Iran Journal of Nursing

Introduction
Global health is undergoing considerable changes. Advances in technologies and methods of patient care have increased the complexity of decision-making in clinical care. The role of nursing profession in responding to new knowledge, political pressures, and technological advances in health care has increased, which has associated with broader decision-making. Clinical decision making is a complex process that requires the nurse’s knowledge, access to appropriate information resources, and a supportive work environment. In intensive care units (ICUs), clinical decisions are made quickly in a stressful environment; nurses must make quick and accurate decisions to avoid the worsening of patients’ condition. In addition, dealing with new and complex technology, being in contact with critically ill patients, and lack of resources, puts a heavy burden on ICU nurses and affects their decision-making skills. 
The nurse’s ability to promote health, prevent disease, relieve pain, and provide high-quality patient care depends on effective clinical decision-making. Clinical decision-making is an essential component of nursing profession which distinguishes professional nurses from non-professional ones. According to annual reports, a large number of patients die due to poor health care decision-making. Numerous factors, including individual and organizational factors affect clinical decision-making. The organizational factors have not been fully understood; identifying them can help hospital managers improve nurses’ clinical decision-making skills. One of these organizational factors is organizational culture. It is a factor to give identify to the organization and commitment of employees. It reflects the norms that determine the attitude and behavior of people in the organization and is a behavioral guide for them. Despite the importance and possible relationship between clinical decision-making and organizational culture, no study was found to examine their relationships. Therefore, this study aims to investigate the participation in clinical decision-making of nurses in the ICUs of hospitals affiliated to Iran University of Medical Sciences and examine its relationship with organizational culture.
Materials & Methods 
This is a descriptive-correlational study. The study population consists of all nurses working in the ICUs of hospitals affiliated to Iran University of Medical Sciences in Tehran, Iran. Of these, 317 nurses who met the inclusion criteria were selected by proportional stratified sampling, sequential sampling, and quota sampling methods. Due to the COVID-19 pandemic, sampling lasted four months (February-May, 2021). The data were collected using three instruments: (a) Demographic form, (b) the clinical decision-making questionnaire (CDMQ) of Kyalo which has 27 items rated on a four-point Likert scale (1=Never: 2=Rarely; 3=Sometimes; 4=Always), (c) Cameron & Quinn’s organizational culture assessment instrument (OCAI), which has 24 items and 6 subscales, each with 4 items. The content validity of these questionnaires was evaluated and confirmed by a panel of experts including three faculty members from the School of Nursing and Midwifery, Iran University of Medical Sciences. The reliability of the CDMQ with Cronbach’s alpha was obtained 0.91. For the OCAI, the reliability in the study by Cameron et al. (1990) with Cronbach’s alpha was reported higher than 0.70. The face and content validity of the Persian version of this questionnaire was confirmed by Darvish et al. (2014), who reported a Cronbach’s alpha of 0.87. The obtained data were analyzed in SPSS v.16 statistical software. Descriptive statistics (mean, standard deviation, frequency, percentage) were used to describe the data, and Pearson correlation test, independent t-test, and chi-square test were used to examine the relationships between the study variables.
Results
The mean score of CDMQ was 70.16±11.65, which is higher than the cutoff point of the instrument (>54). This indicated that the nurses’ participation in clinical decision-making was high. The dominant organizational culture in the current conditions was the market culture, and the clan culture was the dominant culture in the preferred conditions. The organizational culture had no statistically significant relationship with clinical decision-making the current conditions (P=0.130), but this relationship was significant in the preferred conditions (P=0.014). Clinical decision-making in nurses with clan culture was significantly higher than in those with market culture (P=0.013).
Discussion
The findings showed that clinical decision-making of nurses in ICUs of hospitals affiliated to Iran University of Medical Sciences was high. The current organizational culture was different from the preferred organizational culture. Nurses’ organizational culture had a significant relationship with their clinical decision-making. Given that the clan culture was recognized as the preferred culture, planning should be done to establish clan culture in the study hospitals to increase nurses’ participation in clinical decision-making. 

Ethical Considerations
Compliance with ethical guidelines
Ethical approval for this study was obtained from the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1399.111.

Funding
This study was extracted from a master thesis Mrs Nahid Shojaee in nursing management. It was funded by Iran University of Medical Sciences.

Authors' contributions
Supervision, data analysis: Tahmine Salehi; preparing initial draft, project management, editing & review: Nahid Shojaee; Data analysis: Hamid Haghani

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank Iran University of Medical Sciences, the staff of selected hospitals, and all the nurses who participated in the study for their support and cooperation.


References

1. World health organization. Nurseing and Midwifery [Internet]. 2022. [Link]
2. Kalantari M, Sajadi SA, Pishgooie SA. [Evaluation of nurses ‘performance from nurses’ viewpoints on providing safe care to patients in AjA hospitals in 2018 (Persian)]. Mil Caring Sci J. 2019; 5(3):173-81. [DOI:10.29252/mcs.5.3.173]
3. Nibbelink CW, Brewer BB. Decision-making in nursing practice: An integrative literature review. J Clin Nurs. 2018; 27(5-6):917-28. [DOI:10.1111/jocn.14151] [PMID] [PMCID]
4. Shahraki Moghaddam E, Manzari ZS, Ghandehari Motlagh Z. [The evaluation of nurse, s clinical decision making in intensive care unit at the teaching hospitals of Mashhad (Persian)]. J Sabzevar Univ Med Sci. 2017; 24(2):207-13. [Link]
5. Bucknall TK. Critical care nurses' decision-making activities in the natural clinical setting. J Clin Nurs. 2000; 9(1):25-35. [PMID]
6. Maharmeh M, Alasad J, Salami I, Saleh Z, Darawad M. Clinical decision-making among critical care nurses: A qualitative study. Health. 2016; 8(15):1807-19. [DOI:10.4236/health.2016.815173]
7. Standing M. Clinical judgement and decision making in nursing. California: SAGE Publications; 2017. [Link]
8. Samuel H, Sehar S, Afzal M, Gilani SA. Influence of supportive leadership on nursing clinical decision making in critical care units at tertiary care hospital Lahore. Int J Nurs. 2018; 5(2):45-71. [DOI:10.15640/ijn.v5n2a5]
9. Sharifiyana M, Zohari S, Dabirian A, Alavi H. [Evaluation of participation in clinical decision making by nurses in selected hospitals of shahid beheshti university of medical sciences (Persian)]. Nurs Midwifery J. 2016; 13(11):928-34. [Link]
10. Szara M, Ksykiewicz-Dorota A, Klukow J, Lamont M. Review of research on organizational culture in health care system. Pielegniarstwo XXI wieku/Nursing in the 21st Century. 2018; 17(2):32-44. [DOI:10.2478/pielxxiw-2018-0013]
11. Cameron KS, Quinn RE. Diagnosing and changing organizational culture: Based on the competing values framework. Hoboken: John Wiley & Sons; 2011. [Link]
12. Mannion R, Davies HT, Jacobs R, Kasteridis P, Millar R, Freeman T. Do Hospital boards matter for better, safer, patient care? Soc Sci Med. 2017; 177:278-87.[DOI:10.1016/j.socscimed.2017.01.045] [PMID] [PMCID]
13. Musavi M , Shojaee K, Azodi P, Jahanpour F. [Barriers and facilitators of clinical decision making among nurses (Persian)]. Q J Nurs Manage. 2016; 4(3):9-17. [Link]
14. Kyalo MA. Factors affecting clinical decision making by nurses at the critical care unit in Kenyatta National Hospital [PhD dissertation]. Nairobi: University of Nairobi; 2008. [Link]
15. Darvish H, Kolivand P, Kermani B. [Relationship between organizational culture and the involvement of employees in the Khatam Alanbia Hospital in Tehran (Persian)]. Neurosci J Shefaye Khatam. 2014; 2(3):19-27.[DOI:10.18869/acadpub.shefa.2.3.19]
16. Farčić N, Barać I, Lovrić R, Pačarić S, Gvozdanović Z, Ilakovac V. The influence of self-concept on clinical decision-making in nurses and nursing students: a cross-sectional study. Int J Environ Res Public Health. 2020; 17(9):3059. [DOI:10.3390/ijerph17093059] [PMID] [PMCID]
17. Kozlowski D, Hutchinson M, Hurley J, Rowley J, Sutherland J. The role of emotion in clinical decision making: an integrative literature review. BMC Med Educ. 2017; 17(1):255. [DOI:10.1186/s12909-017-1089-7] [PMID] [PMCID]
18. Traczyńska K, Kunecka D. Organizational culture in nursing teams based on the example of a particular hospital. Prog Health Sci. 2018; 8(1):46-54. [Link]
19. Goula A. The present and the desired organizational culture model of Greek public hospitals. J Hum Resour Sustain Stud. 2020; 8(3):203-18. [DOI:10.4236/jhrss.2020.83012]
20. Mesfin D, Woldie M, Adamu A, Bekele F. Perceived organizational culture and its relationship with job satisfaction in primary hospitals of Jimma zone and Jimma town administration, correlational study. BMC Health Serv Res. 2020; 20(1):438. [DOI:10.1186/s12913-020-05319-x] [PMID] [PMCID]
21. Omidi N. [The study of organizational learning level of nurses in hospitals affiliated to Tehran University of medical sciences and the impact of organizational culture component on that (Persian)]. J Nurs Educ. 2017; 6(5):31-8. [doi:10.21859/jne-06055]
22. Sadeghi A, Mohseni Fard J, Poorolajal J. [The correlation between organizational culture and nurses' turnover intention in educational and therapeutic centers of Hamadan university of medical sciences (Persian)]. J Health Promot Manage. 2018; 6(6):37-45.[DOI:10.21859/jhpm-07046]
23. Movafegh N, Zarankesh SM, Naeeni MK. [Investigating the factors affecting participation in clinical decision-making from viewpoint of physicians and nurses of educational hospitals of Qazvin (Persian)]. Med Sci J Islam Azad Univ. 2019; 29(3):249-57. [DOI:10.29252/iau.29.3.249]
24. Wu M, Yang J, Liu L, Ye B. An investigation of factors influencing nurses’ clinical decision-making skills. West J Nurs Res. 2016; 38(8):974-91.[DOI:10.1177/0193945916633458] [PMID]
25. Alsaqqa HH. Assessment of organizational culture types in Gaza Strip hospitals. Saúde Soc. 2020; 29(4):1-13.[DOI:10.1590/s0104-12902020191016]
26. Sokhanvar M, Mosadeghrad A. [Organizational culture of selected hospitals of Tehran city (Persian)]. J Hosp. 2017; 16(2):46-57. [Link]