Juggling multiple priorities to please: A grounded theory of nurse managers' process of decision making

Karen Clark-Burg, University of Notre Dame Australia


This thesis investigates the management role of Nurse Managers (NMs), identifying the processes used by NMs in decision-making in the management of human and material resources on the ward.

The classification of NM is used in Western Australia, also known as Nurse Unit Manager (NUM) in the eastern states of Australia—New South Wales (NSW), Queensland and Victoria. NMs have an important role in the healthcare environment as front-line managers who are responsible for the daily running and operations of the ward. Some of them already have leadership and management experience prior to undertaking this role, others have had theoretical preparation and others have no theory or experience but learn it all on the job and acquire these skills through experience after being assigned to the role.

There have been various studies on leadership and management skills, decision-making theories and the culture of the hospital ward environment. Most of these studies in nursing have focused mainly on upper management levels. To date, no study has specifically focused on the decision-making skills of NMs or the nursing staff’s reactions to the implementation of their NM’s decisions. The decisions made by NMs affect the staff and employees working on the ward, the patients and the other wards within the organisation. This study provides an understanding of the dynamics of the NM’s role and the intricacies of the decision-making process of the front-line leader who is responsible for the day-to-day operations of the workplace.

This thesis examined the decision-making process of NMs in terms of those decisions that affect the ward, as well as hospital-wide directives enforced by senior executives and administrators of the hospital.

A preliminary examination of the literature failed to identify studies that have used Grounded Theory (GT) methods to examine the NM’s decision-making process in relation to staffing and resources. This study was uniquely placed to generate theory about this particular phenomenon from data collected from NMs of two major metropolitan hospitals, one publicly funded hospital and one private hospital in Western Australia. Data was gathered from the sample group of NMs in a cyclical process of in-depth interviews, participant observations and data analysis until saturation of data was reached. Data was also collected informally from registered nurses (RNs) and enrolled nurses (ENs) during participant observations to clarify the information obtained from the NM’s in the study.

Throughout this process, this study identified the role of NMs in decision-making, the decision-making process at the ward level and effective leadership styles for implementing decisions.

A GT is one that is discovered, developed and provisionally verified through systematic data collection and analysis of data pertaining to a particular phenomenon (Corbin & Strauss, 2008). The GT generated from this study was that nurse managers made decisions with the aim of pleasing both their staff and nurse executives. They go through different process of decision-making depending on their level of experience as a nurse manager and the level of experience they have as a staff member on the ward. The participants in this study revealed that they strive to manage the decisions when they are new to their role. As they gain confidence and acquire more experience, they become intrapreneurial when making decisions. When nurse managers gain more experience in their role and have been working on the same ward for many years, they optimise efficiency in their decisions about staff and material resources on the ward. The theory generated from this study is an original contribution to the knowledge base of the field of NMs’ decision-making skills and provides valuable insights into their complex role and responsibilities.