Decision Fatigue in Nursing: An Evolutionary Concept Analysis

ABSTRACT

Background and Aims

Decision fatigue, a critical cognitive challenge for nurses, significantly impacts patient care quality and individual well‐being. This concept analysis aims to thoroughly examine decision fatigue in nursing, a consequence of frequent and challenging decisions for healthcare personnel.

Methods

Utilizing Rodgers' evolutionary method, this concept analysis of “decision fatigue” in nursing involved a systematic literature search across PubMed, Scopus, Web of Science, and Google Scholar. Relevant studies were analyzed using content analysis to extract key themes. Findings were synthesized to define the concept and explore its antecedents, consequences, and practical implications.

Results

Decision fatigue, defined as the cumulative effect of continuous decision‐making and associated decision fatigue, manifests across behavioral, physiological, and cognitive dimensions. It can lead to a decline in optimal decision‐making capacity throughout a shift. Both personal factors (e.g., insufficient sleep, stress, lack of support) and organizational factors (e.g., personnel shortages, heavy workloads, conflicting decisions) contribute. For instance, studies showed that nurses tend to make more cautious and less efficient decisions over time, and patient admission rates decreased in the final hours of emergency department shifts. Consequences include reduced patient care quality and safety, ineffective decision‐making, job stress, burnout, and increased job turnover.

Conclusion

Decision fatigue poses a significant challenge for nurses, with serious implications for both nurses and patient outcomes. Understanding its contributing factors and implementing mitigation strategies are essential to support nurses and improve patient care.

1. Introduction

In the dynamic and demanding realm of healthcare, nurses stand as the unwavering pillars of patient care [1]. Their roles extend far beyond the mere application of medical knowledge, encompassing intricate, multi‐faceted decision‐making processes that have a profound impact on patient outcomes [2]. The term “decision fatigue” has emerged as a pivotal concept in understanding the cognitive challenges faced by nurses in their daily practice [3]. The concept of decision fatigue encapsulates the cumulative effect of continuous decision‐making and the associated decision fatigue that healthcare professionals, particularly nurses, experience throughout their shifts [4]. This phenomenon is not only prevalent but also profoundly significant in the healthcare context, where the quality of decisions made can directly influence patient safety, care effectiveness, and overall well‐being [1].

1.1. Review of Literature

This concept is initially derived from the self‐control strength model proposed by Baumeister in 1998 [5]. A fundamental principle of this model is that humans have a limited capacity to regulate their behavior. Similar to muscle fatigue after physical activity, humans deplete their resources when engaging in acts of self‐regulation, such as processing information for decision‐making. According to studies, decision fatigue is a sign of ego depletion [6]. In addition to the Strength Model of Self‐Control, Inzlicht and Schmeichel [7] Proposed the Process Model of Ego Depletion, this framework posits that ego depletion arises due to alterations in attentional and motivational regulation. In particular, manifestations of ego depletion, illustrated here as decision fatigue, originate from shifts in motivation that heighten impulsivity and lead to lapses in attention. These changes diminish an individual's capacity to identify internal conflicts or discrepancies, which are usually indicative of adaptive behavioral adjustments [7]. Therefore, individuals experiencing ego depletion (decision fatigue) are at risk of experiencing cognitive, psychological, and behavioral manifestations associated with decision fatigue.

As we delve further into the examination of decision fatigue among nurses, it becomes apparent that this concept surpasses the traditional comprehension of mental weariness. In the high‐pressure realm of healthcare, nurses consistently encounter a multitude of decisions that require their focus, discernment, and professional expertise [6]. The ceaseless decision‐making load is borne by nurses, ranging from medication administration and treatment plans to prioritizing patient needs and responding to emergencies.

Decision fatigue, in essence, is not merely a matter of feeling tired but represents a multifaceted phenomenon characterized by a gradual decline in the quality and accuracy of decisions as the day progresses [7]. It emerges from the intricate interplay of various factors, including the complexity of patient cases, the frequency of interruptions, the time pressure associated with tasks, and the emotional toll of witnessing patients suffering [7]. As nurses grapple with these challenges, their cognitive resources are gradually depleted, leading to suboptimal decision‐making and potential lapses in patient care [5]. Furthermore, decision fatigue can manifest itself in diverse ways, affecting not only the clinical judgments made by nurses but also their emotional well‐being [8]. It may lead to increased stress levels, reduced job satisfaction, and even burnout, as nurses grapple with the relentless demands of their roles.

Understanding the intricacies of decision fatigue is essential not only for healthcare professionals but also for healthcare organizations and policymakers [9]. The toll decision fatigue takes on nurses and its potential implications for patient safety underscores the need for tailored interventions and support mechanisms [10]. Strategies such as workload management, structured decision‐making protocols, and regular breaks may help mitigate decision fatigue and its adverse consequences [11].

As the scope of nursing practice broadens, coupled with the escalating demands on nurses in their day‐to‐day responsibilities, the frequency of decision‐making continues to rise. In such a context, there is a discernible necessity for precise clarification and differentiation of the concept of decision fatigue in nursing [3]. Decision fatigue is also a relatively new concept with limited use in healthcare, especially in nursing, as it integrates with emerging models of nursing care delivery [2]. Before extensive integration of decision fatigue into new healthcare decision‐making models, exploring its evolution as an essential concept is necessary. The ultimate goal of conducting a concept analysis is to provide a tangible and actionable definition of that concept [12].

1.2. Objectives

In summary, this concept analysis of decision fatigue in nurses aims to delve deep into the heart of a phenomenon that profoundly affects both the individuals at the frontline of patient care and the quality of care itself. By unraveling the layers of this complex concept, we hope to pave the way for improved nursing practice, enhanced patient outcomes, and ultimately, a more sustainable and fulfilling nursing profession.

2. Methods

This concept analysis study was done in 2023. Since decision fatigue is a concept that is still emerging, an evolutionary concept analysis method was used, based on Rodgers' evolutionary model. Rodger's evolutionary model provides a continuous process that establishes a foundation for the further development of a concept, explaining the ever‐evolving nature of a concept and seeking an understanding of its common application [13]. Rodgers stated that concepts are always changing, thus dynamic and influenced by time and context. Six steps of Rodgers evolutionary model were applied in three phases.

2.1. Phase One

2.1.1. Step One: Concept Selection

In the first stage, performing the task of defining the concept and articulating alternative terminologies and phrases was undertaken. Given the absence of a unified definition for decision fatigue and considering that one of the most fundamental activities in nursing involves multiple decision‐making processes, the concept of decision fatigue was selected for analysis.

2.1.2. Step Two: Literature Search

According to Table 1, a systematic search of databases including PubMed, Scopus, Web of Science, and Google Scholar, without temporal restrictions, was conducted using the keywords “Decision fatigue,” “Decision making,” “Nurse,” “Physician,” “Decision conflict,” “Occupational fatigue,” employing operators such as AND and OR. The articles were sorted based on relevance. Titles and abstracts of the retrieved articles were reviewed, and those lacking the desired keywords in their title or abstract were eliminated. Additionally, articles in languages other than Persian and English were excluded during the screening phase.

Table 1.

Systematic search of databases.

Databases	Search strategy	Preliminary search	Piloting of the study selection process*	Formal screening of search results against eligibility criteria**
PubMed	(Decision fatigue OR Decision making OR Decision conflict OR Occupational fatigue) AND (Nurse OR Physician)	65,360	46	8
Scopus	ALL(Decision fatigue OR Decision making OR Decision conflict OR Occupational fatigue) AND ALL(Nurse OR Physician)	6439	28	2
Web of Sciences	ALL = (Decision fatigue OR Decision making OR Decision conflict OR Occupational fatigue) AND ALL = (Nurse OR Physician)	40,800	39	4
Google Scholar	(Decision fatigue OR Decision making OR Decision conflict OR Occupational fatigue) AND (Nurse OR Physician)	327,000	82	3

^*Excluding based on relevancy to present study.

^**Excluding based on study criteria.

2.1.3. Step Three: Data Collection

During this stage, relevant content for the development of the concept of decision fatigue was gathered from selected articles.

2.2. Phase Two

Content analysis was employed to analyze the desired concept. Each article was thoroughly read, focusing on the implications of the concept and alternative terminologies. Each section was meticulously examined, allowing the researcher to extract key points and labels to present a clear description of every aspect of the concept.

2.3. Phase Three

2.3.1. Step Five: Integration of Results

The researchers categorized the collected data based on similarities and differences, presenting interpretations for each category. They provided a comprehensive interpretation for each category. Finally, they defined the concept considering these interpretations.

2.3.2. Step Six: Application of Results

In the final step, the developed concept's application, based on past experiences and related articles, was articulated.

3. Results

3.1. Concept Description and Model

3.1.1. Phase One

In this stage, referring to Table 1, out of the total number of articles retrieved, 195 articles were initially selected after piloting. Based on reasons explained in Figure 1, ultimately, 17 articles were included for study [4, 6, 10, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27]. Subsequently, the relevant information was extracted from the articles as detailed in Table 2.

Figure 1.

Prisma diagram.

Table 2.

Extracted information from articles.

Row	Author (year)	Title	Method	Results	Interpretation of results
1	Allan (2019)	Clinical decisions and time since rest break: An analysis of Decisional conflict in nurses	This study was conducted to investigate whether nurses employed at the medical call center in Scotland experience decision fatigue. It involved an observational analysis of data from 4,000 calls involving 150 employed nurses	According to the findings, each successive decision made by nurses from their last break tends to result in a predictable shift towards more cautious and less efficient decisions. Significant decision‐making wasn't notably correlated with the overall workload or cumulative load (number of calls or time elapsed since the start of the shift).	Frequent decision‐making throughout the shift, even with breaks, tends to lead nurses towards decision fatigue and inefficient decision‐making.
2	Pignatiello (2022)	Decision fatigue among clinical nurses during the COVID‐19 pandemic	The aim of this study was to report the psychometric properties, including the validity and reliability, of the Decision Fatigue Scale (DFS). A sample of 160 nurses from across the United States was selected online. Participants completed a demographic questionnaire, measures of decision fatigue, the Nursing Work Environment Scale, and traumatic stress.	According to the results, the 9‐item Decision Fatigue Scale with a latent factor showed suitable validity and reliability. Decision fatigue scores had a significant correlation with symptoms of traumatic stress.	Decision fatigue, as an important variable, can lead to stress and fatigue among nurses. Additionally, it stands as a modifiable target for interventions that can enhance decision‐making quality among clinical nurses.
3	Auriemma (2020)	Patterns of Decision Fatigue During Rounds in the Medical Intensive Care Unit	In this study, 17 specialty nurses and 354 patients were examined over 61 days. The data was collected by three researchers and analyzed using logistic regression	A total of 7646 decisions were made during the study. Most decisions taken were to continue the current state. At the patient level, early decisions contribute to maintaining the current status quo.	Patterns of decision fatigue emerge in the work cycles of specialized care units, where most nurses, during the decision‐making process for patients, tend to avoid complex decisions and opt to continue the current situation.
4	Hickman (2018)	Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill	The objective of this study was to evaluate the validity and reliability of the Decision Fatigue Scale (DFS) among substitute decision‐makers for incapacitated patients. An available sample of 101 substitute decision‐makers was Selected and assessed	The DFS was identified as a unifactorial questionnaire with adequate internal consistency (Cronbach's alpha of 0.87) and demonstrated stability reliability.	Substitute decision‐makers for incapacitated patients experience heightened emotional distress and reduced self‐efficacy, making them prone to decision fatigue and healthcare decisions that might not align with the patient's preferences.
5	Hickman (2012)	Decisional conflict and regret: consequences of surrogate decision making for the chronically critically ill	This study aimed to determine the relationship between decisional conflict and decision regret. It collected data from a cross‐sectional study involving 16 substitute decision‐makers in a hospital in the United States. The Decisional Conflict Scale and Decision Regret Scale questionnaires were used for assessment.	According to the obtained results, a majority of the participants experienced a high level of decisional conflict. However, 63% of them had mild regrets about their decisions. There was a direct correlation between these two variables.	Decisional conflict is among the valuable variables that can lead to decision fatigue. It can even be considered on par with decision fatigue. Both decision fatigue and decisional conflict can lead to decisional depression.
6	Cho (2022)	Occupational fatigue, individualized nursing care, and quality of nursing care among hospital nurses	In this cross‐sectional study, data from 858 nurses employed in hospitals in the United States in 2022 was collected. The participants completed the Occupational Fatigue Exhaustion Recovery scale, Individualized Care Scale‐Nurse version, and Nursing Care Quality questionnaires online.	Significantly higher levels of acute and chronic fatigue among nurses were notably associated with a reduction in the perception of individualized nursing activities for patients, personal living conditions, and decision‐making control concerning patients.	Nurse fatigue leads to a decline in the quality of care and inclines toward collective activities. Decision fatigue stands out as a prominent concept, arising from the overall fatigue of nurses during their shifts.
7	Cranley (2009)	Nurses' Uncertainty in Decision‐Making: A Literature Review	This study aimed to review the research conducted on clinical decision‐making uncertainty in nurses. Searches were performed in databases such as Medline, CINAHL, and PubMed to collect articles published between 1990 and 2007.	According to the summary of findings from these studies, unfamiliarity with patient care aspects was the source of uncertainty, and nurses tended to rely on colleagues' expertise or exploration as information sources for practical decision‐making. Studies indicated that nurses face difficulties in diagnosing or articulating ambiguities, hence unidentified information needs and a lack of information‐seeking behavior.	The decision‐making uncertainty among nurses, given the substantial volume of clinical decisions over time, leads to decision fatigue, ultimately impacting the quality of care negatively.
8	Shabestari (2022)	Facilitators of uncertainty in decision‐making in Iranian nurses: A qualitative study	This study aimed to identify the facilitating factors of decision‐making uncertainty among Iranian nurses. The qualitative content analysis was conducted from Khordad to Azar 1399. The participants, 17 nurses holding a bachelor's degree or higher, were purposefully selected from three hospitals affiliated with Tabriz University of Medical Sciences. Data was collected through semi‐structured interviews and analyzed using content analysis methods.	The experiences of participants were categorized into three main categories: uncertain nurse, complex situations, and unclear guidelines and policies.	Nurses might experience decision‐making uncertainty when facing ambiguous clinical situations or when lacking sufficient decision‐making skills. This uncertainty can lead to professional burnout, decision fatigue, and professional dissatisfaction.
9	Kowalski (2010)	Associations between emotional exhaustion, social capital, workload, and latitude in decision‐making among professionals working with people with disabilities	This study was conducted in five elderly care centers involving 175 care specialists. Occupational burnout was measured using the German version of the Maslach Burnout Inventory‐General Survey (MBI‐GS).	Based on the obtained results, three significant factors for the occurrence of emotional and occupational burnout were workload, frequency of decision‐making, and male gender.	Decision fatigue or fatigue is indeed crucial among caregivers and medical professionals. One of its significant contributing factors is the repeated instances of decision‐making, leading to occupational and emotional fatigue.
10	Treasure (2022)	Effects of decision fatigue on throughput and resource utilization over 12‐h shifts in the emergency department	This study aimed to understand the impact of decision fatigue on emergency department activity, a crucial aspect in minimizing cognitive errors. Through a retrospective examination, 9848 patients admitted during 2020 were assessed to identify potential differences between admission rates at the beginning and end of a shift.	Based on the observed results, a majority of patients were recorded in the first 8 h of the shift, while the rate of patient admission reduced in the last 4 h.	“Decision fatigue” is a significant dilemma among emergency nurses and physicians, leading to inefficient decision‐making. The primary reason for decision fatigue is more related to the number of patients rather than the duration of the shift.
11	Hatami (2022)	Decision Fatigue in nurses in the COVID‐19 pandemic: A commentary	Letter to editor		Making an irrational decision often leaves nurses feeling guilty and regretful, leading to a subsequent passive behavior. This passivity can result in simple and unenforceable decisions, which are components of decision fatigue.
12	Moscote‐Salazar (2023)	Decision Fatigue and Neurosurgeons' Clinical Decision Making: An Enemy in the Shadow	Letter to editor		The concept of decision fatigue is a fascinating and evolving subject that deserves special attention, particularly among healthcare personnel. Decision fatigue encompasses behavioral, physiological, and cognitive features and involves the reduced ability to make the best decisions as the day progresses.
13	Dubash (2020)	Decision fatigue in the emergency department	Letter to editor		Multiple personal (lack of sleep, inadequate support, occupational fatigue, and frequent decision‐making) and organizational (such as staffing shortages) factors are involved in decision fatigue. It's necessary to reduce the number of decisions to prevent errors and fatigue.
14	Zheng (2020)	Decision fatigue in the emergency department: how does emergency physician decision making change over an 8‐h shift?	The cohort study of adult patients who visited two hospitals over a period of two years was conducted. Patients were evaluated initially by an emergency physician based on their shift hour and were subsequently analyzed. The study examined the rate of patients who underwent CT scans, consultation, discharge, and patient return after 72 h of discharge, as well as the average length of stay.	About 87,752 patients were examined. Half of the patients were discharged without consultation, and 9% of this group returned after 72 h. A significant decrease in patient referrals for CT scans and consultations was observed during the final hours of the shift.	Decision fatigue is a critical issue in hospitals and among healthcare staff. Neglecting it will have irreparable consequences on patient health and the well‐being of the staff.
15	Parhizi (2013)	Mining the relationships between psychosocial factors and fatigue dimensions among registered nurses	Recent challenges related to patient safety and medical errors in healthcare have prompted a focus on improving quality across healthcare organizations. Psychological, social, and fatigue factors have been identified as crucial elements affecting nurses' performance. Data from 1006 nurses were collected through a simple sampling method and analyzed.	The results showed that psychological dimensions and nursing discretion have a strong correlation with all dimensions of fatigue. Significant changes in mental and overall fatigue levels are notably associated with the level of decision‐making discretion.	Decisional fatigue is one of the critical dimensions of fatigue in nurses, leading to reduced job quality. Social support from colleagues can assist in diminishing decisional fatigue and improving favorable decision‐making.
16	Persson (2019)	The effect of decision fatigue on surgeons' clinical decision making	In this study, data from 848 orthopedic patients related to 8 different surgeons were analyzed across various shifts. Collected data included wait times for visits, site of injury, patient age and gender, visit times during the day (morning, afternoon, or evening), and whether the specific surgeon was working one or two shifts during the day over a 3‐month period.	The results indicated that patients visited at the end of a surgeon's shift were 33% less likely to be scheduled for surgery compared to those seen at the beginning. Additionally, the likelihood of undergoing surgery reduced by 5.10% for each additional patient per shift handled by the surgeon.	The pattern of increasing erroneous decisions among healthcare personnel during a work shift is referred to as decision fatigue. Decision fatigue is an essential and impactful factor affecting patient health outcomes.
17	Fernández‐Miranda (2023)	Compassion and decision fatigue among healthcare workers during COVID‐19 pandemic in a Colombian sample	In this study, 856 healthcare workers from Colombia in 2020 were gathered and assessed for decision fatigue using the Decision Fatigue Scale (DFS).	The findings revealed a negative correlation between compassion, kindness, and decision fatigue. Additionally, in situations of decision fatigue, turnover rates were higher among nurses, specialists, and emergency personnel compared to other staff.	Decision fatigue is a prevalent and concerning issue, particularly for emergency personnel, as it may increase the risk of job turnover.

3.1.2. Phase Two

Based on the presented results in each included article, key points and labels were extracted and analyzed, as detailed in Table 2. Also, Table 3 demonstrates the themes emerging from the content analysis. Decision fatigue and its factors were not directly discussed in most articles; therefore, they are derived indirectly from the text. This concept analysis discusses decision fatigue in three parts: definition, related factors, and consequences.

Table 3.

Extracted themes from content analysis.

Main category	Sub category	Frequencies
Definition of decision fatigue	Behavioral dimension	18
	Physiological dimension	14
	Cognitive dimension	23
Factors related to decision fatigue	Personal factors	21
	Organizational factors	26
Consequences of decision fatigue	reduced patient care quality and safety	17
	ineffective decision‐making	19
	job stress	12
	burnout	15

4. Definition

The definition of decision fatigue varies. As a result of making an unreasonable decision, nurses feel regret and guilt and show passive behavior when making the next decision. This passiveness can lead to simple and unworkable choices, which is decision fatigue [4]. Decision fatigue is an emerging and evolving issue that should be addressed, especially among medical personnel. Decision fatigue is characterized by three dimensions encompassing behavioral, physiological, and cognitive aspects, manifesting in the gradual decline of optimal decision‐making capacity over the course of the day [22]. In another definition, the pattern of increasing incorrect decisions in medical personnel during a work shift is called decision fatigue. Decision fatigue plays a significant and impactful role in determining the health outcomes of patients [25].

5. Factors Related to Decision Fatigue

Studies have investigated factors related to decision fatigue, which can be categorized into two general parts, personal and organizational.

5.1. Personal Factors

Nurses frequently experience decision‐making fatigue due to insufficient sleep, physical and decision fatigue from working multiple shifts, and inadequate support from colleagues. These factors are generally within the nurse's control, though organizational actions can also contribute to them. For example, Allan, Johnston [14] observed that each successive decision made by nurses tended to result in a predictable shift towards more cautious and less efficient decisions, independent of overall workload or time elapsed since the start of the shift. This suggests a personal depletion of decision‐making capacity.

Pignatiello, Tsivitse [10] found a significant correlation between decision fatigue scores and symptoms of traumatic stress among 160 nurses, indicating that decision fatigue can lead to stress and fatigue. Cranley, Doran [18] highlighted that unfamiliarity with patient care aspects was a source of uncertainty, leading nurses to rely on colleagues' expertise, and that difficulties in diagnosing ambiguities resulted in unidentified information needs and a lack of information‐seeking behavior. This uncertainty, over time, contributes to decision fatigue.

Kowalski, Driller [20] identified the frequency of decision‐making as a significant factor for emotional and occupational burnout among 175 care specialists.

5.2. Organizational Factors

These factors can include a shortage of personnel, leading to frequent decisions during shifts, heavy workloads, inadequate support from personnel, and conflicts that result in decisions conflicting with organizational policies or patient interests. Auriemma, McKenzie [15] found that among 17 specialty nurses and 354 patients, 7646 decisions were made, with most decisions tending to maintain the current state, suggesting a pattern of decision fatigue where nurses avoid complex decisions. Treasure, Lam [21] observed that the rate of patient admission in the emergency department reduced in the last 4 h of a 12‐h shift, with a majority recorded in the first 8 h, suggesting that decision fatigue is more related to the number of patients than shift duration.

Zheng, Kwok [23] found a significant decrease in patient referrals for CT scans and consultations during the final hours of an emergency physician's shift, illustrating the impact of decision fatigue on clinical actions. Persson, Barrafrem [25] analyzed data orthopedic patients and found that patients seen at the end of a surgeon's shift were 33% less likely to be scheduled for surgery, with a 5.10% reduction for each additional patient handled per shift. Dubash, Bertenshaw [27] noted that organizational factors such as staffing shortages are involved in decision fatigue, emphasizing the need to reduce the number of decisions to prevent errors.

6. Consequences of Decision Fatigue

Fatigue in nursing decisions leads to inappropriate consequences, including reduced patient care quality and safety, ineffective decision‐making, job stress, and burnout. Ultimately, these negative consequences can threaten patients' health and expose them to various health risks and errors. Hickman, Pignatiello [6] found that substitute decision‐makers experienced heightened emotional distress and reduced self‐efficacy, making them prone to decision fatigue and healthcare decisions that might not align with patient preferences.

Hickman, Daly [16] reported that a majority of 16 substitute decision‐makers experienced high levels of decisional conflict, with 63% having mild regrets, and noted a direct correlation between decisional conflict and decision regret, both contributing to decision fatigue. Cho, Sagherian [17] concluded that nurse fatigue, including decision fatigue, leads to a decline in the quality of care.

Shabestari, Tabrizi [19] identified that decision‐making uncertainty among Iranian nurses, when facing ambiguous clinical situations or lacking sufficient skills, could lead to professional burnout, decision fatigue, and dissatisfaction. Parhizi, Steege [24] found a strong correlation between psychological dimensions and nursing discretion with all dimensions of fatigue, indicating that decision‐making discretion significantly impacts mental and overall fatigue levels. Fernández‐Miranda, Urriago‐Rayo [26] found a negative correlation between compassion, kindness, and decision fatigue. In situations of decision fatigue, turnover rates were higher among nurses, specialists, and emergency personnel.

6.1. Phase Three

Upon reviewing the results and analysis of the collected studies, researchers found no contradictions between them. However, as a general classification, it can be stated that all researchers similarly regard decision fatigue as a vital and impactful concept on the activities of healthcare workers, especially nurses. Due to the nature of their profession and frequent decision‐making, nurses are prone to experiencing decision fatigue, which can impact patient health. Finally, the definition of decision fatigue in the present study is “a comprehensive concept consisting of cognitive, behavioral, and physiological dimensions that occur in nurses due to the frequency of decision‐making and poses a risk of incorrect decisions or, in some cases, neglecting necessary decisions.”

Nurses face multiple decision‐making scenarios from the beginning of their shifts in their workplace. Since the onset of the COVID‐19 pandemic and the influx of patients into healthcare centers, this issue has garnered more attention among nurses. In some cases, these decisions are critical to the patient's life, while in others, they are more routine. Overall, the high pressure of making numerous decisions leads to the emergence of a concept known as decision fatigue. Based on experiences, the repetitive pressure of decision‐making, coupled with the nurse's accountability for each decision, can lead to impaired judgment and, in some cases, the making of incorrect decisions, a phenomenon known as decision fatigue. Various efforts are needed to identify more precise aspects of this concept and assess its levels among nurses. According to conducted studies, one mitigating aspect of decision fatigue is the social support provided by colleagues in the clinical environment, which should be given attention as an influential factor.

7. Discussion

Nursing is a demanding profession that requires a high level of mental, emotional, and physical energy. Nurses work long hours, often in fast‐paced and high‐stress environments, making numerous critical decisions every day. The constant pressure and decision‐making can lead to a phenomenon called decision fatigue, which can have negative consequences for both nurses and their patients [26].

Beyond the identified factors and consequences, it is crucial to consider the broader context in which decision fatigue occurs. While the core concept of mental exhaustion from continuous decision‐making appears to be a universal challenge for nurses, its specific manifestations, contributing factors, and the efficacy of mitigation strategies can vary significantly across diverse healthcare systems and cultural contexts.

For instance, studies from Western countries, such as those by Pignatiello, Tsivitse [10] and Cho, Sagherian [17] in the United States, often highlight the impact of high‐stress, high‐volume environments and the recent pressures of events like the COVID‐19 pandemic on nurses' decision fatigue. These studies frequently correlate decision fatigue with individual well‐being, burnout rates, and a decline in quality of care, reflecting a system that often prioritizes efficiency and individual responsibility. Conversely, qualitative findings from Iranian nurses by Shabestari, Tabrizi [19] emphasize the profound role of uncertainty in ambiguous clinical situations, which may stem from different training methodologies, varying levels of systemic support, or cultural norms around seeking external consultation. This suggests that the sources of decision fatigue might have different weightings depending on the local professional and cultural landscape.

Similarly, observations from emergency departments in some regions underscore how factors like patient volume, shift duration, and staffing models contribute to decision fatigue, suggesting shared operational challenges despite geographical distance [15, 18]. However, the specific coping mechanisms or organizational responses might differ due to distinct labor laws, funding models, or nursing professional bodies [18]. The study by Fernández‐Miranda, Urriago‐Rayo [26] from Colombia further broadens this perspective by linking decision fatigue with compassion, kindness, and even higher turnover rates, indicating that cultural and emotional dimensions, along with resource availability in lower‐to‐middle‐income settings, may play a distinct role in how the phenomenon is experienced, reported, and managed.

Understanding these rich, contextual nuances is not merely an academic exercise; it is vital for developing tailored, effective interventions and policies. What mitigates decision fatigue effectively in one healthcare system might require adaptation or a completely different approach in another. This comparative lens highlights the need for context‐specific research and interventions to truly support nurses and elevate patient care quality globally.

Decision fatigue is a mental state that occurs when a person becomes mentally exhausted from making too many decisions. When nurses are fatigued, they may experience a decrease in their ability to make sound decisions. This can result in poor judgment, decreased attention to detail, and a reduced ability to prioritize tasks effectively [10]. All of these can lead to mistakes, missed opportunities for preventative care, and decreased quality of care for patients. The factors that contribute to decision fatigue in nurses are varied and complex. One of the primary contributors is the sheer volume of decisions that nurses are required to make every day [4].

Nurses are responsible for assessing patients, developing care plans, administering medications, and monitoring vital signs, among many other tasks. Each of these tasks requires making decisions that can have a significant impact on patient outcomes [28]. Another factor that contributes to decision fatigue is the complexity of the decisions that nurses must make. Nurses must consider a variety of factors when making decisions, such as a patient's medical history, current condition, and medications.

They must also consider the potential risks and benefits of various treatment options and the patient's preferences and values [14]. All of these factors can be mentally exhausting and can lead to decision fatigue. The working environment can also contribute to decision fatigue. Nurses often work in high‐stress environments with high patient volumes and limited resources. They may be constantly interrupted by calls, alarms, and other distractions, making it difficult to focus on their work.

The physical demands of the job, such as lifting and moving patients, can also contribute to fatigue, making it harder for nurses to maintain their focus and decision‐making abilities. The consequences of decision fatigue in nurses can be serious. When nurses are fatigued, they may be more likely to make mistakes, overlook important details, or miss critical information. These mistakes can lead to adverse patient outcomes, including medication errors, infections, falls, and other complications. Patients may also receive suboptimal care, leading to prolonged hospital stays, increased healthcare costs, and reduced quality of life [1, 8, 17].

The effects of decision fatigue on nurses can be significant. One of the most significant effects is burnout. Burnout is a state of emotional, physical, and decision fatigue caused by prolonged stress. Nurses who experience decision fatigue may become burnt out due to the constant demand for decision‐making. Burnout can lead to reduced quality of care, absenteeism, and turnover. Additionally, decision fatigue can lead to errors in decision‐making.

When nurses are mentally fatigued, they may make errors in judgment or overlook important details, which can have serious consequences for patient care including medication errors, misdiagnosis, and delayed treatment [8].

To combat decision fatigue in nurses, healthcare organizations can take several steps. One approach is to implement electronic health record systems that can automate some decision‐making tasks, such as medication orders and dosages. This can help reduce the cognitive load on nurses, allowing them to focus on more complex decisions [8]. Organizations can also provide training and support for nurses to help them develop their decision‐making skills and manage stress and fatigue. Another approach is to ensure that nurses have access to the resources they need to make informed decisions.

This can include providing access to up‐to‐date clinical guidelines and protocols, as well as ongoing education and training [29]. Organizations can also provide tools and technology that can help nurses prioritize tasks and manage their workload, reducing the risk of decision fatigue [22]. In addition to the strategies mentioned above, there are other approaches that healthcare organizations can take to help prevent decision fatigue in nurses. For example, implementing standardized processes and procedures can help reduce the number of decisions that nurses need to make on a daily basis. This can include standardizing the way that patient assessments are conducted, or the way that medications are administered [6].

Another approach is to encourage collaboration and communication among healthcare professionals. By working together as a team, nurses can share the workload and support each other in making decisions. This can help reduce the stress and pressure on individual nurses and ensure that patient care is being delivered in a coordinated and effective manner [30]. It's also important for healthcare organizations to recognize the impact of fatigue and stress on nurses, and to take steps to support their well‐being. This can include providing opportunities for rest and relaxation, as well as access to mental health resources and support.

Encouraging healthy lifestyle habits such as regular exercise, healthy eating, and adequate sleep can also help nurses build resilience and manage stress more effectively [31, 32]. Acknowledging organizational factors such as staffing and workload is imperative in understanding the broader context of challenges faced by nurses and their impact on patient care. Despite their inherent difficulty to change, these factors play a pivotal role in shaping the work environment and directly influence the well‐being and effectiveness of nursing. nursing shortages and heavy workloads can lead to increased stress, burnout, decision fatigue and diminished job satisfaction among nurses, ultimately compromising the quality of care provided to patients [31].

Finally, healthcare organizations can use technology to help reduce decision fatigue in nurses. For example, AI‐powered decision support systems can help nurses quickly access relevant patient information and clinical guidelines, making it easier for them to make informed decisions [33]. Similarly, telehealth and remote monitoring technologies can help reduce the burden on nurses by enabling them to monitor patients from a distance, reducing the need for frequent physical assessments.

7.1. Limitations

The analysis might focus on a specific aspect of decision fatigue, potentially overlooking other contributing factors or nuances that could be significant in understanding decision fatigue within nursing. The study might have been conducted in a specific time frame or context, and the findings might not necessarily be applicable or relevant in different settings or eras. Nursing practices, technology, and working conditions evolve, which could impact the nature of decision fatigue. In the present study, only articles in Persian and English languages were examined. Additionally, full‐text access to some articles was not possible which may affect the results.

7.2. Implications for Practice

Identifying the contributing elements to decision fatigue holds the potential to reshape work environments significantly. The implementation of targeted strategies, such as improved scheduling, well‐structured breaks, or the integration of decision support systems, emerges as a promising avenue to alleviate fatigue and enhance the overall well‐being of nurses. The insights gleaned from this study can wield a transformative impact on training programs, enabling the incorporation of essential coping mechanisms, decision‐making skills, and stress management techniques into nurses' skill sets. This proactive approach equips them to navigate the demanding facets of their roles more effectively.

Furthermore, the findings have the capacity to instigate changes in healthcare policies and guidelines. For instance, advocating for more flexible shift patterns or introducing effective workload management strategies could be informed by the study, thereby mitigating decision fatigue and elevating the standard of patient care. Creating awareness about decision fatigue is paramount, fostering increased support and understanding regarding the challenges nurses encounter daily. This heightened awareness may catalyze a shift towards a more empathetic and supportive approach from healthcare institutions and the general public alike.

8. Conclusion

In conclusion, decision fatigue stands as a formidable challenge for nurses, carrying profound consequences for both healthcare professionals and the patients under their care. A nuanced comprehension of the contributing factors to decision fatigue, coupled with the strategic implementation of mitigation strategies, holds the potential to substantially enhance the support for nurses and elevate patient outcomes. This entails furnishing nurses with adequate resources and tools to facilitate informed decision‐making, adeptly managing their workload, and prioritizing their overall well‐being. Through collaborative efforts, healthcare organizations can foster an environment that empowers nurses to sustain their focus, ultimately enabling them to deliver optimal care to their patients. Also, educating nurses on decision fatigue fosters self‐awareness and enables effective fatigue management. This approach emphasizes nursing self‐management and autonomy, empowering nurses to identify and address fatigue triggers. By integrating these principles into practice, nurses can develop personalized strategies to mitigate fatigue's impact, enhancing both their well‐being and patient care outcomes.

Author Contributions

Amir Hossein Goudarzian: conceptualization, methodology, project administration, writing – original draft, writing – review and editing. Seyed Ali Taheri Hatkehlouei: data curation, writing – original draft. Mozhgan Taebi: writing – original draft, writing – review and editing. Mohammad Javad Ghazanfari: writing – original draft, writing – review and editing. Zahra Abbasi Dolatabadi: data curation, writing – original draft. Mahdi Nabi Foodani: conceptualization, methodology, data curation, project administration, writing – original draft, writing – review and editing.

Conflicts of Interest

The authors declare no conflict of interests.

Transparency Statement

The lead author Mahdi Nabi Foodani affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

All the data used in this study are accessible through sending an email to the corresponding author.