The findings of current study indicate that two groups of internal and external variables can facilitate or inhibit the nurses' clinical decision making. According to the participants, "competence" and "self confidence" of a nurse were the internal factors and "being supported," "process of nursing education," and "structure of the health care institute" were the external factors that can enhance or inhibit the nurses' clinical decision-making. It is not uncommon for models of decision-making to focus on one or the other. Perhaps the most effective decision-making requires a model that integrates both dimensions.
Effective clinical decision-making is one of the most important components of professional nursing practice. It consists of gathering, processing and prioritizing critical patient information to choose and implement nursing actions and evaluate the results. As White (2003) mentioned, decision-making is the clinical function that differentiates nursing professional staff from technical ancillary staff [4
]. Our results suggested that there are some barriers to effective clinical decision-making. According to participants, nurses' competence is a key factor in clinical decision-making, and it comes from their professional knowledge, skills and experiences. In a study of nurses' perception of clinical decision-making to patients in pain, Baker (2001) concluded that knowledge and experience place an important role in effective clinical decision-making [15
]. Also Orielly (1993) confirmed, experience and knowledge are two major factors affecting decision-making [5
]. But Louri and Salanteral (1998) reported that the model each nurse uses for decision-making depends mainly on his\her task and context of the situation but not to the level of his\her knowledge and experiences [16
]. However the participants in our research emphasized that it is "proper use" of knowledge and skills that makes the decisions effective. In the other words, competent decision-making is more than the simple application of theoretical knowledge or performing technical skills, but it requires integrating knowledge, skills and experiences and also a close relationship to the patients to make a deep "understanding of the clinical picture" [4
] or "seeing the big picture" [17
]. According to the participants in this research, self-confidence is considered a vital factor in effective clinical decision-making. Those nurses having more confidence have better control over their work, make more efficient decisions and intervene more independently [4
]. Self-confidence has a close relationship with self-efficacy. Roberts et al. (1981) considered the terms self-efficacy and self-confidence interchangeable. Self-efficacy defined by Bandura as a situation specific self-confidence that indicates the level at which one believes one can successfully perform a task [18
]. Bandura's research (1997) has also shown that the individual's self-efficacy may be more significant to task performance than his actual skills [19
]. Self-confident persons have an internal locus of control, and believe in their ability to influence results [20
]. A meta-analysis of more than 80 studies also revealed that employees with high levels of perceived control at work were more satisfied, committed, involved and motivated [21
]. Therefore it appears that self-confidence may be an important factor in effective decision-making [22
Although self-confidence results in better decision-making, about 40% of participants in this research complained of the lack of self-confidence among nurses and nurse managers and considered it as one of the major inhibitors to effective independent decision-making by nurses. The lack of self-confidence in nurses was also confirmed in the studies carried out by Madjar (1997), Fulton's (1997) and Baker (2001) [23
Also environmental factors, amount of relevant professional knowledge and clinical experience, collegial relationship and staffs' interactions with their managers play an important role in nurses' self-confidence and effective clinical decision-making [15
]. It seems that nurses have internalized beliefs about their own inferiority [25
]. Also, their doubt in their own knowledge, ability [24
], and competency have decreased their self-confidence and made them relinquish the authority to those perceived as being better. The findings indicate that variables related to organizational structure and its culture have influenced the nurses' decisions. Although the organizational variables could both enhance or inhibit the effectiveness of staff decisions, participants in this research implied that these variables were among the major inhibiting factors having decreased nurses' perceived control over their work. These variables also have decreased their self-confidence, which in turn, has decreased their participation in clinical decision-making. Findings indicate that the levels of authority, organizational climate and the nursing system used on the units affect the participation of nurses in decision-making. However, the cultural context of the organization seems to have the most inhibitory effect in this regard. Nurses wanted to have authority to make decision related to duties within the nursing domain. Although they implied that job description and official rules were the sources of their diminished authority, the culture of nursing was highly task-oriented and physician controlled. Factors such as unbalanced nurse-patient ratios, heavy workloads, and expectation from nurses to only execute the doctors' orders resulted in a diminished relationship with patients and had them choose a functional and task-oriented nursing system. These results confirmed the findings of Baker (2001) who reported that lack of time and heavy workload negatively affected decision-making, because nurses cannot comprehend patients' requirements [15
Although Krairikish and Anthony (2001) implied that structure and setting process have little influence in decision making related to nursing practice [26
], it seems that lack of time for completion the routine tasks has resulted in little time for nurses to participate in decision-making and independent nursing interventions, as confirmed by Fulton (1997). Perhaps it is for this reason that Anthony (1999) has suggested that authority has a weak relationship with the nurses' actual decision making [27
]. In this research it was discovered that "being supported is an important predictor of nurses' effective participation in clinical decisions. In a study on benefits and outcomes of staff nurses' participation in decision-making, Krairikish and Anthony (2001) reported that nurse managers' leadership had little effects on staff nurses' participation in decisions [26
]. However, nurses in our study implied that unsupportive management was a barrier to effective clinical decision-making. Of course the leadership in the Krairikish and Anthony study was conceptualized as the presence and competence of the manager, while present study emphasizes on the support of the manager. Nonetheless the role of the manager appears to be central to nurses' decision-making. However, heavy workload, poor staffing, low income, not having power for decision-making and partiality of managers with doctors in their conflicts with nurses, were the most causative factors in feeling of being unsupported. These findings have also been confirmed by other researchers [28
Nurses perceived their managers as being unsupportive. Those nurses who directly care for patients chose patient care as their highest value, but they saw the employing institutions and the managers ignoring their welfare. They expect their managers to provide them with 'facilities for care,' financial and emotional support' so that they can participate in patient-related decisions and provide quality care for their patients. According to Macphee and Scott (2002), although all factors and working conditions are not under the control of managers, emotional supporting of nurses can decrease the pressure on them [31
], increase feelings of self-confidence and enhance their effective participation in decision-making.
The participants emphasized the critical role of nursing education in preparing nurses to make effective clinical decisions. As White (2003) argues, the mission of undergraduate nursing education is to prepare nurse generalists who will be able to provide care in a variety of clinical environments [4
], but depending on the educational related variables such as educators and role models, content of the curriculum, methods of education and evaluation, this quality may be enhanced or inhibited. Many authors have emphasized the importance of nursing educators and educational institutions in development of nurses' clinical decision-making skills [15
]. However approaches to the preparation of nursing students for a successful transition into the workplace have been found to be ineffective. According to the participants "Role models," "Content of curriculum," and "Methods of education" all played an inhibiting role in effective clinical decision-making. The curriculum seems to contain a vast range of theoretical content, mostly based on medical model, and faculty members feel pressure to find a way to present a massive amount of content necessary to facilitate passing of the final examination (which is equivalent to licensing examination). They spend more time on theoretical education; so, there will be less time for practical and student-centered learning and developing students' clinical decision making skills. Their educational methods are teacher-centered. They use lectures as the most important method of education. Therefore the manner in which nurses are trained is rigid, controlling and encouraging conformity, passivity, dependency and subordination. In a study of difference between enabling and empowering, Espland and Shanta (2001), argue that empowering is an interpersonal process which increases students' control on their practice, while enabling encourages dependent behavior in students. They believed that, faculty members who enable students do not encourage their development of problem-solving [and decision-making] skills. Such educators decrease students' self-esteem, and negatively affect their self-concept and self-confidence [33
]. Therefore nurses do not try to make independent decisions and rely mostly to executing the doctors' orders.
The findings of the current study indicate that clinical decision-making is a basic social process involving some individual and environmental variables. Precise review of these variables as well as findings and data obtained during the analysis stages of this study suggest the existence of interactive relations among the variables. These interactions are presented in Figure . As this model has shown, although feeling competent is important, self-confidence is a basic requisite for making effective clinical decisions. Organizational structure, supportive or unsupportive management and nursing education also have facilitating or inhibiting effects in this process.
Interactive relationships between variables affecting effective clinical decision-making