How Do Nurses Make Clinical Decisions Via Remote Reviews: A Convergent Mixed-Methods Study

Background

Remote clinical reviews have become an integral component of contemporary nursing practice across community and acute care settings. Nurses increasingly make autonomous clinical decisions using telephone, video, and online/digital systems, often with limited sensory information and under conditions of uncertainty. However, empirical understanding of how nurses make clinical decisions via remote reviews remains limited.

Aim

To explore and understand how registered nurses (RNs) make clinical decisions about patient care via remote reviews.

Methods

A convergent mixed-methods design was employed. Quantitative data (analytic quantitative sample N=53) were collected using validated questionnaires that measured decision-making processes, physician–nurse collaboration, decision-making stress, and perceived decision-making ability. Qualitative data (N=23) were generated through semi-structured interviews. Data collection took place between October 2024 and April 2025. Quantitative data were analysed using descriptive statistics, correlation, and multiple regression. Qualitative data were analysed using framework analysis. Integration was achieved through pillar-building and theory-driven synthesis and illustrated by joint display tables.

Results

Most nurses demonstrated a flexible decision-making style, integrating analytical and intuitive reasoning. Both analytical and intuitive processes were positively associated with perceived decision-making ability. Physician– nurse collaboration emerged as a strong predictor of decision-making confidence, while decision-related stress was not a significant predictor. Qualitative findings identified three themes: characteristics of remote review; making adaptive decisions shaped by both internal and external constraints and enablers; and external influencing factors. The integrated findings informed a theory-informed ICE framework to illustrate how nurses make clinical decisions via remote reviews.

Conclusion

Remote clinical decision-making is a dynamic cognitive–environmental process rather than a purely individual cognitive act. The ICE framework conceptualises this interaction, extending existing decision-making theories to digitally mediated care.

Impact

Understanding remote decision-making supports training design, clinical governance, and the development of Artificial Intelligence-enhanced decision-support tools grounded in ecological bounded rationality.

What is already known about this topic

• Remote clinical review is an increasingly common part of nursing practice in digitally enabled services.

• Nurses undertaking remote reviews often make decisions under uncertainty, using incomplete or indirect clinical information.

• Empirical evidence on how nurses make clinical decisions in remote review contexts remains limited.

What this paper adds

• Most nurses in this study demonstrated a flexible decision-making style, drawing on both analytical and intuitive reasoning rather than one dominant mode.

• Physician–nurse collaboration was positively associated with perceived decision-making ability, while decision-related stress was not a significant predictor in the final models.

• Integrated quantitative and qualitative findings informed a theory-informed Integrated Cognitive–Environmental (ICE) framework for understanding remote nursing decision-making.

The implications of this paper

• Remote clinical decision-making should be supported through service design, training, and digital systems that strengthen collaboration, information synthesis, and cognitive flexibility.

• Artificial Intelligence-enabled or digital decision-support tools for remote care should augment, rather than replace, nurses’ judgment and should be designed around the realities of practice.