Expanding decision-making options

Author(s): Rose O. Sherman, EdD, RN, NEA-BC, FAAN, and Tanya M. Cohn, PhD, MEd, RN

Guide new graduates to broaden their career choices.

Takeaways:

  • Many new nurses make career decisions based on what their peers are doing.
  • Expanding decision-making options can help nurses find a career path that’s right for them.
  • The WRAP decision-making model encourages nurses to widen their options, reality-test assumptions, attain distance before making a decision, and prepare to be wrong.

Katy* is the nurse residency program coordinator for a large health system. Twice each year, a new cohort of recent graduates joins the staff. Katy has noticed that most nurses in recent groups have begun their employment with a specific career goal in mind. They plan to work for 1 to 2 years and then return to graduate school to become a nurse practitioner (NP). Although she believes this is an admirable career goal, she’s concerned about the lack of due diligence residents have conducted in making their career choice. They haven’t investigated the many other career options open in nursing. As part of the program this year, Katy has decided to include content designed to help new graduates expand their career decision-making options.

We make many decisions in our daily life, and how we make them is an interesting process. Many of our choices are so routine that we make them with little thought, but others, such as a professional career change, should demand more consideration. Like many nurse leaders today, Katy is understandably frustrated with new graduates who begin costly residency programs, have short tenures on their units, and then quickly return to school to become NPs. In academic environments, the NP role typically is promoted as offering independence, greater professional responsibility, and higher pay than other nursing positions. Usually not discussed, however, are the high levels of accountability, heavy patient caseloads, and long work hours. For some students, becoming an NP is the right choice, but not for all. Katy has recognized that many new graduates don’t broaden their decision options beyond the NP role.

In their book, Decisive: How to Make Better Choices in Life and Work, leadership authors Chip and Dan Heath suggest that our decision-making frequently is flawed because we fail to consider a range of options. The Heaths argue that humans are hampered by four “enemies” of decision-making rooted in our unconscious behavior: narrow focus, confirmation bias, short-term emotion, and overconfidence. Many of us look at the information in front of us without further research, and we trust our guts too much in making decisions.

Katy is wise to include decision-making content in the residency program. Evidence-based information will help new graduates make more informed career choices and other critical life decisions. Making informed choices and avoiding natural biases are essential skills that all nurses should cultivate. (See What’s confirmation bias?)

What’s confirmation bias?

We frequently think narrowly about our career options and don’t develop systematic approaches to compare our choices. This can be an outcome of cognitive or decision biases. We might

  • conform to groupthink or ingroup bias about a role choice without broadening our horizons or evaluating evidence
  • fear we won’t be successful in a career path different from that of our colleagues
  • misjudge whether our strengths are a good fit for the role by accepting commonly held group ideas.

Accepting group opinions as fact can lead to confirmation bias. We seek out information that fuels our pre-existing views and ignore information that might threaten our worldview.

New graduates are particularly vulnerable to confirmation bias. Being new to the profession, they’re likely unaware of the broad diversity of roles that nurses have within organizations. They also may believe that being a staff nurse should be a time-limited stepping-stone to becoming a nurse practitioner. With this mindset, new graduates may enter the residency program with a short-term plan to apply to the nurse practitioner program, placing them in a time-pressured professional transition scenario. When a career decision occurs this way, new nurses may close off thinking about other options open to them.

The WRAP model of decision-making

To help new graduates make better decisions and avoid biases, Katy will need to ensure that the process she presents includes problem-solving and decision-making skills. Using an effective, robust method helps us improve decision quality and achieve consistently good results. It also avoids the possibility of arriving at a conclusion that supports information we already have and discounting other ideas. Our choices are sometimes flawed because the best alternatives may not be apparent at the outset and we haven’t considered other vital factors.

The Heaths propose a decision-making model called WRAP (Widen options, Reality-test assumptions, Attain distance before deciding, Prepare to be wrong).

Widen options

A pitfall in our decision-making is that we frequently begin with a narrow range of either/or choices. When we widen the possibilities, we have more available options. The Heaths suggest asking this question: “If I couldn’t choose either one of these options, what else would I do?”

Katy found in her discussions with the nurse residents that few had considered options other than the NP role. A strategy she might consider is asking the residents to expand their choices to at least five roles that they might be interested in based on their strengths. In looking at broader options, the Heaths also recommend considering the opportunity costs of a decision. For new graduates, this could mean that returning to school right away prevents them from buying a home or funding their retirement.

Reality-test assumptions

Most of us give greater weight to information that fits our assumptions or is consistent with our beliefs. Many new graduates closely track the career paths of their classmates on social media. If a significant number are returning to school to become NPs, it may seem like a good decision based on collective input but might not be the right one for each person. We need to seek out and listen carefully to dis-confirming opinions. Has the new graduate interviewed or spent time with an NP? Have they talked with students currently enrolled in NP programs to assess the experiences they’re having? Do they know what the job market is like in their geographic area? Have they considered the costs of attending a full-time graduate program, especially if they still have undergraduate student loans?

Attain distance before deciding

Attaining some distance from a decision can help us avoid making decisions on short-term emotions. Although the decision to become an NP seems like the right choice now, will it still be the best choice in 6 months, 2 years, or 10 years? What would be the downside of waiting and revisiting the decision 2 years from now after attaining more nursing experience?

Prepare to be wrong

Regardless of how thoughtful our decision-making process is, we should anticipate both adversity and success. Not every decision made will be the right one. We all need to prepare to be wrong about some of the choices we make today. As an experienced leader, Katy can share times she’s made wrong decisions.

Designing decision-making content

Katy has an excellent opportunity in the residency program to build content and assignments around career decision-making. She can begin by teaching professional decision-making and expanding new graduates’ understanding of nursing roles and scope of practice. Examples of assignments related to decision-making could include having residents debate evidence-based practice options or bioethics clinical case situations. Discussing care options can help new graduates enhance their ability to assess evidence and justify decision-making.

Katy could progress from debating care options to using evidence to make group decisions by assigning small work teams of new graduate nurses on the same or similar units to develop evidence-based projects. To meet expectations, the new graduates need to evaluate current practice, critically appraise evidence, and collectively propose a practice change conducive to the setting and patients. Within the small group work, Katy can sprinkle decision-making stops for team discussion and debate, where the members engage with each other and assess evidence. An activity like this strengthens the new graduates’ decision-making skills in team settings while also investing in their current practice.

With a foundation in place, Katy can build content that addresses career decision-making options within the nursing profession. She can bring in nurses who serve diverse roles to discuss the nuts and bolts of their positions. Exposing the new graduates to these varying experiences allows them to learn about different career paths, why they were chosen, and the potential nursing and patient care successes. Katy could couple these presentations with assignments that require residents to interview and shadow nurses in roles they’re considering so they can better understand the daily work involved. She also could have the new graduates complete an assessment to identify their strengths and use those assessments to match new graduates with mentors and professional nurse guides. Mentorship can be an excellent strategy for clarifying thinking and avoiding decision biases.

Be a guide

Katy is providing a unique gift to the new graduates in her residency program. Most of us aren’t taught good decision-making skills, so we make mistakes because we ignore our biases, accept false assumptions, and select options based on a limited set of choices. Although the career choices ultimately made by the new graduates may not be perfect, Katy can guide them to use a decision-making process that will help them take bolder risks in the right direction.

*Name is fictitious.

Rose O. Sherman is adjunct professor at the Marian K. Shaughnessy Nurse Leadership Academy, Case Western Reserve University in Cleveland, Ohio, and author of the book The Nurse Leader Coach: Become the Boss No One Wants to Leave. You can read her blog at emergingrnleader.com. Tanya M. Cohn is an associate professor of practice and consulting nurse scientist at Simmons University in Boston, Massachusetts.

References

Dwyer C. 12 common biases that affect how we make everyday decisions. Psychology Today. September 7, 2018. psychologytoday.com/us/blog/thoughts-thinking/201809/12-common-biases-affect-how-we-make-everyday-decisions

Heath C, Heath D. Decisive: How to Make Better Choices in Life and Work. New York: Crown Business; 2013.

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