurse administrator’s role from one of “hand-maiden” to an autonomous partner in health care delivery [2].

Although nurses are trained to deal with factors such as a surrounded atmosphere, time forces, extreme noise or undue quiet, no substitute option, unpleasant sights and sounds, and long standing hours, they can be overwhelmed with chronic occupational stress arising from the working environment. In a study [3], it was revealed that nurses posted in critical unit are not only physically stressed, but also psychologically, as they deal with critically ill patients and emotional reactions of patient’s relatives. Nurses’ cognitive and emotional factors influence their work performance; this reflects on patients who may receive inadequate care. Chronically stressed nurses frequently commit mistakes, become aggressive, take hasty decision, lose interest, are depressed and become flustered [4]. Results of work stress affect the quality of health care therefore it is a challenge for nurse executives to handle these stressed nurses. Doing so requires sound experience and skill.

Executive nurses are committed to creating care delivery climates that uphold second-order thinking and innovative solutions to issues within the system of care [5, 6]. Consequently, this author’s theory “Critical thinking and decision making in nursing administration” aims to elucidate the association of critical thinking to the decision-making process in the context of nursing management.

2. Philosophical Underpinnings

With healthcare becoming borderless and philosophical views shifting or interbreeding, there is potential for integration or assimilation of multiple perspectives. It is the author’s contention that pluralism or multiple lenses and perspective is necessary to capture the depth and breadth of the knowledge and essence of nursing administration. Understanding that critical thinking and decision-making are ongoing fluid processes that may change to suit the condition at hand, the author adopts relativist ontology and subjectivist/transactional epistemology. Taken together, relativism and subjectivism manifest a constructivist philosophical standpoint. It is her philosophical belief that multiple realities exist and are dependent on the individual. Furthermore, she acknowledges that people construct their own understanding of reality. In such case, knowledge is cognitively structured from experience and interaction with others and the environment.

Skills and abilities associated with critical thinking are demonstrated at different levels by individuals. The difference in demonstration can be attributed to the dependent concept of person, another philosophical viewpoint. This dependent perspective focuses on the cognitive realm being related to the physical self and the physical world. It allows nurses to develop critical thinking through similar cognitive processes as others but with a unique application that fosters individual differences.

As nurses deal with crucial situations that require important decisions every day, they need to develop their critical thinking skills in a context-based setting. These decisions are expected to impact client outcomes significantly. Relative to determining how knowledge would impact the ability to think critically and make decisions, the perceived viewpoint resonates and corresponds with the multiple ways of knowing. Critical thinking employs inductive reasoning; nevertheless, it also involves deductive reasoning as manifested in the received perspective. Therefore, the entirety of the cognitive skills involved in critical thinking is not certainly captured with the perceived view alone.

Through experience and interaction with the environment, nurses are able to make decisions, solve problems, and develop. Their critical thinking skills and inclination to use these skills influence their decision-making and problem-solving abilities. The ways in which nurse managers engage in decision making and problem solving influence the establishment of work flow and structure for patients on a delivery unit [7].

Nurse administrators are compelled to manage the dynamic health care system and advance excellence at every level of the organization. To foster the culture and climate of positive outcomes in health care, nurse administrators must continue to embrace critical thinking as a very salient component of the decision-making process.

Finally, to illuminate a variety of perspectives on critical thinking and decision-making in nursing, a pluralistic approach is recommended. As situational contexts vary and the nature of nursing varies dependent on the context, critical thinking can transcend these differences and assume a variety of different forms to best suit the situation [8]. Consequently, one perspective alone cannot possibly explain and support critical thinking in nursing.

3. The Theory of Critical Thinking and Decision-making in Nursing Administration

This theory commences with a reciprocal relationship between the institutional goal and the major concepts of the theory: critical thinking, decision-making, and nursing administration (Figure 1). The goal of an institution outlines the common direction for all its operational sections or divisions. Alongside this aspect, nurse administrators promote patient safety and quality initiatives through a practice within the framework of professionalism. Productivity and cost concerns remain important; however, there is an equal if a not greater focus on safety, quality relationships, and healing environments. Hence, the nurse administrator’s expertise in critical thinking and shared decision-making are essential for creating healthy work environments where quality and efficient care can be delivered [10].

Figure 1. Relationships of the Major Concepts of the Theory

The vision, mission, goals, values, and objectives of the facility influence nursing administration by setting the foundation for the establishment of the processes, programs/ interventions, guidelines, and innovations in the nursing unit. Admittedly, nurse executives should manage their operations within the gamut of the institution’s image. The figure also reveals that the development of cognitive skills and the imbuement of internal motivation to involve the self in critical thinking are influenced by organizational politics, priorities, preferences, and leadership and management styles. More evidently, decision-making depends extensively on the envisioned outcomes explicitly presented in the goal and objectives of the institution. Decisions made by the nurses are expected to lean towards the promotion of the objectives and goals, and ultimately, the attainment of the organization’s vision.

A two-way affiliation is shown between critical thinking and nursing administration. The former element improves nursing management while the latter component provides the environmental context in critical thinking. In the same hierarchy, decision-making as a product of the critical thinking process impacts significantly nursing administration and vice versa. In the light of all these relationships, nurse administrators should nurture the development of their critical skills and the dispositions that lead to the use of critical thinking in decision-making.

3.1. Theoretical Assumptions

1. Critical thinking is an essential element of decision-making.

2. Critical thinking requires an inquiry.

3. Decision-making is a hallmark of nursing administration.

3.2. Propositions

1. If nurse administrators demonstrate cognitive skills and dispositions efficiently and effectively, then their ability to make sound decisions will be enhanced. An all-encompassing decision-making process results in better nursing management outcomes.

2. Nursing administration fuelled by the application of critical thinking in decision-making advances the institution’s status through the achievement of the institutional goals.

3. Cognitive skills in critical thinking can be well demonstrated when one gathers salient information related to the issue of concern, anticipates implications and practical consequences, and explores options and creative solutions.

4. If decision-making is expected to advance the overall practice of nursing administration, then it must be grounded on sound critical thinking.

5. Decisions are bounded by cognitive and mental limits; the amount of information processed; and, values and assumptions.

6. Increased (better quality) information can reduce some of the technical uncertainties associated with decision-making and critical thinking in nursing administration.

7. Regulations and standards of care are always changing. Thus, any decision may cause an unanticipated future problem.

3.3. Key Concepts

a) Cognitive skills are mental abilities used to tackle and accomplish tasks.

b) Critical thinking is a voluntary engagement to a process that involves reflection; the identification and appraisal of assumptions; the application of cognitive skills such as interpretation, analysis, reason and judgment; and, the consideration of context.

c) Disposition to critical thinking is characterized by a consistent internal motivation to engage problems and make decisions by using critical thinking [8].

d) Decision-making refers to a systematic cognitive process of identifying alternatives, evaluating those alternatives, arriving at a conclusion, and selecting an option. Baron described further that decision-making involves the weighing up of the potential costs and benefits associated with each option before deciding on a course of action [11].

e) A nurse administrator according to Roussel [12] is as a registered nurse whose primary responsibility is the management of health care delivery services and who represents the nursing department.

f) Nursing administration involves the supervision of both the operations and functions of the nursing and ancillary staff, as well as overseeing the administrative branch, focusing on everything from financial aspects to human resources and protocol compliance.

3.4. Metaparadigm of Nursing According to the Author’s Constructivist Perspective

Person is regarded as an individual who has the potential to be inquisitive about a broad range of issues. As such, this individual maintains open-mindedness regarding divergent views.

Health is viewed as an organizational status characterized by enhanced patient outcomes, patient safety, a satisfactory relationship between nurses and other health professionals, and sustained quality control and improvement.

The environment is a fluid climate of certainty, uncertainty, complexity, and risk. This environment includes the external and internal organizational milieu that influence and determine decisions.

Nursing in the perspective of this theory is presented as a set of interventions employed to achieve a foreseen result. The actions are exemplified by using wisdom, foresight, and critical thinking skills to make good quality choices and, consequently provide more benefit to clients than harm.

3.5. Application to Nursing

Since many decisions are made, problems solved, and strategies developed using critical thinking, nurse managers should, as a primary responsibility, employ critical thinking effectively. Nurse managers’ critical thinking skills and inclination to use these skills influence their decision-making and problem-solving abilities. The ways in which nurse managers engage in decision making and problem solving influence the establishment of work flow and structure for patients on a delivery unit [13].

Nurse administrators are compelled to manage the dynamic health care system and advance excellence at every level of the organization. To foster the culture and climate of positive outcomes in health care, nurse administrators must continue to embrace critical thinking as a very salient component of the decision-making process.

4. Testing of the Theory

In 2009, the Nursing Executive Center developed 25 core competencies related to critical thinking. These nursing competencies are intended to reflect the core skills found at the heart of critical thinking, as identified by nursing industry experts. They are grouped into five broader skill categories: problem recognition, clinical decision making, prioritization, clinical implementation, and reflection. In relation to testing the propositions, the author recommends the development of an instrument or tool to measure these competencies. Additionally, it is best to include in the instrument the parameters that reflect the realization of the institution’s/organization’s vision with critical thinking, decision-making and nursing administration as vectors.

5. Conclusions

Nurse administrators who are adept at using critical thinking and have the “habits of mind” of a critical thinker are in a good position to assume a leadership role and create the changes that will achieve positive outcomes in health care organizations. Operating as a manager and leader requires ongoing development of critical thinking skills and the inclination to use those skills. Critical thinking can have a powerful influence on the decision making and problem solving that nurse managers are faced with on a daily basis.

ACKNOWLEDGEMENTS

This paper would have not been possible without the direction of Dr. Anabelle R. Borromeo. Her straightforward feedback has helped the author improved this output. Immense gratitude is likewise extended to the members of her family: Ryan, CJ, Mooxy and Larz, for providing unending inspiration.