Decision-making is a core part of community health nursing. There are several types of decision-making including programmed decision-making for routine issues and non-programmed decision-making for unique issues. The decision-making process involves defining the problem, gathering facts, evaluating alternatives, implementing a choice, and following up. Three frameworks are outlined for ethical decision-making - the DECIDE model, a six step framework, and considering values of self-determination, well-being, and equity.

1. Decision-Making in
Community Health Nursing
Presented to:
Dr. Sushma Saini
Lecturer, NINE
PGIMER
Chandigarh
Presented by:
Nisha Yadav
M.Sc. Nursing 1st year
NINE, PGIMER
Chandigarh

2. OUTLINE
• Definition
• Characteristics
• Types of decision making
• Decision making process
• Decision making conditions
• Decision making in community health nursing
• Decision making frameworks
• Basic values that guide decision making
• Ethical principles
• Ethical standards and guidelines
• Conclusion

3. Definitions
Decision: making an act of choosing
Decision: solution chosen from
among given alternatives.
Decision-making: It is the process of
responding to a problem by searching
for and selecting a solution or course
of action that will create value for
organizational stakeholders.

4. Decision-making : is a process of converting
information into action.
Venigra (1982)
Decision-making process : is the process of selecting
an alternative course of action that will solve a
problem.
Ethical decision-making: Making a choice that is
consistent with a moral code or that can be justified
from an ethical perspective.

5. Characteristics
• Goal directed activity
• Integral part of management
• An intellectual activity
• Involves choices

6. Types of Decision-Making
• Programmed
• Non-programmed

7. Programmed Decision-Making
• Routine and repetitive and specific ways to handle
them.
• Decision rule is developed.

8. Characteristics
• Highly structured, clear and well known goals
• Procedure already established
• Sources & channels of information clearly defined
• Minimum of uncertainty
• Recurs frequently

9. Non-Programmed
• Typically one shot decision, less structured .
• Recurs infrequently, where no previous rule is
established
• Requires problem solving.
• Problem solving: is a form of decision making in
which the issue is unique & alternatives must be
developed and evaluated with the aid of
programmed decision rule.

10. Characteristics:
• Poorly structured
• Information not available
• No clear procedure
• Goals are vague
• Non-recuring and non-routine
• E.g. staff absenteeism/crisis

11. Decision making- an essence
to problem solving

12. Types of problems and decisions
Structured problems
• involves goals that are clear
• are familiar (have occurred before)
• are easily and completely defined- information
about the problem is available and complete
Programmed decision
• A repetitive decision that can be handled by a
routine approach.

13. Unstructured problems
• Problems that are new or unusual and for which
information is ambiguous or incomplete
• Problems that will require custom- made solutions
Non-programmed decisions
• Decisions that are unique and nonrecurring.
• Decision that generate unique responses.

14. Decision-Making Process
• Define the problem
• Gather facts and develop alternatives
• Select the best alternatives
• Evaluate alternatives
• Implement the chosen alternative
• Follow-up and evaluate the chosen
alternative.

15. Decision-making Conditions
Decision-making under Certainty
Decision-making under Risk
Decision-making under
Uncertainty

16. Decision-making under
Certainty
• A state of certainty exists when a decision maker
knows, with reasonable certainty, what the
alternatives are and what conditions are associated
with each alternative.
• Very few organizational decisions, however, are
made under these conditions.

17. Decision-making under Risk
• A state of risk exists when a decision maker makes
decisions under a condition in which the availability
of each alternative and its potential payoffs and
costs are all associated with probability estimate.
• Decisions such as these are based on past
experiences, relevant information, the advice of
others and one’s own judgement.

18. Decision-making under
Uncertainty
• A state of uncertainty exists when a decision maker
does not know all of the alternatives, the risks
associated with each, or the consequences each
alternative is likely to have.
• Most of the major decision making in today’s
organizations is done under these conditions.

19. A View of Decision-Making
Conditions
Risk and certainty
Uncertainty Absolute Certainty
Level of ambiguity and chances of making a bad decision
Lower Middle Higher
Probabilities
and expected
outcomes are
unknown
Some knowledge
of probabilities
and expected
outcomes
Probabilities and
expected
outcomes are
known

20. Decision-making in Nursing
• The Institute of Medicine has identified that up to
98,000 patients die each year as a result of poor
decision-making in healthcare.
• Decision-making is essential to nursing practice.
• Decision-making in acute care nursing practice is a
complex process.
• Nurses must consider numerous, potentially
competing factors when making decisions to meet
patient and family needs.

21. • Research identifies other factors associated with
decision-making challenges for acute care nurses.
• For instance, critical care nurses can make decisions
every 30 seconds.
• Nurse decision-making in acute care is highly
demanding.
• Improved understanding of decision-making
research in this environment may help to guide
future efforts to support nursing practice.

22. Decision Making in Community
Health Nursing
• All community health nurses need to learn to
identify ethical problems and to learn a process for
resolving these problems that incorporates ethical
perspectives.
• This is particularly critical because nursing
colleagues depend on one another for help in
dealing with ethical problems in practice.

23. Decision-Making Frameworks
• To resolve ethical dilemmas, several frameworks for
ethical decision making have been proposed.
• Among these frameworks, three key steps are
considered as fundamental to choosing alternative
courses of action that reflect moral reasoning:
i. separate questions of fact from questions of
value
ii. identify both clients’ and nurse’s value systems
iii. consider ethical principles and concepts

24. • The identification of clients’ values and those of
other persons involved in conflict situations is an
important part of ethical decision making.
• An ethical decision-making framework referred to
as the DECIDE model is a practical method of
making prudent value judgments and ethical
decisions.
(Thompson et al.2006)

25. DECIDE Model
D—Define the problem (or problems)
E—Ethical review
C—Consider the options
I—Investigate outcomes
D—Decide on action
E—Evaluate results

26. A Framework for Ethical
Decision Making
This framework helps to organize thoughts and acts as a
guide through the decision-making process.
1. Clarify the ethical dilemma
2. Gather additional data
3. Identify options
4. Make a decision
5. Act
6. Evaluate

27. Basic Values That Guide
Decision Making
• When applying a decision-making framework,
certain values influence community health nursing
decisions.
• Three basic human values are considered key to
guiding decision making in the provider-client
relationship:
I. Self-determination
II. Well-being
III. equity

28. Self-Determination
• The value of self-determination or
individual autonomy is a person’s
exercise of the capacity to shape and
pursue personal plans for life (Guido,
2010).
• The outcomes that could be maximized
by respecting self-determination or
autonomy include enhanced self-
concept, enhanced health-promoting
behaviours, and enhanced quality of
care.

29. • Many physicians and other health providers,
including community health nurses, fail to recognize
the high value attributed to self-determination by
many consumers or the differences in views of self-
determination among ethnic groups.
• When self-determination deteriorates into self-
interest, it poses a major roadblock to equitable
health care.

30. There are two situations in which self-determination
should be restricted:
i. when some objectives of individuals are
contrary to the public interest or the interests
of others in society (e.g., endangering others
with a communicable disease)
ii. when a person’s decision making is so
defective or mistaken that the decision fails to
promote the person’s own values or goals.

31. The value of self-determination has implications for
how community health nurses regard:
● The choices of clients
● Privacy
● Informed consent
● Diminished capacity for self-determination

32. Well-being
• Although all therapeutic interventions by health
care professionals are intended to improve clients’
health and promote wellbeing, well-intended
interventions sometimes fall short if they are in
conflict with clients’ preferences and needs.
• Community health nurses, who are committed not
only to helping clients but also to respecting their
wishes and avoiding harming them, must
understand each client group’s needs and develop
reasonable alternatives for service from which
clients may choose.

33. • In addition, when individuals are not capable of
making a choice, the nurse or other surrogate
decision maker is obliged to make health care
decisions that promote the value of wellbeing.
• Wellbeing and self-determination are two values
that are intricately related when providing
community health nursing services.

34. The value of wellbeing has
implications for how community
health nurses seek to:
• Prevent harm and provide
benefits to client populations
• Determine effectiveness of
nursing services
• Weigh costs of services
against real client benefits

35. Equity
• The third value that is important to decision making
in health care contexts is the value of equity or
justice, which means being treated equally or fairly.
• Different people have different needs in health care,
but all must be served equally and adequately.
• Equity generally means that all individuals should
have the same access to health care according to
benefit or needs.

36. • In times of limited technical,
human, and financial
resources, however, it may be
impossible to fully respect the
value of equity.
• Choices must be made and
resources allotted, while the
value obligations of
professional practice create
conflicts of values that seem
impossible to resolve.

37. • The value of equity has implications for community
health nursing in terms of its priorities for:
i. Distributing health goods (macro allocation
issues)
ii. Deciding which populations will obtain
available health goods and services (micro
allocation issues)
• Decisions based on one value means that this value
often will conflict with other values.

38. Ethical Principles
Seven fundamental ethical principles provide
guidance in making decisions regarding clients’ care:
• Respect
• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Veracity
• Fidelity

39. Respect
• This principle emphasizes one’s importance as a
member of the community and of the health
services team.
• To apply this principle in decision making is to
acknowledge community clients as valued
participants in shaping their own and the
community’s health outcomes.
• It includes treating them as equals on the health
team and holding them, as well as their views, in
high regard.

40. Autonomy
• As nurses apply this principle in community health,
they promote individuals’ and groups’ rights to and
involvement in decision making.
• This is true, however, only so long as those decisions
enhance these individuals’ and groups’ wellbeing
and do not harm the wellbeing of others.
• When applying this principle, nurses should make
certain that clients are fully informed and that the
decisions are made deliberately, with careful
consideration of the consequences.

41. Beneficence
• In community health, the nurse applies the principle
of beneficence by making decisions that actively
promote community clients’ best interests and
wellbeing.
• Examples might encompass the development of a
seniors’ health program that ensures equal access
to all in the community who are in need, and the
support of programs to encourage preschool
immunizations.

42. Nonmaleficence
• The principle of nonmaleficence means avoiding or
preventing harm to others as a consequence of a
person’s own choices and actions.
• Community health nurses can apply this ethical
principle in decision making by actions such as
encouraging physicians to prescribe drugs with the
fewest side effects, promoting legislation to protect
the environment from pollutants emitted from
gasoline even if it raises prices, and lobbying for
lower speed limits or gun controls to save lives.

43. Justice
Within this principle are three different views on
allocation, or what constitutes the meaning of “fair”
distribution.
1. Distributive justice, decisions based on this view
particularly help the needy.
2. Egalitarian justice, promotes decisions based on
equal distribution of benefits to everyone,
regardless of need (e.g., Medicare).
3. Restorative justice, determines that benefits
should go primarily to those who have been
wronged by prior injustice, such as victims of
crime or racial discrimination.

44. • The principle of justice seeks to promote equity, a
value that was discussed in the previous section.
Social justice refers to the fair and equitable
distribution of “social benefits and burdens” (e.g.,
economic goods, political rights) and is tied to issues
of human rights.

45. Veracity
• Community clients deserve to be given accurate
information in a timely manner.
• To withhold information or not tell the truth can be
self-serving to the nurse or other health care
providers and hurtful, as well as disrespectful, to
clients.
• Truth-telling involves treating clients as equals, and
it expands the opportunity for greater client
involvement, as well as provides needed
information for decision making (Arrie's, 2006).

46. Fidelity
• Nurses who follow through on what they have said
earn their clients’ respect and trust. In turn, this
influences the quality of the nurse’s relationship
with clients, who then are more likely to share
information, which leads to improved decisions and
better health.
• Conversely, when a promise (e.g., a commitment to
institute child care during health classes) is not kept,
community members may lose faith and interest in
participation.

47. Modern health-care technology has complicated the ethical considerations of
not only diagnosis and treatment but also the social implications of diseases.
Community health nurses are often involved in these challenges. CHNs
sometimes find themselves in situations which is very different from those of
other healthcare workers. Often these situations have a moral component
that cannot be addressed by the traditional problem solving methods.
Knowledge of ethical principles and theories that offer framework for
problem solving is essential as these helps to deal with ethical dilemmas.

49. Conclusion
• The nurse often is faced with decisions that affect client’s
values and involve conflicting moral values and ethical
dilemmas. Several frameworks for ethical decision making
that include the identification and clarification of values
impinging on the making of ethical decisions were discussed
in this chapter.
• Three key human values influence client health and nurse
decision making: the right to make decisions regarding a
person’s health (self-determination), the right to health and
wellbeing, and the right to equal access and quality of health
care.
• Seven fundamental principles guide community health
nurses in making ethical decisions: respect, autonomy,
beneficence, nonmaleficence, justice, veracity, and fidelity.

50. References
• Allender JA, Fresno F, Warner KD. Community Health
Nursing Promoting and Protecting the Public’s Health.
7th ed. Wolters Kluwer Health. 2010; 79-5.
• https://pubmed.ncbi.nlm.nih.gov/2587395/
• https://doi.org/10.1207/s15327655jchn0602_5
• Lanik G, Webb AA. Ethical Decision Making for
Community Health Nurses. Journal of Community
Health Nursing. 1989; 6(2): 95-02.