This site is intended for health professionals only

Can you make decisions?

Dr Raj Persaud
Gresham Professor
Public Understanding of Psychiatry and Consultant Psychiatrist
The Maudsley Hospital,London.
He is the author of the Motivated Mind - How to Get What You Want from Life, published by Bantam Press

In a fascinating study by Daniel Brown and anthropologist colleagues at the University of Hawaii, teachers and nurses were compared on various measures of stress, including blood pressure and adrenaline levels. It was found that nurses had higher levels of stress not just during the day but also when at home and late into the evening after work. Obviously both these professions are associated with high stress at work, but when Brown and colleagues investigated what the different jobs were like they found that nurses had much less "decision latitude" while at work than teachers.
"Decision latitude" is an aspect of one's profession that is increasingly attracting interest from researchers studying why some jobs seem to be so much more stressful than others with consequent dire health implications for the workforce, including in particular cardiovascular disease. It was intriguing that, among the professional nurses, significantly elevated blood pressures were found during times when they were passing out medications, perhaps a key moment in the typical nurses' day in which mistakes could have dire consequences.
Both the nurses and teachers in this study worked in large institutions (eg, hospitals, nursing homes and schools). However, the nature of their work appeared to be very different. Nurses appeared to suffer from more rigid occupational hierarchies where taking "orders" was the norm, whereas teachers, in contrast, had much more autonomy within their classrooms.
In the current climate in which healthcare professionals work, it would appear that precisely because of concerns over safety, guidelines, protocols and subsequent paperwork are multiplying relentlessly - in other words, we appear to live in a culture where we take away autonomy or reduce "decision latitude" to apparently protect the patient. In doing so it seems that we have inadvertently created a highly stressful working environment for nurses specifically and perhaps healthcare professionals more generally.
It is ironic that even when you reduce the decision-making in an attempt to prevent mistakes from happening, the job strain seems to go up. It would appear that nurses in general would prefer more autonomy and would be less stressed if it was given to them. Maybe the key variable that researchers need to investigate is whether you agree that what you are being constrained by in terms of reduced autonomy makes sense to you or provides good outcomes for your patients.
The key advantage of "decision latitude" is that it allows you to do the best for your patients and thus derive some satisfaction from this. If decisions are taken away from you but you still feel that you have a positive impact on your job, then this theoretically shouldn't stress you out so much. Perhaps the real problem with reduced "decision latitude" is that it implicitly betrays a lowered respect for professionalism between those reducing "decision latitude" and those experiencing it. This is the real cause of the high levels of job stress.
One intriguing coping mechanism that nurses who suffer from high stress in their jobs, perhaps as a result of "decision latitude" being taken away from them, is to "go the whole hog" and constantly ask their managers for decisions to be made. This behaviour voluntarily reduces their "decision latitude" to zero but at the same time places an intolerable strain on their colleagues. Theoretically the managers should eventually get fed up with constantly being bombarded with requests for decisions to be made and will then cut the nurse more slack and return their "decision latitude" to where it should have been in the first place.


  1. Brown D, et al. Occupational differences in job strain and physiological stress: female nurses and school teachers in Hawaii. Psychosomat Med 2006;68:524-30.