This was a descriptive cross-sectional study conducted to determine the vigilance of nurses working in ICUs. The total vigilance score was higher than the expected average, indicating that the nurses had a relatively high level of vigilance in clinical practice. Geib (15) also reported a vigilance level higher than the expected range in her study. Other studies using different scales to assess nursing vigilance and patient safety have also reported high vigilance levels in the performance of daily nursing care. For example, Vahidi et al. (6) conducted interviews with nurses working in psychiatric wards and showed that nurses were able to predict events and take appropriate preventive measures by cognitively evaluating patients through the assimilation of data from their observations and available risk assessment patterns. Additionally, O'Brien et al. (19) explained that nurses in the recovery room reduced risk and ensured patient safety using team and instant coordination strategies. In Ajri et al.’s (20) study, nurses noticed and tried to prevent mistakes by monitoring, questioning, and self-reporting errors.
Of the subscales, the CDM showed the lowest score, consistent with Geib (15). According to Maharmeh et al. (21), the difficult and complicated statuses of the health of patients in the ICU highlight the complexity and importance of CDM by nurses. Patients’ unstable and rapidly changing conditions require nurses to make decisions within a limited time. This study’s findings suggest it can be argued that nurses working in ICUs should deal with at least two patients with different characteristics and needs. On the other hand, making independent decisions for each patient can be challenging for these nurses. Accordingly, the nurses participating in this study obtained lower scores in their responses to the statements under the CDM subscale that had inverse scoring. Overall, considering the impact of CDM on patient care and recovery, there is a need to implement effective educational interventions to improve the CDM skills of nurses working in ICUs.
In the CDM subscale, the lowest average scores were related to the phrases, "It is important to me to reach consensus with my colleagues when making decisions" and "I consider my colleagues’ reactions when I think about my options." Most nurses replied to these phrases with "always" or "usually" instead of "never" as the answer with the highest score. This indicates the participants’ perceived interaction with other nurses as a best practice in decision-making, while nurses should play a role as an individual fully informed of their patient’s condition and the main decision-maker, obviating the roles of others in this process. One of the reasons for this observation could be that these wards employed nurses with little experience. It may also indicate that nursing education and internship periods have not significantly improved nurses’ confidence and independence in decision-making, which are among the main professional nursing competency components. Since taking more responsibility requires that professional nurses attain independence in their activities, including decision-making, new educational methods are needed to empower nurses’ critical thinking skills and boost their self-confidence. The curriculum should be modified to help students know themselves and develop independent behaviors and make them familiar with professional rules and duties. Finally, managers must support nurses to promote their independence in decision-making.
Another phrase, "My past experiences have urged me to consider the pros and cons of making decisions about patients," also attained a low score. The expected reply to this phrase was "never;" however, most participants chose either "always" or "usually." This was consistent with the findings of Maharmeh et al. and Clark et al. (21, 22), who declared that clinical experience was one of the main determinants of nurses’ decision making. However, this study suggests that the participants only exploited their experience as a tool for critical thinking and clinical reasoning, setting aside the knowledge and skills learned in nursing school.
Our participants demonstrated the highest score in the TIPC subscale, which is consistent with the findings in Geib (15). The highest scores were related to the phrases, "I monitor symptoms to predict changes in patients’ condition," "I constantly check patients’ hemodynamic indicators on the monitoring system," "I try to be prepared to respond to changes in patients’ conditions," and "I check patients’ test results at specific times to monitor their current condition." These results demonstrate the importance of careful monitoring and immediate responses by nurses. According to Kagan, Nightingale was the first to assert the concepts of vigilance and monitoring in 1850 (23), and defined monitoring as a regular assessment, in addition to analyzing patient information and providing prompt responses to events. Consistent with our observation, Meyer and Lavin (9) specified that being skilled at the main vigilance components is necessary for early detection of patient problems, recognizing the causes of deterioration in patient conditions and timely responses to the consequences. On the other hand, Hillman et al. (24) found that 29% of patients with cardiac arrest had serious physiological instabilities 8 hours before death, and one-third of them experienced these variations 48 hours before death. The most common physiological instabilities were hypotension and tachypnea. Buist et al. (25) reported physiological instabilities before preventable death, such as drops in blood pressure and oxygen saturation and significant changes in heart and respiration rates, were the predominant predictors of mortality; failure to identify these alternations in a timely manner significantly contributed to death. Alexa et al. (26) examined the factors affecting sepsis diagnosis and failure to resuscitate (FTR) among 57 nurses working in an oncology ICU and reported that FTR mainly occurred after nurses failed to monitor, detect, and correctly perceive patient data. The results of these studies, however, are inconsistent with our findings of a high score in detecting changes in patient conditions. This discrepancy may be because the aforementioned studies were retrospective and applied objective measurement tools, unlike the current study which applied a mental tool.
In the present study, a significant relationship was observed between the CDM subscale and participant age. Geib (15) also reported such a relationship; however, it was statistically insignificant. In Parasuraman and Giambra’s (27) review of 13 studies, half the studies indicated that CDM was related to age and delayed by advancing age. Likewise, in Cornelia et al. (28), the reaction time of the youngest age group (20–29 years) was significantly shorter than that of participants aged 60–69 or 70–79 years. These findings indicate that age plays an important role in promoting CDM in nurses. Therefore, implementing educational and practical interventions to improve the ability of young nurses to make informed decisions may potentially impact their caring experience and improve the outcomes of health care services.
As with all studies, this study has some limitations; these include the small sample size, the low ratio of male nurses, and the low number of nurses with master's degrees. Therefore, care should be taken in generalizing our findings to all nurses. In this study, we used a mental tool and self-reporting to assess vigilance; however, it is also important to examine nurses’ vigilance during patient care. Therefore, it is advisable to utilize a combination of both subjective and objective measurement scales to assess vigilance and its relationship with other variables.