Decision Fatigue Among Chinese Nurse Managers: A Multicenter Cross-Sectional Study on Implicit Cognitive Load Determinants.

BACKGROUND: Decision fatigue, conceptualized within Baumeister's strength model of self-control, describes the deterioration of decision-making quality following protracted choice-making processes. The intensive cognitive and managerial demands inherent in nursing leadership render head nurses particularly susceptible to this phenomenon, with subsequent deleterious effects on patient safety, staff well-being, and organizational performance. AIMS: This study aims to delineate the characteristics of decision fatigue among head nurses and identify the specific occupational and environmental factors associated with this phenomenon, particularly within the intricacies of complex clinical management. Furthermore, the research seeks to provide a robust evidence base for healthcare administrators to inform the design and implementation of targeted intervention strategies aimed at mitigating cognitive exhaustion in nurse leaders. METHODS: A descriptive, multicenter, cross-sectional study was conducted. Data were collected between November and December 2024 across 17 healthcare institutions in China. A total of 144 head nurses were recruited via convenience sampling. Data were collected using a sociodemographic questionnaire, the Decision Fatigue Scale (DFS), and the Nurse Manager Practice Environment Scale (NMPES). Statistical analyses included Mann-Whitney U and Kruskal-Wallis H tests for group comparisons, Spearman correlation, and multiple linear regression to identify independent predictors. RESULTS: Participants reported low-to-moderate levels of decision fatigue, with a median score of 9 (IQR = 7.25-10.75), while practice environment scores were relatively optimal (median = 225, IQR = 216-249). Multiple linear regression identified cultural heritage (β = -0.296), physical status (absence of fatigue) (β = -0.234), and organizational planning ability (β = -0.228) as significantly associated with lower decision fatigue. Notably, head nurses in tertiary hospitals exhibited significantly higher fatigue levels (median = 10, IQR = 8.5-12.5), underscoring the impact of systemic institutional pressures. CONCLUSIONS: Decision fatigue may be understood through a proposed dual-pathway framework: a direct pathway involving task overload and ego depletion and an indirect pathway involving emotional labor and cognitive interference. Psychological training was associated with lower fatigue levels, potentially by facilitating cognitive reappraisal of stress. Effective mitigation strategies may benefit from a multifaceted approach incorporating situational leadership and nonmonetary support. Furthermore, cultural heritage and organizational planning ability were identified as factors associated with reduced fatigue, while addressing structural constraints may help optimize decision-making efficacy among nurse leaders. IMPLICATIONS FOR NURSING MANAGEMENT: The identified three-tier protective framework-comprising cultural heritage, organizational planning ability, and physical resilience-offers an actionable framework for intervention. Supported by a robust cultural heritage, nurse managers may benefit from structured daily planning, algorithmic cognitive outsourcing, and proactive fatigue self-monitoring. At the institutional level, administrators could consider formalizing mentorship programs, integrating evidence-based psychological training, and addressing structural staffing constraints. Furthermore, policymakers might re-examine resource allocation strategies that disproportionately burden midtier hospital leaders. Multilevel, coordinated interventions may be essential to safeguard head nurse decision-making capacity, patient safety, and staff well-being.