Decision Making in District Nursing
The aim of this assignment is to discuss and analyze a decision made in practice. All nurses make clinical decisions; they make clinical judgments about the need of patients in their care.
Nursing clinical decision can be referred to as clinical reasoning, clinical judgment, inference and diagnostic reasoning (Thompson, 2004).
It is an ability of a practicing nurse to correctly identify, define and solve problems which are uniquely nursing in origin.
Nurses’ clinical decisions and actions are evidence-based practices, and involve the nurse using scientific knowledge and nursing processes (assessment, diagnosis, planning, implementation and documentation) to consider a client care situation and then make judgments about what to do in that situation. The clinical judgments and decisions about actions underpinning the care are essential for the outcome and quality of care.
WHY DO CLINCAL DECISIONS MATTER TO PATIENTS
The patient is the direct receiver of the intervention resulting from a nursing decision. The client should receive well planned individualized intervention, and participate in all steps of the process of decision making and he is assured of continuity of care through well written planned care. Thus to some extent he could feel confidence in this form of caring unlike the one he could receive elsewhere from technical ancillary staff with no plan (Warr, J (2006))
The use of nursing decisions does not only benefit the clients who receive the care; they also benefit the nurses who provide the care, because it provides an increasing autonomy in nursing practices, helping nurses identify their independent practice domain. The use of nursing decisions provides a common referencing system, and common terminology to serve as a base for improving clinical practices. Most importantly, it serves as a framework through which quality of care can be evaluated.
Other health care institutions also benefit from nursing decisions, the nursing process through better resource utilization, and increased client satisfaction and improved documentation of care.
This case will analyze a 44 year old man who had an accident and was been referred to district nurses from the care team. For the purpose of identity and in accordance with (NMC, 2004) code of professional conduct of confidentiality, the name of the patient shall not be revealed.
The patient had an abscess developed on his hip, had a history of diabetes Type 2, drug misuse and aggression. The nurses visit the patient and assess him. The patient is in a very distressed situation and was not allowing anybody to move him from his bed. His personal hygiene was very poor and the nurses found it very difficult to move him around to do the dressings. Different nurses in the team offered help to change his clothing and position, but he doesn’t like them to do that. Even though the patient didn’t want to let others check his pressure area, the district nurse took the decision to check his pressure area anyway. First of all, the patient denied access to her to check his pressure area, but the District Nurse (DN) was very assertive and tried to persuade him and make him understand that the need of pressure area check, care and prevention, and she gained consent eventually.
DN conducted an assessment of the patient with Pressure Ulcer Risk Assessment Tool (PURAT) by following the trust policy. While checking physically the patient had already developed a pressure sore of Grade II on his sacral area. Based on the assessment DN coordinated with the medical equipment team to have a hospital bed with pressure relieving (air-flow) mattress, hoist and slide sheet and a treatment plan then agreed upon. Usually factors such as mobility impaired, diabetes, incontinence etc, are risk factors to pressure ulcer (Lesley, 2006)
During an informal conversation with the patient, he expresses his depression over his chronic condition, incontinence and impaired mobility, resulting in his feeling of worthlessness. He claimed to have given up on himself to seek any further medical treatment. Patient feelings are not possible to detect unless verbalized by the patient, Andrew (2004). From this reason, it becomes imperative to rely on patient response. In order to protect him from harming himself more, this decision was agreed upon by DN and inter professional team.
HOW PRIORITY WAS DECIDED
The priority was decided based on the assessment of the risk; priority is given to risks that pose immediate danger to patient. In this case immobility and patient history of diabetes is considered as a priority to make the aforementioned decision. According to the National institute for health and clinical excellence (NICE) (NHS) quick reference guide (2005) distributed to health professional in NHS across England, the key priorities were mentioned. It is said patient should receive an initial and ongoing risk assessment in the first episode of care (within 6 hours). Research suggests that hourly turn and using of ripped mattress are the main intervention for pressure ulcer (NICE Clinical Guideline No. 7).
All those who are vulnerable to pressure ulcer should as a minimum be placed on a high specification foam mattress. The pressure relieving devices should be choose on the risk assessment, location and causes of the pressure ulcer if present and skin assessment. A registered nurse must act to identify and minimize the risk to the patient. NMC (2004)
TOOLS AND SERVICES USED
The tool that was helpful in making this decision is called Pressure Ulcer Risk Assessment Tool (PURAT). This is completed on the patient first visit and regularly re-assessed. This assists registered health care professionals to assess the patient. Any form of tools that gives an opportunity to carry out assessment on various risk factors as priority before making a decision could be considered adequate. The rational model approach is based around cognitive judgments of pros and cons of various options. It is organized around selecting the most logical and sensible alternative that will have desired effect.
Forms of service had being set up to govern and manage pressure ulcers in accordance with National institute of health and clinical excellence (2005), such as European Pressure ulcer advisory panel guidelines (EPUAP, 2010). Safeguarding Vulnerable Adults policy (Wiltshire, 2008)
ROLE OF KNOWLEDGE, SKILLS AND EXPERIENCE IN DECISION MAKING
Effective clinical decision-making is a vital and essential component of professional nursing practices. In every human activity, including nursing, there is always a risk of errors of judgment or faulty reasoning: that is human error.
Jane Coiffed, a researcher, manages to illustrate the complex interplay between clinical experience, judgment tasks and accuracy. Nurses’ competency is a key factor in clinical decision making, and this could only come from their personal knowledge, skills and experiences according to Bakalis (2006).
Decisions are drawn from a variety of sources of information and this requires knowledge and skills. Being able to weigh up merit of evidence from number of sources and apply a systemic approach to determine conclusions upon which to make course of actions is the essence of acquired skills. The personal knowledge that a nurse brought to the diagnostic task play an important role in the way the problem will be interpreted. This could affect the outcome for the patient, which depends on the nurse interpretation.
In every institution, people makes decisions and it is no different in the case of nursing clinical decisions; however, the emphasis is being placed upon knowledge and experience gained over an extended period of time through clinical practice (war ,2006). Such knowledge and skills are necessary to help in making clinical decisions about the patient, with expected positive outcomes.
DECISION MAKING USING INTUITION APPROACH
Addressing the fundamental of problem identification, ideas flows only when a person is able to identify a problem and communicate with others. When making decisions, nurses, like all people, are subject to uncertainty, error and heuristic short-cuts (Dowding and Thompson 2004). It was further proved that these heuristics are fallible and can introduce unhelpful bias into decision making. Although there are differences in the way a novices and expert make decisions, the finding according to Benner (2008), has it that experts often used less information in making a more accurate diagnosis and generating more alternative actions, more specifically in evaluating alternative actions and developing better nursing plan information than the novice. However, there is potential of intuitive capability. Nurses in whichever setting are articulating significant questions; moreover, they may themselves develop personal theories about patient care.
Partricia Berner (1987) explains nurses decision making along the intuition approach, intuition being the immediate and almost instinctive knowing of something without the conscious use of reasoning or rational thought processes. Some nurses practitioners may not have being aware of the significance of the phenomenon they observed, or the relationship of their ‘hunch’ about a situation. In addition, they may not communicate this to others well if at all – for instance, in the case of the observation of a nurse in a medical setting where a decision is made within a few short minutes. One good example is a nurse interacting with patients who comes in weekly for dialysis. The observation of such nurses, who are consistently able to decide within few minutes of interaction with patient, may contribute to a decision as to whether these patients’ daily dialysis will be completed efficiently and effectively without complication. This is uncertain and rather evolves out of outcome criteria that are more predictive. Nurses as health practitioners sometimes appear intuitive to outside observers and feels internalized within the practice. Clinical knowledge could be communicated; this will be a step to further development of conceptual ideas.
On the other hand, the analytical approach uses information process theory (hypothetical-deductive approach ), which examines how nurses and doctors reason when making judgment and decision and this approach can be demonstrated to others if necessary. Orielly (1993) confirmed that experience and knowledge are two major factors affecting decision making, and that this will in turn affect the outcome. War (2006) reports that the model each nurse uses for decisions depends on the task and context of the situation, but not the level of knowledge and experiences.
The weakness in the intuition types of approach is the lack of inability to formulate questions about an important phenomenon where that could warrant conceptualization of an important aspect of care. Intuition types of approach is an unconscious types of decision making, as such it does not give rooms to linear thinking. Notwithstanding, this approach has the advantage of being very relevant in the situation where carrying out an emergency action becomes a priority.
According to Nordgren (2006), describing the informative approach of decision making observed that human conscious minds has limited ability to understand information, thus supporting collecting information and investigating it before making a final decision. The outcome of decision could be predicted in informative approach theory. Another advantage of this is that it could be applied to solve complex matters. Scientifically based rules can aid formative (hypothetical –deductive approach) theory. Going by the hypothetical-deductive approach may be rewarding, research suggests that an individual goes through a number of phrases in their reasoning process: the cue acquisition, hypothesis, interpretation and evaluation. This provides enough information about the patient as well as enabling nurses to communicate the situation with the patient. In a scenario such as an emergency situation, the choice of using the hypothetical-deductive approach may not be realistic.
DIFFICULTIES AND DEFICITS AFFECTING DECISION MAKING
Multifarious social, political and economic changes have had a dramatic effect on health and nursing. Numerous factors influence clinical the decision making process, such as:
CRITICAL THINKING. Problem solving and decision making are predicted on individuals ability to think critically. Critical thinking is defined by the National council for excellence in critical thinking instruction (Nordgren (2006)) to be an intellectually disciplined process of actively and skilfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from or generated by observation, experience, reflection, reasoning or communication as a guide to belief and action. This ability is manifested whenever nurse practitioners could ask why, what or how. A nurse who asks why a patient is restless is engaging a critical thinking. This avoids making any assumptions, but is rather the investigating the possible causes through a decision making process.
This is an essential criterion for the generation of option or solution. Creative individuals are able to conceptualize new and innovative approaches to a problem or issues by being more flexible and independent in their thinking. There is a relationship between the clinical judgment, decision making, creativity and critical thinking.
Situation that leads to stress can sometimes be unbearable situations. An individual perceives a stressful environment as being demanding and threatening to their personal well being. Those who have internal locus of control view life as challenging and have motives of having influence on the outcome of stressful life events. Those with internal locus are able to deal with stress more effectively than those without it. Therefore, it could be said that because stress interferes with a person’s concept of self efficacy, extreme stress can have negative impact affecting thinking and decision making.
Deficient performance could be observed in shift workers principally because of circadian rhythm disruptions (Bakalis, 2006). Performance and cognitive functioning are influenced by circadian rhythms: natural rhythms of day and night in a 24 hour day. Shift workers are prone to alertness as well as performance problem as a result of altered circadian rhythm; this could result in impaired attention, judgment, accuracy and safety. This suggests shift working sometimes to be a barrier to the effective nursing decision process.
ETHICAL AND LEGAL CONSIDERATIONS. The large number of ethical issues facing nurses in clinical practice makes the established codes of ethics for nurses critical to the moral and ethical decision making process. The ICN Code of Ethics for nurses (2006) helps guide nurses in setting priorities, making judgments and taking action when faced with ethical dilemmas in clinical practices. Beliefs, practices, habits, likes, customs and rituals are all forms of ethical consideration that could affect the decision making process in nursing practice.
KNOWLEDGE AND EXPERIENCE. According to Banner (1984), nursing practice does not require knowledge alone for an individual to be a perfect practitioner or to be able to make good clinical decision; clinical experience is also an important tool for good clinical practice and performances.
This is another aspect that contributes to decision making clinical decision, and is a social activity involving health care team members and the patient. One of significant influence for nurses involves their relationship with the physician. Haddad, Stein (1967) saw the communicating pattern used by physician and nurses as a nurse-doctor game.
The principle is that overt disagreement must be avoided; in order to obey the rules, nurses must communicate their recommendations without appearing to make recommendations (Porter, Haddad 1991). According to an observation by Joseph (1985), experienced nurses are less likely to feel that nurses should assume responsibility, and this reluctance to assume responsibility creates a barrier to effective clinical decision making.
In this aspect, competence is a major factor: nurses’ personal intelligence and knowledge brings about belief in one’s ability. Perception of being less intelligent, competent or educated brings about the feelings which could result in relinquished authority to those perceived as being better (Joseph1985:22). The extent to which a person believes they can control events and outcome relies on level of self efficacy as well as any self concept.
Sometimes inadequate number of staff for the task required could affect the decision making process; likewise, this inadequacy could be related to the skill index as well. For instance, in a situation where novice nurses were being added or replaced experienced staff, experienced nurses encountered the additional effort of educating, advising and supporting inexperience nurses. Young and inexperienced nurses require more supervisory and coping support than their older counterparts. The performance of a task for the first time as novices staff nurse and the presence of highly skilled people, are all factors that can increase anxiety and alter the decision making process.
Why these difficulties arise could be as a result of differing factors: increasing diversity in employment settings (especially in the NHS), types of health care providers, hospital policy and governance, cost of effective results, people’s sexual orientation, believes and cultures, races/ethnicities and customs.
Clinical decision making is a complex process. It is necessarily an integral part of the nursing profession to make decision about their patients, and it is the responsibility of every nurse to make judgments about the need of the patients in their care. It therefore really matters how nurses make decisions, and how careful should they be before making them. Nursing is a noble profession and has the obligation to reduce the risk to patients to the absolute minimum possible, and thus provide safe treatment. The decision nurses made must be explicable and defensible; therefore, it becomes necessary to follow a set of clinical guideline and base their actions on evidenced based practices.
The demanding nature of nursing practice involves the making of clinical decisions that are informed by the most relevant and valid evidence available. This becomes necessary in order to have a safe practice, and also as necessary protection against legal action, for individuals and institutions. A number of policies and professionals today have been in place to ensure every clinical practice has checks and balances. A great many agencies and bodies across the country are responsible for regulating health care services in order to maintain, as well as upgrade, the standard of the services: bodies such as the NHS, the Nursing medical council-NMC UK, the National institute of health and clinical guidance etc.
In the UK and western world generally, great emphasis is placed on the need for health care professionals to account for all decisions they make when caring for the patient – with or on behalf of their client. The national library of guidelines based on guidelines produced by the NHS has been produced in the UK specifically for the systemic review of evidence and to have extensive consultation with clinicians, patient and – where relevant – the profession itself.
The World Health Organization has initiated recent innovation and improvement by recently publishing, in international journals, articles about quality care, and has launched performance assessment tools for quality improvement in hospitals. This was specifically aimed at assessing, as well as improving, the performance of clinical work in every hospital worldwide. It can therefore be deducted that the nursing practitioner as well as health care cannot just make decisions: they have to be based on real clinical evidence.
Moreover, nurses can ensure making the best possible decision they can by combining knowledge from various sources, including personal knowledge, experience, theoretical and evidence based practices. As long as a decision is based on the best evidence, information and clinical judgment available, it will be best decision that can be made at the time with knowledge available at the time – though that does not mean it will always be always be the ‘best’ decision, in retrospect: life – and decision-making – will never be perfect.
Nurses’ use a range of information to make clinical judgments and always have; but whatever the outcome, competency and knowledge as well as firsthand experience increase the cognitive resources available for interpretation of data, resulting in more accurate – and better – decision making to the benefit of all.
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