April 11, 2019

Nursing Leadership: What Decisions Can I Make?

Clinician Leadership | Leadership Development

Reading Time: 2 minutes

Most of us would probably agree that making a decision isn’t difficult. We make decisions on a regular basis in our personal life – what to wear, what to eat, when to purchase a car, etc. The steps are clear: identify the issue, gather the evidence, consider options, act, evaluate for effectiveness….and then start again.

On the other hand, oftentimes in a hospital environment, it’s not always that clear. Especially for nurse leaders.

I recently asked a group of nursing leaders what decisions they can make. There was a hesitation and then a few examples. And to be honest, they weren’t all in agreement on where their decision authority started and stopped.

Yet today, we regularly hear from upper level administration that they would like to see more independent decision-making from nursing leaders.

Thornton, Shrestha, & Jenkins (2019) asked general care staff nurses, who had an average of 11 years of experience, how often they raise issue or clarify about choosing new equipment and supplies for their unit. A shocking 47% replied they never did. This statistic is even more surprising when you consider that these were primarily staff in Magnet-recognized organizations, where shared decision-making and shared governance are an expectation.

Research has found that people at all levels in organizations describe a sense of purpose and well-being when their capacity for judgement matches the challenges they face. They feel energized, competent, and confident in their ability to make decisions.

In healthcare, we may need to step back and consider what in our culture is making us hesitate to make decisions or contribute to a decision. Often it has to do with fear of failure or making the wrong decision, “paralysis by analysis”, bad timing, or unclear expectations.

One way to help nursing leaders, and organizations in general, with decision making is to set clear expectations.  To achieve this, an authority matrix for decision-making is helpful.

RACI Authority Matrix

One of our go-to coaching tools is the simple, yet effective, RACI model. Not only is it helpful in clarifying expectations, but it also helps to involve the right people. The acronym stands for:
R [Recommendation]: the person who makes the recommendation or is assigned to do the work.
A [Approval]: the person who makes the final decision and has the ultimate ownership.
C [Consulted]: the person(s) who must be consulted for input before a decision or action is taken.
I [Informed]: the person(s) who must be informed (no action needed) before a decision or action has been taken.
The beauty of this model is that it can be used in a several ways. For example:

  • As a discussion with a direct supervisor to clarify expectations on decision making
  • As a model to use with dyad and triad partnerships to clarify who does what
  • As a tool for unit co-leaders to avoid duplicate assignments
  • As a checklist prior to the roll-out of a new decision/project

For nursing leaders, we need to own the power we have in decision making. We need to create an environment where decisions are supported and encouraged. By having clear expectations, our nurse leaders will gain confidence in decision authority and be able to practice this imperative leadership skill.
What a great way to develop our leaders and future leaders.

Thornton, C. Shrestha, S. and Jenkins, M. (2019). Nurses’ Participation in Clinical and
Administrative Decisions in Different Types of Hospital Units. JONA, 49 (3); 163-170.

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About the author

Debra Harrison, DNP, RN, NEA-BC

Debra Harrison, DNP, RN, NEA-BC was the Chief Nursing Officer for Mayo Clinic in Jacksonville, Florida from 2006–2016. She retired in May 2016 and joined MEDI as an Executive Coach early 2017.

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