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Qualified nurse during a clinical placement Essay

Decision making essay

Decision making is important to nurses in today’s society, ( Thompson et al 2002) as a number of policy and professional imperatives mean that nurses have to worry about the decisions they make and the way in which they make them. The government has produced several policy initiatives (DOH 1989, 1993a, 1993b 1913c,1994, 1995, 1996a, 1996b,1997, 2000, 2000) which have led to the creation of an evidence based health care culture ( Mulhall & Le May 1999). Thompson et al (2002) believe that poor decision making will no longer be acceptable, the government aim to examine professional performances and the outcome of clinical decision making for the first time. Evidence based practice will no longer be an optional extra but a requirement of all health care professionals.

The aim of this essay is to analyse and evaluate a decision made by a nurse in a community practice. The author will highlight why she chooses the particular issue and how it is important to nursing. The author will provide an overview of two general approaches to decision making, rational and phenomenological, by evaluating and analyzing them. The author will consider decision making theories, and try to apply them to the decision making process witnessed in her community placement. She then aims to show, how they should or could have been used as an aid in effective decision making. She will also consider influencing factors that effected the decision making process. A pseudonym is used throughout the essay to protect the patient’s identity, as stated in NMC (2002) code of professional conduct section 5.

The patient chosen for the purpose of this essay will be referred to as Jo. Jo is 53 year old women who suffer with rheumatoid arthritis. This also resulted in Jo having bilateral hip replacements. Jo is on steroid treatment, which leads to thinning of the skin and susceptibility to trauma (Mallet and Dougherty 2001). Jo lives with her husband and two grown up sons. Jo was refereed to the district nurse on her discharge from hospital following her second hip replacement. The initial referral was to check the surgical wound. However on arrival it was pointed out by Jo that she had a skin tear on her left shin that wasn’t healing. The district nurse performed an assessment and concluded the wound was a venous leg ulcer as it had been present for 6 weeks. The district nurses used Sorbisan and Telfa to dress the wound. Twice weekly visits were carried out to Joe for a further 4 weeks, and it became obvious that the ulcer was not improving. The district nurse had to make a decision on what care to provide. The decision was to try another dressing Aticoat which is impregnated with silver, and not to refer the patient to the leg ulcer clinic at the local hospital. The district nurse involved with Jo’s care was a G grade nurse and in charge of a community practice that had 3 other nurses working in it.

The author decided to focus on this particular decision, as she was influenced by the amount of evidence based research available on the issue, and how the district nurse chose to ignore the evidence, and made a decision on the basis of personal knowledge. The author visited a leg ulcer clinic while on her community placement, and asked the expert nurses running the clinical at what stage they would like to see patients referred to them. She was told if a wound wasn’t healing after 4 weeks the patient should be referred, this information was passed on to the district nurse and ignored.

The district nurses felt that if he referred all his patients after 4 weeks the leg ulcer clinic at the hospital wouldn’t be able to cope. In doing this he chooses to ignore the expert advice. I found this very frustrating and interesting, and as Scott (2004) said we ought to promote good and not cause harm, in Jo’s case, the action of not referring her to the appropriate expert nurse could be seen as prolonging healing thus causing her harm. I decided to investigate further what issues led to him making his decision.

To achieve excellence in care nurses need to base there decision on evidence based care (Parahoo 2002). There is no shortage of research on wound care and the management of venous leg ulcers. However because research is based mostly on opinions or experience, hence the development of guidelines and protocols that have practical use is difficult (Leaper et al 2004). There are many sources of evidence, Journal; the Cochran Library database relevant to wound care, however there is so much information it would be difficult for nurses to know where to start. Evidence suggest the management of patients with venous leg ulcers is fragmented and poorly managed ( Carrington 1999).

Vowden (1997) agrees and suggests healing rates are poor and treatment costs are high, this could be as a result of nurses not referring patients to appropriate experts for assessment and using expensive, inappropriate dressings such as aticoat, which is impregnated with silver. Although there is evidence to suggest that dressing impregnated in silver and sorbisan are highly effective in heavily exudating wound (Leaper et al 2003& BNF (2004) Jo’s ulcer was shallow and not heavily exudating. The evidence for the care of venous leg ulcers strongly points to the uses of 4 layer bandaging. This is demonstrated in Allen and Nelson (1996) work, they found that healing rates improved for patients who attended a leg ulcer clinic and had 4 layer bandaging applied.

This is also backed up by evidence printed by the RCN(`1998), and Research carried out by Nelson (1996), which suggests that between 40 and 80% of leg ulcers heal with the application of compression bandaging. Jo had suffered with her leg ulcer for 10 weeks before a decision was made by the District nurse to change the dressing from Sorbisan to Aticaoat. The use evidence based care, provides the foundation for evidence based practice ( Harding et al 2002), the ulcer healing rate and outcome for Jo could have been improved by a quick referral to the leg ulcer clinic, as this is seen as the most effective way to treat leg ulcers ( Musgrove and Woodham 1995).

One of the reasons the district nurse was hesitant about referring Jo to the ulcer clinic, was that he felt compression banging is uncomfortable and requires a strict regime (House 1996), and his experience patients didn’t often comply. However Jo was not offered the choice. Taylor (1996) believes
that communication with patients is crucial to compliance, he suggest by educating patients it will enable them to understand the importance of the compression and assist patient to comply to treatment. Patients need to be given the option of whether they are involved in the decision making process. In Jo’s case the district nurse made the decisions, he didn’t explain alternative treatments to Jo, or explain the 4 layer bandaging to her. In the authors opinion the patient was not given an informed choice.

There is a professional responsibility to obtain informed consent from patients before a nursing care procedure is carried out (Cable 2003, Averyard 2000, NMC 2002). The ethical issue of informed consent came essentially from the Nuremberg Code (1947) as a result of human experimentation in world war two. This was aimed specifically at humans involved in medical research, however consent is now applied to nursing clinical procedures (General Medical Council 1988). There is increasing evidence to suggest that well-informed patients manage their health and treatment better, this enables them to feel in control of there illness (Ogden 2001) and have better psychological outcomes (Gibson 2001).

Although Gibson (2001) argues that knowledge alone does not change health outcomes for patients, to allow Jo to give informed consent she would need information that was relevant to her condition and treatment. Jo is an intelligent women and giving her a choice of treatment would have protected her autonomy (Edwards 1996) and individual rights (Caress 2003), however Jo was not offered a choice in treatment, and alternatives were not discussed. The district nurse made a decision and applied the treatment.

In doing this the district nurse used his power to manipulate Jo into accepting the treatment the he wanted to give. Giving restricted information the nurse restricted the patient’s choices to secure her compliance (Lukes 1974). The district nurses actions went against advocating the government Expert Patient Policy (DOH 2000), which highlights the need for changes in society that mean individuals expect to have choices, and be involved in decision making (Kenney 2003). Although Jo gave consent for the treatment given, she did not, in the author’s opinion, give informed consent.

Decision making can be divided into two groups, decision making from a rationalist perspective and from a phenomenological perspective ( Tanner 1987). Rational decision making is a step by step approach that follows a logical course, and clearly definable stages (Harbison 1991), taking into account obvious starting points and objectives, assessment tools, policies and protocols. It gives clear predictable outcomes and is process driven. Rational decision making works, on the basis that when a problem arises, the decision maker agrees a definition of the problem and discovers all the possible solutions, matches the problem with the recourses and chooses a solution that best matches the problem, and then implement solution ( Harbison 1991).This approach fits in well with the current trend towards research and evidence based care (Harbison 1991). Using the rational approach to decision making, makes assumptions that all decision makers will take into consideration all possible options and consequences, in light of a thorough understanding of a situation. However in practice this approach would be influenced by time constraints, habit and routine, and Harbison (1991) argues that sensitivity could be lost when following a rational approach.

Using Phenomenological process in decision making can be seen as a subjective individual approach (Easen et al 1996). This approach takes into account nurses opinions and views, for this reason as discussed by Thompson (1999) it can create bias, as it is based on experienced expert knowledge. Using expert clinical reasoning the nurses draws on a deep understanding of the patient situation and holistic care needs. Intuition is a quality that nurses have traditionally valued (Trueman 2003), however with the development of evidence based care it is now seen be some to be unreliable, unscientific and unsuitable for nursing practice (Trueman 2003). Intuition has been criticised for not being able to provide a rational for the decision made, however Benner (1984) believes intuition is understands without a rational.

Benner (1984) argues that during a long nursing career, nurses can gain a great deal of knowledge and skill practice, this leads to them being intuitive about the decisions they make. Intuition is not something that is measurable according to Benner (1984), it is developed through experience, expertise and knowledge, along with personal awareness and personality. McCutcheon and Pincombe (2001) also believe that there are benefits derived from intuition in practice, such as enhanced clinical judgment and effective decision making. Although Cioffi (1997) argues that holistic patient assessment and improving nurse-patient relationships are being undermined by a drive for evidence based care. Intuition has been identified as a useful tool as nurses can analysis the situation as a whole rather that a series of tasks (McCutcheon and Pinchcombe 2001).

Both the phenomenological and rational decision making theories have a number of strengths and limitations. McKenna (1997) argues that knowledge can only become known by others if it is shared knowledge and communicated to others. McKenna (1997) suggests this causes a problem for the phenomenological model it is almost impossible to communicate something which is intangible, and which the practitioner is unable to express. Using a mixture of both theories can create a holistic and well documented procedure.

Lauri and Saklantera (1995) using a factor analytical approach found evidence that both Benners (1984) intuitive model, and the hypothico- deductive approach of information processing, had a degree of analytical usefulness in explains the decision making of nurses. The implications were that both had something to offer and neither is often a single solution to explain decision making in practice.

Using a decision making model such as Carroll and Johnston (1990) would have enabled the district nurse to reflect and evaluate the effectiveness of the care delivered. Carroll and Johnston (1990) outline seven stages of temporal decision making, and acknowledged that these stages may not simply be followed through there sequence, but the nurse can backtrack at any stage. The first two stages of recognition and formulation involves the examination and classification of the situation by the district nurse. During a home visit the community nurse may be confronted with a range of patient problems (Bryans and McIntosh 1996). Some of these are discrete and easily recognised, while others are likely to dependent upon various circumstances in the patients life, which are likely to remain hidden unless they are explored by the nurse (Bryans and McIntosh 1996).

In view of the fact that patient and nurses are strangers to each other, Thompson et al (2002) believe this exploration must be skillfully negotiated by the community nurses, if nurses appropriately identify needs, and thus begin the process of addressing these needs and planning suitable care. If this part of the assessment had been undertaken effectively by the district nurse, the patient may not have suffered for a long period with the leg ulcer. Bryans and McIntosh (1996) suggest this phase of decision making is generally less conscious and deliberate, and more difficult to articulate, than subsequent phases. Although Elstein et al (1978) suggest this a very important part of decision making it often gets neglected.

Many decision making models start with an assessment phase such as Walsh (1998) nursing process, which has four stages of decision making, assessment, planning,

implementation and evaluation. If the assessment carried out by the District nurse is poor then the rest of the planning and care delivered will be poor. It has been highlighted in many publications Lait & Smith (1998), Lawrence (1998), Thompson (1999) that a holistic assessment is needed in the care of patients with leg ulcers. Holistic assessments help to identify underlying pathology, and ensure correct diagnosis (Moffat & O’Hara 1995). However the way each individual nurse views the wound will depend on there experience and whether they have come across a similar situation before (Thompson et al 2002). Walsh (1998) highlights the need for a goal to measure against in the assessment phase. In Jo’s case the tool used, could have been a wound chart.

A wound chart was however was not used, so on subsequent visits the nurse’s used there own judgment on whether the wound had changed. It was however difficult to clearly classify the wound, a point highlighted by Flanagan (1997) who warns wound classification can lead to inconsistencies in care. Different nurses visited each time making it difficult to provide continuity of care. The district nurse had defined the objective, which was to treat the leg ulcer. However the planning phase of Walsh (1998) model was not implemented, the nurse did not consider an alternative as identified as important in Schaefer (1974) theory. The best outcome, in the district nurses view, was considered although not in an evidence based way.

Carroll and Johnson (1990) refer to the common sense view of decision making, in stages 3,4, and 5, alternative generation, information search and judgment or choice. These three stages can be associated with problem solving approaches and with hypothetic deductive models such as Dowie & Elstien (1988). Hypothetic deductive method could have been used to identified what was going on with the wound e.g. blood test could have been taken to test for clotting factors, a Doppler could have been used to test for circulation. However nurses can’t always wait for a lab test to give a hypothesis so the district nurse then

drew on his experience. However using reflection in action (Schon 1983) and taking into consideration of the added problem of Jo being on steroids, he could have put these things into action to help create an evidence based care plan. Carroll and Johnston (1990) usefully includes decision making and subsequent (stages 6, 7) action and feedback. The inclusion of action and feedback in models of decision making has particle relevance to Jo’s community nursing assessment, because her assessment was continuous in nature ( Cowley et al (1994). If the district nurses had utilized the information properly the outcome for Jo may have been more successful. The best outcome for the patient depends on the patient’s response to treatment the nurse’s intervention and appropriate use of information gained from the evaluation (Luker and Kenrick 1992).

District nurses need to be flexible in providing care in patients own homes, because of the sheer diversity of home environments and lifestyles of there patients. Luker & Kenrick (1992) believe that community nurses have there own personally owned knowledge that they find difficult to describe. Benner (1984) would describe this as intuition. However many influencing factors are involved with the nurses decision making, the district nurse that treated Jo had 20 years experience, but in the authors opinion had not used reflective and evidence based practice. The use of reflection enables nurses to learn from there experience and build up an expert knowledge base. However if you don’t learn from your mistakes it doesn’t make you an expert.

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Experience doesn’t always equal expertise. If you are a ineffective nurse to start with you may always be a ineffective nurse. The district nurse involved with Jo’s case didn’t seem to reflect upon his actions and learn from practice but just performed a task. As long as the patient was being visited twice a week it didn’t seem to matter how long the wound took to heal, as Thompson et al (2002) suggest 20 years experience may be no more than one years experience repeated 20 times.

According to Walsh and ford (1990) there is a need for assertiveness and this was sadly lacking. Walsh & Ford (1990) argues the lack in assertiveness may be generated from being a mainly female profession, and Corbetta (2003) suggests women that work tend to be judged as inferior. However the district nurse involved in this decision making essay was a man, so I would question whether social conditioning had rubbed of on him. The district nurse seemed to resist altering his practice as directed by the ulcer clinic, it was almost as if he had ownership of the patient’s problem and care, and he saw it as a failure if he had to refer the patient on to a specialist service.

It is the resistance to change practice that is cited by several authors (Gould 1986, O’Conner 1993, Koh 1993) as major influence inhibiting the introduction of research into practice. However Parahoo (2002) suggests to change the way nurses work, using evidence based practice, nurses need to think about what they do, how they relate to the people they care for and generally stimulate a more reflecting and questioning attitude. Reading research articles can generate a reflective approach (Parahoo 2002) although the author is aware that changing practices based on one research article is unsafe.

Nurse managers have an important role in coordinated efforts, aimed at providing effective evidence based care. Although not all nurses are inclined towards academic work (Jootun 2003), the district nurse was the manager so without him being aware and appreciative of nursing research his team of community nurses provided an inadequate service. However as Sleep (1992) states it is unfair and unrealistic for educational programmes to place upon practitioners the burden of introducing research into the workplace, unless the climate prevailing in both service and management spheres is receptive to change.

The organisation needs to facilitate changes in nursing to allow the professional as a whole to practice evidence based care (Parahoo 2002). The district nurse worked in a small isolated practice and his priority seemed to be the setting up of new PCT policies. Patients with leg ulcers were almost in the way. If the district nurse had a positive attitude towards research and regularly read research articles on wound care, which as Gould (2001) suggest are available in digestible form, the care provided would have been evidence based effective care.

Recommendations

Joint education and clinical career pathways are needed to close the theory practice gap. Many nurses working in small practices are not getting the education they need to prove the government with a highly effective and trained workforce. Many organizations within the NHS are busy and overworked. The time is not available for them to update their knowledge and training. To help nurses who work in isolated community practices the setting up of groups or research meetings could enable them to keep up to date with relevant research, and would enable the effective utilisation of research findings. Nurses can also be encouraged to use expert nurses that are available at many hospitals and PCT. The use of computer networks and interactive software and research newsletters could also aid in the implementation of research practice.

Evaluation

Carroll & Johnston (1990) provide a framework for decision making, the author feels if the district nurse had used such a framework the care delivered to Jo could have been more effective and evidence based. The District Nurse didn’t evaluate or reflect on the care he delivered. Using decision making model such as Carroll and Johnston (1990) and Walsh (1998) nursing process, the nurse could have delivered evidence based reflective care. Models such as these are used as a guideline to nursing procedures, if they are followed it ensures that patients get best care and that nurses don’t become complacent in the care they deliver, but use a systematic approach alongside there experiences and expertise

Conclusion

Intuition has been identified as a useful tool that needs to be recognised within nursing, however a need for a ration approach along side it is necessary. This will enable nurses to provide evidence based care with clear rationales. There are many aspects of nursing that cannot be subjected to measurement, and intuition is one of them, and so is caring. To ignore intuition as a nursing skill would be to deny the patient of truly holistic care. However I would say that the nurse involved with Jo’s care was not an expert in the care of leg ulcers, and was baseing his care on limited research. The effect this had on the patient was a poor standard of care.

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