Factors influencing nurses’ involvement in decision-making in Jordanian governmental hospitals: A cross-sectional study

Abstract

Decision-making is a vital aspect of nursing, influenced by factors like experience and specialty. The aim of study to assess the perceived level of decision-making involvement among Jordanian nurses and identify influencing factors. This descriptive cross-sectional study was conducted in 3 major governmental hospitals in Jordan. A convenient sampling method was employed to recruit a total of 230 Jordanian nurses currently working in various departments within these hospitals. Data were collected through an online self-administered questionnaire, specifically the Nursing Decision-Making Instrument (NDMI), which measures nurses’ participation in clinical and organizational decision-making processes. The collected data were analyzed using Pearson’s correlation coefficient (Pearson’s r) to examine the relationship between selected demographic and professional variables (e.g., years of experience, educational level, and department) and the nurses’ levels of involvement in decision-making. The sample’s age ranged from 22 to 54 years (mean = 32.95), and nursing experience spanned 1 to 22 years (mean = 12.35). Nurses managed an average workload of 14.76 patients per shift. Decision-making scores, as measured by the nursing decision-making instrument, ranged from 61 to 92, with a mean score of 71.76. The majority of participants (86.5%) demonstrated a flexible decision-making orientation, while the remaining 13.5% exhibited a more intuitive or analytical style. Statistical analyses revealed significant positive correlations between decision-making scores and age (r = 0.283), total nursing experience (r = 0.371), and departmental experience (r = 0.246). In contrast, workload showed a significant negative correlation with decision-making scores (r = –.460), suggesting that higher patient loads may hinder effective participation in decision-making. The study highlights the need to strengthen nurses’ involvement in decision-making in Jordan. Findings suggest that nursing education should place greater emphasis on building decision-making skills through both training and experience. Health policies should support nurses’ roles in clinical decisions, while workload management such as improving nurse-to-patient ratios can enhance their ability to make effective decisions. Empowering nurses in these areas is essential for improving patient care and overall healthcare outcomes.

1. Introduction

Decision-making is a critical skill in nursing and is essential for ensuring safe, effective, and high-quality patient care across diverse healthcare settings. It is considered an integral component of a nurse’s daily responsibilities, influencing clinical outcomes, ethical practice, and patient satisfaction.^[1] Decision-making in nursing is a broad concept that encompasses routine tasks such as adjusting a patient’s position or offering fluids to highly complex and ethically charged decisions, such as withdrawing life support.^[2] Every moment in a nurse’s shift demands some form of decision-making, ranging from basic care activities to high-stakes interventions.

Nibbelink^[3] identified 3 primary types of decision-making in nursing: clinical, intuitive, and analytic. These types reflect the range of cognitive and experiential processes that nurses employ when making choices, whether deciding to administer as needed medication or change a ventilator circuit.^[4] The complexity of these decisions is influenced by the nurse’s ability to synthesize knowledge, experience, emotions, and available evidence.^[5] Contextual factors such as experience level, education, stress, and workplace environment also play a significant role in shaping how decisions are made.^[6] For example, Nilsson and Lindström (2016) found that decision-making in emergency settings depends on factors like situational awareness, collaboration, and patient familiarity,^[7] while Flannery et al (2016) observed that intensive care unit decisions are often constrained by ethical, legal, and resource-related challenges.^[8] These findings underscore that decision-making is not a linear process but a dynamic integration of multiple internal and external influences.

Despite the acknowledged importance of decision-making, existing research in Jordan and similar contexts has tended to focus on isolated dimensions such as autonomy,^[9] end-of-life experiences,^[10] and shared governance^[6] rather than providing a comprehensive understanding of nurses’ overall involvement in decision-making processes. For instance, Al-Hamdan et al^[11] found low levels of perceived involvement among Jordanian nurses, with notable differences across departments and facilities. However, limited attention has been paid to exploring how frequently and effectively Jordanian nurses engage in various types of decision-making and what factors enhance or hinder their involvement.

While nurses in Jordan are central to patient care, there is limited evidence on the extent and nature of their involvement in clinical decision-making. This gap in knowledge raises concern, as insufficient participation in decision-making can undermine care quality, nurse autonomy, and job satisfaction. Moreover, factors influencing decision-making such as workload, experience, and education remain underexplored in the local context. This study is necessary to fill the existing gap in research by assessing the perceived level of decision-making involvement among Jordanian nurses working in governmental hospitals. Understanding these perceptions is critical for informing nursing education, improving policy and staffing strategies, and ultimately enhancing patient outcomes. The findings will benefit healthcare administrators, nursing educators, and policymakers by providing evidence to support initiatives aimed at empowering nurses in their decision-making roles, improving job satisfaction, and ensuring safer and more effective healthcare delivery. The purpose of the study was to assess the perceived level of involvement in decision-making among Jordanian nurses working in governmental hospitals.

2. Materials and methods

2.1. Research design

The study used a descriptive, cross-sectional design.

2.2. Research settings

The study was conducted in 3 governmental hospitals. Those hospitals were selected because they are 3 major governmental multispecialty hospitals distributed over 3 major cities in Jordan.

2.3. Sampling design

The study used a convenient sampling design with inclusion-exclusion criteria to identify, select and recruit nurses who are eligible to join the study. A G*Power analysis indicated that a minimum sample size of 220 participants was required, based on an independent samples t-test, with a power of 0.8 and a significance level (α) of 0.05. Ultimately, a total of 230 registered nurses were included in the study. The inclusion criteria of the study were must be a registered nurse and must be employed by the hospital for a minimum of 1 year. Nurse Managers are excluded to join the study because one of the objectives is to assess involvement in decision-making activities, and nurse managers would already be practicing this regularly as part of their job role.

2.4. Data collection

Data collection commenced once relevant ethical considerations are obtained from Zarqa University ethical committee and the Ministry of Health. The researcher linked with the heads of the department where the study was carried out. A master list of all nurses employed was obtained from the head of the department. From this list, the researcher screened nurses for eligibility to join the study. Those found eligible to join were invited to participate via their work email. Invitations were sent via their work emails. Once the nurses accepted the invitation, the researcher asked the nurse to fill out the online survey Google form that includes consent and a cover letter explaining the purpose and the risks and benefits of joining the study. The participants were given 2 weeks to complete the survey to allow enough time, even though the survey took no >15 minutes, start from August 20, 2023 until September 15, 2023. All filled-out surveys were extracted as an excel sheet from Google Forms once the sample was completed.

2.5. Instrument

2.5.1. Participant information sheet

The participant information sheet included data on nurse participants’ sociodemographic and professional characteristics. Data included age, sex, educational attainment, length of time employed by the hospital, length of time working in the current place of work, workload.

2.5.2. Nurse Decision Making Instrument

The Nursing Decision-making Instrument, originally developed by Lauri and Salanterä,^[12] and later revised in 2014 is a tool based on scientific research that measures the decision-making process of nurses. It’s designed to analyze whether a nurse uses an analytical or intuitive approach to decision-making, or a mix of both. The instrument consists of 24 items, each scored on a scale from 1 to 5, where 1 = Never or almost never; 2 = Rarely; 3 = Not rarely or not often; 4 = Often; and 5 = Almost always or always. The scores for odd-numbered items are reversed, with the scoring scale inversed; for instance, a response of 1 would be scored as 5, and a response of 5 would be scored as 1. Even-numbered items are scored as given. The overall score is interpreted as follows: <67 points suggests an analytically oriented decision-making approach; between 68 and 78 points suggests a flexible decision-making approach, where the nurse applies both analytical and intuitive methods depending on the situation; and >78 points suggests an intuitively oriented decision-making approach. The instrument has been culturally adapted and tested for validity in the Jordanian healthcare setting, confirming its applicability and relevance for use among nurses in Jordan. The reliability of the instrument was measured using internal consistency with Cronbach α values of 0.81 to 0.92 for the whole instrument.

2.5.3. Ethical considerations

Relevant ethical approvals were obtained from Zarqa University/Faculty of Nursing ethical review boards as well as from the Ministry of Health ethical review board (24/2022).

2.5.4. Data analysis plan

All statistical analysis was performed using the Statistical Package for the Social Sciences version 26. Descriptive statistics were performed to obtain means and standard deviations of sociodemographic and professional characteristics, as well as levels of decision-making of Jordanian nurses working in hospital settings. Pearson’s r was used to test the relationship between variables and levels of decision-making involvement.

3. Results

Regarding age, the participants varied from 22 to 54 years, with a median age of 32.95 years (standard deviation [SD] = 5.98). In the nursing field, the total years of experience among the participants ranged from 2 to 22 years, with a median of 12.35 years (SD = 5.88). The experience in their current department ranged from 1 to 11 years (SD = 3.22). The workload, ranging from 2 to 70 patients. In terms of gender distribution, 31.3% were males (n = 72), and 68.7% were females (n = 158). Regarding the department, 24.3% (n = 56) of the participants were from Medical-Surgical departments. Finally, the educational level of the participants was predominantly Bachelor of Science in Nursing with 85.2% (n = 196; Table 1).

Table 1.

Sociodemographic characteristics of participants.

Variable	Minimum	Maximum	Median	Standard deviation
Age	22	54	32.95	5.978
Total years of experience in nursing	2	22	12.35	5.880
Total years of experience in the current dept.	1	11	4.41	3.218
Workload (number of patients in the last shift)	2.0	70.0	14.756	10.3029
Variable	Frequency		Percentage
Gender
Male	72		31.3
Female	158		68.7
Department
Medical-surgical	56		24.3
Pediatric	19		8.3
Maternity	37		16
OR	59		25.7
ER	23		10.0
ICU	36		15.7
Educational level
BSN	196		85.3
Master	30		13.0
PhD	4		1.7

BSN = Bachelor of Science in Nursing, ER = emergency room, ICU = intensive care unit, OR = operating room, PhD = Doctor of Philosophy.

The overall decision-making total score, which encompasses all the individual item scores, ranged from 61.00 to 92.00, with an average score of 71.7609 and a standard deviation of 3.69. The item “I make assumptions about forthcoming nursing problems during the first contact with the patient” has a mean score of 3.3696, indicating a relatively high tendency among nurses to make initial assumptions about nursing problems. On the other hand, items related to comparing patient information with prior knowledge or nursing experiences (“I compare information I have received about the patient with my earlier knowledge of similar individual patients’ cases” and “I compare information I have received about the patient with my own experiences in nursing practice”) scored 2.5739 and 3.4870 respectively, highlighting variations in how nurses integrate past experiences into current patient care. The item “It is easy for me to assess the impacts of my actions on the patient’s condition” had a mean score of 3.4043 and a standard deviation of 1.24927, suggesting that nurses feel relatively confident in evaluating the consequences of their actions on patient outcomes (Table 2).

Table 2.

Level of decision-making skills of nurses.

Items	Minimum	Maximum	Mean	Standard deviation
I collect as much advance information as possible from the patient’s records	1.00	5.00	2.5522	1.26227
I rely on my own interpretations when it comes to defining the patient’s condition	1.00	5.00	3.3130	1.26674
On the basis of my advance information, I specify all the items I intend to monitor and ask the patient about	1.00	5.00	2.6870	1.25636
I make assumptions about forthcoming nursing problems during the first contact with the patient	1.00	5.00	3.3696	1.19238
I confirm the impression I have formed on the basis of advance information by seeking for symptoms that support my views	1.00	5.00	2.5870	1.19270
It is easy for me to make a distinction between relevant and irrelevant information in defining the patient’s condition	1.00	5.00	3.2652	1.25176
I compare information I have received about the patient with my earlier knowledge of similar individual patients’ cases	1.00	5.00	2.5739	1.22963
I compare information I have received about the patient with my own experiences in nursing practice	1.00	5.00	3.4870	1.20671
I compare information I have received about the patient with research knowledge about the nursing care and its impacts	1.00	5.00	2.8304	1.25100
It is easy for me to see, even without closer analysis, which pieces of information are relevant to defining the patient’s nursing problems	1.00	5.00	3.1783	1.19257
I define the patient’s nursing problems objectively on the basis of the symptoms and complaints observed	1.00	5.00	2.6261	1.23246
It is easy for me to form an overall picture of the patient’s situation and major nursing problems	1.00	5.00	3.3130	1.25636
I draw up the patient’s nursing plan according to the stages of the nursing decision-making process	1.00	5.00	2.6957	1.25850
I base the patient’s nursing plan on my own nursing views and/or the patient’s views on his/her care	1.00	5.00	3.2043	1.22456
I base the patient’s nursing plan on the general regimes prescribed for the patient’s disease	1.00	5.00	2.6609	1.22483
I document without difficulties the general directions concerning the patient’s care to the patient’s records	1.00	5.00	3.3783	1.18964
I set out targets for the patient’s care that are easy to measure	1.00	5.00	2.6391	1.20234
I anticipate the impacts of nursing interventions on the patient	1.00	5.00	3.3304	1.20205
I follow as closely as possible the patient’s existing nursing plan for his/her disease and situation	1.00	5.00	2.6348	1.22443
I anticipate changes in the patient’s condition on the basis of individual cues even before there are any clear symptoms	1.00	5.00	3.3043	1.20170
I use specific information about the treatment of the patient’s disease when making decisions about nursing care	1.00	5.00	2.6174	1.23686
I flexibly change my line of action on the basis of feedback on the patient’s situation	1.00	5.00	3.4348	1.15695
I try to find reasons for my own observations of changes in the patient’s condition	1.00	5.00	2.6739	1.25476
It is easy for me to assess the impacts of my actions on the patient’s condition	1.00	5.00	3.4043	1.24927
Decision-making total score	61.00	92.00	71.7609	3.66849

Table 3 reveals that a small proportion of the nurses, accounting for 10.4% (n = 24), are predominantly analytically oriented in their decision-making process. The majority of the nurses, representing a significant 86.5% (n = 199), exhibit flexible decision-making skills. A smaller segment, comprising 3.0% (n = 7), is intuitively oriented in their decision-making (Table 3).

Table 3.

Distribution of decision-making orientations among nurses.

Category	Frequency	Percent
Analytically oriented	24	10.4
Decision-making is flexible and it is both analytical and intuitive depending on the situation	199	86.5
Decision-making is intuitively oriented	7	3.0

The study found a statistically significant positive correlation between age and decision-making scores, with a Pearson correlation coefficient of r = 0.283 (P < .001). However, this represents a weak to moderate correlation, and the text does not explicitly interpret its strength. A stronger positive correlation was observed between total years of nursing experience and decision-making scores (r = 0.371, P < .001), suggesting that experience may be a more influential factor than age alone. Interestingly, workload, measured by the number of patients cared for during the last shift, showed a moderate negative correlation with decision-making scores (r = –0.460, P < .001), indicating that higher patient loads may hinder optimal decision-making. Additionally, years of experience within the current department also correlated positively with decision-making scores (r = 0.246, P < .001), though again, this is a relatively weak association. Overall, while the statistical significance of these findings is clear, the study would benefit from explicitly discussing the practical implications and strength of these correlations (Table 4).

Table 4.

Relationships and differences in perceived levels of decision-making based on sociodemographic characteristics of nurses.

Variables		Decision-making total score
Age	Pearson correlation	0.283*
	Sig. (2-tailed)	0.000
Total years of experience in nursing	Pearson correlation	0.371*
	Sig. (2-tailed)	0.000
Workload (number of patients in the last shift)	Pearson correlation	−0.460*
	Sig. (2-tailed)	0.000
Total years of experience in the current dept.	Pearson correlation	0.246*
	Sig. (2-tailed)	0.000

^*Pearson correlation.

The significant predictors include “total years of experience in nursing” with a coefficient of .0644 and a significant P-value of .000, suggesting a positive relationship with decision-making skills. “workload (number of patients in the last shift)” shows a negative relationship with decision-making, indicated by a coefficient of −2.956 and a P-value of .004. “Total years of experience in the current department” also positively affects decision-making skills with a coefficient of 3.044 and a P-value of .002. The age of the nurses also showed a significant but less pronounced effect (coefficient = 2.206, P = .035). These results provide insights into the factors that significantly influence the decision-making abilities of nurses in this setting (Table 5).

Table 5.

Predictors of perceived decision-making among nurses.

Model	Unstandardized coefficients	Standardized coefficients	T	Sig.	Collinearity statistics
	B	β			Tolerance	VIF
(Constant)	39.562		5.833	0.000
Age	2.206	0.118	−2.119	0.035	0.714	1.400
Total years of experience in nursing	0.644	0.242	−4.304	0.000	0.702	1.424
Workload (number of patients in the last shift)	−2.956	−0.155	2.913	0.004	0.780	1.281
Total years of experience in the current dept.	3.044	0.159	−3.178	0.002	0.888	1.126

Sig. = significant, VIF = variance inflation factor.

4. Discussion

The study focused on examining the decision-making skills of Jordanian nurses employed in governmental hospital settings. An exploration was conducted into how various sociodemographic factors influence these skills, and efforts were made to identify significant predictors that could impact nurses’ involvement in decision-making processes. The results uncovered notable nursing decision-making orientations, predominantly highlighting a tendency towards flexible decision-making styles.

The majority of the nurses, representing a significant 86.5%, exhibit flexible decision-making skills. They adapt their decision-making style according to the situation, demonstrating a balance between analytical and intuitive approaches. This flexibility suggests that these nurses are capable of switching between logical analysis and intuition-based decision-making, depending on what the situation demands. These results were not aligned with national study that found the Jordanian nurses had poor decision-making skills.^[13] Results showed that Jordanian nurses had low scores on their decision-making when it comes to health policy activities.^[14] The exploration of decision-making orientations among Jordanian nurses, with a specific focus on their preference for a flexible decision-making approach, necessitates a deeper understanding within the broader context of nursing and healthcare theories. This preference is reflective of the complexities inherent in modern healthcare, where adaptability and responsiveness are crucial.

In current study, total years of experience in nursing were showed a positive relationship with decision-making skills, the similar with study that found that nurses who developed the experience necessary to develop competencies and confidence in their roles and responsibilities were more likely to exhibit better decision-making involvement and behaviors.^[3] In another study, years of experience attainment were found to improve levels of decision-making skills significantly.^[13] Johansen and O’Brien, highlight the role of experience in honing nurses’ decision-making capacities, suggesting that over time, nurses acquire a more profound understanding of clinical intricacies.^[4] Experienced nurses, having encountered a wider array of clinical scenarios, are better positioned to make informed and effective decisions.^[3] Also, the findings of Melin-Johansson et al^[1] and Mackey and Bassendowski,^[15] suggested that seasoned nurses can more effectively integrate evidence-based practice into their decision-making due to their extensive clinical exposure.

The study also identifies workload as a complex predictor of decision-making skills, revealing a negative correlation between excessive workload and decision-making efficacy. This finding aligns with Young et al,^[16] who highlighted the detrimental effects of high patient loads on nurses’ ability to make accurate clinical judgments. Similarly, Kozlowski et al^[17] examined the emotional toll of workplace stress, noting that cognitive overload can compromise the quality and timeliness of decision-making. Bomhof-Roordink et al^[18] further emphasized the interconnectedness of workload, decision-making, and patient engagement, indicating that when nurses are overwhelmed, their ability to involve patients meaningfully in care decisions also declines.

In practice, these findings suggest that managing nurse-to-patient ratios and supporting workload distribution are critical to maintaining high-quality clinical decision-making. It also underscores the importance of organizational support systems, such as access to decision-making tools, debriefing opportunities, and emotional support, especially during high-stress shifts. Moreover, the emphasis on collaboration – reflected in the works of Nilsson and Lindström^[7] and Rababa et al^[13] highlights the practical necessity of fostering interdisciplinary teamwork and shared decision-making. In real-world settings, this translates to nurses regularly consulting with colleagues, involving patients and families in care planning, and participating in team huddles or rounds. These practices mirror the principles of collaborative leadership, which promote inclusive, team-oriented approaches to clinical challenges. Ultimately, applying these insights can lead to more balanced, resilient care environments that empower nurses to make thoughtful, patient-centered decisions even under pressure.

5. Limitations of the study

This study has several limitations that should be considered when interpreting its findings. First, the sample was limited to nurses working in governmental hospitals in Jordan, which may affect the generalizability of the results to other healthcare settings or regions. Second, although the sample size was adequate, there may have been limited diversity within the participant group, potentially restricting the scope of insights into decision-making skills across a broader nursing population. Third, the reliance on self-reported data introduces potential biases, including social desirability and recall bias, which may compromise the accuracy of the reported decision-making practices. Future research should consider incorporating observational or objective assessment methods to validate and enhance the reliability of self-reported data.

6. Conclusion

The findings of this study carry important implications for nursing practice and healthcare policy, particularly within the Jordanian context. The observed preference for flexible decision-making highlights the necessity of cultivating dynamic clinical environments that support both analytical and intuitive approaches. Healthcare institutions should implement targeted training programs that enhance nurses’ decision-making skills, emphasizing situational adaptability and critical thinking. Policymakers should consider integrating decision-making competencies into nursing curricula and continuous professional development programs to ensure alignment with real-world clinical demands. Additionally, the influence of sociodemographic factors and identified predictors suggests the need for personalized support and mentorship strategies that account for nurses’ backgrounds and experiences. Future research should explore how organizational factors – such as leadership style, workload, and access to clinical resources – interact with nurses’ decision-making styles, using mixed methods or longitudinal designs to strengthen the evidence base and guide practical improvements.

Acknowledgments

The authors extend their appreciation to Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2025R293), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Author contributions

Conceptualization: Khalid Al-Mugheed, Nadiah A. Baghdadi.

Data curation: Islam Ali Oweidat.

Formal analysis: Huda R. Aboskoot.

Investigation: Ghada M. Abu Shosha, Ala’a F. Dalky.

Methodology: Omaima Nassar.

Writing – original draft: Sally Mohammed Farghaly Abdelaliem.