Paediatric healthcare is constantly evolving as health professionals strive to provide the best possible care for infants and children in order to protect and promote optimal healthy physical and psychosocial development. Bronchiolitis, a common lower respiratory tract infection of infancy, is the leading cause of hospitalisation for children aged under two years in developed countries (Tian et al., 2023: Dalziel et al., 2022). Of these infants, recent data indicates an increase in the annual numbers of Paediatric Intensive Care Unit (PICU) admissions (Linssen et al., 2022). In a collaborative Australian and New Zealand study, Schlapbach et al. (2017) identified that 28% of non-elective paediatric intensive care unit (PICU) admissions were due to bronchiolitis. With an increasing healthcare burden evident, bronchiolitis continues to be an area of research interest.

Multiple studies investigating different pharmacotherapies have been conducted, with a recent narrative literature review proposing adequate nutritional support and standard oxygen therapy as the primary interventions recommended (Fainardi et al., 2021). HFNC therapy has recently emerged as an alternative to standard oxygen therapy in bronchiolitis treatment. Utilisation of HFNC therapy for bronchiolitis has proliferated, especially outside of the PICU environment, but data describing the current use and impact is limited and often conflicted (Van Winkle et al., 2021). A Cochrane systematic review by Armarego et al. (2024) reported that HFNC therapy, compared to conventional low-flow oxygen therapy, was associated with modest but clinically meaningful benefits, including a statistically significant reduction in the need for escalation of respiratory support. HFNC therapy delivers heated, humidified air, blended with oxygen via nasal cannula. The primary mode of action which has been postulated includes reduced airway resistance by generating an increased positive airway pressure, and washout of the nasopharyngeal dead space (Dalziel et al., 2022). HFNC therapy has become a popular mode of respiratory support, mainly due to the ease of device application by clinicians; it is generally well tolerated by patients and has an emergent but promising safety profile (Nolasco et al., 2022; Schlapbach et al., 2017).

Effective implementation of HFNC therapy protocols is contingent upon the clinical decision-making capabilities of paediatric nurses, particularly in regional and rural settings where infants with bronchiolitis may deteriorate rapidly. Clinical decision-making is a core nursing competency including gathering data; data processing and problem identification; planning to act; and lastly implementing, monitoring and evaluating (Nibbelink & Brewer, 2018; Rababa & Al-Rawashdeh, 2021). Despite the development of guidelines for management of bronchiolitis, global studies conducted in the United States (Hester et al., 2021; Pittet et al., 2023), Canada (Maki et al., 2020), Italy (Barbieri et al., 2021; Manti et al., 2023), Australia, and New Zealand (Ramsden et al., 2022) have each identified many variations in practice and non-adherence. Implications of non-adherence are varied but include the potential exposure of patients to unnecessary treatment and/or adverse sequelae, increased length of stay, and increased hospitalisation costs (Bryan et al., 2017; Hester et al., 2021; Pereira et al., 2022). The impact of non-adherence to guidelines is amplified in regional and rural facilities that are generally under resourced due to skilled workforce shortages (Jones et al., 2021). Historically, rural areas have poorer health outcomes (McEvoy et al., 2024). Nurses working in these areas require support to develop clinical decision-making skills which promote optimal outcomes for this vulnerable patient cohort.

Despite rapid uptake of HFNC therapy in Australian paediatric settings during the last decade, only two Australian studies were identified in the published literature, to have specifically examined weaning of HFNC therapy in bronchiolitis. Stewart and Lines (2024) conducted a mixed methods study exploring paediatric nurses' perceptions of barriers and facilitators to weaning HFNC therapy in Australian settings, recruiting participants through social media nursing groups. Findings revealed inconsistent weaning practices and a lack of guidelines as key barriers, while robust education and nurse confidence were major facilitators. Elks et al. (2025) used a cross-sectional survey and the 24-item Nurse Decision-Making Instrument (NDMI) to examine paediatric nurses' decision making in managing infants with bronchiolitis on HFNC therapy in regional Australian settings. The majority of participants (80%) used quasi-rational clinical decision-making models, indicating both analytical and intuitive cognitive processes were employed within this clinical context, aligning with the findings of Nibbelink & Brewer, 2018).

Previous research has examined the role of protocols in nurse decision-making (Nibbelink & Brewer, 2018; Vázquez-Calatayud et al., 2020). Studies suggest that nurses often view protocols as too general for specific clinical situations (Rycroft-Malone et al., 2009) and may prefer to rely on personal knowledge and experience to guide decision-making (Dougherty et al., 2012). An integrative review of decision-making in nursing practice by Nibbelink and Brewer (2018) highlighted a persistent gap in understanding how best to support nurses' evidence-based decision-making. Results from this review, consistent with previous findings by Dougherty et al. (2012), suggested that selective use of protocols was evident in clinical practice with nurses predominantly relying upon previous clinical experience rather than evidence-based practice guidelines (Nibbelink & Brewer, 2018).

Ericsson and Simon (1993) proposed that information relating to decision-making is immediately accessible by participants and can be verbalised, forming the basis of the think-aloud technique. The think-aloud method has been widely used to explore nurse decision-making, applied through various formats including audio-visual scenarios (Teece et al., 2022), written scenarios (Lee et al., 2016), virtual patients (Forsberg et al., 2014), and real clinical settings (Johnsen et al., 2016). Combined with protocol analysis, this approach has proven effective in examining clinical decision-making (Laukvik et al., 2023; Lundgrén-Laine & Salanterä, 2010). However, literature specifically addressing paediatric nurse decision-making remains limited. Despite their central role in managing bronchiolitis, a common condition in infancy, little is known about how paediatric nurses make decisions when caring for critically ill children, particularly regarding the use of HFNC therapy.

To address this gap, the present study investigates the real time clinical decision-making processes of nurses caring for infants with bronchiolitis receiving HFNC therapy in two Australian regional hospitals. Specifically, it explores how nurses apply HFNC therapy weaning guidelines and respond to clinical changes in infants (0–12 months of age). By capturing nurses' verbalised thought processes during clinical decision-making, this study aims to inform the development of evidence-based decision support tools. The findings have potential to enhance protocol adherence, improve patient outcomes, and support nurses working in resource constrained regional settings. Findings will be used to inform the development of education, policy and practice strategies which support paediatric nurses to make competent evidence-based decisions.

The aim of this study was to describe the decision-making processes of paediatric nurses caring for infants with bronchiolitis receiving HFNC therapy in regional settings. The primary research question underpinning this study was ‘What are the predominant cognitive processes utilised by paediatric nurses caring for infants with bronchiolitis receiving HFNC therapy?’