Revista Publicando, 5 No 16. (1). 2018, ISSN

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1 Studying the effect of systemic thinking and positive thinking on nursing decisionmaking processes in hospitals of Tehran University of Medical Sciences Nader Shahamat 1, Nazafarin Hosseini 2, Parvin Razmjooei 3, Abolfazl Dehbanizadeh 4, Seyed Mohammad Hadi Hoseini Hesamabadi 5, Marziyeh Hosseini 6 * 1- Department of Educational Administration, Marvdasht Branch, Islamic Azad University, Marvdasht, Iran. nader-shahamat@yahoo.com 2- Social Determinants of Health Research Center, Department of Nursing Yasuj University of Medical Sciences, Yasuj, Iran. hosseinichenar@yahoo.com 3- Marvdasht branch, Islamic Azad University, Marvdasht, Iran. p.razmjooei571@gmail.com 4- Department of Nursing, Faculty of Yasuj University of Medical Sciences, Yasuj, Iran. Abolfazl.dehbanizade@gmail.com 5- Department of Educational Sciences, Marvdasht Branch, Islamic Azad University, Marvdasht, Iran. hadipars@yahoo.com 6- * Social Determinants of Health Research Center, Department of Nursing Yasuj University of Medical Sciences, Yasuj, Iran. m.hosseini235@yahoo.com Abstract: Aim and literature: Nurses are a prominent example of those who judge in ambiguous and uncertain situations. They gather the present information for the decision- making process in order to increase their decision quality. Therefore, the main aim of the present study is analyzing the effect of systemic thinking and positive thinking on nursing decision- making processes in public hospitals of Tehran. Methodology: The present research is an applied- descriptive study in terms of gathering data and it is a field study. It is also a casual- survey study in terms of the relationship between research variables. Its most important benefit is the ability of generalizing the results which was done in 1397 periodically. The statistical population of this study included the employed nurses of hospitals of Tehran University of Medical Sciences. The sample size was 170 persons which were selected by a cluster multistage sampling method. The standard questionnaire was used for gathering information. Its validity and reliability was confirmed. Pearson correlation test and structural equation modeling were used for analyzing the relationship 152

2 between variables, measuring the fitness of the research model and testing the hypotheses using SPSS 22 and Lisrel8.80 software. Findings: results showed that the research model has a good fitness. Systemic thinking has a significant effect on nursing decision- making processes. Positive thinking has a significant effect on nursing decision- making processes. Conclusion: Therefore, we can expect that nurses can be able to make decisions better than before and at last, their effectiveness and efficiency increases by creating the necessary platforms of creating a positive attitude and increasing systemic thinking. Keywords: systemic thinking, positive thinking, decision- making process, nurses. 153

3 Introduction: Nurses are a prominent example of those who judge in ambiguous and uncertain situations. They gather the present information for the decision- making process in order to increase their decision quality (1). Nurses play a key role in overcoming the major challenges which are facing health systems, reducing health inequity, using evidence-based practice in order to get major health benefits through effective ways (2). Health systems require nurses' decisions and judgments in order to improve the quality of their outputs because improving the quality of nursing care requires improving decision-making and judgment skills. (3). Decision making is one of the basic concepts of nursing which influences the process of patient care and recovery process (4). Luri and Salantra state that more than 60% of nurses use combination methods for decision making (5). The necessity of nurses' attention in different ways has been proposed for proper decision making in various nursing care settings (6). Systemic thinking has been developed as a tool of integration and effective decision making in order to find a sustainable solution in a complex world and it is also an important tool of strategic planning and decision making (7). Systemic thinking is developed in order to study and manage complex reflection systems as what a person discovers in social systems. Systemic thinking has a scientific value based on the research field which is known as system dynamics. It emphasizes on the integrated and theoretical foundation (8). Palaima consider systemic thinking as the competence of cognitive intelligence and he believes that systemic thinking is not described as intelligence competence sufficiently. Although systemic thinking has been used as a very valuable competence, it has not been addressed in the context of performance adequately (9). On the other hand, nowadays, nurses are very important in health care centers so that they are considered as a valuable tool of developing the key assets of health systems. We should study the internal dimensions of the nurses in order to taking steps in improving the nurses and we should prepare the ground of nurses' improvement and productivity of care and health centers ultimately by considering their states and their morale. One of the topics that has attracted the attention of experts recently is positive thinking. Positive Thinking is defined as the study and application of positive strengths of human resources and the psychological capacities that can be measured and developed and are effectively used for improving the performance of the workplace (10). Psychological capital is a positive psychological development whose characteristics are committing and having the necessary efforts in order to be successful in 154

4 challenging tasks (self-confidence / self-efficacy); having positive documents about current and future achievements (optimism); and sustainability while confronting with hardships and difficulties in order to achieve success (flexibility). The main objective of positive organizational behavior is paying more attention to empowerments and human resources strength and improving them than paying attention to their weaknesses and inefficiencies. Thus it is trying to resolve the weaknesses (11). Researches show that being happy and positive thinking has a direct effect on the effectiveness of nurses. There is a fundamental rule in this context. When nurses have a sense of happiness, success and success regarding their occupation, it is more possible that they improve their performance and thus achieving more efficacies. On the other hand, the aim of systemic thinking is improving understanding and recognizing the nurses based on internal structure and operational policies of the organization in order to plan effective decision-making systems according to this recognition. Systemic thinking is trying to explore the ways by which nurses are inclined to associate with the outof-work environment intrinsically and get positive effects from this relationship (12). It should be said that positive thinking presents strategies of eliminating negative thoughts and moving toward a sense of hope, empowerment and prosperity by explaining the relationship between systemic thinking and positive thinking. Positive thinking leads to a general understanding of positivist psychology in the framework of system theory that improves the nurses' decision making process. The positive attitude of health care centers will enable nurses to think, consider, create, innovate and achieve systematic attitudes (13). Since there has been not been done a lot of research about evaluating the effect of systemic thinking and positive thinking on nursing decision-making processes, this research is going to study the effect of these issues on the nurses who are employed in Tehran public hospitals. Methodology: The present research is an applied- descriptive study in terms of gathering data and it is a field study. It is also a casual- survey study in terms of the relationship between research variables. Its most important benefit is the ability of generalizing the results. The statistical population of this study included all of the employed nurses of hospitals of Tehran University of Medical Sciences. Subjects of book of Azar et al were used for determining the sample size (3). They suggested 200 to 400 samples for the models included 10 to 15 indicators in the literature of structural equation model generally. They also suggested that MIS researchers have achieved 155

5 a temporal rule of thumb in order to determine the minimum sample size since the early 1990s. It needs 10 observable cases per index according to this rule (rule 10). The sample size will be 170 cases in accordance to the rule 10 according to the number of indexes of this study which is equal to 17 but 200 questionnaires were distributed in order to be more reliable. Cluster sampling method was used for selecting the sample. Standard questionnaire was used for gathering information. Decision- making style questionnaire of Scott and Bruce was planned in 1995 (14). This questionnaire has 25 questions. It includes 5 styles of rational decisionmaking, intuitive decision- making, avoidance decision- making, immediate decision- making and dependent decision- making (Each one has 5 questions) which are scored based on five score Likert (1= never, 2= rarely, 3= some times, 4= most of the times and 5= always). Each style has 5-25 score. The higher the mark, the more dominant the style. Systemic thinking questionnaire of Rahnavard et al was planned in 1395 (15). This questionnaire has 18 questions. It includes six dimensions of dynamic thinking, interaction, systemic logic, pivotal process, recognition of mental models and continuous learning (Each one has 3 questions) which are scored based on five score Likert (1= strongly disagree, 2= disagree, 3= neutral, 4= agree, 5= strongly agree). Positive thinking questionnaire of Rahnavard et al was planned in This questionnaire has 20 questions. It includes four dimensions of self- efficacy, optimism, hope and resilience (Each one has 5 questions) which are scored based on five score Likert (1= strongly disagree, 2= disagree, 3= neutral, 4= agree, 5= strongly agree). Content validity method is used for estimating the validity and Cronbach's alpha method is used for testing the questionnaire's reliability. The reliability coefficient of the research variables is shown in Table 1. (Table1: Cronbach's alpha coefficients of the research variables) Cronbach's alpha coefficient Index Decision - making process Systemic thinking Positive thinking The more closer the Cronbach's alpha index to 1,, the more internal correlation between more questions, so the questions will be more homogenous. Cronbach's alpha index showed that the reliability coefficient (45%) is low, the reliability coefficient (75%) is moderate and the 156

6 reliability coefficient (95%) is high. The values which are above 0.7 are considered desirable in many sources. Research indicators have good reliability in according to table 1. Research findings: Results of demographic profile of the sample members showed that 60% of them were women and 40% of them were men. 2% of the members had associate of arts, 78% of them had bachelor degrees, and 20% of them had Master of Arts or sciences in terms of educational degrees. 62 percent of them had a formal employment contract and 38 percent of them were contracted. The average age of the participants of this study was 37years. Data were analyzed by SPSS22 and Lisrel8.80 software after gathering data through questionnaire. Normal distribution of variables was studied by different methods. One of the most appropriate methods is use of the distribution form or on the other word, kurtosis and skewness test of the research variables. The zero-order of these indices indicates that they are normalized completely but researchers believe that when kurtosis and skewness test of data is between -2 and +2, the variables distribution is normal. Values of kurtosis and skewness test are shown in the following table. Results of this test are shown in table2. (Table2: Table of variables' kurtosis and skewness) Test type Condition Kurtosis 1 Skewness 2 Variable Parametric Normal Decision - making Parametric Normal Systemic thinking Parametric Normal Positive thinking As it is shown in table 2, kurtosis and skewness test of data is between -2 and +2, so the variables distribution is normal. Therefore, Pearson correlation test should be used in order to investigate the relationships between the above data variables. (Table3: Results of correlation test of research variables) 1 Kurtosis 2 Skewness 157

7 Correlation coefficient Significant level Error level Dependent variable Decision - making Decision - making Positive thinking Independent variable Systemic thinking Positive thinking Systemic thinking Row As it is shown in the above table output, the decision criterion value (Sig) is <0.05, so these correlation coefficients are significant. Factor analysis results: At first, it is necessary to test all of the observation variables separately in order to determine whether measurement indices (observation variables) are acceptable to measure hidden variables or not after gathering information. Therefore, total fit indices of measuring patterns (confirmatory factor analysis) were evaluated. Fit indices test of confirmatory factor analysis models suggests that measurement indicators (obvious variables) can measure the hidden variables well. (Table4: Results of factor analysis of selected items questions in order to assess the case study variables) Significant value Standard factor load Index Variable (factor ) dynamic thinking Systemic thinking interaction systemic logic pivotal process recognition of mental models continuous learning rational Decision making process intuitive 158

8 avoidance Immediate and dependent self- efficacy Positive thinking optimism hope resilience Since it is suggested statistically that factors with a regression weight (factor load) > 40% are meaningful and acceptable, so all of the regression weights of this model are >40% and all of the critical ratios (t-value) are meaningful at P<0/01. Therefore, all of the considered factors are confirmed and the general fit indicates that the measured model has a well fitness with the observed data. As it is outlined in the previous sections, the structural equation modeling is used for rejecting or confirming the present study hypothesizes. Research first hypothesis: Systemic thinking affects decision-making processes of nurses of public hospitals of Tehran. (Chart1: Standard output of structural equation modeling) (Chart2: t-value output of structural equation modeling) 159

9 As it is shown in table 3, the correlation coefficient of these two variables is equal to at the significant level of because the significant level value is less than the error value (0.01). Therefore, the existence of a significant relationship between systemic thinking and nursing decision making process is confirmed at the error value (0.01). As it is shown in Chart1 and Chart2, since the standard coefficient value is equal to 0.85 and the significant t-value is >1.96 (= 9.61) at 95%, it can be said that there is a significant relationship between these two variables. Therefore, the null assumption is not confirmed and systemic thinking has a positive and significant effect on nurses' decision making process. So, the first hypothesis is confirmed. Research second hypothesis: Positive thinking affects decision-making processes of nurses of public hospitals of Tehran. (Chart3: Standard output of structural equation modeling) (Chart4: t-value output of structural equation modeling) 160

10 As it is shown in table 3, the correlation coefficient of these two variables is equal to at the significant level of because the significant level value is less than the error value (0.01). Therefore, the existence of a significant relationship between positive thinking and nursing decision making process is confirmed at the error value (0.01). As it is also shown in Chart3 and Chart4, since the standard coefficient value is equal to 0.87 and the significant t- value is >1.96 (= 9.20) at 95%, it can be said that there is a significant relationship between these two variables. Therefore, the null assumption is not confirmed and positive thinking has a positive and significant effect on nurses' decision making process. So, the second hypothesis is confirmed. Fit test: As it is shown in Lisrel output in table5, X2/df value is equal to X2/df< 3 represents the appropriate fit of the model. Root of mean square error approximation (RMSEA) should also be <0.08 which is equal to It can be said that according to Lisrel output and indices that data matched the model and the presented indices indicate that the presented model is a suitable model and empirical data are matched it. (Table5: Fit indices of the research model) Result Acceptable limit Value Index Acceptable X2/df Acceptable (0.9 and more)> Normative Fitness Index (NFI) 161

11 Acceptable (0.9 and more)> Goodness Fit Index (GFI) Not acceptable Close to Adjusted Goodness Fit Index (AGFI) Acceptable (0.9 and more)> Tucker- Lewis Index (TLI) or Non- Normed Fit Index (NNFI) Acceptable (0.9 and more)> Incremental Fit Index (IFI) Acceptable (0.9 and more)> Comparative Fit Index (CFI) Acceptable > Parsimonious Normed Fit Index (PNFI) Acceptable < Root mean square deviation Not acceptable > Relative Fit Index (RFI) Acceptable Close to Residual Mean Root (RMR) Discussion and conclusion: The main aim of the present study is analyzing the effect of systemic thinking and positive thinking on nursing decision- making processes in public hospitals of Tehran. The results of the present research show that systemic thinking and positive thinking have a significant and positive effect on decision making processes of nurses in public hospitals of Tehran. Since this research has been done for the first time in Iran, there are no available similar results. Therefore, it can be deduced that since systematic thinking is a systematic way of organizing information and strengthening nurses in order to carry out their job duties and the nursing profession is a busy occupation and individuals may not be able to decide properly due to their stress and work 162

12 load, systemic thinking presents the mechanisms that nurses can use them to make proper decisions in decision making processes. On the other hand, the positive attitude of nurses toward their work environment and their duties has an important role in their effectiveness. As a result, the higher the systematic thinking, the more the nurses' productivity and the more positive thinking, the better decision- making. Systemic thinking and positive thinking are key and important dimensions of health care centers especially the personnel and they are considered as important elements of nurses' success and development. In fact, systematic thinking has the power of facing tension issues. Therefore, it can be expected that nurses be able to make decisions better than before and their effectiveness and efficiency increases by creating the necessary platforms of positive attitude and increasing the systemic thinking of nurses. As it is suggested, this research was done for the first time in nursing communities, therefore limitations such as a significant shortage of Persian and English resources to complete the research background of all of the so-called three variables are observable. References: [1]. Hammond KR, Kelly KJ, Schneider RJ, Vancini M. Clinical inference in nursing: Revising judgments. Nursing Research. 1967; 16(1): [2]. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Affairs. 2010; 29(5): [3]. Thompson C, Dowding D. Essential decision making and clinical judgment for nurses: Elsevier Health Sciences, UK, London; [4]. Shaban R. Theories of clinical judgment and decision-making: A review of the theoretical literature. Australasian Journal of Paramedicine 2012; 3(1):8. [5]. Moghadam AH, Tehrani M, Amin F. Study of the relationship between emotional intelligence (EI) and management decision making styles. World Applied Sciences Journal 2011; 12(7): (Persian) [6]. Johansen ML, O'Brien JL. Decision Making in Nursing Practice: A Concept Analysis: Wiley Online Library; [7]. Batra R, Ahuvia A, Bagozzi R. Brand Love. Journal of Marketing 2012; 76 (2): [8]. Palaima T. Systems thinking as a platform for leadership performance in a complex world. Baltic Journal of Management 2010; 5(3):

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